Biomedical subjects
Publications and source records attributed to J L Doppman.
Angiographic visualization of a vein or artery partly or completely encircling small adenomas of islet cell or parathyroid origin is an occasional helpful localizing sign, particularly when the overlying pancreas or thyroid glands are intensely stained. Three examples (two islet cell; one parathyroid) are presented.
One hundred abdominal and chest CT scans in 29 patients with American Burkitt lymphoma were reviewed. Abdominal and/or pelvic masses were the most common finding and were detected in 13 (45%) patients. Masses indicating relapse were noted in three (10%) additional patients. Ascites and retroperitoneal involvement were noted in seven and five patients, respectively. Other findings included hepatic lesions, splenomegaly, gastric wall abnormalities, renal enlargement, urate nephropathy, and bony involvement. Pleural effusions and two mediastinal masses were noted on chest scans. CT was found to be a rapid screening procedure and especially useful in delineating the size and intrathoracic extension of abdominal masses, defining deep pelvic diseases, assessing the response to therapy, and defining areas of relapse. Lack of retroperitoneal fat and inadequate opacification of bowel loops were frequent problems that limited the value of CT scans.
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The diagnostic ranking and importance of computerised tomography was examined in 116 patients with abnormal findings in the mediastinal region, and was compared with conventional, non-invasive x-ray examinations. This method also yielded significant CT-specific additional information in the anterior mediastinum in 74.4% of the cases, in the mesomediastinum in 69.1%, in the posterior mediastinum in 79.2% in the upper thoracic aperture in 94.4% and in the paracardial region in 100% of the cases. The hilar region is an exception; in 68.8% of the cases, both methods were rated equal, whereas in 28.1% of the cases assessment via the CT method was even inferior. The specific additional information furnished by the CT method justifies a wider application of CT in solving the following problems concerning the mediastinum. -- clarification of a suspected but not yet established space-occupying growth in the mediastinum, before using invasive diagnostic methods such as mediastinoscopy and angiography; -- staging of an already identified primary mediastinal tumor of malignant lymphoma; -- in case of suspected changes in the large mediastinal vessels before employing angiography; -- on-target in the following diseases: bronchogenic carcinoma (because of improved pretherapeutic staging according to the TNM system), myasthenia gravis and identification of thymoma, hyperparathyroidism with suspected dystopic parathyroid glands.
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Gelfoam embolization of parathyroid adenomas causes temporary remission of hypercalcemia, but collateral circulation revascularizes the gland. Embolization with silicone permanently infarcts the gland, but is associated with all the risks of capillary bed occlusion. The staining of parathyroid adenomas with contrast material avoids the risks of particulate embolization and appears to produce permanent ablation. We carried out embolization or staining procedures in 14 parathyroid adenomas. In three of the four cases in which Gelfoam embolization was performed, hypercalcemia recurred within six months to two years; in the fourth case, in which persistent normocalcemia has been found, intense staining had been demonstrated before embolization. In eight of the remaining 10 cases, adequate staining was achieved, and normocalcemia has been maintained in all up to 36 months.
The capacity of endocrine neoplasms to give rise to intravenous tumor extensions is a feature that is recognized preoperatively by the use of venography employed primarily for tumor localization. A series of adrenocortical tumors, a pheochromocytoma and an extraadrenal chromaffin tumor are reported in which the intravenous tumor component was recognized and the surgical approach was modified to include extirpation of the intravascular tumor. Although intravenous tumor propagation has implied a grave prognosis because of the possibility of blood-borne metastases from the intravascular tumor or physiologic disruption from clot or tumor embolus, resection designed for cure, including distal venous control and tumor thrombectomy, was carried out in each patient. Wider application of preoperative venography enables recognition of these intravenous neoplastic extensions from endocrine tumors; the results of surgical management suggest that this invasive feature should not be a grave prognostic indicator that inhibits attempt at operative eradication of the primary tumor and its intravenous extension.
Abdominal computed tomography was performed on seven patients with primary hepatocellular carcinoma. The liver appeared normal in one patient, while in the other six patients the tumor was identified as an area of decreased attenuation. In four cases, the tumor was seen better following intravenous administration of a contrast agent, and, in two of these cases, it was not seen on the precontrast scans. In only one case was the hepatoma better seen on the precontrast examination, and it could still be identified following contrast enhancement. Hepatomegaly and an irregular hepatic contour were other findings in these patients.
Thoracic extramedullary hematopoiesis is a compensatory mechanism usually seen in thalassemia. Four thalassemic patients with this finding are reviewed and studied by computed tomography.
The major clinical problem in patients with thalassemia is iron overloading usually resulting from increased exogenous iron absorption from transfusions. Diseases of various organ systems result, including cirrhosis, cardiomyopathy, diabetes, and other less well appreciated endocrinopathies. Since 1976, we have routinely studied these patients with abdominal computed tomography (CT) and also have scanned other areas of clinical interest. It is the purpose of this report to examine the findings in 35 patients with severe beta-thalassemia and associated hemochromatosis in whom we have tabulated the pertinent CT, clinical and laboratory data.
The authors describe a simple ultrasonic technique for monitoring arterial patency of the limb distal to the site of the arterial catheterization as well as the heart rate. The same system may be used to guide the puncture in obese patients and monitor patency of the artery while applying pressure with a clamp following catheter removal. This technique has been used in 800 patients over a three-year period with no untoward complications.
Twenty-five patients with nonbeta pancreatic islet cell tumors were examined by computed tomography (CT). In eight patients (32%), the primary pancreatic tumor was identified, and in ten patients (40%), hepatic metastases were seen. Only one of the eight tumors seen on CT was loager tha 10 cm; the other seven ranged from 4 to 9 cm in diameter. Tumors in ectopic locations or possible cellular hyperplasia rather than a discrete tumor may account for the relative insensitivity of CT visualization, particularly among patients with Zollinger-Ellison syndrome.
Two patients with metastatic islet-cell carcinoma underwent multiple hepatic artery catheterizations for streptozotocin infusion. An intimal flap was raised during one of the initial arteriographic procedures and a false aneurysm developed. The progression of the aneurysm was documented on sequential studies. False aneurysm formation appears to be a relatively unappreciated complication of intimal dissection, and these 2 cases permitted observation of their natural history.
The thyroidea ima artery is an anomalous vessel supplying the thyroid gland; it can also supply enlarged parathyroid glands, as illustrated in three cases in this report. In one case the ima artery was the only arterial supply, and in two instances it was part of a dual arterial supply. An ima artery should be sought if routine arteriography is negative, especially if the inferior thyroid arteries are small or absent, or if a portion of the expected thyroid stain is missing.
Ten patients with disseminated cancer were given intravenous injections of 0.2 ml/kg (40 mg l/kg) of the experimental contrast material EOE 13. Ct scans of the liver and spleen were taken prior to and 30 minutes after contrast infusion. Visualization of the liver was significantly improved in 5, moderately improved in 3, and not appreciably improved in 2. The spleen showed an obvious increase in density in all cases. No significant toxicity was encountered: untoward side effects consisted of fever, headaches, foul metallic taste, and weakness for a short period. Four patients had no side effects, and 2 experienced only abnormal taste sensation. Further experimental and clinical work is needed before the advantages and safety of this contrast material can be documented.
Clinical experience with a new embolization and perfusion microballoon catheter system is presented in 34 patients with angiomas, arteriovenous fistulas, and cerebral hemorrhages. The system uses two separate balloon tips, one for detachment as an embolus and one for perfusion of elastomer. The criteria for catheter and perfusate selection are described. One permanent complication, two temporary complications, and one death occurred in this series. The technique represents a primary mode of therapy for treatment of certain vascular lesions, especially in nonsurgical candidates by virtue of their lesion or clinical state. Abdominal and extremity applications in 15 additional patients are also described. No complications occurred in these patients.
Four patients with intravenous extension of endocrine tumors are described. Three had adrenal carcinoma with extension along the adrenal veins into the inferior vena cava. In two of these, the extension into the inferior vena cava was demonstrated by computed tomography. The fourth patient had a glomus jugulare with extension down the jugular vein into the superior vena cava. In ech case preoperative radiologic evaluation demonstrated the tumor and its venous extension.
Twenty-one patients with hyperinsulinism were studied to localize the source of the insulin production. Nineteen patients had pancreatic tumors and two patients studied after pancreatectomy had hepatic metastases. Of the 19 pancreatic tumors, 16 were identified by angiography. CT found six tumors in 14 patients studied while sonography correctly localized only three of 12 tumors. Neither CT nor sonography was positive in those patients with a negative arteriogram. Noninvasive imaging methods can localize large tumors and may be useful for detecting hepatic metastases. Angiography, however, remains the most accurate method for detecting smaller lesions.