Biomedical subjects
Publications and source records attributed to E K Fishman.
The authors describe a technique for directly correlating high resolution CT scans and gross and histologic sections of the lung. They conclude that HRCT provides anatomic detail comparable to that seen on gross tissue inspection.
The contribution of computed tomography with multiplanar reconstructions (2D CT) and animated three-dimensional reformatting (3D CT) has been well documented in the adult hip. The applications and utility in the pediatric hip prove to be similar. Coronal and sagittal 2D images are superior to transaxial CT in defining the superior pole of the femur, the superior joint space, and the acetabular roof and dome. 3D CT provides the best overview of morphology, integrating the 2D information for therapeutic planning. Studies can be modified or tailored for dose control, particularly in the youngest patients.
Internal mammary lymph nodes are an important site of occult metastasis in clinically operable and recurrent breast carcinoma. Anatomic distribution of enlarged internal mammary nodes in patients with breast cancer was analyzed in a review of thoracic computed tomographic studies of 219 women with operable, advanced, or recurrent cancer. Enlarged nodes were observed in 45 patients (20.5%), 32 with unilateral and 13 with bilateral involvement. Mean nodal diameter was 1.95 cm (0.6-6.0 cm). Lymphadenopathy was limited to one anterior intercostal space in 43%, two spaces in 26%, three spaces in 22%, and four spaces in 9%. Solitary or dominant nodal enlargement was centered at the first space in 14%, second space in 60%, and third space in 26%. Isolated lymphadenopathy in the fourth or fifth spaces was not observed. Metastases to internal mammary nodes frequently occur at multiple levels and are most common in the second and third spaces. This finding concurs with current surgical practice when internal mammary nodes are sampled.
The computed tomographic (CT) scans of 30 patients with solitary bronchioloalveolar carcinoma were reviewed. Common features at CT included the peripheral or subpleural location of a pulmonary mass (25 cases), pseudocavitation (18 cases), heterogeneous attenuation (17 cases), irregular margins forming a star pattern (22 cases), and pleural tags (21 cases). Using these CT criteria, four independent observers attempted to identify cases of bronchioloalveolar carcinoma from a larger sample of lung cancers and benign lesions by categorizing a series of test cases into four probability categories. Although the bronchioloalveolar carcinomas were correctly ranked in the two highest probability categories 75% of the time (in 45 of 60 cases), there was considerable overlap with other lung lesions, particularly with adenocarcinoma and large cell undifferentiated carcinoma. However, even though the typical features of bronchioloalveolar carcinoma are not invariable or highly specific, they are characteristic enough to suggest the diagnosis.
The computed tomographic scans of 200 consecutive patients with Crohn disease were studied to determine the frequency and patterns of perirectal and perianal involvement. In 163 patients (82%) abnormalities in the perirectal-perianal region were demonstrated; findings included inflammation of fat planes (73%), bowel wall thickening (30%), fistulas or sinus tracts (22%), and abscesses (14%). Fistulas or sinus tracts occurred with equal frequency above or below the level of the anterior symphysis pubis. Abscesses, rectal thickening, and inflammatory infiltration of fat occurred more than twice as often above the symphysis pubis. However, 37% of patients had manifestations of Crohn disease below the symphysis pubis, emphasizing the importance of extending scanning sequences to the perineum.
Nineteen patients with suspected or possible fracture nonunion underwent computed tomography (CT) with multiplanar reconstruction (MPR). Each case represented a difficult problem in fracture management in which clinical and conventional radiographic examinations had failed to provide a definitive diagnosis. CT with MPR demonstrated nonunion in 13 of 19 cases by delineating the lack of bone bridging across the fracture site in multiple planes. Variable amounts bridging were detected in six cases, indicating partial healing or delayed union. Evaluation of fracture healing with MPR was possible despite remaining metal hardware (ten cases), multiple operations (15 cases), or bone grafting (five cases). CT with MPR aided surgical planning and affected treatment options by providing a more detailed assessment of malalignment and angular deformities, the magnitude of the gap in bone, and the integrity of the adjacent weight-bearing joints in multiple projections. It is an important new modality for evaluating fracture nonunion.
Because the cost of managing an expected greater number of adverse reactions when high-osmolality contrast media (HOM) are used could offset the higher material cost of low-osmolality contrast media (LOM), a prospective study was done of 795 inpatients undergoing any of four procedures involving intravascular injection of HOM: cardiac catheterization, peripheral angiography, head computed tomography (CT), or body CT. The resources used in managing HOM-induced adverse reactions were measured, and the costs of these resources were estimated. Four hundred five patients (51%) had adverse reactions. Reactions were grouped into three classes according to their severity. Class 1 (mild) reactions occurred in 358 patients (45%), class 2 (moderate) reactions occurred in 44 patients (6%), and class 3 (severe) reactions occurred in three patients (0.4%). Ninety-nine patients (12%) consumed resources as a result of an adverse reaction. The average cost of these resources per patient undergoing examination was $1.07 to the radiology department, $5.83 to the hospital, and $12.93 to a charge-paying insurer. Mean (+/- standard deviation) cost to the hospital for managing class 1, class 2, and class 3 reactions were $2.52 +/- $5.33, $24 +/- $54, and $910 +/- $749, respectively. By comparison, the difference in material cost of HOM versus LOM ranged from $93 for body CT to $179 for cardiac catheterization. Even if LOM were to induce no adverse reactions, the increased material cost associated with universal substitution of LOM for HOM would be greater than the expected cost of managing adverse reactions when HOM are used.
The computed tomographic (CT) appearance of urachal carcinoma in ten patients was studied and compared with the pathologic findings. Magnetic resonance images were available in one case. All tumors were mucinous adenocarcinomas; four were solid, three were cystic, and three were mixed. The tumor had a characteristic location along the expected midline course of the urachus directly behind the anterior abdominal wall. The main tumor mass was supravesical in eight patients. Seven tumors contained calcification. CT correctly depicted bladder wall involvement and supravesical extent of tumor in all cases. CT provided incorrect information about invasion of the perivesical fat in three patients and about bladder mucosal invasion in two patients.
Five patients with bronchogenic or enteric cysts were diagnosed by using a combination of CT and transbronchial or transesophageal needle aspiration. Serous or mucoid fluid was successfully aspirated in each case. Cultures of the fluid were negative for pathogens, and cytologic examinations showed no malignancy. Mediastinoscopy and thoracotomy were avoided in all patients, including one symptomatic patient whose symptoms resolved after needle aspiration. CT with transbronchial or transesophageal needle aspiration represents a practical alternative to surgery in the evaluation of congenital mediastinal cysts.
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To better understand how the internal composition of ovarian teratomas influences their sonographic features, we compared their sonographic and CT appearances in 23 cases. Sixteen lesions had a mixed echo texture, with hypoechoic as well as echogenic components; two were anechoic and five were entirely echogenic. Correlation with the CT images showed that the fat present in most teratomas had variable sonographic appearances. Pure sebum was anechoic or hypoechoic, but fat intermixed with hair strands was echogenic and often attenuated the sound beam because of the numerous tissue interfaces created within the mass. The hypoechoic component of the teratoma corresponded, on CT, to low-attenuation fat in 12 tumors and to fluid in five. Most teratomas contained a dermoid plug, a protuberance arising from the tumor wall and containing hair follicles and often fragments of bone or teeth. On sonography, all dermoid plugs were seen as an echogenic mass, often associated with distal acoustic shadowing and protruding into the hypoechoic portion of the teratoma. When the dermoid plug was large and occupied most of the tumor, the entire teratoma appeared echogenic, with no discernible anechoic component. We found that three factors greatly affected the sonographic appearance of ovarian teratomas: the size of the dermoid plug, the presence and location of calcified elements, and the histologic composition of the fatty component.
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Volumetric three-dimensional imaging is a new technique for CT image processing which generates realistic, three-dimensional models of complex musculoskeletal anatomy from routine transaxial CT data. Volumetric three-dimensional imaging is particularly helpful in evaluating complex shoulder trauma, demonstrating significant advantages over plain film radiography. Multipartite fractures involving the shoulder girdle are displayed in a comprehensive fashion with 3D imaging. With volumetric imaging as implemented on a Pixar Imaging Computer, a 3D model of the injured shoulder can be generated with overlapping structures removed from view, and then rotated about the vertical and horizontal axis for better understanding of abnormal anatomy prior to surgical correction.
Widening of the lumbosacral spinal canal was found in 63% of 57 patients with the Marfan syndrome and in none of 57 age- and sex-matched non-Marfan control patients, who underwent CT scanning for routine clinical indications. The bony abnormalities in mild cases consisted of thinning of the pedicles and taminae and erosion of the neural foraminae and were generally limited to L5 and S1. More severe changes were present in 13 patients, two of whom had associated neurologic signs, and included meningoceles or near total erosion of a pedicle. Presence and severity of vertebral abnormalities were associated with neither any other clinical feature nor overall phenotypic severity. Dural ectasia can be added to the list of pleiotropic manifestations of the Marfan syndrome.
Between June 1984 and August 1985, computed tomography (CT) was performed upon seven patients with diverticulitis of the cecum and ascending colon who presented with acute right lower quadrant symptoms of unknown origin. Three of these patients had undergone an appendectomy, while in the remaining four patients, the history and physical findings were atypical of acute appendicitis. CT findings suggestive of acute diverticulitis including thickening of the intestinal wall and pericolonic inflammation were present in all seven patients. In four patients, the colonic inflammation was limited to the segment of ascending colon superior to the ileocecal valve. In one patient, the inflammation involved both the ascending colon and the cecum, while in the two remaining patients, the inflammatory changes were limited to the cecum. An associated diverticular abscess was present in five patients and all were correctly identified preoperatively by CT. One patient in whom the diagnosis of uncomplicated diverticulitis of the ascending colon was made on the basis of the CT scan, was successfully managed nonoperatively with antibiotics. Five patients required a right hemicolectomy for perforated diverticulitis with abscess. The remaining patient underwent a right hemicolectomy for recurrent episodes of acute diverticulitis. Our experience suggests that CT is useful in the early diagnosis of diverticulitis of the cecum and ascending colon.
Four patients with hematomas of the calf are presented. The diagnosis was made by computed tomography (CT) in three cases and CT/magnetic resonance imaging (MRI) in one case. In all cases, CT or MRI clarified a confusing clinical picture. CT and MRI can help differentiate the types of calf mass (i.e., hematoma, tumor, Baker cyst, thrombophlebitis) and assist proper clinical management in a rapid, noninvasive fashion.
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