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MR assessment of retrosternal goitre
ABSTRACTS
767
DOES THE PRESENCE OR ABSENCE OF AIR IN THE BIL1ARY TREE PREDICT STENT OCCLUSION: PROSPECTIVE STUDY USING ULTRASOUND AND PLAIN FILM R. E. ENGLAND, A. T R O U G H T O N , P. GRECH, C. SCHMITT and J. BAILLIE
PRIMARY O S T E O S A R C O M A OF THE SPINE R. GREEN, A. SAIFUDDIN, S. C A N N O N and P. RENTON
Department of Radiology and Division of Gastroenterology', Duke University Medical Center, Durham, ArC, USA
in the spine and sacrum. The imaging features of 11 cases that presented to the London Bone Tumour Service have been reviewed. Subjects and Method: There are 6 males and 5 females (age range 1346 years, mean age 25.6 years). Imaging consisted of varying combinations of plain radiography, myelography, bone scintigraphy, CT and MRI. Results: Sites included cervical spine (1), thoracic spine (1), lumbar spine (4) and sacrum (5). Plain radiography demonstrated a purely Iytic lesion in 5 cases, a mixed lytic/blastic lesion in 3 cases and an osteoblastic lesion in 3 cases. An associated extraosseous mass was identified in 6 cases. Extradural extension was demonstrated in 3 cases (2 by myelography, I by CT). In I case, MRI demonstrated far greater involvement of medullary bone than could be seen on plain films and CT. Several examples of spinal osteosarcoma are shown. Conclusion: Although rare, osteosarcoma needs to be considered in the different diagnosis of a Iytic lesion of the spine, the major clue to the diagnosis being the young age of the patient.
Introduction: Biliary stenting is an established technique for management of benign and malignant biliary disease. Stent blockage is almost inevitable, with time. Is the absence ofpneumobilia, on ultrasound (US) and plain film predictive of stent occlusion? Design: Prospective study of endoscopic stent removed between 1991-1994. Subjects andMethod: 16 males, 24 females, mean age 65.5 years (range 37-91), had 50 procedures. Stents were 10FG or greater in diameter. Patients with sphincterotomies were excluded. Each patient had a biliary US and a plain film prior to ERCP. Following removal, the top o f the stent was placed through the base of a Styrofoam cup, filled with water. Flow through the stent into a 60 ml syringe over 20 seconds was recorded. An occluded stent was defined as a flow rate of < 10mls/min. Results: US negative for pneumobilia, is 79% sensitive, 52% specific, (PPV 70%), for stent blockage. Absence of biliary air on plain film is 83% sensitive, 43% specific (PPV 67%) for stent occlusion. Clinical presentation did not correlate with stent occlusion (R 2 = -0.05). Conclusion: Absence of pneumobilia on US or X-ray is a sensitive predictor of stent occlusion, and may be more reliable than clinical presentation.
MR ASSESSMENT OF RETROSTERNAL GOITRE R. J. E T H E R I N G T O N and G. ABBOTT
Countess of Chester Hospital, Chester Confirmation of the nature of an upper mediastinal mass and preoperative extent of a retrosternal goitre are conventionally performed by plain radiography, ultrasound and isotope scanning. We have prospectively assessed the ability of M R to answer these questions. Scans were performed on a Siemens Impact IT Scanner in 7 patients, using a head/neck coil. Sequences included coronal and axial TI weighted and axial T2 weighted spin echo scans and coronal and axial FLASH scans in inspiration and expiration. The T2 weighted scans defined the internal structure of the thyroid to best effect. The coronal T1 weighted scans were particularly useful to show the degree of intrathoracic extension and vascular compression. The gradient echo scans clearly demonstrated the degree of tracheal displacement and compression, especially in patients with COAD where conventional assessment of airway obstruction by flow loop was difficult. Conclusion: M R is a useful one stage procedure for defining the extent and compressive effects of intrathoracic goitre.
CLINICAL EXPERIENCE OF GIANTURCO Z STENT IN M A J O R AIRWAY OBSTRUCTION L. GOMERSALL and J. WEIR
Aberdeen Royal Hospitals NHS Trust, Aberdeen Introduction: Expandable metal stents are of proven value in major airway obstruction with stridor. We report our experience of stenting 9 patients, 8 with malignant disease, all of whom had stridor. Design: Retrospective. Method: 9 patients had 12 Gianturco Z stents inserted over a period of 21/2 years. All patients had pre-operative assessment by computed tomography, bronchoscopy and when feasible pulmonary function tests. All stents were introduced by one operator with the patient under general anaesthesia. All 8 patients with malignancy had tumour requiring stent insertion in a major bronchus with 1 patient requiring stenting of the distal trachea. One patient, aged 88, with extrinsic compression of the trachea by a multi-nodular goitre had two overlapping 5 cm trachael stents deployed. Results: All stents were correctly positioned. Continued stent expansion was noted on follow-up chest radiographs. Seven patients had symptomatic improvement in their dyspnoea and stridor. Pre and post insertion pulmonary function tests also showed improvement when measured. Two patients, 1 with benign disease, were alive and well at 8 months. The other 7 patients died between 4 and 123 days, from their malignant disease. Conclusion: Gianturco Z stents are of proven value in benign and malignant major airway obstruction with stridor.
The London Bone Tumour Service, Royal National Orthopaedic Hospital Trust, London Introduction: Approximately 1-3.2% of primary osteosarcomas occur
C O M P A R I S O N OF SMALL BOWEL RADIOLOGY AND P U S H ENTEROSCOPY IN THE INVESTIGATION OF SMALL INTESTINAL PATHOLOGY F. O. B. G R E G A N , C. HAWKINS, J. Y. Y I A N N A K O U , I. T. GILMORE, A. I. MORRIS and C. J. GARVEY
Departments of Radiology and Gastroenterology, Royal Liverpool University Hospital, Liverpool Push enteroscopy (PE) is a new technique allowing small bowel (SB) visualisation, biopsy, and therapy, and early results of its efficacy are encouraging. We have retrospectively compared this technique with small bowel radiology (SBR) in 37 patients with suspected SB disease. Eighteen patients had SB meals and 19 SB enemas. PE was performed under sedation. All procedures were well tolerated. Indications for investigation are shown in the table below, together with those cases where positive findings allowed a diagnosis to be made. SYMPTOM/ PROBLEM ANAEMIA OVERT G.I. BLEEDING DIARRHOEA
NO.
Lesion identified by Lesion identified by Endoscopy only Both modalities Angiodysplasia (1) NIL
7
Lesion identified by Radiology only Crohn's (1) Jejunal Tumour (1) Crohn's (1) Jejunal Tumour (1) NIL
5 3
11 8
Angiodysplasia (4)
Jejunal Tumour
Coeliac disease (1)
Eosinophilic enteritis
Crohn's (1)
NIL
Fibrotic jejunal stricture (1) NIL
NIL
Extensive Crohn's. Biopsies quiescent (1) NIL
NIL
NIL
(bleeding)(1)
(1) CROHNS DISEASE ABDOMINAL PAIN POLYPOSIS
3
Lesions identified by SBR alone (6) were in the distal small intestine. Lesions identified by PE alone (6) required direct mucosal visualisation or biopsy. When both were positive (4 cases) each contributed to the diagnosis, SBR showing disease extent, and PE providing histology and treatment. In five cases negative investigations influenced patient management. Endoscopic laser therapy was given to four patients who had actively bleeding lesions with excellent results. We conclude that these techniques are complementary and should be used together in the investigation of small intestinal disease. IMAGING OF PERIOSTEAL OSTEOSARCOMAS H. HALE, A. S A I F U D D I N and S. C A N N O N
The London Bone Tumour Service, Royal National Orthopaedic Hospital Trust, London Introduction." Periosteal osteosarcomas are rare primary bone tumours accounting for 1% of osteosarcomas and 22.5% of surface osteosarcomas. In the last five years eight cases have presented to the London Bone Tumour Service. The imaging features of these cases were reviewed with particular emphasis on the M R findings. Subjects and Methods: There were six females and two males (age range of 11 to 72 years; mean age 24 years). All patients were imaged with a varying combination of plain films, bone scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI). Results: Sites of presentation wer femur (3) tibia (3) humerus (!) and ulna (1). Plain films demonstrated a variably mineralised soft tissue mass adjacent to the bony cortex. Scintigraphy demonstrated activity
767
DOES THE PRESENCE OR ABSENCE OF AIR IN THE BIL1ARY TREE PREDICT STENT OCCLUSION: PROSPECTIVE STUDY USING ULTRASOUND AND PLAIN FILM R. E. ENGLAND, A. T R O U G H T O N , P. GRECH, C. SCHMITT and J. BAILLIE
PRIMARY O S T E O S A R C O M A OF THE SPINE R. GREEN, A. SAIFUDDIN, S. C A N N O N and P. RENTON
Department of Radiology and Division of Gastroenterology', Duke University Medical Center, Durham, ArC, USA
in the spine and sacrum. The imaging features of 11 cases that presented to the London Bone Tumour Service have been reviewed. Subjects and Method: There are 6 males and 5 females (age range 1346 years, mean age 25.6 years). Imaging consisted of varying combinations of plain radiography, myelography, bone scintigraphy, CT and MRI. Results: Sites included cervical spine (1), thoracic spine (1), lumbar spine (4) and sacrum (5). Plain radiography demonstrated a purely Iytic lesion in 5 cases, a mixed lytic/blastic lesion in 3 cases and an osteoblastic lesion in 3 cases. An associated extraosseous mass was identified in 6 cases. Extradural extension was demonstrated in 3 cases (2 by myelography, I by CT). In I case, MRI demonstrated far greater involvement of medullary bone than could be seen on plain films and CT. Several examples of spinal osteosarcoma are shown. Conclusion: Although rare, osteosarcoma needs to be considered in the different diagnosis of a Iytic lesion of the spine, the major clue to the diagnosis being the young age of the patient.
Introduction: Biliary stenting is an established technique for management of benign and malignant biliary disease. Stent blockage is almost inevitable, with time. Is the absence ofpneumobilia, on ultrasound (US) and plain film predictive of stent occlusion? Design: Prospective study of endoscopic stent removed between 1991-1994. Subjects andMethod: 16 males, 24 females, mean age 65.5 years (range 37-91), had 50 procedures. Stents were 10FG or greater in diameter. Patients with sphincterotomies were excluded. Each patient had a biliary US and a plain film prior to ERCP. Following removal, the top o f the stent was placed through the base of a Styrofoam cup, filled with water. Flow through the stent into a 60 ml syringe over 20 seconds was recorded. An occluded stent was defined as a flow rate of < 10mls/min. Results: US negative for pneumobilia, is 79% sensitive, 52% specific, (PPV 70%), for stent blockage. Absence of biliary air on plain film is 83% sensitive, 43% specific (PPV 67%) for stent occlusion. Clinical presentation did not correlate with stent occlusion (R 2 = -0.05). Conclusion: Absence of pneumobilia on US or X-ray is a sensitive predictor of stent occlusion, and may be more reliable than clinical presentation.
MR ASSESSMENT OF RETROSTERNAL GOITRE R. J. E T H E R I N G T O N and G. ABBOTT
Countess of Chester Hospital, Chester Confirmation of the nature of an upper mediastinal mass and preoperative extent of a retrosternal goitre are conventionally performed by plain radiography, ultrasound and isotope scanning. We have prospectively assessed the ability of M R to answer these questions. Scans were performed on a Siemens Impact IT Scanner in 7 patients, using a head/neck coil. Sequences included coronal and axial TI weighted and axial T2 weighted spin echo scans and coronal and axial FLASH scans in inspiration and expiration. The T2 weighted scans defined the internal structure of the thyroid to best effect. The coronal T1 weighted scans were particularly useful to show the degree of intrathoracic extension and vascular compression. The gradient echo scans clearly demonstrated the degree of tracheal displacement and compression, especially in patients with COAD where conventional assessment of airway obstruction by flow loop was difficult. Conclusion: M R is a useful one stage procedure for defining the extent and compressive effects of intrathoracic goitre.
CLINICAL EXPERIENCE OF GIANTURCO Z STENT IN M A J O R AIRWAY OBSTRUCTION L. GOMERSALL and J. WEIR
Aberdeen Royal Hospitals NHS Trust, Aberdeen Introduction: Expandable metal stents are of proven value in major airway obstruction with stridor. We report our experience of stenting 9 patients, 8 with malignant disease, all of whom had stridor. Design: Retrospective. Method: 9 patients had 12 Gianturco Z stents inserted over a period of 21/2 years. All patients had pre-operative assessment by computed tomography, bronchoscopy and when feasible pulmonary function tests. All stents were introduced by one operator with the patient under general anaesthesia. All 8 patients with malignancy had tumour requiring stent insertion in a major bronchus with 1 patient requiring stenting of the distal trachea. One patient, aged 88, with extrinsic compression of the trachea by a multi-nodular goitre had two overlapping 5 cm trachael stents deployed. Results: All stents were correctly positioned. Continued stent expansion was noted on follow-up chest radiographs. Seven patients had symptomatic improvement in their dyspnoea and stridor. Pre and post insertion pulmonary function tests also showed improvement when measured. Two patients, 1 with benign disease, were alive and well at 8 months. The other 7 patients died between 4 and 123 days, from their malignant disease. Conclusion: Gianturco Z stents are of proven value in benign and malignant major airway obstruction with stridor.
The London Bone Tumour Service, Royal National Orthopaedic Hospital Trust, London Introduction: Approximately 1-3.2% of primary osteosarcomas occur
C O M P A R I S O N OF SMALL BOWEL RADIOLOGY AND P U S H ENTEROSCOPY IN THE INVESTIGATION OF SMALL INTESTINAL PATHOLOGY F. O. B. G R E G A N , C. HAWKINS, J. Y. Y I A N N A K O U , I. T. GILMORE, A. I. MORRIS and C. J. GARVEY
Departments of Radiology and Gastroenterology, Royal Liverpool University Hospital, Liverpool Push enteroscopy (PE) is a new technique allowing small bowel (SB) visualisation, biopsy, and therapy, and early results of its efficacy are encouraging. We have retrospectively compared this technique with small bowel radiology (SBR) in 37 patients with suspected SB disease. Eighteen patients had SB meals and 19 SB enemas. PE was performed under sedation. All procedures were well tolerated. Indications for investigation are shown in the table below, together with those cases where positive findings allowed a diagnosis to be made. SYMPTOM/ PROBLEM ANAEMIA OVERT G.I. BLEEDING DIARRHOEA
NO.
Lesion identified by Lesion identified by Endoscopy only Both modalities Angiodysplasia (1) NIL
7
Lesion identified by Radiology only Crohn's (1) Jejunal Tumour (1) Crohn's (1) Jejunal Tumour (1) NIL
5 3
11 8
Angiodysplasia (4)
Jejunal Tumour
Coeliac disease (1)
Eosinophilic enteritis
Crohn's (1)
NIL
Fibrotic jejunal stricture (1) NIL
NIL
Extensive Crohn's. Biopsies quiescent (1) NIL
NIL
NIL
(bleeding)(1)
(1) CROHNS DISEASE ABDOMINAL PAIN POLYPOSIS
3
Lesions identified by SBR alone (6) were in the distal small intestine. Lesions identified by PE alone (6) required direct mucosal visualisation or biopsy. When both were positive (4 cases) each contributed to the diagnosis, SBR showing disease extent, and PE providing histology and treatment. In five cases negative investigations influenced patient management. Endoscopic laser therapy was given to four patients who had actively bleeding lesions with excellent results. We conclude that these techniques are complementary and should be used together in the investigation of small intestinal disease. IMAGING OF PERIOSTEAL OSTEOSARCOMAS H. HALE, A. S A I F U D D I N and S. C A N N O N
The London Bone Tumour Service, Royal National Orthopaedic Hospital Trust, London Introduction." Periosteal osteosarcomas are rare primary bone tumours accounting for 1% of osteosarcomas and 22.5% of surface osteosarcomas. In the last five years eight cases have presented to the London Bone Tumour Service. The imaging features of these cases were reviewed with particular emphasis on the M R findings. Subjects and Methods: There were six females and two males (age range of 11 to 72 years; mean age 24 years). All patients were imaged with a varying combination of plain films, bone scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI). Results: Sites of presentation wer femur (3) tibia (3) humerus (!) and ulna (1). Plain films demonstrated a variably mineralised soft tissue mass adjacent to the bony cortex. Scintigraphy demonstrated activity