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671

Letters

A Small

Cloud

Radiologists

on the

may

cloud on the horizon. in our direction.

Horizon

be aware

that

the

federal

government

has

The pertinent

question

eIim

Compensation

Depending

on

for interpretation

the

of ECGs of their own patients.

government’s

experience

with

this

provision,

Gray School of Medicine Winston-Salem, NC 27157-1088

REFERENCE 1 . Federal Register. November

ciated

exposure

examinations.

ever,

sonography

cardiology,

pulmonology,

surgery,

and

include

neurology,

emergency

provide formal logic studies.

involved

medicine.

orthopedics,

neurosurgery, Cardiology

urology,

cardiothoracic

and

neurology

training in the performance and interpretation of radioThe others mentioned provide informal training and

incorporate questions on

radiology

in their

board

examinations.

If the experiment of asking physicians to interpret their own ECGs produces no adverse consequences, the Health Care Financing Administration (HCFA) may have succeeded in demonstrating that specific

fees

for

unnecessary.

the The

interpretation patient’s

of many physician

diagnostic would

examinations

be expected

are

to interpret

these examinations as part of the evaluation of the patient’s condition. Any remuneration for interpretation of diagnostic examinations, as with ECGs, would be incorporated in the patient’s general fee. With

the precedent

set by the Change

in reading

of ECGs,

Diagnosis

I can

Intrathoracic

it has

for

and

is useful

certain

about

5-1 1%

real-time

monitoring

nography

to diagnose

no

the

costs

of mediastinal

How-

of mediastinal

masses,

It is inexpensive,

exposure [1-3].

to

We

can

radiation,

present

intrathoracic

scanning the asso-

are disadvantages.

in the evaluation

advantages.

involves

and

our

be used

can

be

experience

at the

used

with

in using

so-

goiters.

The study included five women and one man 41 -82 years old (mean, 68 years) who had histologically or cytologically proved intrathoracic

goiter

palpation perior

over

of the

functioning

a 3-year

neck

in five

thyroid.

Chest

mediastinal

guided

mass

fine-needle

examination

period. of the

Cervical

goiter

patients.

All six had

radiographs in all six.

aspiration

confirmed

six Five

of the

that

the

showed

an

patients

had

mediastinal

mass

was

was anterior

Sonograms

were

obtained

with

linear-array

by

or

a su-

sonographically

mass, an

found a normally

and

cytologic

intrathoracic

goiter.

Two patients had thoracotomy and excision of the mediastinal for relief of respiratory signs and symptoms, and histologic nation showed intrathoracic goiter.

graphic

or convex

mass exami-

transducers

(3.5-MHz Aloka SSD-630; 3.75- or 7.5-MHz Toshiba SSA-1 OOA) via a suprasternal, supraclavicular, or parasternal approach. The sonocharacteristics

of the

intrathoracic

goiters

were

as

follows:

radiologic

exam-

clear continuity

radiology

would

(Fig.

1) in six

have serious financial consequences for radiologists. At its worst, it could result in the partial disassembly of radiology as a medical

siX,

well-defined

hyperechoic

bands

speCialty.

a hypoechoic goiter were

area in four. The sonographic features of the cervical similar to those of intrathoracic goiters: well-defined

inations.

At

Although

best,

the

it is difficult

new

ECG

to feel

very

policy

sorry

of most

account

to radiation

bedside,

means

from the interpretation

goiters

Goiter Based on

masses resected at thoracotomy. Although radionuclide and CT can be used to detect most intrathoracic goiters,

foresee a situation in which the HCFA tells those physicians who have wanted to interpret their own radiographs that they should do so. However, they will not receive a bonanza of fees for interpretation of radiologic studies, only a slight increase in general fees for the effort involved. As with the cardiologists, radiologists could by this be excluded

25, 1991:56:59515

Intrathoracic Findings

of

Sonographic

and

already

W. Gelfand

Bowman

the implications for radiologists could be considerable. Basically, the government has told all physicians that they must now interpret the ECGs they order on their patients. Of most interest to radiologists is that cardiologists are no longer paid for interpreting ECGs for other physicians, as has been the customary arrangement in many hospitals. It is not difficult to recognize that the same process applied to the interpretation of radiologic examinations could threaten the practice of radiology as currently constituted. For years, many of our nonradiologist colleagues have been saying that they are willing and able to interpret their patients’ radiologic The specialties

it is moving

David

nated specific fees for interpreting routine ECGs by cardiologists and other physicians [1 ]. Instead, most physicians are now receiving an increase of approximately $1 per visit for Medicare patients as a general

is whether

applied

for

to

the

cardiologists

about

ECG fees, considering their efforts to divest radiology of every aspect of cardiovascular imaging, the matter exists as a storm their

loss

of

borders focal

between patients,

the mediastinal heterogeneous

borders

in six calcification

in five,

or spots

patients, in four,

in four,

heterogeneous and

cystic

mass and the cervical hyperechoic

focal and

texture

calcification cystic

change

hyperechoic changes

in three.

thyroid (Fig.

manifested

as

manifested

texture

2) in as

in four,

LETTERS

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672

AJR:159,

September

1992

‘:‘

A Fig. 1.-Longitudinal sonogram shows direct extension of cervical roid (arrowhead) into superior mediastinum (m). c = carotid artery. Fig.

2.-Transverse

thy-

sonogram shows direct connection of intrathoracic

goIter (arrowhead) well-defined border

with cervical thyroid (arrows). lntrathoracic goiter has with halo sign and heterogeneous hyperechoic texture. Hypoechoic area in cervical thyroid represents cystic change. c = common carotid artery, s = subclavian artery, v = innominate vein, L = lung, and m = mediastinum.

B

Fig. 1.-Bronchiolitis obliterans with organizing pneumonia. A, Chest radiograph shows enlargement of right hilum and widening of right paratracheal space. B, CT scan obtained 2 days after admission shows an apparent mass within right hilum.

space (Fig. 1A). CT scans showed hilum Sonography

has

racic goiter. thyroid

several

It clearly

and the goiter

advantages

shows and

in the

the continuity the high

diagnosis

of intratho-

between

the cervical

similarity

in the echotextures

of the two (e.g., calcification, cyst formation, well-defined borders, and echogenicity). In our experience, the continuity of the cervical thyroid and mediastinal mass was not found in other clinical conditions [2, 31. Primary intrathoracic goiter, without any connection to the cervical thyroid, is rare. We have seen no such case. However, sonographically

guided

fine-needle

aspiration

may

also

be helpful

in

the diagnosis of primary intrathoracic goiter. In certain patients with a superior mediastinal mass, sonography may be the most convenient and useful technique for diagnosing intrathoracic goiter. Dun-Bing

Chang

Pan-Chyr

Yang

Sow-Hsong

Kuo

and colleagues National Taipei,

Taiwan

University

Taiwan,

Aepublic

2.

of mediastinal

masses.

Chest

lesion within the right

lower

lobe

of the lung

(Fig.

1 B). The paratracheal and subcarinal lymph nodes were grossly enlarged. On follow-up chest radiographs and CT scans, the size of the masslike lesion had increased rapidly, and a right-sided pleural effusion had developed. The patient had bronchoscopy twice, and

the results indicated biopsy

was

Deerfield, long.

that the mass was not a tumor. A percutaneous

performed;

a Tru-Cut

needle

IL) was used to obtain

Histologic

examination

(Baxter

a cylinder

showed

plugs

Health

Care

Corp.,

of lung tissue

of connective

1 .5 cm

tissue

filling

alveolar spaces and respiratory bronchioles. These plugs consisted of fibroblasts and a few admixed inflammatory cells in an edematous stroma, sometimes with a central capillary vessel. Some alveoli were filled with alveolar macrophages and remnants of a fibninous exudate in organization.

moderate

Interstitial

changes

were

much

less

pronounced,

thickening of alveolar septa due to accumulation cells and hyperplasia of type II pneumonocytes.

with

of inflam-

matory On the basis of the histologic finding and compatible clinical signs and symptoms, idiopathic bronchiolitis obliterans with organizing

of ultrasonically

guided

1991;100:399-405

our

patient,

were

also

nipheral radiologic

was

were rare

rather findings

diagnosed.

present (4.8%).

than

However,

in only Furthermore,

central. in bronchiolitis

monia. To our knowledge, adenopathy

Bronchiolitis Pneumonia:

right

cause of the atypical appearance on the radiographs. The unilateral masslike consolidation associated with hilar adenopathy and a pleural effusion suggested bronchogenic carcinoma, malignant lymphoma, tuberculosis, or pleuropneumonia. McLoud et al. [1] reported findings in 29 patients with bronchiolitis obliterans with organizing pneumonia. Unilateral opacities, as seen in

PE, Galanski M. Mediastinal tumors: evaluation with Radiology 1986:159:405-409 Yang PC, Chang DB, Lee YC, Yu CJ, Kuo SH, Luh KT. Mediastinal malignancy: ultrasound guided biopsy through supraclavicular approach.

biopsies

a masslike

of the

pneumonia

sonography.

Thorax 1992;47:377-380 3. Vu CJ, Yang PC, Chang DB, et al. Evaluation

infiltration

Hospita!

K, Peters

suprasternal

moderate

of China

REFERENCES 1 . Wemecke

and

Our

diagnosis

was

be-

4.8% of all cases. Pleural effusions pulmonary

case

infiltrates

were

the

diversity

illustrates

obliterans

with

organizing

pe-

of

pneu-

this is the first report of gross mediastinal

in this disease. A. Knapp

Obliterans with Organizing Atypical Appearance on Radiographs

We report a case of biopsy-proved idiopathic bronchiolitis obliterans with organizing pneumonia in which intrapulmonary changes were confined to the right lung and were accompanied by a unilateral pleural effusion and gross mediastinal adenopathy. A 57-year-old man had a history of cough, increasing dyspnea, chest pain, and moderate fever. Chest radiographs showed an apparent mass in the right hilum and a widening ofthe right paratracheal

delayed

Ch.

Prior

F. Fend D. zur Nedden University

A-6020

of !nnsbruck

!nnsbruck,

Austria

REFERENCES 1 . McLoud TC, Epler GR, Colby TV, Gaensler obliterans. Radiology 1986:159:1-8

EA, Carrington

CB. Bronchiolitis

AJR:159,

September

Breast

Gas-Fluid

Previously

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include

Level

reported

fat necrosis,

on Chest

mammographic oil cysts,

Radiographs

findings

hematomas,

after

breast

infection,

skin

biopsy

thickening,

contour deformity, keloid formation, architectural distortions, asymmetric parenchyma, parenchymal stellate scar, dystrophic calcification, and calcified sutures [1 , 2]. Rabin and Murray [3] have described the appearance on chest radiographs of nipple shadow, mastectomy, calcified cysts, phleboliths, carcinomatous masses, dense fibroadenomas, and density caused by cystic mastitis. Additionally, radiologists are familiar with the appearance of various breast implants and prostheses on chest radiographs. We report the unusual appearance on chest radiographs of a gas-fluid level within a postbiopsy hematoma. A 69-year-old woman had chest radiographs before undergoing a right-sided biopsy

mastectomy.

for

an area

intraductal

carcinoma

One

week

of thickening

earlier,

in the

with tumor

she had

right

extending

breast

had incisional

that

showed

to the specimen’s

an

level (Fig.

1 B) showed the cavity was within the right breast. Physical examination of the breast showed no evidence of erythema, tenderness to

palpation, or fistula. Multiple superficial sutures were present in the area of incision, with satisfactory healing. A radical mastectomy was performed, and pathologic examination of the area in question showed a 5.5-cm collection of fat necrosis and clotted blood in the Cavity.

No residual

tumor

was present.

At the time of the original biopsy, no surgical drain was inserted into the biopsy cavity. Only superficial sutures were placed to allow development of hematoma and a better cosmetic result. Because the patient had no signs or symptoms of local infection, the possibility of infection

by a gas-producing

organism

was thought

to be unlikely.

Although liquified fat above a hematoma could produce a radiolucent area simulating a gas-fluid collection, it was the consensus of multiple radiologists that the density on the chest radiographs was that of gas not fat. We think the most plausible explanation in this case is that air was introduced into the breast during open incisional biopsy and sealed

off by superficial closure. At the time of radiography, the gas had not yet been completely resorbed and therefore caused the gas-fluid level. In conclusion, the finding of a gas-fluid level in the breast after biopsy should suggest the possibility of retained, nonresorbed gas in addition to other diagnostic considerations such as infection with

gas-producing organism or air introduced that Could produce a similar finding.

via a postoperative

B, Lateralchest

radiograph

confirms

gas-fluid

after

breast

bi-

level is within right breast.

tion

has

not

been

reported.

We describe

a patient

in whom

the fistula

was clearly shown on CT. A 78-year-old man with hypertension was referred to our hospital because of massive hemoptysis. Seven years before, he had had atherosclerotic aneurysm of the descending aorta, which was repaired with a synthetic graft (woven Dacron). The chest radiograph

showed

an enlarged

thoracic aorta with homogeneous

density in the

upper part of the left lung. Findings on contrast-enhanced CT scans suggested a connection between the dilated aortic arch and a pulmonary hematoma (Fig. 1A). During the next few hours, hemoptysis gradually increased, and the patient died before aortography and surgery

could

be performed.

of the thoracic resulted lobe

in a fistula

of the

Postmortem

aorta above

left

lung

between (Fig.

study

the proximal the

aorta

showed

anastomosis and

that

rupture

of the graft had

a hematoma

in the

upper

1 B).

Although several methods have been used to detect aortopulmonfistula [1 -4], conclusive diagnosis has been difficult. In most cases, the fistula has been confirmed at surgery or autopsy. Because delay in treatment may result in catastrophic hemorrhage, early and accurate diagnosis is desirable. Aortography is useful in detecting any

aneurysms

and

in showing

the

adjacent

structures.

CT

is also

useful

for detecting although

formation

not only aortic aneurysm but also pulmonary hematoma, it usually has not shown the true connection [1]. Thrombus

in

the

fistula

may

prevent

detection

of the

fistulous

conti-

drain

Mark

J. Bluth

Burton Winthrop-University

Fig. 1.-A, Posteroantenor chest radiograph obtained opsy shows gas-fluid level over right lower part of chest.

margin.

Posteroanterior chest radiograph (Fig. 1 A) showed a gas-fluid over the right lower part of the chest. A lateral chest radiograph

biopsy

673

LETTERS

1992

M. Gold Hospital

Mineo!a,

NY

11501

REFERENCES 1 . Tabar L, Dean PB. Teaching Stratton, 1985:172 2. Stigers KA, King JG, Davey

caused by biopsy:

spectrum

atlas of mammography. DO, Stelling

New York: Thieme-

CB. Abnormalities

of mammographic

findings.

of the breast AJR

1991;156:

287-291

3. Rabin CB, Murray GB. Radiology & Wilkins, 1980:183-1 89

Aortopulmonary

Fistula

ofthe

chest,

Detected

2nd ed. Baltimore:

Williams

by CT

Although CT has been used in the diagnosis of aortopulmonary fistula [1], to our knowledge, direct detection of the fistulous connec-

Fig. 1.-Aortopulmonary fistula. A, Contrast-enhanced CT scan at level of aortic arch shows contrast medium (arrows) connecting thoracic aorta (A) and pulmonary hematoma (H). B, Autopsy specimen shows fistula (white arrows) from anastomosis (black arrow) just above synthetic graft (S) to hematoma (H) through pulmonary parenchyma.

LETTERS

674

[3, 4]. In our case,

nuity bolysis

however,

or dislodgement,

which

the reperfusion may

occur

caused

by throm-

in recurrent

hemoptysis

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141, enabled us to visualize the connection. Mortality associated with such a CT finding is high, and surgery should be carried out as soon as possible. Masahito

AJR:159,

CT in the diagnosis system

of aortic

dissection

Suresh

Brigham

Japan

1 . Hampson S, Pepper J. Aortopulmonary raphy. Thorax 1987;42:395-396

2. Demeter SL, Cordasco management.

fistula:

EM. Aortobronchial

Angiology

1980;31

role of computed

:431 -435

fistula compli-

AJR 1988:150:535-538 4. Graeber GM, Farrell BG, Neville JF Jr, Parker FB Jr. Successful diagnosis and management of fistulas between the aorta and the tracheobronchial tree. Ann Thorac Surg 1980:29:555-561 aortic

cating

aneurysm:

diagnosis

REFERENCE

in four cases.

Choledochal Cysts: Classification Cholangiographic Appearance

Artifact

Simulating

Aortic

Dissection

Recently, Burns et al. [1 J described a motion artifact aortic dissection on a CT scan obtained on a Somatom (Siemens

Medical

System,

artifact,

flap.

but

we

Iselin, were

We recently

NJ).

We

unaware

have

tract

may

common

encountered

a case

Dynamic aorta

were

contrast-enhanced obtained

scans of the aortic obtained

before

with

a Somatom

arch, aortic

emphasized

the

toms

of a possible

aortic

Plus

of the thoracoabsystem.

the administration

Selective

aorta were Sections 1

cm thick, obtained after the IV administration of contrast material, showed a low-attenuation thin line within the posterior aspect of the ascending thick

aorta,

sections

1 cm above obtained

after

the aortic

root (Fig. 1). Repeat

a second

bolus

of

contrast

as that

illustrated

by Burns

sections

was

not particularly

et al.

helpful.

However,

evaluation

We base ducts

and

the

anomalous

duct

(Fig.

confirmed

insertion

1 in [1]).

[3-5].

channel

During

frequent

the

and

simu-

symp-

we confirm

the anatomic

distal

to the

papilla

KI. D. Ebel M. Gharib Children

‘5 Hospital

of the 5000

City

KO!n

of Cologne

60,

Germany

REFERENCES 1 . Savader cation

Si,

Benenati

JF, Venbrux

and cholangiographic

AC, et al. Choledochal

appearance.

AJR

cysts:

classifi-

1991;156:327-331

2. Babbitt DP. Congenital

3.

choledochal cyst: new etiological concept based on anomalous relationships of common bile duct and pancreatic bulb. Ann Radiol (Paris) 1969;1 2:231-240 Jona ZJ, Babbitt DP, Starshak RJ, LaPorta AJ, Glicklich M, Cohen RD. Anatomic observations and etiologic and surgical considerations in choledochal cysts. J Pediatr Surg 1979:14:315-319 Suarez F, Bemard 0, Gauthier F, Valayer J, Brunelle F. Bilio-pancreatic common channel in children: clinical, biological and radiological findings in 12 children. Pediatr Radiol 1987;17:206-21 1 Gharib M, Ebel Kl-D, Engeiskirchen R, Bliesener JA. Abnormal choledochopancreatico ductal junction causative of cystic-cylindric dilatation of intraand extrahepatic bile ducts. Monatsschr Kinderheilk 1982;130:783-788 Okada A, Oguchi V. Kamata S. Common channel syndrome-diagnosis anrlnrni

agement.

CT scan shows low-attenuation linear structure within lumen of aortic root. On closer inspection, this line cxtends beyond confines of aorta.

of and

of Vater to show the common channel by retrograde filling of the common bile duct and the pancreatic duct with contrast material. We have used this approach to manage this syndrome in 21 cases, and we think that percutaneous transhepatic cholangiography and ERCP are unnecessary and not without risk.

at lung-

artifact

[6]

Dilated

signs

To define

duodenum

al.

cause

in children

the laparotomy,

cholangiography.

compress

et

but the term

ducts clinical

the

concept

on sonographicfindings.

appropriate

for surgery.

carefully

we

solely with

bile

of

This

Okada

syndrome,”

intrahepatic

our diagnosis

in connection

are an indication

with

dissection.

extra-

by using direct

6.

aortic

the

changes,

5.

Fig. 1.-Motion

and

“common

the diagnosis

4.

lating

of

pancreatic

accepted

material

Our experience with the Somatom Plus scanner has been similar to that of Burns et al. We have adjusted to the circumferential artifact surrounding the ascending aorta. However, this was our first experience with the artifact mimicking an intimal flap. Repeat imaging with thin

the

4-mm-

showed persistence of the presumed flap in that same region. However, scans obtained with lung-window settings showed extension of the low-attenuation line beyond the medial wall of the ascending aorta, into the adjacent mediastinum. This artifact was in the same location

consequence into

widely

of

infants.

circum-

the

the anomaly

dilatation biliary

root, and descending of contrast material.

simulating

and

abnormally long common channel may be better. In our experience, this syndrome is the most

an

that

CT scans

an

Plus system the

been

simulating

artifact

importance of recognizing this artifact. A 58-year-old man was admitted for evaluation dissection.

simulating

be

bile duct

named

on CT

observed

of the

artifact

In their article on the classification and cholangiographic appearance of choledochal cysts [1 ], Savader et al. do not mention clearly if they accept the concept of Babbitt [2] that dilatation of the biliary

has

Motion

Hospital

MA 02115

tomog-

fistula: keys to successful

3. Coblentz CL, Sallee DK, Chiles C. Aortobronchopulmonary

dominal

Women’s

1 . Bums MA, Molina PL, Gutierrez FR, Sagel SS. Motion aortic dissection on CT. AJR 1991;1 57:465-467

REFERENCES

intimal

and

Boston,

Hospital

529-04,

Varma

Paul Stark

Bamba

General

Shiga,

Plus

K. Mukherji

Pardeep

ltsuro Nishigaki

ferential

when the Somatom

is used.

Morikawa

Michio

1992

window settings was beneficial. This case emphasizes the importance of the observations made by Burns et al. and illustrates a pitfall of

Higashikawa

Junichiro

Kohoku

September

ratrnnrarie

Surgery

thnlanninncintrncrtii,.nnrRnhv

and

stiraical

man-

1983;93:634-642

Rep!y

We thank Drs. Ebel and Gharib for their interest in our paper [1]. We wish to clarify that we do support the theory of Babbitt [2] on the mechanism

an anomalous

of choledochal

insertion

cyst

formation.

of the common

Babbitt

bile duct

has

theorized

that

into the pancreatic

LETTERS

September1992

AJR:159,

675

duct results in chronic reflux of pancreatic enzymes into the biliary tree, which leads to inflammation, dilatation, and scarring. Although this theory most likely does not account for the formation of a type III choledochal cyst (choledochocele) or a type V choledochal cyst

Downloaded from www.ajronline.org by 119.102.107.215 on 10/23/15 from IP address 119.102.107.215. Copyright ARRS. For personal use only; all rights reserved

(Caroli’s

disease),

it does seem to explain

the occurrence

of the other

types of choledochal cysts, as the anatomic variation of the common channel has been documented in 10-58% of cases [3]. We have also noted this anatomic variation in a large percentage of our patients with more typical choledochal cysts. We agree with Drs. Ebel and Gharib that many diagnostic approaches can be used to evaluate choledochal cysts, and we agree that in children, the findings of dilated biliary ducts and a cystic mass in the

region

of the

extrahepatic

biliary

tree,

in conjunction

with

appropriate clinical signs and symptoms, are an indication for surgery. However, our population of patients consisted mostly of adults, many of whom had previous surgical evaluation or attempts at reconstruction. We havefound that in this population, percutaneous transhepatic cholangiography

anatomy,

provides

the

most

thorough

site of biliary origin, extent

assessment

of

cyst

of both intra- and extrahepatic

disease, and associated biliary tract anomalies. As noted in our article [1], six of our 14 patients had associated hepatobiliary disease, only

one case of which (intrahepatic noninvasive

imaging

abscesses)

techniques.

was detected

In addition,

we

have

by using found

that

A

B Fig. 1.-Benign

schwannoma of pancreas.

A, CT scan at level of pancreatic tail shows a solid mass (long arrow) in distal part of pancreas. Portal venous confluence is clearly visible (short arrow). B, Aortic angiogram shows tumor blush in left upper quadrant, overlying upper pole of left kidney.

Antoni

A and

palisading

B areas

of closely

woven

spindle

cells

in a

arranged

fashion.

placement of a percutaneous transhepatic drain is useful during surgery for location of the common hepatic duct. This is particularly true in patients who have had previous attempts at reconstruction and who have distortions of the porta hepatis, in addition to adhesions. In regards to the risk associated with percutaneous transhepatic cholangiography, we think that when the technique is performed

A schwannoma, or neunlemoma, is a benign tumor from the nerve sheath along the course of a peripheral

by an experienced radiologist, the risk should be minimal. In our group of 1 4 patients, the only complication associated with percuta-

SChwannomas of the retroperitoneum are mostly benign [3]. Interestingly, those associated with Recklinghausen’s disease have a worse prognosis. A 5-year survival of 75% for patients who have

neous transhepatic cholangiography and biliary drainage was one episode of transient bacteremia, which was effectively treated with antibiotics. Scott The Johns

J. Savader

DP. Congenital

choledochal

relationships

(Pans) 1969:12:231

sification.

SL, Mckinley

cyst:

new

rare

may

tumors

undergo may

necrosis

occur

in any

decreases to 30% when the patient with Recklinghausen’s disease.

schwannoma

associated

The differential

MD

21205

neoplasia

diagnosis

etiological

concept

based

values

varied

from

mass includes

tumors

5 to 40 H, according

necrosis

[2]. For complete

evaluation

techniques

is recommended,

including

and, possibly,

vascular

of the tumor, sonography,

such as islet

to the degree

Previously

Schwannoma described

CT,

Douglas

surface

when

cut. Histologic

examinations

MA

01604

REFERENCES of the

pancreas

have been associated with Recklinghausen’s disease. We describe the first case not associated with this disease. A 73-year-old man had pain in the right upper quadrant. Sonograms showed gallstones and a mass in the body of the pancreas. Contrastenhanced abdominal CT scans (Fig. 1A) confirmed a 2-Cm, isodense, well-Circumscribed, solid pancreatic mass without adenopathy or biliary duct dilatation. After ERCP showed pancreatic duct obstruction, angiography was performed. Injection of the superior mesentenc artery resulted in a blush in the pancreatic tail without vascular encasement (Fig. 1 B). At surgery, a 2-cm mobile mass was found at the junction of the pancreatic body and tail. Pathologic examination showed a well-defined nodule with a mottled, gelatinous-appearing brownish

Tyagi

David A. Bader St. Vincent Hospital

cyst: clinical features and clas-

schwannoma

A. Burd

Girish

1985;80:643-647

of benign

angiography,

MR.

bulb. Ann

of the Pancreas cases

of

use of multiple

Worcester,

Benign

least

the

has schwannoma

for such a pancreatic

as well as benign

-240

Am J Gastroenterol

hemorrhagic

location,

cell tumors. Studies have shown, however, that CT and MR findings cannot be used to distinguish benign from malignant lesions [3]. CT

Hospital

of common bile duct and pancreatic

MJ. Choledochal

nerve. Smaller

and

common of which is the retroperitoneum [1 ]. The association between schwannoma and Recklinghausen’s disease is well described [1 , 2].

attenuation

on anomalous 3. Crittenden

These

ones

Hopkins

1 . Savader SJ, Benenati JF, Venbrux AC, et al. Choledochal cysts: classification and cholangiographic appearance. AJR 1991;1 56:327-331

Radiol

degeneration.

larger

malignant

REFERENCES

Babbitt

are solid;

John L. Cameron Baltimore,

2.

tumors

that originates

showed

classic

1 . Das Gupta TK, Brasfield RD. Strong EW, Hajdu SI. Benign solitary schwannoma (neunlemoma). Cancer 1969;24: 355-366 2. Kumar AJ, Kuhajda FP, Martinez CR, Fishman EK, Jezic DV, Siegelman 55. Computed tomography of extracranial nerve sheath tumors with pathologic correlation. J Comput Assist Tomogr 1983;7:857-865

3. Levine E, Huntrakoon in neurofibromatosis: techniques.

AJR

M, Wetzel LH. Malignant nerve-sheath neoplasms distinction from benign tumors by using imaging

1987;149: 1059-1 064

Stress-Induced Adrenal Hyperplasia Simulating Metastatic Disease: CT and MR Findings Elevation of serum levels of adrenocorticotropic hormone and cortisol can occur in response to stress [1 Experiments in animals have also shown that adrenal hypertrophy occurs in association with ].

LETTERS

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676

elevated levels of corticosterone in response to stress [2, 3]. To our knowledge, however, such hypertrophy has not been shown by using any imaging technique. We report the CT and MR findings in a case of adrenal hyperplasia that appeared to be stress induced and that resolved when the patient received corticosteroid therapy. A 58-year-old man had a left radical nephrectomy, including left adrenalectomy, for stage 2 renal cell cancer. CT scans obtained 1 year later showed a nodule in the right lung and a well-defined 2-cm mass in the right adrenal gland, which was thought to represent an incidental

adenoma,

as it had not changed

since a CT scan obtained

before the nephrectomy. Over the ensuing 8 months, the nodule in the lung enlarged; it was resected 2 years after the nephrectomy. A CT scan obtained 6 months later showed that the mass in the right adrenal gland had increased to 4 cm (Fig. 1A), which suggested that it was

a metastasis.

The

mass

had

high

signal

intensity

on

This

rather

adrenal

than

mass

almost

metastatic

certainly

disease,

was

and T2-weighted

MR images showed

in size

had

however,

and

now

had appeared

a low

signal

an

undergoing

corticosteroids this

in our patient

hyperplasia

[4].

This

most

case

likely

also

and were enlarging

(Fig.

1 D).

adenoma,

change,

played

as it

a role in reversing

reemphasizes

that

intensity of adrenal lesions on T2-weighted MR images The signal intensity of the mass was high on images it was largest and low on images obtained later when Thus, the signal intensity of adrenal lesions may be only by the cellular composition of the lesion of adrenal stimulation or suppression.

the

signal

is nonspeCific. obtained when it was smaller. influenced not

but also by the degree

Ahalya Premkumar

T2-

Catherine

K. Chow

Peter L. Choyke John L. Doppman Institutes of Health

National

Bethesda, MD 20892 University Medical Center Washington, DC 20007

Georgetown

-

that the mass had decreased

intensity

incidental

hyerplastic

1992

decreased in size at the same time that metastases in the lung and liver were enlarging. The stress associated with detection and treatment of a new metastatic focus in the lung presumably caused the adrenal hyperplasia we observed. The combination of topical and oral

weighted MR images (Fig. 1 B), which, although nonspeCific, supported the impression that it represented metastatic disease. The patient elected not to have surgery. An extensive skin rash that had developed was treated with topical and oral corticosteroids. Followup CT scans showed regression of the mass in the right adrenal gland; the gland eventually beCame normal (Fig. 1 C). Follow-up Ti

September

AJR:159,

Metastases,

REFERENCES

in the lung and liver.

1 . Ney RL, Shimizu N, Nicholson WE, Island DP, Liddle GW. Correlation of plasma ACTH concentration with adrenocortical response in normal human subjects, surgical patients and patients with Cushing’s disease. J Clin Invest 1963;42: 1669-1677

2. Khasina El, Kurilenko LA, Kirillov 01. Adrenal hypertrophy in rats during long-term movement restrain. Z Mikrosk Anat Forsch 1985;99 :603-610 3. Spencer RL, McEwan BS. Adaptation of the hypothalamic-pituitary-adrenal axis to chronic ethanol stress. Neuroendocrinology 1990;52:481-489 4. Ohman EM, Rogers 5, Meenan FO, McKenna TJ. Adrenal suppression following low-dose 80:422-424

Metastatic Simulating AIDS

A

B

topical

clobetasol

propionate.

J A Soc

Med

1987;

Papillary Adenocarcinoma to the Brain Toxoplasmosis on CT in a Patient with

Neurologic

disease

associated

with

HIV

infection

is common,

oc-

reported that both primary CNS lymphoma and toxoplasmosis cause ring-enhancing lesions on CT. Although lymphoma is frequently solitary, multifocal lesions occur in up to 50% of cases [1 -3]. This report describes a patient with AIDS and metastatic adenocarcinoma to the brain whose CT scan was highly suggestive of toxoplasmosis or multifocal lymphoma. A 44-year-old man who was seropositive for HIV and who was cumng

in 40%

having

follow-up

of patients.

It has been

for pulmonary

tuberculosis

had had diplopia,

loss of

motor coordination, and headaches for 3-4 weeks. He had no associated fevers, chills, weight loss, or nuchal rigidity. Physical examination showed a cranial nerve VI palsy on the left side. The titer in a test for Toxoplasma was less than 1 : 1 6. CT showed multiple lesions in the cerebral Fig. 1.-Stress-induced

adrenal

hyperplasia

simulating

metastatic

dis-

ease. A and B, CT scan (A) and T2-weighted MR image (B) obtained 2.5 years after nephrectomy and left adrenalectomy for renal cell cancer and 6 months after resection of a pulmonary metastasis show a mass (arrows) In right adrenal gland. Mass has high signal intensity on MR image. C and 0, CT scan (C) and T2-weighted image (D) obtained after corticosterold therapy and resection of right lobe of liver show normal adrenal gland (long straight arrows). Mass has decreased in size and now has low signal intensity on MR image. Short straight arrow = portal vein. Curved arrow = inferior vena cava.

hemispheres,

characterized

by rim enhancement

and

modest mass effect (Fig. 1). The patient was treated with pyrimethamine and sulfadiazine for possible CNS toxoplasmosis. Despite this, the lesions

enlarged,

were performed; adenocarcinoma.

with increasing

the pathologic An

extensive

edema.

A craniotomy

findings indicated workup

did

not

and biopsy

metastatic show

papillary

a primary

site

of the carcinoma. Evaluation of CNS mass lesions in patients with HIV infection may be complex. CT and MR imaging may be helpful in the differential diagnosis

and

ring-enhancing

management

lesions,

of these

differentiation

lesions.

between

In those

patients

toxoplasmosis

with

and

AJR:159,

September1992

LETTERS

677

:A

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V

.:.

.iL

: ‘ h..

A

‘-__-__-

‘.

I

Fig. 1.-Metastatic papillary adenocarcinoma to the brain simulating toxoplasmosis In a patient with AIDS. A and B, CT scans with contrast material show multiple lesions with ring enhancement.

Iymphoma may be difficult [4]. Increases in titers in tests for Toxop!asma and responses to empirical therapy may suggest toxoplasmosis. CT findings of metastatic adenocarcinoma include predisposition for gray and white matter, diffuse or ring enhancement, and moderate to marked edema. To my knowledge, metastatic adenocarcinoma mimicking the CT findings of toxoplasmosis has not been reported

before. College

Involving lesion

large with

WI 53226

The patient was treated with rifampicin, splint was put on his knee;

isoniazid,

and ethambutol;

and he was discharged

Two months later, local signs and symptoms

were greatly reduced.

Tuberculosis of the patella is rare. It has been reported in only four cases [1 , 2]. In one [2], CT scans showed a lytic lesion similar to the

one seen in our case;

both lesions

a sequestrum.

for bacterial

definitive

had a dense

The radiologic

area centrally,

appearance

of a malignant

and pathologic

diagnosis

in such

analysis

in order

to establish

C. Bonnet M. DeBandt

E. Palazzo D. Malaizier

Neurosurg 1990;73:720-724 2. Dma TS. Primary central nervous system lymphoma versus toxoplasmosis

3.

in AIDS. Radiology 1991;179:823-828 Goldstein JD, Zeifer B, Chao C, et al. CT appearance

lymphoma in patients with acquired immunodeficiency Assist Tomogr 1991;1 5:39-44 of patients

with

human

Bichat Hospital Paris, France

of primary CNS syndrome. J Comput REFERENCES

4. Cimlno C. Upton RB, Williams A, Feraru E, Harris C, Hirschfeld A. The evaluation

immunodeficiency virus-related Med 1991;151 :1381-1384

disor-

1 . Hartofilakidis-Garofalidis

2. Hemandes-Gimenez Gomez

Involving

No effusion

or synovial

thickening

of the knee was detected.

Radiographs showed an osteolytic lesion involving a large part of the patella. The surrounding bone did not show sClerosis or osteoporosis (Fig. 1 A). Bone scintigrams showed an area of increased uptake of radionuclide in the right patella; no abnormal uptake was seen in the rest of the skeleton. CT scans of the right knee showed an osteolytic lesion of the patella without destruction of the articular surface (Fig. 1 B). A dense focus was present inside the lytic area, suggesting a sequestrum. The preoperative diagnosis was osteoid osteoma. The anterior

part

showed

necrosis

of the and

patella

tuberculosis

of the patella.

J Bone Joint

M,

E. Tuberculosis

Tovar-Beltrann

of the patella.

JV, Pediatr

Frieyro-Segui Ml, PascualRadiol 1987;17:328-329

the Patella

We describe a case of tuberculous osteomyelitis in which patellar disease was the only clinical and radiologic abnormality. A 48-year-old man had had pain on the surface of the patella for 3 months.

G. Cystic

Surg (Am) 1969;51-A:582-585

ders and brain mass lesions. Arch Intern

Tuberculosis

a

cases.

ML. Use of CT and MR imaging to distinguish and to define the need for biopsy in AIDS patients. J

lesions

a

from the hospital.

SF, Rosenblum

intracranial

a central

a sequestrum.

tures of subcutaneous tissue obtained by puncture near the patella; the subcutaneous tissue probably was contaminated after surgery.

tissue

REFERENCES 1 . Ciricillo

part of

bone tumor or a chronic infectious process can be similar to that of a benign tumor. This case highlights the importance of obtaining

of Wisconsin

Milwaukee,

dense area, suggesting

suggesting

Barry Bernstein Medical

Fig. 1.-Tuberculosis Involving the patella. A, Lateral radiograph shows an ostaolytlc lesion right patella. B, CT scan of right patella shows an osteolytic

was

surrounding

excised. granulomata,

Histologic

examination

consistent

with

a

diagnosis of tuberculosis. Tests with Ziehl-Neelsen stain were negative. However, Mycobacterium tuberculosis was isolated from cul-

Psychogenic

Urinary

Retention

in a Child

Tu and Scanlan [1] report findings in an 1 1-year-old boy who had urinary dribbling. They consider the case an example of psychogenic retention.

This

may be correct,

but we disagree

with

some

of their

findings. The voiding cystourethrogram is described as showing “a large, trabeculated . . . , atonic bladder” and a “normal urethra.” In fact, the figure shows a widening in the posterior part of the urethra and a narrow sphincter region, consistent with dyssynergia. This may be a voluntary dyssynergia, but, nonetheless, we would not regard this sphincter as normal. The authors’ comment that the bladder is atonic

appears

to be an assumption.

having gone through sphincteric obstruction,

It is possible

that

the

bladder,

a stage of hypertrophy in reaction to the has now become atonic; however, without urodynamic assessment [2], it is impossible to say this. The dilatation of the upper tracts is a matter of concern. If this is due to reflux, even

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678

LETTERS

AJR:159,

September1992

at low pressure, it could be harmful, and if the pressure increased, damage could be severe. Even noncontractile bladders may show an increase in pressure when they are fully distended. This is one reason

thorough neurologic, urologic, and radiologic studies, which our patient indeed had. Our patient had comprehensive uroflometric, bladder electromyo-

intermittent

graphic,

self-catheterization

is beneficial

in such patients.

Considerable problems may arise if cystourethrographic findings in patients with neuropathic and similar disorders are interpreted without

regard

to the information

provided

by urodynamic

ment [3, 4]. Those who make therapeutic pictures

alone may be putting

decisions

their patients

at some

assess-

on the basis of risk. M. Borzyskowski

H. M. Saxton Guy’s Hospital London,

England

SE1 9AT

REFERENCES 1 . Tu RK, Scanlan KA. Psychogenic urinary retention (Hinman syndrome) in a child (letter). AJR 1992;158:460-461 2. Saxton HM. Urodynamics: the appropriate modality for the investigation of

3.

4.

frequency, urgency, incontinence 1990;175:307-316 Mundy AR, Borzyskowski M, Saxton neuropathic vesico-urethral dysfunction 645-649 Mundy AR, Shah in myelomeningocele.

PJR,

Borzyskowski

and voiding difficulties.

Radiology

HM.

Videourodynamic evaluation of in children. Br J Urol 1982;54:

M, Saxton

HM. Sphincter behaviour

Br J Urol 1985;57:647-651

cranial

MA, and complete

spinal

in addition

namic

evaluation.

In addition,

we agree completely

that dilated

upper

tracts may imply refiuxive renal atrophy, and that this may be harmful. This was recognized early in our evaluation, and intermittent selfcatherization by the patient was recommended. A letter to the editor is a brief, concise format that requires pertinent details to illustrate the issue at hand; in our case, we emphasized the importance of including psychogenic causes in a differential diagnosis of urologic dysfunction. Inherent to such a format is subordination of other details, which unfortunately Drs. Borzyskowski and Sexton assumed were not considered; nothing could be further from the case. In particular, they assumed that we interpreted cystourethrographic findings without considering information provided by urodynamic

assessments.

They

the basis of pictures Saxton that American tive

team

details

effort

and

imply

we made

“therapeutic

decisions

on

alone.” We assure Drs. Borzyskowski and radiologic consultation is indeed a corroborathat

we

do

include

all physiologic

and

anatomic

available.

Raymond K. Tu Kathleen A. Scanlan

Reply

We appreciate the letter from Drs. Borzyskowski and Saxton about our letter to the editor, “Psychogenic Urinary Retention (Hinman Syndrome) in a Child” [1]. We agree with their discussion that Hinman syndrome is not a diagnosis made exclusively on the basis of radiologic studies,

MR examinations

to those studies illustrated in our letter. We agree with Drs. Borzyskowski and Saxton that the bladder, having gone through a stage of hypertrophy in reaction to sphincteric obstruction had eventually become atonic; however, our patient did have appropriate urody-

and that the syndrome

is a complex

entity

that requires

University of Wisconsin Madison, WI 53792-3252

REFERENCES 1 . Tu AK, Scanlan

KA. Psychogenic

urinary

retention

a child (letter). AJR 1992;158:460-461

Letters are published at the discretion of the Editor and are subject to editing. Letters to the Editor must not be more than two double-spaced, typewritten pages. One or two figures may be included. Abbreviations should not be used. Limit the number of authors to four, or we will list only the first three and add “and colleagues” to the end of the list. See Author Guidelines. Material being submitted or published elsewhere should not be duplicated in letters, and authors of letters must disclose financial associations or other possible conflicts of interest. Letters concerning a paper published in the AJA will be sent to the authors of the paper for a reply to be published in the same issue. Opinions expressed in the Letters to the Editor do not necessarily reflect the opinions of the Editor.

(Hinman

syndrome)

in