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897

Letters ‘.!:

Requisition Our radiology

department,

“ We

“case of the week. the

week.”

This

of its illegible, physician, out. fun

and

that

of the

section

week”

it could

of the

turns

handle

concern

might be confrontational

concurrently

posting

would

from

come

own

be omitted.

Our

clinical

of the

on because

misgivings

as

departments

written

their

may

be

to encourage

here.

We

week

might

suspect

value less

content.

reticent

readers that

attract

would

attention

also

CT

(our

only ideas.

of the

data prefer

us with

They

differences regard,

report

would

most

of

Other and

week

and

is

of the

a report

than

the nearby

case of the week. Each has a message. Ferris

M.

Norman

Beth Israel Harvard Medical Boston,

Upper Lobe Sarcoidosis A 27-year-old pregnancy.

Collapse black

In addition

woman to her

Hall Joffe

Mark

of predicted.

Fiberoptic

were

performed,

and

granulomas.

negative.

A biopsy

showed

multiple

examination

of

the

specimens

Special stains for acid-fast organ-

of an external

iliac lymph

and examination

noncaseating

granulomas.

node

was

of the specimen The

patient

was

treated with prednisone, and in 2 weeks, symptomatic improvement and a 50% improvement in the FEy1 occurred. A chest radiograph taken 1 month after discharge from the hospital showed total reexpansion of the right upper lobe. Although lobar atelectasis as a result of sarcoidosis has been described [1 -3], bobar collapse involving segments other than the middle

lobe is unusual.

patients

who had

of

the

had

Olsson

et al. [lJ described

severe

bronchostenosis.

atelectasis

bronchus.

of the

right

upper

eight patients Only

lobe.

one

Stinson

with

of

and

these Hargett

Guenin

Olsson

et

al.

thought

that

bronchostenosis

was

poor prognosis, with little regression of symptoms despite treatment. Munt [31 described a patient with sarcoidosis with atebectasis of the middle lobe who had rapid regression of symptoms after treatment with corticosteroids. Our experience is similar; our patient had relief of her symptoms associated

with the ideas expressed

and discussion

of77%

a case of sarcoidosis with bobar atelectasis of the right middle lobe that was thought to be caused by extrinsic compression

and

letter

capacity

[2] reported

radiology

this

lung

at the time oflaparotomy,

sarcoidosis

have not been

of opinion

appropriateness. in this

of the

and personal

supply

were

different

be selected

undoubtedly

isms

tissue

performed

radiologic would

the

be both

of a “requisition This

a total

showed that the bronchus of the right upper lobe was pearly white granulation tissue. Transbronchial biopsies

showed noncaseating

staff, we have discussed also

and

of

requisition

All names

to experiment

a requisition

more

and

capacity,

bronchoscopy occluded by

blanked

good taste and

preparation,

week.”

colleagues

and

basis

alone).

of intradepartmental

to

in

the

and

the “report of the day” and probably the material for that display. Unfortunately, these ideas remain acted

done

vital

of

referring

be

would

display

department

on the basis of its inappropriate would

load

of the

access,

to the clinical

a “report our

little

on the

name

would

public

the

a popular

a “requisition

forth

supplying

the

that

so

week,

without require

take

The

and

of the

It would might

insisted

Because

patient,

displays

specifically

history.

in an area

sections

others,

introducing

be selected

a requisition

displayed educational.

imaging

would

or misleading

name

think

and

like many

are considering

request

inane,

the

We

spirit

paratracheal adenopathy (Fig. 1). Pulmonary function tests revealed a reduced forced expiratory volume in 1 sec (FEy1), a reduced forced

of the Week

with

a

over several

weeks

right

setting,

clinical

ential diagnosis portend a poor

with

reexpansion

sarcoidosis

of collapse clinical

of the right upper

should

be considered

lobe. in the

of the right upper lobe, and it

outcome.

Resolution

of endobronchial

In the differ-

need

not

granu-

Hospital School MA

02215

Due to Endobronchial was

admitted

abdominal

for treatment complaints,

she

of ectopic had

had

a

for 2 months and wheezing and dyspnea on exertion. Right supraclavicular and bilateral epitrochlear lymph nodes were palpable. The patient did not react to purified protein derivative or to a panel of antigens used to detect anergy. Chest radiograph showed collapse of the right upper lobe of the lung with left hilar and right-sided cough

I

11br

Fig. 1.-Chest radiograph shows atelectasis ofrightupperlobeof lung and left hllar adenopathy.

898

lomas as a result of steroid therapy is coincidental hilar and paratracheal due

lobe,

to enlarged

lymph

disease

of the

chial occlusion

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adenopathy. nodes upper

caused

Although

may lobe

account

most

by sarcoid

with regression

bronchial

for occlusion

likely

is the

of

compression

MR Imaging Transposition

Having read with interest

granulomas.

would

James Witko William D. Strazzella Benjamin H. Safirstein Medical

like

to point

REFERENCES 1 . Olsson

T, Bomstad-Petterson H, Stjemberg N. Bronchostenosis due to sarcoidosis: a cause of atelectasis and airway obstruction simulating pulmonary neoplasm and chronic obstructive pulmonary disease. Chest i979;75:6 2. Stinson JJ, Hargett 0. Prolonged lobar atelectasis in sarcoidosis. J Nat! Med Assoc i98i;73:699-671

3. Munt PW. Middle lobe atelectasis in sarcoidosis: report of a case with prompt resolution concomitant with corticosteroid administration. Am Rev Respir Dis i973;1 11:279-294

2 may or,

Fistula

I noted a short letter entitled “Coronary Artery-Left Ventricle Fistula” [11 in the November 1989 issue of the AJR. The authors cite

one reference

from the French

relatively

and apparently

small

literature

isolated

and present

coronary

a case of a

artery-left

ventricular

Second,

(closer)

morphologic

and

Pelikan

The entire spectrum of such abnormalities ranges from large isolated fistulas to a plexus of small vessels with multiple fistulous channels opening into the left ventricle that, when extensive, is thought to be the cause of signs and symptoms of transient myocardial ischemia

and angina

pectoris.

If a discrete

large fistula

is likely to

cause the signs and symptoms, surgical repair is indicated. Unfortunately, multiple, small, widespread communications, even when positively identified as causing steal from the myocardium, cannot be treated in this way. I have no argument with the authors’ decision not to recommend surgery in their case; the isolated fistula was rather small and probably unrelated

transient from

to the patient’s

signs

regional myocardial

a stress

to establish

As other

causes

of

ischemia exist, the patient might benefit

test in combination

this diagnosis

and symptoms. with

myocardial

thallium

firmly. Parenthetically,

scanning

I might add, some

cardiologists in the United States would recommend prophylactic antibiotics for dental or surgical procedures in a patient who has a

small coronary in a condition infective

fistula. Recommendation that,

presumably,

endocarditis,

however,

of such protective

has a low, albeit might

not

measures

undeniable,

be as common

risk of

in Norway.

Sven Paulin Harvard

Medical

School

of the chest.

instead

likely,

(b)

Figure to the

right

in Figure

Therefore,

either

the situation

(a) situs

heterotaxia

or

36,

the

situs

cardiac

authors

the

ventricle,

whether

right-

and

situs nor the

conclude

than

with

ambiguous

right ventricle

apex

seen

inversus

that

because

is attached

septal

more

leaflet

of the In any

valve is present. or

left-sided,

the

septal

the

identification

of the

morphology

of the

right

ventricle

in

specimens and on echocardiograms and MR images and allows the lateralization of the morphologic right ventricle [2, 3]. In Ebstein anomaly, however, the septal leaflet of the tricuspid valve is either absent or plastered against the ventricular wall [4] and would not have the normal appearance of the leaflet shown in Figure 36. On the contrary,

[3].

First,

leaflet of the tricuspid valve characteristically is attached more anteriorly (i.e., closer to the apex) than the anterior leaflet of the mitral valve [2]. This behavior of the septal leaflet of the tricuspid valve

classifying

McLellan

essay by Park et al. [1], I statements.

mitral valve, Ebstein anomaly of the tricuspid

those

and

more

regarding

anteriorly

is dysplasia

et al. [2]

side

represent

the septal leaflet of the morphologic

communication. In order to dispel any misunderstanding, the English literature on this topic has a sizable number of publications, including by Vogelbach

the pictorial questionable

two

dextrocardia. Thus, in this case, neither the visceroatrial atrioventricular connection is clarified.

allows

Ventricle

out

in the right

in Figure levocardia

Artery-Left

Corrected Vessels in Adults

2A the gastric air bubble under the right hemidiaphragm is said to suggest situs inversus. However, the apex of the heart is in the left side of the chest. In situs inversus, by definition the heart and apex are located

Center

Newark, NJ 07102

Coronary

of Congenitally of the Great

of the middle

of endobron-

result

St. Michael’s

54, April 1990

AJA:1

LETTERS

the main rather

lower location with

1 -cardiac

of the tricuspid

displacement

[5].

valve

in Ebstein

Therefore,

ventricle loop

as

and

of rapidly

an

inverted

corrected

ventricle

morphologic

transposition

increasing

interest

of the

in MR

anomaly

the characteristic

of the septal leaflet of the left-sided

this

Because

feature

than

imaging

justifies

right

ventricle

great

arteries.

of congenital

defects, a clear understanding of the anatomic pictures is necessary, and, therefore, I think that clarification of these two points is of both academic and practical importance. heart

Augustin Bowman

Gray

G. Formanek

Schoo!

of Medicine

Winston-Salem,

NC

27103

REFERENCES 1 . Park JH, Han MC, Kim CW. MR imaging of congenitally corrected position of the great vessels in adults. AJR i989;153:491-494 2. Losekoot TG, Anderson RH, Becker AE, Danielson GK, Soto tally corrected transposition. Edinburgh: Churchill Livingstone,

3. Guit GL, Bluemm

A, Rohmer

identification of segmental 1986;161 :673-679

4. Lev M, Liberthson

J, et al. Levotransposition

cardiac

AR, Joseph

anatomy

using

trans-

B. Congeni1983

of the aorta:

MR imaging.

RH, et al. The pathologic

Radiology

anatomy

of

Ebstein’s disease. Arch Patho! 1970;90:334-343 5. Becker AE, Decker MJ, Edwards JE. Pathologic spectrum of dysplasia of the tricuspid valve: features in common with Ebstein’s malformation. Arch Pathol i97i;91 :167-1 78

Beth Israel Hospital Boston, MA 02215 Reply

REFERENCES 1 . Pedersen

HK, Simonsen

S. Coronary

artery-left

ventricle fistula (letter).

AiR i989;153:1098 2. Vogelbach KH, Edmiston WA, Stenson RE. Coronary artery-left ventricular communications: a report of two cases and a review of the literature. Cathet Cardiovasc Diagn i979;5: 159-1 67 3. McLeIIan BA, Pelikan PCD. Myocardial infarction due to multiple fistulas. Cathet Cardiovasc Diagn i989;16:247-249

I would like to respond to Dr. Formanek’s letter regarding my recent article [1]. First, he suggests that the heart and its apex should be in the right side of the chest in situs inversus. However, the

position of the cardiac apex is not necessarily The

diagnosis

position

three may

of the

visceral

of the hepatocavoatrial

different be right-sided,

directions medial,

situs

complex.

in each

correlated

is established

situs.

or directed

The

cardiac

In situs to the

by

left

with situs.

identifying apex

may

the have

inversus,

the apex

[2].

patient

In the

in

AJR:154,

LETTERS

April 1990

899

i986;161 :673-679 4. Zuberbuhler JA, Allwork

anomaly

RH. The spectrum of Ebstein’s valve. J Thorac Cardiovasc Surg i979;77:

SP, Anderson

of the tricuspid

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202-211

Castleman

Disease

Castleman

in a Mother

first reported

and

Daughter

a case of benign giant mediastinal

lymph

nodes in 1 954 [1]. Two years later, he called attention to 1 3 patients with massively enlarged lymph nodes primarily in the mediastinum [2]. Castleman considered this abnormality to be lymph node hyper-

Fig. 1.-Transverse septal leaflet (arrow)

MR image of 30-year-old woman shows displaced of tricuspid valve suggesting Ebstein anomaly.

Fig. 2.-Transverse

MR image of 29-year-old woman septal leaflet (long arrow) of tricuspid valve suggesting associated with atrial septal defect (short arrow).

Figure

2 in the

inversus

pictorial

on the

plasia, probably caused by a chronic low-grade inflammatory process. Since then, about 300 more cases have been reported. The condition has been termed Castleman disease, angiofollicular hyperplasia, lymphovascular pseudotumor, follicular lymphoreticuloma, and benign

essay

basis

of the

[1],

the

anatomy

situs

determined

liver,

inferior

to

vena

I agree

Second,

more

that

the

anteriorly

septal

in any

leaflet

of the tricuspid

morphologic

right

to chronic

valve

is

That

is

ventricle.

vessels

in Figure

3B

normally

to the

displaced

downward,

anulus.

associated [1].

with

In Ebstein

and

being that

anomaly

anomaly,

anulus,

It is known

Ebstein

the

leaflet, with

varying

from

dysplasia

anomaly.

[4].

posterior

attached

to the

Ebstein

minimal I think

However,

anterior

the

our

to marked

the diagnosis

has

cases

of the

pneumonia.

right-sided wheezing and cervical and history and laboratory findings were

benign

lymphoid

Low-dose

hyperplasia,

radiation

therapy

thought (5.7

to be due

Gy

in air) was

patient.

The

for 2 weeks

below

the

physical

daughter

that was

examination

was

admitted

refractory

because

to medical

and laboratory

tests

daughter she

had

therapy.

were

of the first had

wheezing

The results

normal.

of

A chest

of features

of the attachment

patient

confirmed

administered through an anterior mediastinal port. Over the next 6 years, the patient was asymptomatic and had slow but progressive decrease in the size of the hilar and mediastinal lymph nodes. A chest radiograph made when the patient was 22 years old was normal,

are

is a spectrum

showed

infection.

leaflets wall

showed Family

describe

her daughter. because of recurrent

of the hyaline vascular variety. The second case was the 12-month-old

shown

is attached

septal

ventricular

displacement

that

leaflet

and

anomaly

related to the degree of displacement

in the patient

We

with no evidence of lymphadenopathy. Reevaluation of the original pathologic specimen confirmed the diagnosis of Castleman disease

one of the criteria used to identify the morphology of ventricles [3]. The problem is the severity of Ebstein anomaly. The clinical diagnosis after two-dimensional echocardiography was corrected transposition of great

examination adenopathy.

lymph nodes

cava,

ambiguous.

attached

[3-5].

in a mother and girl was admitted

unremarkable. A chest radiograph showed large subcarinal and bilateral hilar lymph nodes (Fig. 1). Biopsy specimens of bilateral axillary

be

and atrial appendages; this was proved during open heart surgery. The situation could be called situs inversus with levocardia, but not situs

lymphadenopathy

disease occurring A 9-month-old

Physical axillary

was

of the

giant

shows displaced Ebstein anomaly

of the valve displacement

a mild

form

was not confirmed

of Ebstein

surgically

or

pathologically.

However, merely

I disagree

indicates

Ebstein

anomaly.

proved

Ebstein

that

anterior

right

Figures

1 and

anomaly

without

displacement

morphologic admit

that a lower

morphologic

of

right ventricle

thatthe

legend

inasmuch

as

think

that

the

worth

further

such

2 in this letter transposition.

the

septal

the

does

were normal

leaflet

suggests

anomaly.

not

position

not

leaflet suggest

show two cases of These cases show

described. of

not

only

Nevertheless,

3B in the essay [1] was

controversies of

of the septal and

but also Ebstein

of Figure

range

location

ventricle

too

I

conclusive

In addition,

the

septal

leaflet

I is

investigation.

Jae Hyung Park Seoul

National

University Seoul

Hospital

1 10-744,

Korea

REFERENCES 1 . Park JH, Han MC, Kim CW. MA imaging of congenitally position

of the great

vessels

2. de Ia Cruz MV, Berrazuetu

in adults.

AJR i989;1

JA, Arteaga

53:491

corrected

trans-

-494

M, Attie F, Soni J. Rules for

diagnosis of arterioventricular discordances and spatial identification of ventricles: crossed great arteries and transposition of the great arteries. Br Heart J 1976;38:341-354 3. Guit GL, Bluemm A, Rohmer J, et al. Levotransposition of the aorta: identification of segmental cardiac anatomy using MR imaging. Radiology

Fig. 1.-Serial chest radiographs in a patient with Castleman disease. A, Radiograph obtained when patient was 9 months old shows hilar adenopathy. B, Radiograph obtained when patient was 7 years old shows persistent hilar adenopathy.

Chest radiograph obtained when patient was 22 years old was normal. Fig. 2.-Chest radiograph of 12-month-old child, daughter of patient in Figure 1, shows hilar and mediastinal adenopathy.

LETTERS

900

radiograph

showed

massive

hilar and mediastinal

adenopathy

2). CT scans confirmed the presence of mediastinal nopathy and showed retroperitoneal lymphadenopathy. thoracotomy

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formed. hyaline

and

biopsy

of

the

mediastinal

patients

mont

was

showed given.

that

The

the

was

To our

reported

knowledge,

these

in a mother

were

identical.

at different

are the

were

gone

Chest films made at that time showed of the hilar and mediastinal adenopathy.

both

lymph

abnormalities

wheezing

node

first

The

disease

also

were

disease findings

identical.

a 7-month

marked

decrease

cases

follow-up.

of Castleman

in the size disease

The pathologic

has

occurred

per-

of the in the

No treat-

at

and her daughter.

(Fig.

and hilar adoA right-sided

Histologic examination showed Castleman vascular type. Comparison of the histologic

two

changes

in identical

in

twins

Raymond

A. Gagliardi

Manuel

Victor

P. Meza

University,

Mercy

School

Hospital

of Medicine

State

University,

Sonography the Liver

MI 48201

Chung-ho Wayne

Chang

Hospital

of Michigan

School

of Medicine

Detroit,

MI 48201

].

of mediastinal

lymph

nodes.

N EngI

J Med

i954;250:26-30

in the

hyperplasia

confirmed neous,

2. Castleman B, Iverson L, Mendendez VP. Localized mediastinal lymph node resembling

thymoma.

Cancer i956;9 :822-830 Radio! Clin North Am i968;6:

3. Abell MR. Lymphoid hamartoma. 4. Bargoli E, Massarelli G, Soggia G. Multicentric

right

15-24

ment.

giant lymph node hyperpla-

6. Martin C, Pena M, Angelo F, Garcia F, Vaca D, Serrano A. Castleman’s in identical

twins.

Virchows

Arch

liver,

i982;395:77-85

the

with

no

Simulators 4]. Recently,

Simulation

of a breast an additional

In this instance,

have

simulator

the patient

been was

described seen

previously

at my

was a ballet dancer

[1

of the rib cage. Spot mammograms

Edmonton,

Alberta,

is an

uncommon

invasion

Sonographically

quadrant.

She

radiograph

finding

enlargement

was

was

and

of

vessels

guided

or

pattern biopsy

signs

had pain and

normal.

Fl, Woods

JA. Simulators

(letter). Radiology i989;171 :877 2. Jackson Fl. A further simulator Radiology

of a breast

a solid,

of

cirrhosis

(Fig.

revealed

that

the lesion

multiple

myeloma,

and Albers-SchOnberg

---:-;

(marble

-:

:

T6G,

1Z2

on a mammogram

of a breast mass on a mammogram.

1989;170:272

1 ).

CT

enhancewas

due to extramedullary hematopoiesis. Hepatic extramedullary hematopoiesis is a normal feature in the fetus and neonate up to 5 weeks of age, and it may persist in the presence of anemia. In the adult, it is associated with loss of bone marrow due to myeloproliferative disease. Other causes include aplastic anemia, marrow replacement syndromes, disseminated car-

Institute

1989:173:284 Radiology

heteroge-

with patchy contrast

with metallic

3. Gilula LA, Destouet JM, Monsees B. Nipple simulating a breast mass on a mammogram.

had

in the right lobe of the

with marked

Cancer

Canada,

mass

and

Sonography

REFERENCES 1 . Jackson

in adults

anemic

showed

mass (1 5 cm in diameter)

of

-

markers over this region showed that the cause of the density on the mammograms was an unusual prominence of the ribs on that side. F. I. Jackson Cross

a breast

Hematopoiesis

institution.

scoliosis and spondylolisthesis. A density was noted posteriorly on the medial aspect of the craniocaudal view of one breast (Fig. 1) but not on the oblique or lateral views. Clinical examination showed

marked prominence

simulating

bone)

disease. The sonographic features of extramedullary hematopoiesis of the liver have been reported for only one case, a patient with agnogenic

on a Mammogram

mass

organ

a mixed attenuation

cinomatosis,

Mass

upper A chest

hypoechoic

showed

sia: a hyperimmune syndrome with a rapidly progressive course. Am J Clin Pathol i980;73:423-426 5. Libson E, Fields 5, Strauss 5, et al. Widespread Castleman disease: CT and us findings. Radiology 1988:166:753-755

Breast

hematopoiesis

hepatosplenomegaly. B. Hyperplasia

muscle

The most common sites are the liver and spleen. A 31 -year-old woman with l-thalassemia intermedia

a mass

1 . Castleman

Pectoralis

of Extramedullary

Extramedullary

[1

REFERENCES

disease

PC, Lee AR. AdA i989;152:481-482

mass.

Ml 48053

Detroit, Children’s

4. Meyer JE, Stomper

D. Steele

Pontiac, State

B

Maldonado

Robert St. Joseph

A

Fig. 1.-A, Craniocaudal mammogram of breast shows posterior density (arrowhead). B, Spot compression mammogram of breast in region of density shown in A shows “mass” in relation to skin markers.

ages [6].

Wayne

AJR:154, April 1990

Fig. 1.-Extramedullary hematopoiesis of liver. A, Longitudinal sonogram shows a large hepatic mass. B, CT scan shows a hepatic mass with mixed attenuation.

LETTERS

AJR:154,

April 1990

myeloid

metaplasia

with

a large,

similar

[2].

Sonograms

heterogeneous,

solid

showed mass

hepatosplenomegaly

in the

right

lobe

of the

REFERENCES liver,

to

the findings in our case. The differential diagnosis of hepatic lesions is wide, including hemangiomas, abscesses, focal nodular hyperplasia, adenomas, hemorrhage, focal fatty infiltration, hepatoma, and metastases [3]. It is now necessary to add extramedullary hematopoiesis to this list, especially when the

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hypoechoic

patient

has

marrow

disease.

J. Bradley Con Metreweli

Michael Prince

of Wales

New Territories,

Shatin

901

1 . Edelman AR, Zhao B, Liu C, et al. MR angiography and dynamic flow evaluation of the portal venous system. AJR 1989;1 53:755-760 2. Miller VE, Borland LL. Pulsed Doppler duplex sonography and CT of portal vein thrombosis. AiR i985;145:73-76

3. Alpem Doppler

MB, Rubin JM, Williams US with angiographic

DM, Capek P. Porta hepatis:

correlation.

Radiology

duplex

i987;162:53-56

4. Nelson AC, Lovett KE, Chezmar JL, et al. Comparison of pulsed Doppler sonography and angiography in patients with portal hypertension. AJR i987;149:77-81

Hospital

Hong Kong Reply

REFERENCES 1 . Macswoon RM, Anthony P. Scheuer I. Pathology York: Churchill Livingstone, 1987:665

liver, 2nd ed. New

ofthe

2. Wiener MD, Halvorsen RA Jr, VolImer AT, Foster WL, Roberts L Jr. Focal intrahepatic extramedullary hematopoiesis 1987;149:1171 -1172 3. Cosgrove D, McCready A. Liver metastases. liver. New York: Wiley. 1983: 149-1 94

mimicking

neoplasm.

In: Ultrasound

AiR

imaging

of the

We appreciate the comments of Yucel et al. on our article [1 ] about MR angiography and flow evaluation of the portal venous system. Their letter raises several issues. First, they suggest that Figure 4C in our article represents segmental occlusion of the extrahepatic portal vein with reconstitution of the intrahepatic portion. This is certainly something to be considered from the projection images, but in fact the extrahepatic portal vein is patent as shown by the individual gradient-echo images (Fig. 1 this reply), which were not included in the paper because of space limitations. As we have emphasized

,

previously,

Portal

Vein

MR Angiography

We are writing authors

state

in reference

that

Figure

to the article

4 shows

of Edelman

a patent

portal

flow. The coronal projection (Fig. 4B) shows signal intensity and caliber involving the distal veins

with

the right

a return

to normal

it is important

to view the individual gradient-echo

images

as well as the projection images when interpreting MR angiographic studies [2]. The low signal from the portal vein is due to reduced flow velocity, as would be anticipated from reduced flow with reversal of the flow direction. (By the way, the images in Figure 4C are coronal, not axial.) Also, we saw no evidence of thrombus in the repeat

intensity

and

vein

et al. [1]. The with

sonographic

examination.

reversed

a marked decrease in splenic and main portal caliber

at the

junction

of

and left portal

veins. This finding is confirmed on the axial gradient-echo images (Fig. 4C) in which a gap is shown between the splenic vein and the intrahepatic portal vein. The demonstration of hepatofugal flow in the intrahepatic portal vein segment does not exclude occlusion more proximally. Another possible interpretation of the image is segmental occlusion of the extrahepatic portal vein with reconstitution of the intrahepatic portion. This interpretation is supported by the presence of massive gastroesophageal collaterals and by the sonographic finding of occlusion of the portal vein. The residual but diminished flow signal in the region ofthe extrahepatic portal vein may represent flow around thrombus or flow in periportal collaterals. The gold standard for evaluation of the portal vein is contrast angiography.

It is noteworthy

that

none

of the

patients

in the

series

of Edelman et al. had angiographic confirmation of the MR findings. Doppler sonography is accurate for diagnosing occlusion of the portal vein [2-4], and because angiography is an invasive procedure, sonography can be used to validate MR findings when the results of sonography

and

MR

agree.

However,

when

the

sonographic

and

MR

findings disagree, especially when the MR images are problematic, diagnosis on the basis of MR angiography should not be considered firm in the absence of confirmation by contrast angiography. At this early stage of development, we should be cautious about conclusions not

supported

by the

gold

standard

of contrast

angiography.

E. Kent Yucel

Fred L. Steinberg Arthur Massachusetts

C. Waltman

Genera! Boston,

Hospital MA

02114

Fig. 1.-A-C, Contiguous coranal gradient-echo MR images show patency of main portal vein and superior mesenteric and splenic

veins.

LETTERS

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902

AJR:154,

April 1990

Second, Yucel et al. make an important point that new imaging modalities (in this case, MR angiography) need to be compared with established techniques. However, this is an irrelevant issue to our paper, which describes a new approach for evaluating the portal venous system. We never claimed to have made a comparative study with conventional angiography. MR did show good correlation with duplex sonography for determination of flow velocities, and these preliminary results also suggest ways in which MR might be superior to sonography as a noninvasive technique for evaluating the portal

venous system. In order to determine

the accuracy of the MR imaging

method, a much larger study angiography, surgical results, progress.

be needed comparing MR to so forth; such a study is in

Third,

Yucel

conventional

et al. state

that

angiography,

would and none

yet

of the

patients

it is stated

in our

clearly

in our

patient 3 had this procedure. In fact, although this was not mentioned in Finally, conventional angiography portal venous system. Only vessels are shown; as a result, the method

patient 2 also the paper. has limitations opacified with is operator and

Vessels not shown by conventional

angiography

series

had

paper

that

had angiography, for assessing the contrast material flow dependent.

nonetheless

may be

patent, depending on the flow pattern. On the other hand, MR can show vessels independent from the direction of flow. Also, conventional angiography can be limited markedly by the presence of ascites, which is less of a problem for MR.

Robert A. Edelman Beth

Israel

Hospital

Boston, MA 02215 Heinrich P. Mattle New England Deaconess Hospital Boston, MA 02215 Henri M. Hoogewoud H#{226}pitalCantonal CH-1700

Fribourg,

Switzerland

Fig.

i-Angiogram

shows

some intimal hyperplasla (arrow) in distal end of stent and no stenosis In renal artery.

Metastatic Carcinoma of the Proximal Femur Closely Resembling Hematopoietic Hyperplasia MR For 2 weeks,

a 55-year-old

woman

had

had

increasing

on

pain

in the

left hip that radiated along the anterior aspect of the thigh. The results of physical graphs showed

examination

of the

left

hip

and routine and

lumbar

blood spine

a small focal area of increased

tests were

were

normal.

normal.

uptake

Radio-

A bone

scan

in the proximal

left

femur. MR of the pelvis showed mottled confluent areas of decreased signal intensity involving the proximal femurs (Fig. 1A), iliac crests, and right acetabulum on Ti -weighted images. These findings resembled those of hematopoietic hyperplasia. T2-weighted images showed a small focus of increased signal intensity involving the

proximal left femur slightly anterior to the lesser trochanter

(Fig. 1B).

An open bone biopsy of this region revealed undifferentiated metastatic carcinoma of the intramedullary bone. A CT scan and radiograph of the chest showed a 1 .5-cm nodule in the apex of the right lung that was found to be poorly differentiated non-oat cell carcinoma.

This

REFERENCES 1 . Edelman AR, Zhao B, Liu C, et al. MA angiography and dynamic evaluation of the portal venous system. AJR i989;153:755-760 2. Edelman AR, Wentz KU, Mattle H, et al. Projection arteriography venography: initial clinical results with MR. Radiology 1989;172:351-357

flow

Recently,

of Endovascular my colleagues

and

Stented I published

AJR on the use of an endovascular dissecting

aneurysm

of the

renal

Renal

a technical

stent

artery.

in the

the

One

year

MR findings

to the editor of hematopoietic

almost [1].

identical

Deutsch

to

those

et al. [2] initially

hyperplasia

and

stressed

a peripheral blood smear. In our case, without the previous bone scan, it would be easy to overlook the small focal finding on the T2-weighted MR image and importance

of

misinterpret

a complete

examination

and

it as an artifact.

of the T2-weighted also shows further

[1] in the

treatment after

characteristics

letter

This case not only reinforces the importance sequence in evaluating the bone marrow but

Artery note

MR

described

possibly

Follow-up

had

in an earlier

the and

patient

described

of a

treatment,

the patient, who was doing well clinically, had follow-up angiography. It was clear from the results that some intimal hyperplasia was present in the distal end of the stent but that no serious stenosis of the renal artery had occurred (Fig. 1). Furthermore, compared with the results of the study done 1 0 days after placement of the stent, the aneurysm was thrombosed cornpletely at the 1 -year follow-up. This finding suggests that endovascular stenting can be an excellent treatment in cases of dissecting aneurysm of the renal artery. W. P. Th. M. Mali University

Hospital

Utrecht,

Utrecht

the Netherlands

REFERENCE 1 . Mali WPThM, treatment

Fig. 1.-Probable

carcinoma. A and B, Coronal Geyskes

GG, Thalman

with an endovascular

stent.

A. Dissecting AJR

renal artery

1989;1 53:623-624

aneurysm:

hematopoietic

hyperplasia

with a focus

of metastatic

MR images, 500/20 (A) and 2000/80 (B), of proximal femurs show mottled areas of decreased signal within bone marrow of both femurs (A) and a small focus of increased signal (arrow) in metadiaphyseal region (B).

AJR:154,

cause

LETTERS

April 1990

for a more

of hematopoietic

cautious

approach

to MR findings

similar

to those

903

nuchal

cystic

hygroma

diagnosed

early

in the

second

trimester

Israel Meizner Arie Levy

David J. Czarnecki William S. Goell

St. Luke’s Medical Milwaukee,

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of

pregnancy.

hyperplasia.

Jacob

Center Soroka

WI 53215

Beer

REFERENCES

Cohen

Medical

Sheva

Center

84101

Israel

REFERENCES

1 . Schuck JE, Czarnecki plasia involving the

DJ. MR detection knees, proximal

of probable hematopoietic hyperfemurs, and pelvis (letter). AJR

1989;153:655-656 2. Deutsch AL, Mink JH, Rosenfelt hematopoietic hyperplasia on 333-336

FP, Waxman routine knee

AD. Incidental detection of imaging. AJR 1989:152:

Spontaneous Resolution of a Nuchal Fetal Cystic Hygroma Diagnosed Early in the Second Trimester of Pregnancy

1 . Distell BM, Hertzberg neck mass in a fetus 2. Meizner

BS, Bowie with normal

I, Katz M, Carrni

associated

JD. Spontaneous resolution of a cystic karyotype. AJR 1989;153:380-382

A. Prenatal

with fetal hydrops:

ultrasonic

report

diagnosis

of

cases.

two

of cystic hygroma lsr J Med Sci

1989:25:51-53 3. Bronshtein M, Rottem 5, Yoffe N, Blumenfeld Z. First trimester and early second trimester diagnosis of nuchal cystic hygroma by transvaginal sonography: diverse prognosis of the septated from the nonseptated lesion. Am J Obstet Gynecol 1989:161:78-84

Reply

the article, “Spontaneous Resolution of a with Normal Karyotype,” by Distell et al. [1 ]. The authors reported a case of a fetus in which complete resolution of a cystic hygroma diagnosed in the second trimester of pregnancy was evident on further sonograms. They stressed that a normal fetal karyotype was found on chromosomal analysis of amniotic fluid. We recently detected in utero two cases of cystic hygroma early in gestation (1 4 and 1 5 weeks, respectively). In both cases, nuchal cystic hygroma was the only sonographic finding (Fig. 1). No signs of fetal hydrops as may be observed in such cases were detected. In both fetuses, the sonographic findings disappeared within 3 weeks.

We appreciate the interest that Drs. Meizner, Levy, and Cohen have shown in our report on spontaneous resolution of a fetal cystic hygroma. We were pleased to learn that their experience supports our observation that in the absence of hydrops, prenatal detection of a cystic hygroma in a fetus with a normal karyotype can be associated with a normal outcome. In their letter, Meizner et al. further comment that karyotyping should be performed in all cases of prenatal diagnosis of nuchal cystic hygroma. Given the high prevalence of chromosomal anomalies occurring in association with cystic hygromas, we fully agree with this statement. Although it is becoming increas-

In one

with

We read with

Cystic

Neck

interest

Mass

in a Fetus

of the fetuses,

of pregnancy

genetic

revealed

amniocentesis

normal

46,XX

performed

karyotype,

and

at 1 6 weeks the

pregnancy

was allowed to continue, resulting in a delivery of normal healthy infant. However, chromosomal analysis of the second fetus revealed trisomy 1 8, and the pregnancy was terminated. Both these cases

ingly

clear

sionally

that

prenatal

detection

is associated

cystic

hygromas

with are

of

nuchal

a normal

cystic

outcome,

abnormal.

Therefore,

karyotyping, a careful search for other graphic follow-up in such cases.

hygromas

many we

Every

University

Medical

serves

Hedge

of isolated

nuchal

cystic

hygroma

does

not necessarily indicate an unfavorable outcome provided a normal karyotype is found, thus supporting the observations of Distell et al. It

should when

be stressed, normal

however, fetal

that

karyotype

fetal

fetoprotein is supported

for

karyotyping

hydrops

is encountered

Until more data are collected to support nosis of those cases not associated with amniocentesis

to

resident

hedge.

“enclose

quickly

As defined or

protect

learns

the

by Webster’s the

user”

official

plant

dictionary, or

acts

as

of our

the an

hedge

“evasive

statement . . . to avoid the risk of commitment.” Actually, this symbol is appropriate for any physician who performs diagnostic examinations and communicates this information via written reports.

Fig. i.-Sonogram shows nonseptated nuchal cystic hygroma (arrow) in a 14-week-old fetus.

even

the

Center NC 27710

Hedge

radiology

speciality:

detection

sono-

Bruce M. Distell Barbara S. Hertzberg James D. Bowie

The Radiologic

in utero

fetal

and close

Durham,

that

fetuses

recommend

anomalies,

Duke

show

occa-

more

and

must

the relatively hydrops, we

measurement

be excluded

[2].

frequently good progrecommend

of levels

of alpha-

in each case of nuchal cystic hygroma. This suggestion by Bronshtein et al. [3], who reported eight cases of

cultivation

is a linguistic

art

that,

in our

opinion,

is under-

emphasized in residency training. Terms such as appears, apparent, unusual, opacity, probable, doubtful, equivocal, suboptimal, and indeterminate are the bread and butter of the radiologist’s lexicon. Their use needs to be taught during training and then subsequently honed during many years of practice. In our department, we recommend a limit of two hedge terms per sentence, but this rule is tiple

hedge

broken.

Attempts

sentences

with

should short

be made definitive

to counterbalance statements,

even

mulif the

latter, of necessity, provide nonpertinent information. The best radiologic defense is often an offense: don’t hesitate to pose questions in the report. And remember, a good department never produces a poor exam, only suboptimal ones.

LETTERS

904

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The proper generic report

use of hedge terms of a typical intensive

Ferris

Jonathon Beth

of Foot-in-Mouth

M. Hall

perfectly

Israel

Hospital MA

A middle-aged

evaluate

[1

woman

02215

Disease1

We are now

] is

was

referred

definitely

not

abdominal

for

gas

complaints.

CT

of

the

abdomen

in the fundus

of the

to

Clinical

stomach

because

forefoot

with

five

toes,

superimposed

in the process

of studying

the sensitivity

Peninsula

may

1 . Chapman,

Abbreviations

should

left

specificity

Hospital

Center NY

11691

AL., New dictionary of American slang. New York: Harper and Row, 1986: 144. Foot-In-Mouth Disease: The uttering of embarrassing, stupid, or indiscreet speech. [Blend of the veterinary term hoof-and-mouth disease and the idiom to put “one’s foot in one’s mouth.’]

are published at the discretion of the Editor and are subject to editing. to the Editor must not be more than two double-spaced, typewritten pages. be included.

the

REFERENCE

it clearly

1AprilFools!

figures

and

FarRockaway,

extended beyond the borders of the stomach and obscured adjacent organs. By the time the postcontrast CT scan was processed, the patient had left the CT site. When we reviewed the images with lung windows and inverted gray scale, the abnormality appeared to be a

Letters Letters

on

of CT for this diagnosis. Whenever a verbal gaffe is committed in the radiology department, its perpetrator is rushed into the CT scanner, but to date, no other cases of an ingested foot have been documented. Stanley Sprecher Richard Steinberg Leon Serchuk

and laboratory findings were normal. The initial unenhanced CT scan of the abdomen showed normal liver, spleen, and kidneys. The left upper quadrant, pancreas, and retroperitoneal structures were normal. After the injection of contrast material, CT showed a lobulated, well-circumscribed, very-low-attenuation, 9 x 5 cm mass that obscured the spleen, the left kidney, and portions of the fundus of the stomach (Fig. 1 A). This was

nonspecific

formed

upper quadrant (Fig. 1 B). (The manufacturer, when consulted, could not explain this computer-generated artifact, and it is being temporarily blamed on a transient voltage surge that is commonplace with our local electrical utility.) The diagnosis appeared to be an unusual complication of foot-inmouth disease, with the patient having ingested the “foot.”

a common disorder, which at one point or another has afflicted everyone. To our knowledge, this is the first demonstration of the use of CT to diagnose a complication of this disorder, that is, swallowing of the foot. disease

1990

Fig. 1.-A, Postcontrast CT scan shows low-attenuation pseudomass in left upper quadrant (arrows) extending beyond borders of stomach (arrowheads). B, Reprocessed image shows pseudomass has appearance of a foot, including phalanges (arrows).

S. Movson

Boston,

Foot-in-mouth

April

is demonstrated in the following care chest radiograph.

This is a suboptimal examination due to bedside technique and inability of the patient to cooperate. The cardiovascular status is difficult to assess with borderline cardiomegaly. There is equivocal vascular plethora but no overt edema. Is the patient short of breath? The poorly defined opacities that overlie the lungs are unusual and of uncertain significance. I doubt but cannot exclude infiltrates. No evidence of an obvious mass is identified. No rib fractures. The prominent mediastinum appears to relate to semierect positioning. No subcutaneous emphysema. There is possible diaphragmatic flattening which is of indeterminate significance but raises the question of chronic lung disease. Does the patient smoke? The apparent costophrenic angle blunting is consistent with a small effusion but does not specifically suggest that diagnosis. There is probable osteoporosis in this 98-year-old woman. The interpretation of this exam is limited because previous films are not immediately available for comparison. Impression: Indeterminate examination. Recommend clinical correlation. A repeat study may be useful.

CT Diagnosis

AJR:154,

not

be used.

See

Author

Guidelines,

One or two

page

A5.

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 AJR 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.