Transrectal ultrasound-guided prostatic biopsy — A report of 45 patients with clinically suspected disease

ABSTRACTS recurrent stenosis rate. We present the early results in a small series of patients in whom we have employed a new device to manage venous stenoses resistant to conventional angioplasty. The Simpson atherectomy catheter was designed to resect focal eccentric atheromatous material from short segment arterial stenoses, using a high speed rotating cutting blade and stabilising balloon. The advantages and disadvantages of application of this device to venous stenoses will be discussed.

exocrine secretions is reviewed. The normal appearance of the transplant on ultrasound, isotope scan and cystogram is presented. Doppler ultrasound can be used to demonstrate flow in the pancreatic vessels. The method of Doppler scanning is described. The usefulness of these non-invasive investigations in the diagnosis of complications is shown. CAN ULTRASOUND REPLACE THE INTRAVENOUS UROGRAM IN PRELIMINARY INVESTIGATION OF RENAL TRACT DISEASE? A PROSPECTIVE STUDY H. G. LEWIS-JONES, G. H. R. LAMB and P. L. H U G H E S

QUANTITATIVE ASSESSMENT OF PORTAL VEIN BLOOD FLOW BY DUPLEX ULTRASOUND SCANNING A. M. SEIFALIAN, J. M. YOUNG, and K. E. F. HOBBS

Royal Liverpool Hospital, Liverpool

Royal Free Hospital, London

The intravenous urogram has long been the mainstay of urinary tract imaging in adult practice. It has been recently shown that in many clinical situations the routine use of intravenous urography is no longer justified and in some situations ultrasound is as good as if not superior to urography. In addition, ultrasound has the advantages of no radiation exposure, avoidance of adverse contrast reactions, reduced examination time and significant cost reduction. In order to assess the clinical and financial aspects of a change in practise in our department, a prospective study was undertaken over a total of 10 weeks when 328 patients who attended for intravenous urography were also examined independently by ultrasound combined with the plain abdominal film. The results were compared and we found that in 81.4% the two techniques yielded identical information. Ultrasound plus a plain abdominal film provided more diagnostic information in a further 12.5% and the reverse was true in only 6.1%. The findings of the study are discussed by considering the main clinical groups and comparing the relative yields of ultrasound and urography. A scheme of routine urinary tract investigations using ultrasound and the plain abdominal film is proposed. We estimate a 68% reduction in number of urographic examinations while retaining diagnostic accuracy. The financial and planning implications for our department are discussed.

Various techniques have been described for measuring portal blood flow but all are invasive. We are evaluating a non-invasive quantitative measurement of portal blood flow using a duplex ultrasound scanning system (Vingmed Colour Mapping System 700, Diasonics). To calibrate the instrument a simulation model of blood circulation was set up, consisting of pump (Bio-Console, Bio-Medicus Inc.), flexible plastic tubing surrounded by Kiteco Silicon Gel and the tubular probe of an electromagnetic flowmeter (EMF). Blood flow calculated by duplex ultrasound correlates (r=0.9810.988) well with that calculated by EMF for flow rates ranging from 200 to 2000 ml/min using silicon tubes with internal diameters of 6.6 and 9.5 mm. Tube diameter 9.5 mm EMF (ml/min) 2000 1800 1600 1400 1200 1000 800 600 US (ml/min) 1882 1827 1685 1544 1399 1011 828 749 6.6 mm EMF (ml/min) 2000 1800 1320 1220 1000 900 800 700 600 500 400 300 200 US (ml/min) 1925 1743 1437 1342 1044 1153 944 708 590 521 472 338 243 Clinical study demonstrates an increase in portal vein blood flow after food. Preliminary results show that this technique of non-invasive measurement of portal blood flow may have great physiological and clinical promise. ASSESSMENT OF PORTAL VEIN INVASION IN PATIENTS WITH PRIMARY HEPATOCELLULAR CARCINOMA: SONOGRAPHY COMPARED WITH ANGIOGRAPHY J. PRICE, M. CHAN, C. HAMILTON-WOOD, N. A. F. CHRONOS, S.D. MOK and C. METREWELI

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ENDOVAGINAL ULTRASOUND OF THE NON-PREGNANT PELVIS B. KEEFE

University of North Carolina Memorial Hospital, Chapel Hill, North Carolina, USA

Primary hepatocellular carcinoma (HCC) is the second commonest lethal malignancy among Hong Kong Chinese males, exceeded only by bronchial carcinoma. A characteristic pathological feature of HCC is its propensity for invasion of the portal venous system. This is important in management since the presence of tumour thrombus in the main portal vein will usually preclude surgery. If tumour invasion is confined to portal branches of one or other lobe distal to the bifurcation, hepatic lobectomy may be possible. Ultrasound is a cheap and non-invasive method with an inherent advantage in examining vessels in that it is possible to scan in any plane. In patients with HCC, tumour thrombus can sometimes be seen sonographically as echogenic material within the lumen. The results of sonographic and angiographic assessment of the main portal vein were reviewed in 65 patients with documented primary hepatocellular carcinoma. When compared with fully diagnostic angiograms obtained in 54 patients, the sensitivity of ultrasound was 64% and the specificity 98%. We conclude that ultrasound is a valuable first-line investigation in the pre-operative assessment of the portal vein in patients with HCC.

Endovaginally performed ultrasound has been largely employed in the evaluation of the pregnant patient. We report.our experience in 86 non-pregnant patients who underwent endovaginal pelvic ultrasound. The age range was 13 to 70 years. Twelve patients had a normal uterus and ovaries. Twenty patients had uterine masses compatible with fibroids. Eleven patients had other abnormalities of the uterus including endometrial masses, endometrial fluid, myometrial masses and placenta increta. Three patients had congenital abnormalities. With regard to the adnexa, 14 patients had simple cysts, 18 patients had complex cysts, and three patients had solid adnexal masses. Of 86 patients, both ovaries could not be visualised in six, in one patient only one ovary could be visualised. Four fluid collections and two complex masses were visualised in the cul-de-sac. Forty-four patients underwent an endovaginal study only. Forty-two patients underwent both an endovaginal and transabdominal pelvic ultrasound. In 38 of these patients the endovaginal study yielded more diagnostic information. In three patients both studies were equal in quality; in one case both modes of study were indispensable for the patient work-up. Patient acceptance of the endovaginal study was 100%. Advantages of the endovaginal approach include a marked increase in resolution of both normal and abnormal pelvic structures, no need for a distended urinary bladder and greater detection of bowel. We recommend endovaginally performed pelvic ultrasound over the transabdominal route as the initial ultrasound examination in patients being evaluated for pelvic pathology.

THE RADIOLOGY OF PANCREATIC TRANSPLANTATION R. J. ETHERINGTON

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Prince of Wales Hospital, The Chinese University of Hong Kong

University Hospital of Wales, Cardiff Pancreatic transplantation is gaining acceptance in the treatment of diabetes, particularly in patients with diabetic nephropathy. The types of transplant and the surgical techniques of vascular anastomosis and drainage are briefly summarised. The radiology of eight patients who have undergone pancreatic transplantation with urinary diversion of

TRANSRECTAL ULTRASOUND-GUIDED PROSTATIC BIOPSY A REPORT OF 45 PATIENTS WITH CLINICALLY SUSPECTED DISEASE J. GLOVER, D. RICKARDS and P. W O O D H E A D

Middlesex Hospital, London The ultrasound appearances of prostatic malignancy has altered over the years. Initially it was thought to be echogenic but now it is thought to be echo-poor. In this report, 45 patients were referred for TRUS

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CLINICAL RADIOLOGY

and biopsy all of whom had abnormal clinical findings on digital examination, suspicious, but not diagnostic of malignancy. Biopsy was performed on predominantlY echo-poor lesions in 43 patients and echogenic lesions in two. Lesions measured 0.7-2 cm in diameter. Prostate cancer was found in 15 patients (33%) all of whom had predominantly echo-poor lesions, confined to the peripheral zone of the gland in nine and extending into the central zone of the gland in six. Biopsy of 28 echo-poor lesions revealed benign prostatic hypertrophy in four and prostatitis in three. The two echogenic lesions biopsied were also benign. This report supports the currently held concept that small prostatic tumours are echo-poor on TRUS, but that both histologically benign hypertrophy and prostatitis have similar ultrasound appearances. In patients in whom there is clinical suspicion of prostatic abnormality on digital examination and in whom echo-poor lesions are identified prostatic biopsy is indicated.

RADIOLOGY BEFORE PARATHYROID SURGERY M. N. H. LLOYD, W. R. LEES and E. MILROY

Middlesex Hospital, London Two hundred and seven cases having parathyroid exploration over 4 years were studied. Skeletal complications of hyperparathyroidism were demonstrated in 14% (24 of 176) and urological complications in 42% (72 of 172). Evidence of past or present gallstones was seen in 30% (32 of 106). Of 173 patients without previous parathyroid exploration, adenomas were found in 152, hyperplasia in 19 and two had negative explorations. Pre-operative localisation in these was usually performed with parathyroid venous sampling (PVS) and ultrasound. PVS had a sensitivity of 67% (78 of 117), localised precisely in 44% (51 of 117) with false positive rate of 14% (16 of 117). Ultrasound had a sensitivity Of 32% (51 of 158), localised precisely in 20% (33 of 158) with 8% false positives. Relatively poor results from ultrasound were related to operator inexperience, small glands, thyroid abnormality, previous neck surgery and multigland disease. The most experienced ultrasonologist achieved a sensitivity of 65% (28 of 43) with precise localisation in 60% and a false positive rate of 16%. Combined, the two techniques had an overall sensitivity of 61% but with 16% false positive results. Parathyroid venous sampling is very expensive and carries a small morbidity but is relatively simple to perform. Ultrasound is cheap and rapid to perform with no morbidity but requires good equipment and an experienced operator. ASSESSMENT OF RECTAL TUMOURS BY ENDOLUMINAL ULTRASOUND M. J. BULL, W. P. MORGAN and R. W. BURY

Royal Hallamshire Hospital, Sheffield The close apposition of a high frequency (7 MHz) ultrasound probe against the rectal wall allows for a high resolution image in which distinct layers can be seen corresponding to known histological structures. In particular, the good visualisation of the serosa is a good guide to any spread of tumour beyond the rectal wall. A study is described of over 30 cases of rectal tumours which were assessed by endoluminal ultrasound (ELU), computed tomography, biochemical markers and clinical evaluation. These are correlated with the operative findings and final histology. Endoluminal ultrasound is shown to be an easy, safe, well tolerated procedure which allows more accurate local staging of both benign and malignant rectal tumours to be made.

in association with flexion-distraction injury. In 17 patients the level of injury was between T12 and L3. The highest level involved was T6 and the lowest L5. In patients who had both CT and tomography, CT was more difficult to interpret and yielded additional information in a minority of patients (apart from avulsion injuries of the transverse and spinous processes). Minor degrees of rotation were noted to affect the visibility of abnormalities on sagittal reformatting. CT most often missed fractures in the axial plane which is the orientation favoured by this mechanism of injury. We prefer conventional tomography for the evaluation of these patients, recommending CT for investigation of the patient with a neurological deficit and for assessment of suspected compromise of the bony spinal canal.

FATIGUE FRACTURES OF THE PROXIMAL TIBIA SIMULATING MALIGNANCY A. M. DAVIES, N. EVANS and R. J. GRIMER

Royal Orthopaedic Hospital, Birmingham Although the proximal tibia is a classic site for the fatigue type of stress fracture they are commonly mistaken for a malignant sarcoma of bone. We present the clinical and radiological features of nine cases seen in a 2V2 year period. Seven of the cases referred to the Bone Tumour Service with the diagnosis of a probable sarcoma. All 9 patients were male but only two gave a history of a recent increase in physical activity. The plain radiographic findings consisted of an uninterrupted lamellar periosteal reaction arising posteromedially in the proximal tibia with the fracture visible through the thickened posterior cortex. Bone scan revealed a fusiform focus of increased uptake in the posteromedial cortex of the tibia with varying degrees of activity in the adjacent metaphysis. CT on a soft tissue window showed perifracture oedoma in the absence of a soft tissue mass. The attenuation of the underlying medulla was increased due to fibrosis and hyperaemia. On an extended window setting both periosteal and endosteal callus was identified, maximal in the posteromedial tibia and the fractures were best demonstrated on a cortical window. Clinical and radiological features that differentiate a fatigue fracture from a sarcoma are discussed. THE ANATOMY OF THE SHOULDER JOINT ON CT ARTHROGRAPHY AND THE ROLE OF THE TECHNIQUE IN RECURRENT DISLOCATION J. V. COOK and R. T A Y A R

St Helier Hospital, London Fifty-one patients (37 men and 17 women) with a history of documented recurrent dislocation (41) or suspected instability of the shoulder joint (10) were examined by CT arthrography. Those with recurrent dislocation showed most abnormalities, plain double contrast arthrography was abnormal in seven and abnormalities were noted on CT in 36. These patients often have multiple abnormalities and unless extensive exploration is undertaken at the time of surgery, some lesions may be overlooked and lead to continuing morbidity. We consider that pre-operative CT arthrography is useful in identifying the site and extent of capsular and labral abnormalities, thus aiding in the selection of the appropriate surgical procedure and avoiding the necessity for lengthy surgery. This paper: 1 Describes the technique involved. 2 Demonstrates the normal appearances and some anatomical variants which may lead to misinterpretation. 3 Identifies the main abnormalities seen in recurrent dislocation.

IMAGING OF FLEXION-DISTRACTION INJURIES OF THE THORACOLUMBAR SPINE R. G. W. LAMBERT, E. J. BECKER and J. D. RUBENSTEIN

CT SCANNING OF DISTAL TIBIAL EPIPHYSEAL FRACTURES IN ADOLESCENTS K. UDJUS and P. McDONALD

Toronto General Hospital and Sunnybrook Medical Centre, Toronto, Canada

Children's Hospital of Eastern Ontario, Ontario, Canada

We reviewed 21 cases of flexion-distraction injury of the thoracolumbar spine. Eighteen patients had computed tomography (CT), 14 had conventional tomography and 11 had both. In our experience, these injuries are of greater diversity than previously emphasised. In five patients the radiographic findings were asymmetrical making analysis of the injury more difficult. Four patients had a sagittal fracture of the vertebral body, usually considered pathognomonic of a 'burst' injury and not previously reported

Since our GE 8800 CT scanner was installed in 1980, 90 patients have undergone CT examination of the ankle for distal epiphyseal fracture of the tibia. Eighty-eight of those were between the ages of 10 and 17-years-old, and were included in the study. Sixty-two of the fractures were of triplane type, over two-thirds of the total. There were 13 juvenile Tillaux fractures, as well as nine of Salter-Harris type II, two of Salter-Harris type Ill and two of SalterHarris type IV. The age distribution showed a peak for girls at age 13 and for boys at