HORMONE RECEPTORS A N D BREAST CANCER HAMILTON. T.H. ( i w i ) , Symp. Biochem. SOC., 32: 49. HAWKINS, R.A.. HILL. A. and FREEDMAN,6 . (1975). Clin. chim. Acta, 64: 203. HAWKINS.R.A.. HILL,A,, FREEDMAN,B., GORE, S.M., ROBERTS, M.M. and FOREST.A.P.M. (1977). Brit. J. Cancer, 36: 355. HORWITZ. K.B. and MCGUIRE, W.L. (1977a), Cancer Res., 37: 1733. HORWITZ, K.6. and MCGUIRE,N.L. (1977b) in MCGUIRE, W.L.. RAYNALJD. J-P and BAULIELJ. E.E.. Progesterone Receptors in NormalandNeoplastic Tissues, Raven Press, N.Y.: 103. JENSEN. E.V., DE SOMBRE.E.R. and JUNGBLUT, P.N. (1967) in WISSLER, R.W., DAO. T.L. and WOOD, S.. Endogenous Factors Influencing Host-Tumour Balance, University of Chicago Press, Chicago: 15. JENSEN.E.V. and JACOBSON,H.I. (1962), Recent Prog. Horm. Res., 18: 387.
KEiGHTLEY JENSEN.E.V.. MOHLA,S., GORELL,T.. TANAKA, S. and DE SOMBRE, E.R., (1972). J. Steroid Biochem. 3: 445. KORENMAN.S.G., (1975), J. naf. Cancer tnsf., 55: 543. MCGUIRE, W.L. (1975). Cancer (Philad.) 36: 638. MESTER. J., ROBERTSON.D.M., FEHERTV.P. and KELLIE. A.E. (1970), Biochem. J., 120: 831. PICHON. M.F. and MILGROM.E. (1977), Cancer Res., 37: 464. RATAJCZAK. T. and HAHNEL,R. (1974). Biochim. (Amst.), Biophys. acta, 338: 104. SCATCHARD.G . (1949), Ann. N.Y. Acad. Sci., 51: 660. STOLL. B.A. (1969), Hormonal Management in Breast Cancer, Pitman Medical Publishing Co., London. WITTLIFF. J.L. and SAVLOV, E.D. (1975), in MCGUIRE.W.L., CARBONE,P.P. and VOLLMER.E.P., Estrogen Receptors in Human Breast Cancer, Raven Press, N.Y.: 73.
COMPUTED TOMOGRAPHY OF ABDOMINAL AORTIC ANEURYSMS L.V. PERRETT’, AND M.R. SAGE* Computed tomography is an excellent non-invasivemethodforvisualizationof the sizeandextent of abdominal aortic aneurysms. It demonstrates the size of the lumen and the amount of thrombus in the aneurysm, and detects complicatlonssuch as dissection and leakage. ,
COMPUTED tomography of the body has numerous applications, particularly in the assessment of retroperitoneal structures, and since the installation of two E.M.I.C.T. 5005/6 body scanners in Adelaide early in 1977, we have been impressed by the value of this examination in the diagnosis and surgical management of aortic aneurysms. The early reports on computed tomography and aortic aneurysms (Alfidi et a h , 1975; Axelbaum et alii, 1976) did not indicate the use of intravenous contrast medium in conjunction with their scans, so the lumina of the aneurysms were not displayed. With the use of contrast medium, the extent and size of the aneurysm, its lumen, and the amount of thrombus, are shown. The examination can be used serially to assess change in the size of an aneurysm and also detect complications such as dissection and rupture. MATERIAL ANDMETHODS Thirty-three patients with aortic aneurysms were examined, and most were given an intravenous >
F R.A.C.R.. F.R C.R , Memorial Hospital, North Adelaide. M R.A.C.S, M.R.C P I F.R.C.R.. Flinders Medical Centre. Adelaide Reprints Dr L V
Perrett. X-ray Department Memorial Hospital. North
Adelaide S A 5006 AUST N.Z. J. SURG Voc 4 8 - 4 0 . 3 , JUNE,1978
bolus of Angiografin 65% in a dose of 100 to 150 ml depending on the size of the patient, followed by tomographic cuts two or three centimetres apart to display the full length of the aneurysm. If the aneurysm extended proximally to involve the thoracic aorta, the examination was continued into the thorax. Later in the series, in those patients with infrarenal aneurysms, tomographic cuts were obtained at 1 centremetre intervals to assess the length of relatively normal aorta present between the renal pedicles and the aneurysm. This wasdone at the request of vascular surgeons. The tomographic sections were recorded initially on Polaroid film, and later on X-ray using the Dunn camera. RESULTS In eight of the 33 patients the aneurysm was shown t o extend above the renal arteries. With one exception, all aneurysms showed calcification in their walls. In seven patients operated upon the size of the aneurysm was confirmed. One patient had a leaking aneurysm confirmed by operation. Another patient was diagnosed as having a haematorna following replacement of an aneurysm by a prosthesis, and this also was confirmed at operation.
275
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of our 33 patients showed calcification in the wall of the aneurysm, usually quite marked. Aortography shows the lumen of the aneurysm, its relationship to the renal arteries, and the presence of other atheromatous disease and collateral circulation, but does not show the presence of thrombus and the true size of the aneurysm. Another disadvantage is that it is an invasive procedure. Both computed tomography and ultrasound have shown to be accurate in assessing the size of aneurysms (Axelbaum et alii, 1976; Wheeler et alii, 1976). The size of the aneurysm has prognostic significance, as Szilagyi and Elliott (1972) showed
FIGURE 1: Calcified aortic aneurysm 8 cm in diameter. The oval lumen of the aorta and also of the mesenteric artery (arrow) have been opacified by intravenous contrast medium and stand out against the relatively low density of adjacent thrombus.
DISCUSSION Plain radiographs are of limited value in the diagnosis of aortic aneurysms, as 15% to 45% fail to show calcification (Steinberg and Stein, 1965; Ester, 1950). As computer tomography is much more sensitive to the presence of calcium than conventional radiography, it is not surprising that 32
FIGURE 3: The leaking aortic aneurysm (A) measures approximately 10 cm in diameter, and extravasated blood (arrows) is extending posteriorly and laterally into the left flank at the L3 level
FIGURE2: Leaking aortic aneurysm. The margin of tne aorta (A) is ill defined because of rupture, and dense extravasated blood (arrows) has passed into the left retroperitoneal tissues displacing the left kidney anteriorly.
276
that patients with an aneurysm six centimetres or less in diameter had a 75% one-year survival, and 47.8% a five-year survival, whereas those patients with an aneurysm greater than six centimetres in diameter had a 50% one-year and a 6% five-year survival rate. Computed tomography and ultrasound are both excellent non-invasive methods for detecting any change in the size of the aneurysm, and both show the lumen and the amount of thrombus (Figure 1). In our series an unusually large number of the aneurysms (24%) extended above the renal arteries, and the C.T. scan was valuable in assessing the degree Of involvement Of the thoracic aorta. “Itrasound, although able to show the aneurysm in both AUST.N.Z. J. SURG.V O L . ~ ~ - N O3,. JUNE,1978
COMPUTED AORTIC ANEURYSM TOMOGRAPHY
PERRETT AND SAGE
aorta and displaces retroperitoneal structures such as the kidneys (Figure 2). Within a day or so extravasated blood becomes more dense than intraluminal blood because of clot retraction and is readily detected on the scan (Figure 3). The normal density of intraluminal blood is 28 E.M.I., units and this density is mainly due to the protein content of haemoglobin. Following extravasation and absorption of fluid from the clot, the density rises to between 30 and 42 E.M.I. units (New and Aronow, 1976). After approximately one week the density of the haematoma begins to decrease because of breakdown of red cells and removal of protein by phagocytes. In addition, adjacent oedema fluid may move back into the clot, so that by the end of two to
4: A large irregular low-density haematoma (H) lies in FIGURE front of the aortic prosthesis in the low lumbar region. Its lateral margins are defined by arrows. Artefacts are due to barium remnants within the bowel.
the transverse and the longitudinal planes in the abdomen, cannot assess the thoracic aorta because of air in the lungs, nor can it display accurately the distance between the renal arteries and the upper margin of an infrarenal aneurysm. Occasionally the presence of paralytic ileus will interfere with the ultrasound examination (Winsberg et alii, 1974). One advantage of computed tomography is that the quality of the examination is not impaired by obesity of the patient, and it was of value in diagnosing a leaking aneurysm in a very large patient who could not be assessed adequately by clinical means (Figures 2,3). Recently extravasated blood causes loss of definition of the outline of the
AUST N.Z. J. SURGVOL 48-No
3, JUNE.1978
three weeks the clot may become less dense than normal blood (Figure 4). One further use of computed tomography is in the diagnosis of complications following aneurysmal surgery, e.g., Figure 4 illustrates a low-density haematoma approximately three weeks old complicating replacement of an aortic aneurysm by a Dacron graft. REFERENCES ALFIDI.R.J , HAAGA,J.R., MEANEY,T.F., MaclNTYRE, W.J., GONZALEZ. L., TARAR. R., ZELCH.M.Q., BOLLER, M., COOK. G. (3975), Radiology, 117: 257. S.A. and JELDEN, AXELBAUM, S.P., SCHILLINGER, D.. GOMES.M.N.,FERRIS, R.A. and HAKKAL. H. (1976). Arner. J. Roentgenol., 127: 75. ESTER, J.E.. JR (1950), Circulation, 2: 258. NEW,P.J.F. and ARONOW, S . (1976), Rad/ology, 121: 635. STEINBERG. I. and STEIN,H.L. (1965), Arner. J Roentgenol., 95: 684. SZILAGYI. D.E. and ELLIOTT. J.P. (1972), Arch. Surg. 104: 600. WHEELER, W.E., BEACHLEY. M.G. and RANNIGER.K (1976),Arner. J. Roentgenol., 126: 95. WINSBERG. F., COLE-BEUGLET.C. and MULDER, D.S. (1974),Arner. J. Roentgenol., 121: 626.
277
KEiGHTLEY JENSEN.E.V.. MOHLA,S., GORELL,T.. TANAKA, S. and DE SOMBRE, E.R., (1972). J. Steroid Biochem. 3: 445. KORENMAN.S.G., (1975), J. naf. Cancer tnsf., 55: 543. MCGUIRE, W.L. (1975). Cancer (Philad.) 36: 638. MESTER. J., ROBERTSON.D.M., FEHERTV.P. and KELLIE. A.E. (1970), Biochem. J., 120: 831. PICHON. M.F. and MILGROM.E. (1977), Cancer Res., 37: 464. RATAJCZAK. T. and HAHNEL,R. (1974). Biochim. (Amst.), Biophys. acta, 338: 104. SCATCHARD.G . (1949), Ann. N.Y. Acad. Sci., 51: 660. STOLL. B.A. (1969), Hormonal Management in Breast Cancer, Pitman Medical Publishing Co., London. WITTLIFF. J.L. and SAVLOV, E.D. (1975), in MCGUIRE.W.L., CARBONE,P.P. and VOLLMER.E.P., Estrogen Receptors in Human Breast Cancer, Raven Press, N.Y.: 73.
COMPUTED TOMOGRAPHY OF ABDOMINAL AORTIC ANEURYSMS L.V. PERRETT’, AND M.R. SAGE* Computed tomography is an excellent non-invasivemethodforvisualizationof the sizeandextent of abdominal aortic aneurysms. It demonstrates the size of the lumen and the amount of thrombus in the aneurysm, and detects complicatlonssuch as dissection and leakage. ,
COMPUTED tomography of the body has numerous applications, particularly in the assessment of retroperitoneal structures, and since the installation of two E.M.I.C.T. 5005/6 body scanners in Adelaide early in 1977, we have been impressed by the value of this examination in the diagnosis and surgical management of aortic aneurysms. The early reports on computed tomography and aortic aneurysms (Alfidi et a h , 1975; Axelbaum et alii, 1976) did not indicate the use of intravenous contrast medium in conjunction with their scans, so the lumina of the aneurysms were not displayed. With the use of contrast medium, the extent and size of the aneurysm, its lumen, and the amount of thrombus, are shown. The examination can be used serially to assess change in the size of an aneurysm and also detect complications such as dissection and rupture. MATERIAL ANDMETHODS Thirty-three patients with aortic aneurysms were examined, and most were given an intravenous >
F R.A.C.R.. F.R C.R , Memorial Hospital, North Adelaide. M R.A.C.S, M.R.C P I F.R.C.R.. Flinders Medical Centre. Adelaide Reprints Dr L V
Perrett. X-ray Department Memorial Hospital. North
Adelaide S A 5006 AUST N.Z. J. SURG Voc 4 8 - 4 0 . 3 , JUNE,1978
bolus of Angiografin 65% in a dose of 100 to 150 ml depending on the size of the patient, followed by tomographic cuts two or three centimetres apart to display the full length of the aneurysm. If the aneurysm extended proximally to involve the thoracic aorta, the examination was continued into the thorax. Later in the series, in those patients with infrarenal aneurysms, tomographic cuts were obtained at 1 centremetre intervals to assess the length of relatively normal aorta present between the renal pedicles and the aneurysm. This wasdone at the request of vascular surgeons. The tomographic sections were recorded initially on Polaroid film, and later on X-ray using the Dunn camera. RESULTS In eight of the 33 patients the aneurysm was shown t o extend above the renal arteries. With one exception, all aneurysms showed calcification in their walls. In seven patients operated upon the size of the aneurysm was confirmed. One patient had a leaking aneurysm confirmed by operation. Another patient was diagnosed as having a haematorna following replacement of an aneurysm by a prosthesis, and this also was confirmed at operation.
275
COMPUTED AORTIC ANEURYSM TOMOGRAPHY
PEARETT AND SAGE
of our 33 patients showed calcification in the wall of the aneurysm, usually quite marked. Aortography shows the lumen of the aneurysm, its relationship to the renal arteries, and the presence of other atheromatous disease and collateral circulation, but does not show the presence of thrombus and the true size of the aneurysm. Another disadvantage is that it is an invasive procedure. Both computed tomography and ultrasound have shown to be accurate in assessing the size of aneurysms (Axelbaum et alii, 1976; Wheeler et alii, 1976). The size of the aneurysm has prognostic significance, as Szilagyi and Elliott (1972) showed
FIGURE 1: Calcified aortic aneurysm 8 cm in diameter. The oval lumen of the aorta and also of the mesenteric artery (arrow) have been opacified by intravenous contrast medium and stand out against the relatively low density of adjacent thrombus.
DISCUSSION Plain radiographs are of limited value in the diagnosis of aortic aneurysms, as 15% to 45% fail to show calcification (Steinberg and Stein, 1965; Ester, 1950). As computer tomography is much more sensitive to the presence of calcium than conventional radiography, it is not surprising that 32
FIGURE 3: The leaking aortic aneurysm (A) measures approximately 10 cm in diameter, and extravasated blood (arrows) is extending posteriorly and laterally into the left flank at the L3 level
FIGURE2: Leaking aortic aneurysm. The margin of tne aorta (A) is ill defined because of rupture, and dense extravasated blood (arrows) has passed into the left retroperitoneal tissues displacing the left kidney anteriorly.
276
that patients with an aneurysm six centimetres or less in diameter had a 75% one-year survival, and 47.8% a five-year survival, whereas those patients with an aneurysm greater than six centimetres in diameter had a 50% one-year and a 6% five-year survival rate. Computed tomography and ultrasound are both excellent non-invasive methods for detecting any change in the size of the aneurysm, and both show the lumen and the amount of thrombus (Figure 1). In our series an unusually large number of the aneurysms (24%) extended above the renal arteries, and the C.T. scan was valuable in assessing the degree Of involvement Of the thoracic aorta. “Itrasound, although able to show the aneurysm in both AUST.N.Z. J. SURG.V O L . ~ ~ - N O3,. JUNE,1978
COMPUTED AORTIC ANEURYSM TOMOGRAPHY
PERRETT AND SAGE
aorta and displaces retroperitoneal structures such as the kidneys (Figure 2). Within a day or so extravasated blood becomes more dense than intraluminal blood because of clot retraction and is readily detected on the scan (Figure 3). The normal density of intraluminal blood is 28 E.M.I., units and this density is mainly due to the protein content of haemoglobin. Following extravasation and absorption of fluid from the clot, the density rises to between 30 and 42 E.M.I. units (New and Aronow, 1976). After approximately one week the density of the haematoma begins to decrease because of breakdown of red cells and removal of protein by phagocytes. In addition, adjacent oedema fluid may move back into the clot, so that by the end of two to
4: A large irregular low-density haematoma (H) lies in FIGURE front of the aortic prosthesis in the low lumbar region. Its lateral margins are defined by arrows. Artefacts are due to barium remnants within the bowel.
the transverse and the longitudinal planes in the abdomen, cannot assess the thoracic aorta because of air in the lungs, nor can it display accurately the distance between the renal arteries and the upper margin of an infrarenal aneurysm. Occasionally the presence of paralytic ileus will interfere with the ultrasound examination (Winsberg et alii, 1974). One advantage of computed tomography is that the quality of the examination is not impaired by obesity of the patient, and it was of value in diagnosing a leaking aneurysm in a very large patient who could not be assessed adequately by clinical means (Figures 2,3). Recently extravasated blood causes loss of definition of the outline of the
AUST N.Z. J. SURGVOL 48-No
3, JUNE.1978
three weeks the clot may become less dense than normal blood (Figure 4). One further use of computed tomography is in the diagnosis of complications following aneurysmal surgery, e.g., Figure 4 illustrates a low-density haematoma approximately three weeks old complicating replacement of an aortic aneurysm by a Dacron graft. REFERENCES ALFIDI.R.J , HAAGA,J.R., MEANEY,T.F., MaclNTYRE, W.J., GONZALEZ. L., TARAR. R., ZELCH.M.Q., BOLLER, M., COOK. G. (3975), Radiology, 117: 257. S.A. and JELDEN, AXELBAUM, S.P., SCHILLINGER, D.. GOMES.M.N.,FERRIS, R.A. and HAKKAL. H. (1976). Arner. J. Roentgenol., 127: 75. ESTER, J.E.. JR (1950), Circulation, 2: 258. NEW,P.J.F. and ARONOW, S . (1976), Rad/ology, 121: 635. STEINBERG. I. and STEIN,H.L. (1965), Arner. J Roentgenol., 95: 684. SZILAGYI. D.E. and ELLIOTT. J.P. (1972), Arch. Surg. 104: 600. WHEELER, W.E., BEACHLEY. M.G. and RANNIGER.K (1976),Arner. J. Roentgenol., 126: 95. WINSBERG. F., COLE-BEUGLET.C. and MULDER, D.S. (1974),Arner. J. Roentgenol., 121: 626.
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