Letters
to the
U Ductal Carcinoma in Situ: Mammographic Appearances
From:
Daniel
Department Box 3808,
C. Sullivan,
Editor Atypical
MD
of Radiology, Duke Durham, NC 27710
University
Medical
Center
Editor: In the September 1989 issue of Radiology, Drs Ikeda and Andcrsson reported interesting and useful statistics on atypical mammographic appearances of ductal carcinoma in situ (DCIS) (1). They suggest that their data arc more representative of the relative frequency of various radiographic patterns because they reviewed the data on all patients with DCIS who also underwent mammography (italics mine) at their hospital, whereas many previous studies reviewed only cases detected with mammography (ic, some of the cases of Drs Ikeda and Andersson
were
detected
clinically
or incidentally).
This
cer-
tamnly adds value to their findings, but they omit two pieces of information that would be helpful in placing their findings in perspective: First, how many patients with and without mammograms received a diagnosis of DCIS during the study penod of January 1976 and March 1988? Second, what time intervals occurred between mammography and the diagnostic procedures? Their article suggests, but does not state, that most or all of the patients with DCIS at their hospital during the 12year study period had undergone mammography immediately prior
to diagnosis
of DCIS.
Clarification
of these
Reference
Drs
Ikeda DM, mographic
Ikeda
Andersson appearances.
and
I.
Ductal carcinoma Radiology 1989;
Andersson
in situ: atypical 172:661-666.
mam-
respond:
The answer to Dr Sullivan’s first question about our recent antide (1) is that all patients who received a diagnosis of DCIS during the period in question also underwent mammography. In answer to the second question, most women (176 of 190 [93%]) underwent surgery about or within 3 months of mammography (83% within 2 months of breast imaging). Of the remaining 14 women who underwent surgery 4 months or longer after mammography (7% of the 190 patients), seven had calcifications; of these women, four underwent resection 4_41/2 months after imaging, and two underwent surgery 7 months after imaging. Of the other seven women who underwent surgery and were included in the noncalcified study group, six had negative mammographic studies. Three patients were operated on at about 4 months for newly diagnosed Paget disease of the nipple, one patient developed bloody discharge (with positive galactographic findings) and underwent resection at 31/2 months, and one patient was operated on at 81/2 months for a nodule that was palpable at the time of a normal mammographic study and that had been followed up clinically. The latter patient had a region of spiculation seen at radiography but deferred surgery for 6 months after mammography. No calcifications were reported in the pathologic specimens of any of these patients. Dr Sullivan did not ask about the incide.tcc of DCIS in the
Volume
175
#{149} Number
1
ferning
physicians
screening
or found
at mammography
outside
the
trial.
References 1.
Ikeda DM, mographic
Andersson appearances.
2.
Andersson
I, Aspegren
points
would help us assess how representative their group of 190 women with DCIS who had undergone mammography might be of the larger group of all women with DCIS, which would make their interesting article more informative.
1.
Swedish population studied. Here are the incidences of DCIS (per 100,000 women per year) for the city of Malm#{246}for some of the years studied: i976, 4.7; 1977, 8.8; 1978, 15.1; 1979, 13.8; i980, 10.6; 1981, 16.4; i982, 12.4; 1983, 13.2; 1984, 12.4. These figures include cases with a combination of DCIS and lobular carcinoma in situ (LCIS) but not cases of LCIS alone. As would be intuitively surmised, the number of noninvasive carcinomas seen in this population is related to the amount of mammographic activity in the city, in this case in part related to the Malm#{246}Mammographic Screening Trial (2), which began in 1976. This would shift some of the percentage of DCIS tumors (found in a “normal” population by means of palpation or report of bloody discharge) to a larger number of cases that arc nonpalpable and arc detected radiographically. For example, the incidence of DCIS in the control group of the screening trial was approximately 20 per 100,000 women pen year, whereas 35 cases per 100,000 women per year were seen in the invited group. The DCIS cases described in our article (1) were originally referred for surgery from a variety of sources and included cases from both the invited and the control portions of the screening trial, as well as cases found in the community by re-
ing and screening
mortality trial.
I.
from Br Med
Debra M. Ikeda, MD Department of Radiology, 1500 East Medical Center Ingvar Andcrsson, MD Department of Radiology, S-21301 Malm#{246},Sweden
Ductal carcinoma Radiology 1989; K, Janzon
in situ: atypical 172:661-666.
L, et al.
breast cancer: the J 1988; 297:943-948.
University Drive, Ann
Mammographic
of Michigan Hospitals Arbor, MI 48109-0326
Malm#{246}General
Hospital
in Primary
From: Hcrmann
MD, Gent Judmaicr,
Kathrein,
Vogel, MD of Internal Medicine, 35, A-6020 Innsbruck,
screen-
Malm#{244}mammographic
U Lymphadenopathy CT Observations
Wolfgang Department Anichstrassc
mam-
Innsbruck Austria
Biliary
Cirrhosis: MD, and
University
Editor: We read with interest the article by Outwater et a! on computed tomographic (CT) observations of lymphadenopathy in primary biliary cirrhosis (1), which appeared in the June 1989 issue of Radiology. In a prospective ultrasound study in 234 paticnts of the significance of enlarged lymph nodes in the porta hepatis for the diagnosis of liver disease, we found similan results (2). Of 112 patients with inflammatory liver discase, 29 (26%) showed lymph node enlargement in the porta hepatis. Malignancy had been excluded in all these patients. The highest percentage of lymph node enlargement (72%) was found in patients with acute hepatitis. Patients with chronic hepatitis of different causation (all biopsy proved) were found to have a lower percentage of lymph node enlargement (17%). Of 19 patients with histologically proved
Radiology
#{149} 285
primary biliary cirrhosis (stages I-Ill), five were found to have lymph nodes enlarged to over 1.0 cm in diameter. We speculate that the lower percentage of patients with lymph node enlargement in our study might reflect earlier stages of disease. Furthermore, none of the remaining 122 patients with metabolic or noninflammatory liver disease (eg, steatosis, hemochromatosis, and a-l-antitrypsin deficiency) had enlarged lymph nodes in the porta hepatis. Finally, in our experience, it has never been a problem to distinguish vascular structures from enlarged lymph nodes, particularly with the help of duplex sonography. We were glad to learn that the conclusion made in our study, namely, that enlargement of lymph nodes in the porta hepatis can be a sign of inflammatory liver disease after exclusion of malignant disease, was confirmed in a CT investigation.
neum
of the
fossa,
the
clips.
The
stone
vantage
that
in pri171:731-
1.
Martin
H,
lymph
Vogel
node
er disease.
W,
Dietze
B, Judmaier
enlargement
in
Ultraschall
1989;
the
G.
liver
hilum
The in
significance
2.
EC,
Percutaneous System
Transjejunal
RN,
Access
to the
3.
RN,
Adam
hilar
and
puncture
in
with
rates patients
recurrent
of Roux-en-Y
calculi
after
radiologic
with
primary
jejunal
AG,
tern
colonized
obstructed
mation. Our lems
by
segments,
or strictures.
dilation
are
sclerosing
own
approach
generally
tion
of the
286
#{149}
bacteria and
efferent
Radiology
(4), may
The
5.
Gibson
limb
R.
skin
the ad-
with
infection,
Percutaneous
system.
the
and
the
A,
transjejunal
Radiology
A, Czerniak
1989;
A, et al.
and
Yeung
Benign
biliary
strictures:
management.
Percutaneous
Aust
techniques
J Intervent
strictures.
ap-
172:1031-1034.
radiological
E, et a!.
intrahepatic
Cotton
PB,
1988;
108:546-553.
RN.
J, et a!.
Rode
a light
In:
Louis:
by
and
in
Radiol
ed.
1990;
stent
1988;
blockage
microscopy
radiology
JT,
Mosby,
Biliary
electron
Interventional
Ferrucci
for
Advances
in
benign
with
study.
Ann
biliary
stric-
hepatobiliary
In-
radiology.
St
395-412.
of Increased Lung Scans
Tank
and
complex access
Roux-en-Y
U
for stone biliary
by
superficial
loop
to the
Oxford,
the
OX3
interest
the
authors’
9DU,
England
by
perfusion
microaggregated size only. Thus,
of a pulmonary
segment
on
Hospital
Meignan
issue
et al (1), I was
of Radiology.
criterion (“hot
selection
of increased
tion of injected on is based on
Radcliffe
1989
for excluding spots”) caused
at least
two
views
which surprised
ap-
artifactual by aggrega-
human albumin. hot spots smaller
all
on
BAO
John
article
October
Spots)
This cnitenithan 25%
are
dismissed
as
artifactual and excluded from consideration. This, I believe, might be rather inaccurate. Work by Duffy et al (2) emphasizes that since aggregates of radiopharmaceutical vary in radioactivity and distance from the radiation detector, estimation of their size with lung scintigraphy is difficult. Indeed, many of the hot spots illustrated in that article are certainly larger than 25% of a pulmonary segment. These hot “clots” (3) might
be
more
peripheral
appropriately
location
suspected
(4)
and
focal
basis of their size. In fact, as circular areas of increased ure).
I believe
that
distribution these more
such
hot
the
basis
(2,4)
than
clots
of their on
the
are represented
radiopharmaceutical uptake investigation of radiopharmaceutical
any
on lung definite
most
on
character
perfusion characteristics
scans
should of artifactual
take
(Fig-
into account hot clots.
References 1.
Meignan
M,
creased
perfusion
with 2.
Palmer
pulmonary
Duffy
GJ,
EL,
(hot
AC,
GL,
pulmonary
Strauss
on perfusion
arteriograms.
DeNardo
dioactive
Waltman
spots)
Radiology Abington
emboli
in
Origin
Zones
scans:
1989;
RB. man.
HW.
lung
of in-
correlation
173:47-52. and
Radiology
evolution
1968;
of ra-
91:1175-
3.
Neumann
4.
tilation-perfusion Johnson PM. Semin
RD.
NucI
Sostman
HD,
Gottschalk
A.
imaging. Semin NucI role of lung scanning
The Med
1971;
Current
Med 1980; in pulmonary
status
of yen-
10:198-217. embolism.
1:161-184.
reg-
formasupare
of infection
a nidus
be
with
radiologic
of the
a source
MB, BCh,
of Radiology,
in the
(Hot
1180.
over
(3).
a
Perfusion
F. Massoud,
with
zones
reported
19%-34%
cholangitis
are
well
in patients
is to create
Bixon
biofilm: Med
peared
loops
Martin et al argue that long-term access by means of tube is preferable in at least some patients, since it allows ular flushing, which may help prevent recurrent stone tion. As they point out, there are as yet no good data to port this. Furthermore, tubes placed in the biliary tract rapidly
has
catheter
3:125-130. Speer
Editor: I read
when the loop has not been fixed surgically to the anterior abdominal wall. The second message, which is implicit, is that fixation of Roux-en-Y jejunal loops should be considered at the time of hepaticojejunostomy, especially when dealing with complex biliary problems. It is vital that interventional radiologists encourage our surgical colleagues to do so, in order that simple long-term percutaneous transjejunal biliary access is provided for subsequent stricture dilation or stone extraction, as required. As Martin et al emphasize, the use of both radiologic and surgical approaches to complex biliary strictures can be invaluable. The techniques can be combined in a number of ways (2), but one of the major requirements is the availability of safe and easy long-term radiologic access to the biliary tract. Repeated radiologic procedures are needed in many pa-
50%
Adam
benign
Department
The article by Martin et al (1), which appeared in the Septemben 1989 issue (RSNA-SCVIR special series) of Radiology, contains two important messages for biliary interventional radiologists. The first is the description of a number of innovative techniques for gaining access to the biliary system by means
to deal
KJ, biliary
Gibson
From:
Biliary
Editor:
restenosis
dilation
approach
liv-
Robert N. Gibson, MD,’ Neil A. Collier, MD,2 and Antony G. Speer, MD3 Departments of Radiology,’ Surgery,2 and Gastroenterology,3 Royal Melbourne Hospital Parkvillc, Victoria, Australia 3050
tients
percutaneously
This
leakage, (5).
iliac
of surgical
stricture
drainage
combined surgical 1987; 57:361-368.
Headington,
percutaneous
punctured and
external
right
ring
10:127-131.
From:
of direct
Laffey
a proposed NZ J Surg
U Zones Perfusion
U
be
as necessary. is no
to the
Gibson
of
non-malignant
removal
proaches
tures.
Kathrein
then
the
a
by
References
733. 2.
can
toward
cholangiography
there
bacterial
Lymphadenopathy Radiology 1989;
marked
inherent problems of bile need for regular replacement
References Outwater E, Kaplan MM, Bankoff MS. mary biliary cirrhosis: CT observations.
wall
being
loop
follow-up
and/or
abdominal
of fixation
jejunal
to allow
4.
1.
anterior
site
in
forprobfixa-
penito-
Dr Strauss We
read
difference
responds: with in
interest the
the patients in our al, the artifacts due shown while of the
the
hot
spots
letter
from
Dr
identified
article is the to microsphere
in the figure accompanying those seen in our patients borders of bronchopulmonary
in
shape
Massoud. his
of the clumping
Dr usually
letter
A major and
those
lesions. In are round
Massoud’s followed segments.
in
gener(as
letter), at least part Clearly, when
April
1990