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Purpose To assess the diagnostic accuracy of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) combined with diagnostic contrast material-enhanced computed tomography (CT) in detecting lymph node (LN) metastasis in high-risk endometrial cancer. Materials and Methods This prospective multicenter HIPAA-compliant study had institutional review board approval, and all participants gave written informed consent. Data were accrued between January 2010 and June 2013. Patients underwent PET/CT and pelvic and abdominal lymphadenectomy. Two hundred seven of 215 enrolled patients had PET/CT and pathologic examination results for the abdomen and pelvis. Mean patient age was 62.7 years ± 9.6 (standard deviation). Data in all 23 patients with a positive abdominal examination and in 26 randomly selected patients with a negative abdominal examination were used for this central reader study. Seven independent blinded readers reviewed diagnostic CT and PET/CT results in different sessions 1 month apart. Accuracy was calculated at the participant level, correlating abdominal (right and left para-aortic and common iliac) and pelvic (right and left external iliac and obturator) LN regions with pathologic results, respecting laterality. Reader-average sensitivities, specificities, and areas under the receiver operating characteristic curve (AUCs) of PET/CT and diagnostic CT were compared. Power calculation was for sensitivity and specificity in the abdomen. Results Sensitivities of PET/CT versus diagnostic CT for the detection of LN metastasis were 0.65 (95% confidence interval [CI]: 0.57, 0.72) versus 0.50 (95% CI: 0.43, 0.58) (P = .01) in the abdomen and 0.65 (95% CI: 0.57, 0.72) versus 0.48 (95% CI: 0.41, 0.56) (P = .004) in the pelvis. Corresponding specificities were 0.88 (95% CI: 0.83, 0.92) versus 0.93 (95% CI: 0.89, 0.96) (P = .11) and 0.93 (95% CI: 0.86, 0.96) versus 0.89 (95% CI: 0.82, 0.94) (P = .27), and AUCs were 0.78 (95% CI: 0.66, 0.89) versus 0.74 (95% CI: 0.63, 0.86) (P = .39) and 0.82 (95% CI: 0.71, 0.92) versus 0.73 (95% CI: 0.63, 0.84) (P = .02). Conclusion FDG PET/CT has satisfactory diagnostic accuracy in the detection of abdominal LN metastasis in high-risk endometrial cancer. Compared with diagnostic CT alone, addition of PET to diagnostic CT significantly increased sensitivity in both the abdomen and pelvis while maintaining high specificity. © RSNA, 2017 Online supplemental material is available for this article.

History A 24-year-old woman from a rural village presented with vague left hypochondrium pain and a cough for the past 2 years. She had a history of occasionally expectorating hairlike strands with her cough. Because the patient was from a rural area, she first consulted with the village priest, as she presumed her illness to be some supernatural phenomenon. The priest advised her to collect the strands for religious rituals ( Fig 1 ). She collected these strands for some time; however, because her cough worsened, she visited the hospital. General physical examination findings were within normal limits. On palpation, there was evidence of a vague lump in the left hypochondrial region. At ultrasonography (US) (images not shown), a large mass with heterogeneous echotexture was seen in the left suprarenal region; cystic areas and calcification were present. Chest radiography (images not shown) revealed bronchiectatic changes, with consolidation in the left lower zone. Results of a blood examination, including assessment of renal function, liver function, and complete blood count, were within normal limits. Unenhanced and contrast material-enhanced computed tomography (CT) images of the chest and abdomen were obtained.

To evaluate the feasibility of positron emission tomography (PET) with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) in patients with germ cell tumor (GCT) to monitor treatment and differentiate residual masses after chemotherapy.Twenty-six FDG PET studies were performed in 21 patients with GCT, FDG uptake of tumors was interpreted visually, and the lean standardized uptake value (SUVlean) was determined. Tumor kinetic rate constants (K1, k2, k3) and net rate of FDG phosphorylation (K = [K1.k3]/[k2 + k3]) in tumors were calculated from the dynamic data by means of a three-compartment model, assuming k4 = 0.Viable tumors (n = 10) showed intense FDG uptake and could easily be differentiated visually from mature teratoma (n = 6) and necrosis or scar (n = 10). The SUVlean of residual viable tumors (4.51 +/- 1.34 [mean +/- SD]) was higher than that of mature teratoma (1.38 +/- 0.71) and necrosis or scar (1.05 +/- 0.29) (P.05). Although neither the visual interpretation nor SUVlean differentiated mature teratoma from necrosis or scar, there were statistically significant differences in the kinetic rate constants K1 and K between mature teratoma and necrosis or scar as follows: K1, 0.113 mL/min/g +/- 0.026 versus 0.036 mL/min/g +/- 0.005 (P.05); K, 0.005 mL/min/g +/- 0.003 versus 0.0008 mL/min/g +/- 0.0001 (P.05).FDG PET with kinetic analysis appears to be a promising method for management of disease in patients with GCT after treatment.

To characterize the imaging features of desmoplastic small round cell tumor of the abdomen and correlate them with the histopathologic findings.Eleven of 14 patients with desmoplastic small round cell tumor had primary abdominal involvement. In nine of these patients (mean age, 20 years), results of imaging studies (computed tomography in nine patients, ultrasonography [US] in three) and histopathologic specimens were retrospectively analyzed.The hallmark imaging feature was lobulated peritoneal masses (mean number, 4.4; range, 1-17) with a mean diameter of 5.0 cm (range, 2-12 cm). Omental and paravesical tumors were each present in six patients. Retroperitoneal masses were present in three patients. The tumors were well defined and hypoechoic at US. Heterogeneity due to tumor hemorrhage or necrosis was seen in seven patients. Ascites was present in five patients. Parenchymal and/or serosal hepatic metastases, punctate calcifications, nodular peritoneal thickening, lymphadenopathy, hydronephrosis, and bowel obstruction were less common associated findings.Bulky peritoneal soft-tissue masses without an apparent organ-based primary site are characteristic of intraabdominal desmoplastic small round cell tumor. Although the findings are nonspecific, this diagnosis can be considered in adolescents and young adults with characteristic imaging findings.

To correlate clinical and pathologic patterns of myelolipoma with the computed tomographic (CT) appearance.All cases of myelolipoma accessioned by the Armed Forces Institute of Pathology from 1981 through 1997 were reviewed. CT images were scored for the location and size of each myelolipoma and the presence of calcification, hemorrhage, fat, and pseudocapsule. Pathologic findings for the pattern of fat and bone marrow elements were correlated with CT findings.In 74 patients, 86 myelolipomas were found, of which 72 were in an adrenal gland (eight were bilateral), and 14 extra-adrenal masses were found in 10 patients. Four clinicopathologic patterns emerged: (a) isolated adrenal myelolipoma in 37 patients (fat evident at CT, no other disorders present); (b) myelolipoma with hemorrhage in nine patients (imaging features similar to those of isolated adrenal myelolipomas but larger [mean diameter, 14.2 vs 9.9 cm; P = .01]; (c) extra-adrenal myelolipoma in 10 patients (imaging findings similar to those of adrenal myelolipomas, found most often in the retroperitoneum); and (d) myelolipomatous foci within other adrenal pathologic conditions in 18 patients (smaller, lower fat content, more heavily calcified).Myelolipomas are adrenal or extra-adrenal masses, with hemorrhage more common in larger lesions (diameter,10 cm). The CT appearance of myelolipomatous foci, which can be found within other pathologic adrenal conditions, is different from that of isolated adrenal myelolipomas.

To explore the mode of spread of disease between the perirenal space and the perivascular central retroperitoneum and to determine the anatomy along the medial border of the perirenal space.Anatomic dissection, injection of latex, and observation of cross sections of the abdomen were performed in nine cadavers. Attention was paid to the juncture of the central prevertebral, perivascular, and extraperitoneal regions, and the perirenal space. Anatomic findings were correlated with observations made at computed tomography (CT) in 82 patients with retroperitoneal hemorrhage (n = 24), inflammation (n = 37), and neoplasia (n = 21) involving the perirenal spaces or the central retroperitoneum.Along most of the length of each kidney, no apparent fascia separates the perirenal space from the central retroperitoneum. At this location, septa between fat lobules form a fenestrated multitier barrier. These septa were imperceptible on CT scans obtained in healthy individuals. After injection of latex in cadavers, this potential barrier was seen. In the clinical study, spread of disease was allowed in only 38 (30%) of 128 instances of potential spread. Spread was facilitated along the renal vessels and the interlobular septa.Beyond the kidneys, the renal fascia is closed, forming a cone superiorly and an inverted cone inferiorly. A network of interlobular septa acted as a barrier or pathway to the free spread of disease from the perirenal space to the central retroperitoneum or from the central retroperitoneum to the perirenal space.

In men who otherwise seem to have responded to chemotherapy for nonseminomatous germ cell tumors (NSGCTs), enlarging masses can represent benign tissue rather than residual or recurrent malignancy. One hundred eighty-five men with negative serum tumor markers after first-line chemotherapy for NSGCT underwent surgical resection of residual masses within 6 months after completing therapy. Radiologic examinations revealed 14 patients who had 17 masses (10 retroperitoneal, five pulmonary, two mediastinal) that had enlarged despite therapy. Fourteen (82%) of the masses were teratomas (13 mature, one immature), two (12%) were necrotic tissue, and one (6%) was a mature teratoma with sarcomatous transformation. All 12 retroperitoneal and mediastinal teratomatous masses were at least partially cystic at posttherapy computed tomography. Seven of the 14 patients had a differential response to therapy: Some masses regressed while others enlarged. Enlarging masses in patients with negative serum tumor markers after chemotherapy for NSGCT frequently represent mature teratomas. Complete surgical resection of such masses usually is curative and identifies patients with residual malignancy who require further therapy.

To quantify intratumoral ultrasonographic (US) contrast agent flow at gray-scale imaging as a measure of functional tumor vascularity in an orthotopic murine neuroblastoma model treated with angiogenesis inhibitors.After Institutional Animal Care and Use Committee approval, retroperitoneal neuroblastomas were established in mice with unmodified NXS2 cells (n = 13) or with cells engineered to overexpress an angiogenesis inhibitor--either tissue inhibitor of matrix metalloproteinase-3 (n = 22) or a truncated soluble form of the vascular endothelial growth factor receptor-2 (truncated soluble fetal liver kinase-1; n = 13). When tumors were approximately 600 mm3, contrast material-enhanced gray-scale US was performed, and the imaging was recorded on cine clips. Regions of interest within tumors were analyzed off-line to determine postcontrast change in signal intensity (SI) from baseline to initial peak (deltaSI), rate of SI increase from baseline to initial peak (RSI), and contrast material washout. The Mann-Whitney test was used to evaluate potential differences in these US parameters between treatment groups. The mean intratumoral endothelial cell (CD34) and pericyte (smooth muscle actin [SMA]) counts at immunohistochemical analysis were also evaluated. Spearman correlation test was used to investigate the relation between US parameters and these histologic markers.The deltaSI and RSI were lower in tumors overexpressing an angiogenesis inhibitor than in control tumors (all P.03). Contrast material washout did not differ between groups. For the entire cohort, the RSI correlated with the immunohistochemical assessment of tumor vascularity (SMA and CD34 counts) (P.003).Quantification of intratumoral flow of a US contrast agent at gray-scale imaging shows promise for monitoring tumor vascular response to antiangiogenic therapy.

To determine the radiologic appearance of ganglioneuromas of the adrenal gland and extra-adrenal retroperitoneum.A retrospective review was performed of imaging findings in nine patients with ganglioneuroma, two with ganglioneuroma-pheochromocytoma, and two with malignant peripheral nerve sheath tumor (PNST) that arose in a ganglioneuroma. Patients underwent computed tomography (CT) (n = 13), magnetic resonance (MR) imaging (n = 5), and ultrasonography (US) (n = 5).In nine patients with ganglioneuroma, the mass ranged in size from 2 x 4 x 4 cm to 21 x 21 x 22 cm. Imaging findings included attenuation entirely or predominantly less than that of muscle on contrast material-enhanced CT images (n = 9); heterogeneous, predominantly high signal intensity on T2-weighted MR images (n = 5); partial or complete surrounding of one or more major blood vessels with little or no luminal narrowing (n = 4) and calcifications (n = 4) on CT scans; and homogeneous, moderate echogenicity (n = 3) on US scans. CT findings in two patients with ganglioneuroma-pheochromocytoma included central necrosis (n = 1) and calcifications (n = 1). In the two patients with malignant PNST that arose in a ganglioneuroma, contrast-enhanced CT showed a large, markedly heterogeneous mass.Diagnosis of ganglioneuroma should be considered when typical CT or MR imaging findings are present. Findings in cases of ganglioneuroma-pheochromocytoma and malignant PNST arising in a ganglioneuroma appear to be nonspecific.

To determine the factors that may be used to predict outcome of stent placement in patients with malignancies obstructing the superior or inferior vena cava.Gianturco stents were placed in 39 patients with malignant obstruction of the superior (n = 16) or inferior (n = 23) vena cava. Thirteen patients with obstruction of the superior vena cava received radiation therapy and/or chemotherapy at some time in their course of treatment. Computed tomographic (CT) scans were obtained in all patients. The authors analyzed treatment outcome with the location, length, and CT appearance of obstruction.Venous congestive symptoms disappeared after stent placement in 35 patients and remained in four. Symptoms did not recur during 1-13-month follow-up in 32 of the 35 patients in whom the symptoms disappeared. Nonfatal complications were observed in nine patients. Results of multivariate analysis showed that the outcome of stent placement is best predicted by the appearance of obstructions on CT scans irrespective of the location and length of the lesions.Good results can be expected from placement of Gianturco stents except when CT shows the obstruction to be totally enveloped by tumor.

The authors retrospectively evaluated radiologic, clinical, and pathologic findings in 19 cases of lymphangioma of the retroperitoneum. The tumors were judged confined to one compartment of the retroperitoneum in 68% of the cases, whereas in 32% of cases the tumor involved more than one compartment. Abdominal radiography depicted the mass in all cases. Excretory urography demonstrated organ displacement without tumor invasion in all cases. Sonography showed multiloculated fluid in 61% of cases and a unicameral mass in 39% of cases. All but one of the multiloculated lymphangiomas had thick septa. Sonography also depicted the fluid as uncomplicated in 56% of cases. The remainder had debris that sometimes layered in the dependent portion of the cyst. Computed tomography (CT) showed a unicameral mass in 57% and a septated mass in 43% of cases. CT also showed thin, smooth walls in 79% and thick, irregular walls in 21% of cases. At CT the fluid contents were found to be homogeneous and of fluid attenuation in 64% and were complex in 36% of cases. The attenuation of fluid in one case was the same as that of retroperitoneal fat. In two cases the mass contained mural calcification. The most characteristic radiologic finding of lymphangioma of the retroperitoneum is an elongated tumor containing uncomplicated fluid with or without septa. Chyle and mural calcification are very uncommon in this location.

The computed tomographic (CT) findings in 118 patients with the diagnosis of leiomyosarcoma were reviewed. The tumor masses visualized in these patients were often quite large; extensive necrotic or cystic change was a frequent finding. Calcification was not observed in these tumors. The liver was the most common site of metastasis in these patients, with marked necrosis of the liver lesions a common finding. Other manifestations of tumor spread included pulmonary metastases, mesenteric or omental metastases, retroperitoneal lymphadenopathy, soft-tissue metastases, bone metastases, splenic metastases, and ascites. The metastatic lesions were often centrally necrotic. Although the CT appearance of leiomyosarcoma is not specific, these findings, when present, suggest consideration of this diagnosis.

Nine patients with colonic carcinoma were studied with I-131-labeled F(ab')2 fragments of an anti-colorectal carcinoma monoclonal antibody. A total of 69% of colon cancer sites were detected without background subtraction; metastases from a concurrent breast carcinoma in one patient were not seen. Lesions ranged from 1.5 to 8 cm. The mean thyroid uptake of I-131 at 24 hours was 0.25%. Half-lives of I-131 in the blood (protein-bound and total) fit a two-compartment model, with half-lives of 3.5 and 27.6 hours for the protein-bound fraction and 3.6 and 23.8 hours for total I-131. Using quantitative methods, a mean value of 0.0047%/cm3 of the administered dose was localized in the tumor at peak concentration, which occurred approximately 48 hours post-administration. This has implications for therapy planning.

Nineteen patients with proven pancreatic disease and 50 control subjects were examined by magnetic resonance (MR) using a variety of spin echo and inversion recovery techniques. The MR results were then compared with CT scans. The normal pancreatic head, body, and tail were identified by MR in approximately 60% of patients. Pancreatic adenocarcinoma and retroperitoneal lymphoma were detected using morphologic criteria similar to those used in CT. Differentiating bowel from pancreas was difficult on MR in patients with little retroperitoneal fat, and tissue relaxation times were usually not helpful in differentiating adenocarcinoma or lymphoma from normal pancreatic tissue. However, MR intensity, T1, and T2 were useful in differentiating pancreatic islet cell tumors from normal pancreatic tissue. MR accurately identified retroperitoneal invasion, vascular involvement, and liver metastases. In pancreatitis, tissue T1 and T2 relaxation times were prolonged and complications such as ductal dilatation, pseudocyst, phlegmon, and ascites were identified. Small pancreatic calcifications were not detected by MR. Pancreatic iron overload was seen in patients with hemochromatosis. Although respiratory motion and spatial resolution are currently limiting factors, MR is a versatile and unique modality for the evaluation of pancreatic disease.

Computed tomographic guided fine needle aspiration biopsy of 25 consecutive patients with a variety of confirmed malignant abdominal and plevic neoplasms resulted in a 100% yield of positive tissue diagnosed, without significant complications. The principal advantage of CT guidance is the continuous direct observation of the needle tip position in relation to the target volume. Simultaneous insertion of 2 fine caliber biopsy needles (tandem needle maneuver) is a new technique developed for rapid, accurate needle repositioning for repeated aspiration attempts. CT guidance, multiple aspirates with the fine needle, and the tandem needle maneuver for precise localization all contribute to a high rate of tissue diagnoses. Because CT guidance permits more precise sampling of smaller, deeper tumors than other procedures, including ultrasonic biopsy transducer systems, it is preferred for percutaneous tissue sampling of abdominal neoplasms. Preliminary experience suggests that a large proportion of symptomatic abdominal malignancies which can be diagnosed by CT are amenable to successful percutaneous biopsy by this technique.

Twenty-eight patients with intra-abdominal mesenchymal sarcomas were examined with gray scale ultrasonography. Masses were present in the mesentery, abdominal hollow viscera, liver, and retroperitoneal areas. Four different ultrasonic patterns were observed in the extra hepatic abdominal masses: (a) hyperechoic masses intermixed with anechoic zones; (b) hyperechoic masses with central fluid-filled zones; (c) homogeneous hyperechoic masses; and (d) homogeneous hypoechoic masses. Three of 6 patients with hepatic masses were totally anechoic alongside other more typical metastatic patterns. The presence of a large mass with sonographic signs of necrosis should strongly suggest the possibility of sarcoma. The differential diagnosis is discussed.

Retroperitoneal teratomas are rare in adults; they are malignant in 25.8% of cases. The authors report two benign cases in which radiologic examination was essential in establishing the diagnosis. Irregular calcifications, which are visible in 61.5% of reported cases, cannot be considered a sign of benignity, since 12.5% of calcified tumors were malignant. Because of the indeterminate course of the disease, surgical removal is indispensable.

Retroperitoneal lymphangiomas are uncommon benign tumors usually presenting in early life. They may cause significant pressure on adjacent structures, most often with superior and medial displacement of the kidney and medial deviation of the ureter. Relative radiolucency on total body opacification during excretory urography, and features of a cystic structure on ultrasonography and computed tomography should further suggest the possibility of a retroperitoneal lymphangioma. Vascular stretching and displacement without neovascularity on angiography and contrast entry into the cysts on lower extremity lymphography are additional features, but such procedures are usually unnecessary.

Percutaneous aspiration biopsies of opacified retroperitoneal lymph nodes, and retroperitoneal, intraperitoneal and paraspinal masses were successfully accomplished in 14 of 17 patients. A 23-guage needle was utilized for the procedure which is performed under fluoroscopic guidance. Metastatic carcinoma, sarcoma and melanoma were readily identified by aspiration biopsy while the diagnosis of lymphoma, especially as to type, was more difficult. No significant complications have resulted from the passage of the needle through the peritoneal cavity.

A technique employing serial ultrasonic B-scans and a computer for measuring volumes of internal anatomical structures is described. Phantom studies indicate that this method is accurate to within 5% for phantom volumes in the 200–2000 cm3 range. The technique was applied to monitor the spleen-tumor volume in a patient with chronic lymphocytic leukemia and the liver-tumor volume in a patient with retroperitoneal rhabdomyosarcoma. The data suggest that the method is clinically useful for determining normal organ and tumor volumes and for evaluating response to therapy.

Catheterization of the adrenal veins is potentially a useful clinical tool since it permits not only detailed visualization of the inner glandular vasculature but also sampling of effluent hormones. Bucht (1) , was the first investigator to study the left adrenal vein angiographically in man; since that time there have been surprisingly few subsequent articles (2, 3) on this subject. We have developed a technic for catheterizing with facility both adrenal veins in man. On the basis of three years experience, we now feel that adrenal phlebography does indeed have wide clinical application. Anatomy The intraglandular venous circulation is complex and incompletely understood (4, 5). The cortex and medulla are drained in series by sinusoids, venules, and muscular veins which join to form the central vein. This then becomes the adrenal vein as it exits on the ventral groove of the gland. It should be noted that the main venous branches are cuffed by invaginated folds of cortex and that even the central vein is...

Numerous terms have been applied to the condition resulting from fibrotic tissue surrounding, compressing, and occasionally occluding one or both ureters (3, 11, 14, 16, 20, 22). While the process usually involves the mid or upper portions of the ureters, involvement of the lower ureters, retroperitoneal vessels, kidneys, bladder, lungs, and mediastinum has been reported (1, 3, 5, 6, 18, 19). Multiple nonneoplastic etiologies have been surmised (3, 4, 6–8, 10, 11, 13, 15, 17, 22). Reticulum-cell sarcoma and Hodgkin's disease, however, have been implicated (9, 21). We wish to report 4 cases in which periureteric fibrosis was found in association with lymphosarcoma, 3 of which were without antecedent irradiation to the retroperi-toneum. Case I: In this 68-year-old white woman generalized adenopathy developed in 1960. Biopsy of a left axillary node disclosed lymphosarcoma (Fig. 1). Intravenous pyelography in November 1960 and again in January 1961 revealed bilateral hydronephrosis and proximal hydroureter (F...

Of 141 cases of plasma-cell myeloma, 24 cases (17%) presented as nonosseous, the largest number of such cases in a single series in the literature. This points to the importance of early soft-tissue and organ involvement in the disease prior to bone involvement. The varied modes of presentation are discussed.

For a number of years at Memorial Hospital for Cancer and Allied Diseases, New York, inferior vena cavography has been found valuable in conjunction with lymphangiography and intravenous pyelography in study of retroperitoneal nodal disease, especially the lymphomas. Generally, however, we have been dissatisfied with the quality of our inferior vena cavograms as performed by technics currently in use. An improved technic has been developed, directed toward better visualization of the upper inferior vena cava. Material and Method Inferior vena cavography was performed 92 times in 90 patients. Three injections per examination were made whenever feasible for comparison of accepted technics with improvements. All were performed intravenously with the Seldinger catheterization method, using meglumine iothalamate 60 per cent, power injection, and anteroposterior and lateral projections. Pressure, volume, and rate of injection, filming rate and delay, exposure time, number, location and design of catheters, pati...

A preliminary report on the clinical use of measurements of the retrogastric space was published by the author in 1958 (13). An increase in the measured retrogastric space was found to be the most consistent roentgen abnormality observed with retroperitoneal masses in the region of the pancreas. It is the purpose of this paper to report an additional five years experience and to suggest that judicious use of the measurements can be of value in early detection of retrogastric masses. Measurements Roentgenologic detection of forward displacement of abdominal viscera by retroperitoneal tumors was described first by Brown (5) in 1928. A decision as to actual displacement was based on the visual experience of the radiologist, and only gross displacements could be reported with confidence. In 1949 Poppel, Sheinmel, and Mednick (10) described a method for measurement of the space behind the barium-filled stomach. These authors noted that the width of this space with the patient supine should not exceed that of t...

Two cases of radiation-induced injury of normal kidney resulting in generalized or localized nephritis are presented. The generalized nephritis follows irradiation of the entire organ and may be associated with intractible hypertension. Localized nephritis results from irradiation of only part of the kidney and may be asymptomatic. Scintillation imaging provides a sensitive means to detect, differentiate, and follow both types of radiation nephritis.

During the past few years, interest has been increasing in lymphangiography as a method of demonstrating abnormalities in lymph nodes and lymphatic channels (8, 10, 13, 14). Oncologists have exhibited a special enthusiasm for this new procedure since it affords a graphic representation of the site and extent of pelvic and abdominal cancer. Prior to the application of lymphangiography, the presence of retroperitoneal masses not detectable on physical examination was inferred from obliteration of the psoas shadows or delineation of a soft-tissue mass on the plain films of the abdomen; the secondary changes produced in the gastrointestinal tract during the course of a barium meal; displacement of either kidney or ureter during intravenous urography; the use of retroperitoneal air insufflation (2, 6); and, more recently, the displacement of the cava as shown by inferior vena cavography (5). The ease with which most of the above procedures can be performed enhances their appeal, particularly when compared with...

The normal position of the renal pelves and ureters in the cross-table lateral projection has been determined, using the vertebral body as a reference point. In general, the renal pelvis between the levels D-12 and L-3, and the ureters at L-l and L-2, should lie posterior to the anterior edge of the vertebral bodies. At L-3, the average ureter is 3/4 of a vertebral width from the posterior edge of the vertebral body and courses along its anterior border at L-4. At L-5, the average ureter is 1/4 of a vertebral width anterior to the anterior vertebral margin.

Perforation of a necrotizing primary retroperitoneal neoplasm, resulting in a fistulous communication with the gastrointestinal tract, occurs rarely. To our knowledge, no cases radiographically docu-mented have been described. In his paper on primary retroperitoneal tumors, Donnelly (2) stated that neoplasms of this group are quite invasive and often become adherent to surrounding vital structures. In view of this circumstance and the great tendency to ischemic necrosis of these tumors, one might expect perforation into surrounding structures to occur more often than is generally recognized. The only direct reference to this complication was found in the Massachusetts General Hospital “Case Records” (1). In this case the diagnosis was established at autopsy. We have recently had the experience of studying two cases in which the diagnosis of excavating retroperitoneal neoplasm with fistulous communication into the gastrointestinal tract was suggested prior to surgery, on the basis of the radiologic examina...

The retroperitoneal space is subject to a variety of tumors. These may originate from retroperitoneal organs or glands, as the kidney, pancreas, and adrenals, or they may arise primarily in retroperitoneal connective, adipose, nervous, muscular, or even embryonic tissue. The lymphatics may be involved by either primary lymphomas or metastatic lesions, the latter being the most common of the retroperitoneal tumors, with lymphomas supplying the majority of the cases (1, 5). Since the diagnosis of retroperitoneal lymphoma is so frequent a clinical problem, it commands special attention. In a considerable number of patients where the clinical evaluation suggests the presence of retroperitoneal node involvement with lymphoma, even the experienced clinician may be unable to delineate the nodes with reasonable certainty. Because the decision in regard to the most dynamic form of radiation therapy depends largely on the exact localization of the tumefactions, the radiologist is usually called upon for aid. He has...

The radiologist is walking along an ever narrowing tightrope in the investigation of a patient with a poorly defined symptom complex. It is easy to stumble between the dangers of the well publicized limits of total-body irradiation and the risk of missing an elusive lesion because of inadequate examination. For this reason roentgenographic procedures should be constantly reappraised to make certain that the simplest possible technics offering the greatest possible rewards are used. The study of retroperitoneal tumors emphasizes this problem. The inaccessibility of the retroperitoneal space masks early symptoms and makes physical diagnosis uncertain. This has led to the development of complex and difficult, though specific, roentgenographic procedures, permitting more accurate evaluation. These complex procedures have in turn increased the value of the comparatively simpler and safer method of barium studies of the digestive tract in the search for retroperitoneal masses. The distortions and the displaceme...

Inflammatory effusions and diffuse neoplasia in the fatty retroperitoneal space, which can alter the perirenal fat, can be recognized radiographically because of density differences. The opacity of fluid and tumor accentuates the remaining fat which conforms to the renal contour. This perirenal fatty border appears as a lucent strip when the perirenal fat is not violated and as abnormal perirenal streakiness when the perirenal fat is infiltrated by fluid or tumor. Six cases are described.

A 22 gauge "skinny core" (Madayag) biopsy needle, an 18 gauge Menghini needle, and a 14 gauge Tru-cut needle were compared in 51 patients. The Madayag needle was found to have a high recovery rate and provided adequate histological information in a large percentage of cases. However, the larger needles more consistently demonstrated a higher recovery rate and diagnostic specimen than the Madayag needle. The authors recommend that the radiologist become familiar with all three types of needles to facilitate selection of the proper instrument in each case.

A system employing an opaque projector mounted on a steel-framed cart was constructed to provide full-scale enlargement of ultrasound echograms for use in radiation therapy planning. Anatomical outlines from the enlarged echograms are traced directly into a minicomputer. Life-sized isodose curves for a selected treatment plan are overlayed on the enlarged echogram to produce a permanent record for treatment field adjustments and retrospective analysis.

It has been appreciated for many years that irradiation of the renal areas in infancy may affect vertebral growth to the extent of causing severe scoliosis in late childhood. In treating unilateral lesions, therefore, some therapists deliberately include in the treatment field the whole width of the spine and incidentally the aorta, in an attempt to equalize subsequent deformity. Radiation effects on the kidney substance and on the capillary vessels have also been recognized and much has been written on the subject of radiation nephritis. Little seems to be known, however, about the effects of radiation on the infantile aorta and renal arteries. The adult aorta is known to be little affected by quite large doses of radiation, but it seems likely that the growing aorta may be more susceptible to damage. In a discussion of the effects of radiation on the growing spine, Neuhauser et al. observed that “growth disturbances produced by radiation in the human vertebrae are directly related to dosage and inversel...

Lymphography has been widely popularized in recent years. Not only is diagnostic accuracy and treatment planning enhanced by this procedure (1), but also follow-up comparisons can often be made. To date, lymphographc opacification has been limited to axillary, supraclavicular, inguinal, pelvic, or para-aortic nodes. Despite technical difficulties, cervical lymphography has been described in the literature (2). There is as yet, however, no established technic in the selective visualization of the lymph nodes within the thorax or along the mesentery of the intestines. Mediastinal lymphatic opacification with Ethiodol3 in a patient with lymphoblastic lymphoma is documented in the following case report. Report of A Case The patient, a 30-year-old farmer, was admitted to the University of Kentucky Medical Center for evaluation of generalized lymphadenopathy. He had noticed gradual enlargement of the cervical lymph nodes over the past two years, followed by progressive swelling in the groin area. More recently,...

Anterior displacement of the abdominal aorta from the anteriormost aspect of the lumbar vertebrae or vertebral spurs indicates a retroaortic mass. Lateral lumbar radiography and ultrasound B-scanning were used to detect the relationship of the abdominal aorta to the lumbar vertebrae. The normal relationship on lateral radiographs was determined in 70 cases. Six cases of retroperitoneal tumor are presented, in which the detection of anterior displacement of the abdominal aorta led to or supported the diagnosis. In normal patients, the range of distance is 0 to 0.5 cm. Greater aortic displacement, in the absence of hypertrophic spurs, indicates retroaortic pathology.

Seventeen cases of hemangiopericytoma of the retroperitoneum were retrospectively analyzed for demographic, morphologic, and radiologic features. These tumors were found in all age groups (2 months to 72 years) and occurred in similar numbers of male and female patients. The tumors tended to be large (11 were greater than 8 cm), were well encapsulated, and occurred less frequently in the pelvic retroperitoneal space (six cases) than in abdominal retroperitoneum (11 cases). All tumors were bulky enough to displace part of the gastrointestinal tract, with only two being inoperable. The most distinctive radiologic feature was hypervascularity (found on 11 of 11 angiograms). Other nondiscriminating radiologic features included well-defined margins and necrosis, with nondistinctive amorphous calcification identified in one case. Angiographic or computed tomographic demonstration of hypervascularity in a retroperitoneal tumor is more suggestive of hemangiopericytoma than of a liposarcoma or malignant fibrous histiocytoma, two of the more common tumors of this region.

The histological nature and angiographic characteristics of two cases of Castleman tumor support the concept that these tumors are hamartomatous. On angiography, both tumors exhibited a dense and homogeneous blush in the later phase. In one, in the mediastinum, hypertrophied branches of the bronchial artery gave rise to multiple irregular vascular spaces within the tumor; in the other, in the retroperitoneum, hypertrophied branches of the lumbar artery gave rise to irregular vascular channels spaced throughout the tumor. Histologically, both lesions contained numerous lymphoid follicles which, in the central portion, contained capillary vessels with thick hyalinized walls and prominent endothelial cells. A pathogenesis of hamartoma formation is suggested based on a disturbance of the normal orderly replacement of somatic cells and tissues.

Retroperitoneal fibrosis can involve the vascular system, producing varying degrees of venous or arterial occlusion, and even insufficiency of the lower extremities. An unusual case of fibrosis retroperitonitis simulating neoplasm, with angiographic hypervascularity and staining associated with “vascular encasement,” is presented with histologic correlation.

Nineteen patients with histologically proved tumor thrombi of the inferior vena cava (IVC) secondary to abdominal neoplasms were studied with the use of ultrasonography (US) and computed tomography (CT). The primary neoplasms were renal cell carcinoma (13 cases), adrenal tumors (two cases), retroperitoneal tumors (two cases), and hepatic tumors (two cases). A positive diagnosis of tumor thrombus was achieved by both methods. The cranial extent of the tumor thrombus was better demonstrated by US studies, which showed echogenic endoluminal material within an enlarged IVC with a bulging anterior wall. On CT scans the tumor thrombus usually appeared as an endoluminal filling defect surrounded by a rim of contrast material. Tumor thrombus was better outlined by CT, particularly when it extended beyond the limits of the IVC wall, as in the retroperitoneal tumors. Neither method could accurately be used to predict IVC wall infiltration when the tumor thrombus remained within the confines of the IVC, nor could either method differentiate tumor from nontumor thrombi. US and CT are complementary in the preoperative assessment of tumor thrombus, and their use obviates the need for venacavography in many cases.

Computed tomographic (CT) scans of 34 cases of abdominal fatty masses were reviewed retrospectively in order to establish criteria for distinguishing benign conditions from malignant tumors. By evaluating location, attenuation, internal consistency, and margination, it is possible not only to make this distinction but frequently to suggest a specific diagnosis. Abdominal fatty masses that are sharply marginated, homogeneous, and that show CT numbers less than or equal to the patient's normal fat can be considered benign. Malignancy should be suspected when an extrarenal abdominal fatty mass displays one or more of the following characteristics: inhomogeneity, infiltration or poor margination, CT numbers greater than the patient's normal fat, or contrast enhancement. Criteria for distinguishing between angiomyolipoma and liposarcoma are also discussed.

Large posterior abdominal masses, particularly those in the right upper abdomen, may be difficult to localize correctly into the peritoneal or retroperitoneal compartments. The following signs were found to be reliable CT indicators of retroperitoneal location: obliteration of the perinephric fat outlining the psoas muscle; lateral displacement of the fat outlining the posterior right lobe of the liver; rotation of the intrahepatic portal veins to the left; anterior displacement of the inferior vena cava and renal veins; and anterior displacement of the ascending colon, descending duodenum, or pancreatic head.

Eleven children in whom a retroperitoneal neuroblastoma was suspected on the basis of plain radiographic or urographic findings underwent computed tomography (CT). CT identified and localized a neurogenic tumor in eight patients. Calcifications were demonstrated by CT in six lesions, but by urography in only four. One neuroblastoma detected by CT was not seen on the urogram; in five patients greater extent of the tumor was defined by CT than by conventional radiologic procedures. In three patients CT excluded a neuroblastoma, but diagnosed other disorders (hepatic tumor, pancreatitis, and retrocaval ureter). Our results confirm that CT is a simple and accurate method for diagnosis, delineation of extent, or exclusion of neuroblastoma.

Twenty-one CT examinations were performed in 19 patients who had undergone previous nephrectomy for renal carcinoma or retroperitoneal malignancy. Nine patients were free of disease and 10 had recurrence. Findings of recurrent disease included masses in the vacant renal fossa, inability to visualize the inferior vena cava or aorta, and ipsilateral psoas muscle thickening. Possible pitfalls in diagnosis are discussed.

Thirty-one adult patients underwent magnetic resonance (MR) imaging after CT scans had demonstrated findings consistent with renal cell carcinoma. MR images were interpreted prospectively and independently of the CT findings. Because the CT scanning was performed at multiple institutions by many examiners, this study was not a direct comparison of CT versus MR. The preoperative diagnoses and staging of the neoplasms, as judged by MR, were compared with those obtained at laparotomy (n = 28), autopsy (n = 1), or biopsy (n = 2). Correct preoperative diagnoses were rendered in 31 patients (100%) on the basis of MR findings. The anatomic staging of 27 renal cell carcinomas was correctly performed by MR in 26 patients (86%). When compared with results of previous studies of the value of CT in the diagnosis and staging of renal neoplasms, MR appears to have several advantages in determination of the origin of the mass; the evaluation of vascular patency; the detection of perihilar lymph node metastases; and the evaluation of direct tumor invasion of adjacent organs. MR is sensitive in determining the extent of tumor thrombus and in evaluating invasion of the inferior vena caval wall. MR should assume an important role in the diagnosis and staging of renal neoplasms.

Ultrasonography can demonstrate the homogeneity, while CT can demonstrate the density of a mass lesion. If a mass appears echo-free at ultrasonography, but is denser than water at CT, a solid tumor with grossly uniform cellular structure (usually a lymphoma or sarcoma), or a hematoma or hemorrhagic cyst is likely. However, if the mass has water density at CT, a cystic lesion is confirmed. One case for each category is presented.

The authors retrospectively evaluated radiologic, clinical, and pathologic findings in 23 cases of mature teratoma arising within peri- or pararenal spaces. Radiologic studies--including abdominal radiographs (21 cases), excretory urograms (12 cases), sonograms (17 cases), and computed tomographic (CT) scans (18 cases)--were evaluated for tumor location, mass effect, calcification, fat, tumor invasion, echo pattern, and tissue characteristics. Most patients were female (3.4:1), younger than 6 months (50%), and asymptomatic. Abdominal radiography demonstrated a mass in 95%, calcium in 92%, and fat in 60% of cases in which CT revealed these components. Similarly, sonography showed uncomplicated fluid in 76% and calcium in 50% of cases. Fat was not reliably distinguished from other soft-tissue components on sonograms. The most characteristic radiologic findings of mature teratoma of the retroperitoneum are a complex mass containing a well-circumscribed fluid component of variable volume, adipose tissue and/or sebum in the form of a fat-fluid level, and calcification in either a congealed or linear strand pattern. These findings are better demonstrated by CT than by sonography.