Congenital diaphragmatic hernia is a condition characterized by the herniation of abdominal contents into the chest leading to respiratory distress shortly after birth. In the present case along with bowel herniation spleen herniation was also noted which is a very rare occurrence. This case was diagnosed antenatally and the diagnosis was further confirmed postnatally with a chest and abdominal X-ray as well as a chest ultrasound. The baby was stabilized and shifted for surgical intervention where the patient underwent a laparotomy revealing a diaphragmatic defect with herniation of the ileum colon and spleen. Surgically the defect was closed and the bowel and spleen were reduced back into the abdomen for proper opening of the lung. No complications were noticed during the postoperative period. Therefore we believe that this rare case of spleen herniation which was managed promptly as a valuable contribution to the existing literature.

Communicated by Ramaswamy H. Sarma.

Acute thyroiditis is very unusual, and fungal thyroiditis is even more rare. Cervical blastomycosis, on one occasion masquerading as a thyroid mass, has been reported. Here we report the first case of acute blastomycosis infection of the thyroid documented by biopsy and imaging studies. The patient was a 23-year-old woodcutter with no history or features of overt immunodeficiency. The initial response to Itraconazole therapy was satisfactory.

We describe 11 cases (8 females, 3 males) of papillary thyroid carcinoma in children treated at St. Jude Children's Research Hospital over a 33-year period, and review the literature. Ages ranged from 7-25 years (median, 16 years). Six patients had primary papillary thyroid carcinoma. Five patients had secondary papillary thyroid carcinoma after treatment of Hodgkin's disease (n = 2), acute lymphoblastic leukemia (n = 2), and neuroblastoma (n = 1) with chemotherapy and cervical radiation. The typical presentation was either cervical lymphadenopathy or a thyroid mass of short duration. Treatment consisted of thyroidectomy, cervical lymph node dissection, and postoperative thyroid hormone replacement (n = 1), parathyroid reimplantation (n = 1), 131I ablation (n = 4), external-beam irradiation (n = 1), and chemotherapy with doxorubicin (n = 1) or carboplatin and topotecan (n = 1). Nine patients are alive without evidence of disease 3.0-22.4 years from diagnosis. One patient has persistent but stable disease 17.3 years after diagnosis. One patient relapsed with metastatic lung disease 0.3 years after the initial diagnosis. He continues to do well after a brief but unsustained complete radiographic remission of disease to combination chemotherapy with carboplatin and topotecan. Our review supports excellent long-term outcome for primary or secondary papillary thyroid carcinoma in pediatric patients although complications may require close follow-up in a multidisciplinary setting.

One hundred transmyocardial revascularization procedures were performed between February 1994 and January 1996, using the C02 Heart Laser on 90 patients with stable angina and 10 with unstable angina. This was the sole therapy in 98 cases and utilized in combination with open-heart surgery in 2 others. Most patients (96) had this procedure without having undergone previous coronary artery bypass graft surgery; 66 patients were deemed to have nongraftable vessels, while 34 patients had coronary artery anatomy that was favorable to bypass graft surgery but elected to undergo laser revascularization instead. The majority (86%) were male and ages ranged from 30 to 82 (mean 55) years. At 12 months after the procedure, 92% of patients reported that they were free of angina, while mean exercise tolerance increased from 7 minutes preoperatively to 15 minutes, and metabolic equivalent units rose from 4.8 to 10.2. The average increase in Karnofsky performance score was 51%, and oxygen consumption improved by 93%. The increase in left ventricular ejection fraction was not statistically significant. Most patients resumed work within 18 days of the procedure. Consumption of antianginal medication was reduced to minimal in 83% of the patients at the end of one year. There were 10 deaths in the series, chiefly in patients with extremely low ejection fractions. We conclude that the application of this rapidly evolving procedure as a primary therapy in ungraftable patients, appears to be safe and deserving further study.

Advancements in imaging technology have led to better diagnoses of ectopic parathyroid adenomas. Although surgery is curative in the majority of patients with parathyroid adenomas in normal preoperative locations, imaging is definitely required in ectopic adenomas in the neck and more importantly in the chest. The various imaging modalities used in the diagnosis of parathyroid adenomas are isotopic techniques, MRI, CT, ultrasound, arteriography, and venous sampling for parathormone. This review presents four patients studied with different diagnostic techniques resulting in cures with surgery or arteriographic ablation. The literature survey suggests the sensitivity of Tc-99m MIBI scanning to be more than 90%, MRI 70-75%, and CT scanning slightly lower. On the basis of the authors' experience and a literature review, a combination of MIBI scanning and MRI appears to be the most logical approach. If these two tests do not provide sufficient diagnostic confidence, then CT or a contrast arteriogram should be considered. Recent advances in arteriography/catheters have made angiographic ablation with alcohol or contrast material possible in patients who cannot undergo surgery.

We were disturbed by the editorial from Drs. Robin and McCauley published in CHEST (1995; 107:3-4). They start off with criticism of P(A-a)O2 tension and its clinical utility in the diagnosis of pulmonary embolism but the discussion turns rapidly to ventilation-perfusion scan. The thrust of our communication is mainly to focus on the comments of the authors on ventilation-perfusion scintigraphy. Robin and McCauley describe a medicolegal case of a 55-year-old patient who suffered cardiopulmonary arrest after a normal perfusion scan and before a ventilation scan could be performed. The defense believed that the arrest was the result of pulmonary embolism and “four experts agreed.” In support, they testified that without a ventilation scan one could not eliminate a pulmonary embolus as a cause of the acute cardiopulmonary arrest! Either the perfusion scan was not normal, or the “four experts” were wrong. A negative perfusion lung scan rules out pulmonary emboli. This fact is so well known that we do not see any wisdom in reporting this anecdotal incident. If they had reported this case, they should have given at least a follow-up—whether the patient survived or died and if the latter, was an autopsy done and if so, what was the cause of death.It is unfortunate that Robin and McCauley have tried to build their argument on this one case that ventilation scans are not required in lung scintigraphy. This is a very misleading statement. Indeed, when the perfusion scan is normal, ventilation study is redundant but when perfusion is abnormal, ventilation scan can be very important. We would like to illustrate this point by the following example.A 47-year-old quadriplegic was brought to the emergency room with a history of abrupt onset of shortness of breath and chest pain. The medical resident suspected pulmonary embolus since the patient was bedridden for 6 months as a result of quadriplegia. The ventilation-perfusion scan (Fig 1) showed absence of ventilation and perfusion in right lung typical of total right bronchial obstruction; in this case, it was probably due to mucus plug. Chest x-ray film showed a reduction in the right lung volume and an infiltrate at the right apex. Since this was the first experience of the medical resident with such a case, he asked for a pulmonary angiogram. Before the angiogram, the patient received bronchial hygiene, which dislodged the mucus plug. This relieved bronchial obstruction with aeration of the lung, relief of vasospasm (which was a result of alveolar hypoxia) and subsequent restoration of perfusion to the right lung. Hence, the pulmonary angiogram was negative for embolus, which was in agreement with the initial interpretation of the ventilation-perfusion lung scan. If the ventilation scan had not been done, the abnormal perfusion would have raised the possibility of pulmonary embolus to the right pulmonary artery. Therefore, the addition of a ventilation scan gave a classical picture of right bronchial obstruction and prevented us from making the diagnosis of possible pulmonary embolism.It is true that in some cases the ventilation scan is not necessary such as when the perfusion scan is normal, but to totally eliminate the ventilation scan is a mistake, as the above case illustrates.Robin and McCauley raise another issue—the reasons they give for people performing ventilation scan when perfusion study is normal are “ignorance and unenlightened self interest.” Ventilation scans are performed using 127Xe gas, 133Xe gas, 81mKr gas, and 99mTc DTPA aerosol.1 127Xe is very expensive and requires linear accelerator for production. 81mKr has a short half-life of 4.6 h and is very inconvenient to use. 99mTc DTPA aerosol does not allow wash-out phase and tends to deposit the activity centrally, in patients with airway obstructive disease who are most likely to benefit from a ventilation study. These radiopharmaceuticals do have some advantages but most of the nuclear medicine departments believe their disadvantages outweigh the advantages. Therefore, they are not used in most of the departments who use 133Xe because of ease and convenience. However, 133Xe also has a problem. Since its energy is 81 kev, which is lower than 140 kev of 99mTc MAA, it has got to be used before 99mTc and not after. Hence, 133Xe is “routinely” used in all patients realizing that it is “wasted” in patients with normal perfusion scan who do not need it. An alternate way would be to do a perfusion scan first and if it is normal, then stop; if it is abnormal, then do a ventilation study the next day. The problem with the latter methodology is that diagnosis is delayed and clinicians do not like this approach. Some physicians believe that 133Xe studies can be performed after 99rnTc MAA scan but most nuclear medicine physicians are skeptical about it. For these reasons, 133Xe is used routinely in all patients before the 99mTc MAA scan despite the unnecessary expense in some of the cases.Some authors use flashy titles to attract the audience, and we believe that the editorial by Robin and McCauley suggests this approach. There is a considerable amount of confusion and misinformation in their communication and we wonder if the Editorial Board published that editorial on the basis of who submitted it rather than its contents. In the last paragraph, they write, “we must learn that bad, even noninvasive tests, can kill or harm patients.” That is absolutely true, but so will the physician who is misguided by such editorials. Indeed, when will we ever learn? We were disturbed by the editorial from Drs. Robin and McCauley published in CHEST (1995; 107:3-4). They start off with criticism of P(A-a)O2 tension and its clinical utility in the diagnosis of pulmonary embolism but the discussion turns rapidly to ventilation-perfusion scan. The thrust of our communication is mainly to focus on the comments of the authors on ventilation-perfusion scintigraphy. Robin and McCauley describe a medicolegal case of a 55-year-old patient who suffered cardiopulmonary arrest after a normal perfusion scan and before a ventilation scan could be performed. The defense believed that the arrest was the result of pulmonary embolism and “four experts agreed.” In support, they testified that without a ventilation scan one could not eliminate a pulmonary embolus as a cause of the acute cardiopulmonary arrest! Either the perfusion scan was not normal, or the “four experts” were wrong. A negative perfusion lung scan rules out pulmonary emboli. This fact is so well known that we do not see any wisdom in reporting this anecdotal incident. If they had reported this case, they should have given at least a follow-up—whether the patient survived or died and if the latter, was an autopsy done and if so, what was the cause of death. It is unfortunate that Robin and McCauley have tried to build their argument on this one case that ventilation scans are not required in lung scintigraphy. This is a very misleading statement. Indeed, when the perfusion scan is normal, ventilation study is redundant but when perfusion is abnormal, ventilation scan can be very important. We would like to illustrate this point by the following example. A 47-year-old quadriplegic was brought to the emergency room with a history of abrupt onset of shortness of breath and chest pain. The medical resident suspected pulmonary embolus since the patient was bedridden for 6 months as a result of quadriplegia. The ventilation-perfusion scan (Fig 1) showed absence of ventilation and perfusion in right lung typical of total right bronchial obstruction; in this case, it was probably due to mucus plug. Chest x-ray film showed a reduction in the right lung volume and an infiltrate at the right apex. Since this was the first experience of the medical resident with such a case, he asked for a pulmonary angiogram. Before the angiogram, the patient received bronchial hygiene, which dislodged the mucus plug. This relieved bronchial obstruction with aeration of the lung, relief of vasospasm (which was a result of alveolar hypoxia) and subsequent restoration of perfusion to the right lung. Hence, the pulmonary angiogram was negative for embolus, which was in agreement with the initial interpretation of the ventilation-perfusion lung scan. If the ventilation scan had not been done, the abnormal perfusion would have raised the possibility of pulmonary embolus to the right pulmonary artery. Therefore, the addition of a ventilation scan gave a classical picture of right bronchial obstruction and prevented us from making the diagnosis of possible pulmonary embolism. It is true that in some cases the ventilation scan is not necessary such as when the perfusion scan is normal, but to totally eliminate the ventilation scan is a mistake, as the above case illustrates. Robin and McCauley raise another issue—the reasons they give for people performing ventilation scan when perfusion study is normal are “ignorance and unenlightened self interest.” Ventilation scans are performed using 127Xe gas, 133Xe gas, 81mKr gas, and 99mTc DTPA aerosol.1 127Xe is very expensive and requires linear accelerator for production. 81mKr has a short half-life of 4.6 h and is very inconvenient to use. 99mTc DTPA aerosol does not allow wash-out phase and tends to deposit the activity centrally, in patients with airway obstructive disease who are most likely to benefit from a ventilation study. These radiopharmaceuticals do have some advantages but most of the nuclear medicine departments believe their disadvantages outweigh the advantages. Therefore, they are not used in most of the departments who use 133Xe because of ease and convenience. However, 133Xe also has a problem. Since its energy is 81 kev, which is lower than 140 kev of 99mTc MAA, it has got to be used before 99mTc and not after. Hence, 133Xe is “routinely” used in all patients realizing that it is “wasted” in patients with normal perfusion scan who do not need it. An alternate way would be to do a perfusion scan first and if it is normal, then stop; if it is abnormal, then do a ventilation study the next day. The problem with the latter methodology is that diagnosis is delayed and clinicians do not like this approach. Some physicians believe that 133Xe studies can be performed after 99rnTc MAA scan but most nuclear medicine physicians are skeptical about it. For these reasons, 133Xe is used routinely in all patients before the 99mTc MAA scan despite the unnecessary expense in some of the cases. Some authors use flashy titles to attract the audience, and we believe that the editorial by Robin and McCauley suggests this approach. There is a considerable amount of confusion and misinformation in their communication and we wonder if the Editorial Board published that editorial on the basis of who submitted it rather than its contents. In the last paragraph, they write, “we must learn that bad, even noninvasive tests, can kill or harm patients.” That is absolutely true, but so will the physician who is misguided by such editorials. Indeed, when will we ever learn?

The scintigraphic appearance of an overuse injury at the insertion of the iliotibial band is described. This injury was depicted on three-phase bone scintigraphy as focally increased radionuclide concentration in the anterolateral tibial condyle (lateral tibial tubercle) where the iliotibial band inserts. Overuse injuries involving the insertion of the iliotibial band are uncommon and are not to be confused with a stress fracture or other bony lesion involving the lateral tibial condyle.

Drug-induced pulmonary toxicity commonly results in interstitial lung disease characterized by the presence of inflammatory cells in pulmonary parenchyma. Gallium-67 citrate lung scintigraphy is currently the most sensitive test for the detection of inflammatory lesions in the lungs. Although chest radiographs often detect interstitial lung disease, they may be normal during the early alveolitis stage, when gallium scans are positive. Therefore, gallium scans can be utilized for the early diagnosis of drug-induced pulmonary reactions, leading to withdrawal of the drug and preventing the irreversible and potentially serious complication of pulmonary insufficiency. Gallium scintigraphy can also be used to follow these patients because it reflects the inflammatory changes in the lungs. This article presents a survey of the literature on gallium-67 scintigraphy in drug-related pulmonary inflammation. Gallium scans have been reported as abnormal in pulmonary toxicity caused by amiodarone, busulfan, bleomycin, procarbazine, nitrofurantoin, pentazocine, cephalosporin, cyclophosphamide, and cocaine, even in the absence of radiographic findings. The role of gallium scintigraphy in the early detection of pulmonary toxicity is emphasized.

TI-201 exercise imaging in patients with left bundle branch block (LBBB) has proven to be indeterminate for significant left anterior descending (LAD) coronary artery stenosis because of the presence of immediate septal perfusion defects with redistribution on delayed images in almost all cases. TI-201 redistribution occurs regardless of the presence or absence of LAD stenosis. Nineteen patients having LBBB were evaluated with dipyridamole TI-201 SPECT. Fourteen of these subjects had normal dipyridamole TI-201 SPECT imaging. Three patients had normal coronary angiograms. None of the remaining 11 patients with normal dipyridamole TI-201 SPECT images was found to have clinical coronary artery disease in a 5—11 month follow-up period. Five patients had abnormal septal perfusion. Four underwent coronary angiography. One had a significant LAD stenosis. The single patient with septal redistribution who refused to undergo coronary angiography died shortly thereafter of clinical coronary artery disease. This preliminary work suggests that dipyridamole TI-201 SPECT may be more useful for excluding LAD stenosis in patients with LBBB than TI-201 exercise imaging.

Most patients with metastatic prostate cancer will have metastasis to bone. Such patients are best monitored by serial radionuclide bone scans. One hundred sixty six men with bone metastasis from prostate cancer who received androgen deprivation therapy had their pretreatment bone scans reviewed using a semiquantitative grading system based upon the extent of disease (EOD) observed on the scan. The EOD on the scan correlated with survival. The 2-year survival rates for EOD I to IV were 94%, 74%, 68%, and 40%, respectively. The survival of patients in categories EOD I and IV significantly differed from the other categories. Men with metastatic prostate cancer entered into trials designed to evaluate the impact of treatment on survival should be stratified based upon the EOD on the bone scan. This analysis also indicates that patients in the EOD IV category have a particularly poor prognosis and may be candidates for alternative treatments.

No AccessJournal of Urology1 Jun 1987Simple Grading System for Bone Scans Correlates with Survival for Patients with Stage D2 Prostate Cancer Mark S. Soloway, Stephen W. Hardeman, David P. Hickey, Barbara B. Todd, Scott M. Soloway, and Mohammed Moinuddin Mark S. SolowayMark S. Soloway More articles by this author , Stephen W. HardemanStephen W. Hardeman More articles by this author , David P. HickeyDavid P. Hickey More articles by this author , Barbara B. ToddBarbara B. Todd More articles by this author , Scott M. SolowayScott M. Soloway More articles by this author , and Mohammed MoinuddinMohammed Moinuddin More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)76171-XAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Simple Grading System for Bone Scans Correlates with Survival for Patients with Stage D2 Prostate Cancer." The Journal of Urology, 137(6), p. 359A © 1987 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 137Issue 6June 1987Page: 359A Advertisement Copyright & Permissions© 1987 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Mark S. Soloway More articles by this author Stephen W. Hardeman More articles by this author David P. Hickey More articles by this author Barbara B. Todd More articles by this author Scott M. Soloway More articles by this author Mohammed Moinuddin More articles by this author Expand All Advertisement PDF downloadLoading ...

To evaluate the utility of liver function tests (LFT) as indicators of metastatic carcinoid tumors, a retrospective study was performed. The LFT results of 17 patients with carcinoid tumors metastatic to the liver were compared with 17 patients with other malignant tumors. In the noncarcinoid group, 82.4% of the patients had elevated alkaline phosphatase (AP) or gamma glutamyl transpeptidase (GGTP), whereas only 28.6% of carcinoid patients had abnormal enzymes. The medians of all LFT values were significantly higher in noncarcinoid patients than in the carcinoid group, except for glutamic pyruvic transaminase (SGPT). Our data indicate that LFT are helpful in screening for liver metastases in patients with noncarcinoid tumors, but are unreliable in carcinoid tumors. Imaging tests should be used to rule out liver metastases in carcinoid tumors, irrespective of LFT results.

The Hyper IgE syndrome is a rare disease consisting of recurrent sinusitis and pneumonia, pneumatoceles, chronic dermatitis, and elevated serum levels of IgE. The primary radiographic abnormalities are recurrent alveolar lung disease and pneumatoceles. Pneumothorax may occasionally occur as in one of our cases. Other causes of pneumatoceles are usually easily excluded by the history and other clinical data. Pulmonary scintigraphy and computed tomography may add information valuable to the management of these patients.

Fourteen gallium scans were obtained in 11 patients suspected of having amiodarone lung toxicity on the basis of clinical findings, pulmonary function tests, and chest radiographs. All 11 patients had abnormal scans. Gallium accumulates in various inflammatory and neoplastic lesions, but despite this nonspecificity, the findings suggest gallium scintigraphy is a useful procedure to detect amiodarone lung toxicity when used in the appropriate clinical setting.