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As a treatment of rectal cancer, lateral lymph node dissection (LLND) is still a controversial issue. The argument against LLND is that the procedure is complicated, and consequently results in a high incidence of postoperative urogenital dysfunction. The surgical modality from fascia to space is adopted by lateral lymph node dissection in "two spaces". This operation has significant advantages of clear location of nerves and blood vessels and simplified surgical procedures, so the surgical procedure can be repeated and modulated. The fascia propria of the rectum, urogenital fascia, vesicohypogastric fascia and parietal fascia constitute the dissection plane for lateral lymph node dissection.Two spaces refer to Latzko's pararectal space and paravesical space. During the establishment of fascia plane, the dissection of external iliac lymph node (No.293), commoniliac lymph node (No.273) and abdominal aortic bifurcation lymph node (No.280) can be performed. While in the "space" dissection, internal iliac lymph node (No.263), obturator lymph node (No.283), lateral sacral lymph node (No.260) and median sacral lymph node (No.270) can be removed. LD2 or LD3 lateral lymph node dissection prescribed by the Japanese Society of Colorectal Cancer can be completed according to the needs of the disease. This article describes the anatomical basis and standardized surgical procedures.侧方淋巴结清扫作为直肠癌的一种治疗手段，一直因手术风险大、术后泌尿生殖功能障碍发生率高而饱受争议。基于膜解剖的直肠癌侧方淋巴结"两间隙"清扫术采取由膜至间隙的手术方式，依据膜解剖标记，层面容易辨识，血管和神经定位明确，从而提高了手术的安全性和精准性。同时简化了手术操作，手术方法可重复和模式化。与侧方淋巴结清扫相关的膜为泌尿生殖筋膜、膀胱腹下筋膜和壁筋膜；两间隙指Latzko直留旁间隙和膀胱旁间隙。在建立膜平面时，能够完成髂外淋巴结（No.293）、髂总淋巴结（No.273）以及腹主动脉分叉部淋巴结（No.280）的切除，而在间隙清扫时，能够完成髂内淋巴结（No.263）、闭孔淋巴结（No.283）、骶外侧淋巴结（No.260）以及骶正中淋巴结（No.270）的切除，可以依据病情需要，完成日本结肠直肠癌学会所规定的LD2或LD3侧方淋巴结清扫。本文基于对关键解剖的认识，概述侧方淋巴结"两间隙"清扫术的模式化操作。.

Despite the concept of membrane anatomy has been widely used in minimally invasive colorectal surgery, the definition of membrane anatomy and the establishment of membrane plane remain controversial. Therefore, it is difficult to establish a unified theoretical system of membrane anatomy. Through embryological studies and anatomical findings on the integrity and continuity of membranes, we try to discuss the theoretical system of membrane anatomy in colorectal surgery from three aspects: membrane anatomical system, membrane anatomical elements and membrane anatomical mechanism. The establishment of a unified theoretical system of membrane anatomy will not only contribute to the standardization operative procedures, but also to the establishment of uniform surgical standards for colorectal cancer.膜解剖的理念虽然已广泛应用于结直肠癌的微创外科，但对膜解剖结构的定义以及膜平面的建立仍存在争议，因而无法建立统一的膜解剖理论体系。本文通过胚胎学、膜的整体性和延续性的研究，尝试从膜解剖系统、膜解剖要素和膜解剖机制三方面来论述结直肠手术膜解剖理论体系。建立统一的膜解剖理论体系，将有助于规范手术操作以及建立结直肠癌手术操作标准。.

There has been an upsurge of the theory of membrane anatomy in China, but it is still in the initial stage of establishing preliminary framework. The concept of fasciae in membrane anatomy actually refers to the fasciae constituting the particular plane or the 'holy plane'. Therefore, the membrane anatomy can't simply be defined as the anatomical relationship among fascia. The application of the membrane anatomy is also not just to pursue the avascular plane in the surgical field. Nowadays, nonstandard anatomical terms and diversification of views impede the development of the theory of the membrane anatomy. Fasciae occur in embryonic stage, undergo a series of changes in rotation and fusion, and lose the original features, which bring difficulties in understanding the anatomy of fasciae. In this paper, we restore the origin and continuity of fasciae related to the colorectal surgery by cadaveric study, surgical observation and literature review. Taking the TME for example, we also discuss the core content about the fasciae and plane related to 'mesenteric envelope' and complete mesorectal excision. From the perspective of the fasciae integrity, we illustrate the definitions of important anatomical structure and standardized the terminology of fasciae. To study the origin and architecture of fasciae in the view of embryology, integrity and continuity will contribute to establish the standard theoretical system of membrane anatomy.膜解剖虽然在国内兴起，但现在还只是初步建立了理论框架。膜解剖的"膜"实际是指构成特定平面或称为"神圣平面"的"膜"，因此不能把"膜"之间的解剖就理解为膜解剖，膜解剖的目的也绝非是为了追求"微出血"和"零出血"。现阶段理论学说的多样化以及解剖名词的不规范，是阻碍膜解剖理论进一步发展的"瓶颈"。膜解剖的膜或层面始于胚胎期，但因为发育过程中出现的旋转、融合等而失去了原来的解剖表现，从而模糊了临床对膜解剖的认识。笔者结合尸体解剖、手术观察和文献复习，还原了结直肠手术相关膜的来源和延续，并以全直肠系膜切除术为例，对"系膜信封"以及完整系膜切除等膜解剖核心内容进行了探讨。同时，从膜的整体性上阐释了重要术语的解剖学定义，以期规范膜解剖名词的使用。从胚胎学、膜的整体性和延续性来理解膜的来源和构成，将有助于建立统一规范的膜解剖理论体系。.

Pelvic fascia is considered to be one controversial human anatomic structure. According to the characteristics of specialized surgery, colorectal surgeons, gynecologic surgeons and urologic surgeons respectively marked the pelvic fascia, but the naming is not unified. For some specific anatomic structures (such as pelvic plexus), different scholars have different descriptions of their positions. The lack of standard anatomic terms makes it difficult to understand the corresponding anatomic structures, and also hinders the communication between disciplines. Combined with autopsy research, surgical observation and literature review, we discussed the common puzzles of pelvic clinical anatomy. The main points of this article are as follows. (1) Urogenital fascia and vesicohypogastric fascia are the components of visceral fascia. (2) The visceral fascia and fascia propria of rectum are two separate layers. (3) The pelvic plexus is located on the outside of the confluence of visceral fascia and Denonvilliers' fascia. (4) To understand the pelvic lateral ligament from the perspective of layers. (5) To understand pelvic fascia from a holistic perspective.盆腔筋膜是争议较大的人体解剖部位之一。结直肠外科、妇科和泌尿外科根据专科手术的特点，分别对盆腔筋膜进行解剖标记，命名未能形成统一。对某些特定的解剖结构（如盆丛），不同学者对其位置的描述存在明显差异。标准解剖术语的缺失，给医师理解相应解剖结构造成困难，也阻碍了学科间的交流。本文结合尸体解剖研究、手术观察和文献复习，对盆腔临床解剖的常见困惑和盆腔关键临床解剖术语进行阐述，包括：（1）尿生殖筋膜和膀胱腹下筋膜是脏筋膜的组成部分；（2）脏筋膜和直肠固有筋膜是两层独立的筋膜；（3）盆丛位于脏筋膜和Denonvilliers筋膜汇合处的外侧；（4）从层面的观点来理解盆腔侧韧带；（5）把握筋膜理解的整体观点。.

To determine the diagnostic yield of Intravenous Urogram (IVU) and the values of plain radiograph of kidney, ureter and bladder (KUB) and urinalysis as screening tests, with the objective to improve the cost effectiveness, in the management of patients presenting with flank pain due to urinary lithiasis.All Intravenous Urogram (IVU) request forms and reports for the month of February 1998 were audited. The case notes, urinalysis, KUB and IVU films were traced and reviewed.There were 110 patients investigated, 61.8% (68) had normal IVU, 38.2% (42) had abnormal IVU. The sensitivity and specificity of KUB alone was 79.4% and 90%. The sensitivity using urinalysis alone was 90.9% and its specificity 33.8%. The sensitivity of combined KUB and urinalysis was 100% and its specificity 26%, with a negative predictive value of 100%. All the patients with both negative KUB and urinalysis in our study were found to have negative IVU.Our study shows that in patients with both negative KUB and urinalysis, the yield of IVU is very low and may not be necessary. This is important, as an IVU examination is not without risk. A combination of KUB with urinary analysis and careful evaluation of clinical symptoms will improve the cost-effectiveness of patient management.

Castleman's disease (CD) is a rare lymphoid tumour usually found in the mediastinum. Extrathoracic sites are uncommon. Its radiological findings may be similar to other retroperitoneal tumours, making diagnosis difficult.A 54-year-old female was found to have an incidental hypoechoic mass in the left posterior perinephric space on routine ultrasound. Abdominal computed tomography (CT) scan demonstrated an isodense mass which enhanced brightly with intravenous contrast. Angiogram confirmed a hypervascular mass.The retroperitoneal mass was excised.Histology revealed CD of hyaline-vascular type.CD should be considered in the differential diagnosis of a retroperitoneal mass, which demonstrates homogeneous and intense enhancement.

Primary lymphoma of the thyroid gland is rare. The histopathology of most low-grade thyroid lymphomas is of a mucosa-associated lymphoid tissue (MALT) type. A typical feature of this type of lymphoma is a close lymphocyte-epithelium interaction. It tends to appear in patients with a history of autoimmune disease or chronic inflammatory disorders. A clinical picture of hypothyroidism may be present. Hyperthyroidism associated with thyroid lymphoma is also rare. Thyroid lymphoma could be misdiagnosed as lymphocytic thyroiditis or small cell anaplastic carcinoma. It is rarely reported in patients with Down's syndrome. In this report, we describe a Down's syndrome patient with MALT thyroid lymphoma and cerebral infarction. The patient, a 42-year-old man, presented with chest discomfort and bilateral leg weakness of one week's duration. Physical examination of his neck showed a right-sided mass lesion. Neurologic examination revealed decreased muscle power and hyperreflexia in both lower legs. Babinski's sign was present bilaterally. Endocrinologic studies showed subclinical hypothyroidism. A thoracolumbar radiograph showed disc space narrowing. Thyroid sonography revealed a hypoechoic mass lesion in the right lobe of the thyroid gland. Fine needle aspiration cytology of the neck mass demonstrated a large amount of lymphocyte infiltration. An I131 thyroid scan and 24-hour uptake revealed the possibility of thyroid malignancy at the upper poles of both thyroid lobes. Computerized tomography of the brain revealed a lacunar infarct in the posterior aspect of the left putamen. Magnetic resonance imaging of the lumbar spine revealed a healed L4 compression fracture with L4-5 retrolithesis. The patient later underwent a right total thyroidectomy. The pathologic finding showed MALT lymphoma. The patient received steroid suppression therapy, and after nine months of treatment and follow-up, he developed clinical hypothyroidism. Neither local tumor recurrence nor distant metastasis was found.

Type I multiple symmetrical lipomatosis (MSL; Madelung's disease) is characterized by lipomas in the nape of the neck and the supraclavicular and deltoid regions, resulting in a bull-necked appearance (Madelung's collar). It is most common in alcoholic men between 35 and 50 years of age. Type I MSL has been reportedly associated with hyperinsulinemia, but its association with diabetes mellitus is rarely discussed. We describe a case of non-insulin-dependent diabetes mellitus (NIDDM) associated with type I MSL. A 47-year-old alcoholic man presented with a seven-year history of hyperglycemia and progressive neck swelling with dysphagia for one year. Physical examination showed diffuse and symmetrical swelling of the bilateral posterior aspects of the neck. Biochemistry profiles revealed elevated concentrations of fasting serum glucose (276 +/- 16 mg/dl), triglycerides (358 +/- 79 mg/dl) and total cholesterol (323 +/- 28 mg/dl). Endocrinologic studies showed normal thyroid function. Neck sonography revealed diffuse thickening and swelling of the fatty structures of both sides of the neck. Normal sonography showed no fatty deposition in the liver. Maxillary and neck computerized tomography revealed diffuse fat accumulation in the submental and posterior neck regions, with no extension to the superior mediastinum. Fine needle aspiration cytology of the neck masses showed only fat cells. The patient received an oral hypoglycemic agent (glibenclamide 5 mg bid) for blood glucose control and lovastatin (20 mg before bed-time) for hyperlipidemia, and ceased drinking alcohol. The neck swelling resolved markedly after 15 months of medical treatment. This suggests that, in addition to the cessation of alcohol consumption, the reduction of blood glucose and lipid concentrations by medication may also assist in resolving the accumulated fat of type I MSL in patients with NIDDM.

To identify and differentiate agenesis and severe atrophy of the right hepatic lobe on computed tomography (CT).The CT examinations of three cases of agenesis and 11 cases of severe atrophy of the right hepatic lobe were reviewed. We evaluated visibility of the three hepatic veins, the two main portal veins (including their branches if necessary), the dilated intrahepatic ducts, enlargement of the medial and lateral segments of the left lobe and caudate lobe of the liver, presence of a retrohepatic gallbladder, hyperattenuation of the atrophic liver parenchyma, posterolateral interposition of the hepatic flexure of the colon, and upward migration of the right kidney.In the three cases of agenesis, no structure can be recognized as the right hepatic vein, right portal vein, or dilated right intrahepatic ducts. In the 11 cases of severe lobar atrophy, the right portal vein (or its branches) was recognized in eight cases, the right hepatic vein in four cases, and the dilated right intrahepatic ducts in 11 cases. The degree of enlargement of the lateral segment does not necessarily change inversely with the size of the medial segment and the caudate lobe. The retrohepatic gallbladder is present in eight cases (two in agenesis and six in atrophy). The phenomenon of hyperattenuation of the atrophic liver parenchyma was noted in six cases.Even though a retrohepatic gallbladder and a severely distorted hepatic morphology due to compensatory hypertrophy of the left and caudate lobes may raise a suspicion of agenesis of the right lobe of the liver, absence of visualization of all of the right hepatic vein, right portal vein and its branches, and dilated right intrahepatic ducts is a prerequisite of the diagnosis of agenesis of the right hepatic lobe on CT. In severe lobar atrophy, at least one of these structures is recognizable.

To study bone mineral density (BMD) in premenopausal adult female patients with systemic lupus erythematosus (SLE) and its relation with clinical parameters, 56 SLE patients (mean age 31 years, mean disease duration 6.3 years) and 15 normal controls were studied. BMD at the lumbar vertebrae (L2-L4) was measured by dual energy X-ray absorptiometry (DEXA). Classification of BMD was made according to the WHO criteria in 1994. Correlation between BMD and clinical parameters was calculated. It was found BMD in the SLE patients (0.942 +/- 0.136 g/cm2) was lower than in the control group (1.055 +/- 0.080 g/cm2) (P0.01). According to the WHO criteria, 17 patients (30%) had normal BMD, 22 patients (40%) had osteopenia and 17 patients (30%) had osteoporosis. BMD was inversely correlated with disease duration in SLE patients (p0.005). The minimal disease duration for a female SLE patient to develop osteopenia was 3.5 years. In conclusion, SLE patients have lower lumbar BMD than normal controls. SLE patients with longer disease duration have lower BMD. In order to achieve early prevention of osteoporosis, we suggest that female SLE patients with disease duration for more than 3.5 years should take a BMD examination.

A 66-year-old Chinese male, diabetic and hypertensive for more than 10 years, had excision of right cerebellar abscess in 1985. Histology then was suggestive of Aspergillus colonies. He presented to the ENT Department 7 years later, in September 1992, with complaints of a left-sided neck lump and fullness for 3 months which was shown on histology and culture to be Aspergillosis. CT scan findings revealed extradural involvement with erosions of parts of the cervical vertebrae. The patient, however, did not show any signs of spinal cord involvement. This case illustrates the long indolent period which Aspergillus infection can take. It also highlights the fact that it can mimic the radiological features of a highly malignant lesion. Follow-up CT scans of the patient revealed resolution of the lesion with itraconazole therapy.

We evaluated the neuroimages of 18 pathologically proven cases of ependymoma, 15 cases by CT evaluation and 9 cases by MRI evaluations. In 7 cases of supratentorial ependymomas, 4 were intraparenchymal and 3 were intraventricular ependymomas originating from the ependymal lining layer, the floor of the lateral ventricle, which was best demonstrated on a sagittal MR image. For the cases of infratentorial ependymomas, all were intraventricular. Evidence of seeding through the cerebrospinal fluid pathway to the basal cisterns, spinal cord or ventricles was presented in 6 cases which were particularly well demonstrated in the sagittal section with gadolinium-DTPA enhanced MR imaging. On CT scan, isodense tumors with various portions of high enhancement within a moderate enhancement mass were the most frequent features. In MRI, isointensity relative to gray matter on T1-weighted images and hyperintensity on mild and heavy T2-weighted images were most frequently seen. The signal heterogeneity representing soft tissue, small cysts, necrosis, calcification, vessels or hemosiderin was better visualized in MRI which offered a better assessment of the character of tumor compositions. The soft tissue mass, calcification and cysts as revealed in both CT and MRI are nonspecific, but the location, ages, CSF seeding and particularly, superior MR images can offer very important clues for the diagnosis of ependymoma.

The imaging features in 12 adult patients with histologically documented hepatocellular carcinoma (HCC) and head and brain metastasis are presented. Usually, the metastatic lesions showed as an isodense tumour mass on CT and high density following i.v. contrast. There were 6 patients (50%) with evidence of tumour haemorrhage. HCC should be considered in the differential diagnosis of metastatic lesions of the head and brain, particularly when evidence of haemorrhage appears in the image study.

Osseous hemangioma is a benign neoplasm, rarely located in the ribs. A 56-year-old female patient without specific complaint had a large extrapleural lesion on chest posteroanterior radiograph. Expansile destruction of left seventh rib and relatively fine trabeculation were noticed in the mass from plain roentgenogram and computed tomography (CT). Contrast enhancement in noncalcified component of the lesion was revealed. Pleural effusion, lung parenchymal or mediastinal abnormality were not identified. Resection of the lesion with part of the originating rib was carried out. The pathologic diagnosis was cavernous hemangioma. We present a case with a large rib hemangioma which often leads to difficulty in radiologically differential diagnosis with other common malignant rib tumors. We also review the literature about hemangioma and malignant neoplasms of the ribs.

The diagnosis of leptomeningeal or ventricular metastasis by cranial computerized tomography (CT) contributes to earlier treatment and sometimes alters the management of patients with intra- or extra-cranial malignancy. In 20 cases whose metastasis were spreaded via CSF seeding, the abnormal CT findings were 1) mass or nodule in the ventricles or subarachnoid space, 2) ependymal, subependymal enhancement, 3) sulcal, gyral or cisternal enhancement, 4) hydrocephalus not related to the obstruction of primary tumor, 5) falx or tentorial enhancement. In another 8 cases, the metastasis developed through hematogeneous spreading to the choroid plexus or paraventricular parenchyma. The mass or nodule within the ventricles could be well identified with enhanced CT scan. The involved ventricles, in order of frequency, were lateral, 3rd, and 4th ventricles in our series.

Magnetic resonance (MR) imaging of the thighs of 26 baseball athletes and one softball athlete were studied to evaluate muscle injuries. We documented the abnormalities present in MR imaging after a muscle injury and evaluated the role of MR imaging in muscle injuries. Fifteen of the athletes showed muscle abnormalities in MR images. These include muscle strains without tear, muscle tear, scar and chronic tendon injury. Having the advantages of high tissue contrast and multiplanar display capability, MR allowed direct visualization of the injured muscles and characterization of traumatic lesions. We conclude that MR could be a good imaging modality for evaluating muscle injuries.

Twenty-six cases with leptomeningeal metastasis were analyzed and Gd-DTPA enhanced MR imaging was found to be the most useful tool for making the diagnosis. The important manifestations in order of frequency were: 1) leptomeningeal enhancement; 2) ependymal enhancement; 3) plaque, nodule or mass in the subarachnoid space or ventricles; 4) nerve root thickening; and 5) ventricular dilatation not related to the obstruction of the primary neoplasm. A review of the literature has shown that intracranial leptomeningeal metastasis from spinal cord astrocytoma are very rare. In our series, 3 cases with primary brain tumors developed spinal subarachnoid involvement. This paper also reviews 1 case with thoracic cord astrocytoma which developed multiple intracranial leptomeningeal metastasis.

High-resolution computed tomography (HRCT) was used to study 23 patients with congenital temporal bone deformities. One patient had an inner ear abnormality and 3 patients were combined together with inner, middle and external ear malformations. Embryological development of the outer and middle ears is linked. Development of the inner ear occurs independently. These abnormalities included vestibule dilatation in 2 patients, a lateral semicircular canal defect in 1 case, dilatation of lateral and superior semicircular canals in 1 patient, only dilatation of the lateral semicircular canal in 1 case, oval-window non-development in 3 cases, oval aqueduct dilatation in 1 patient and inner ear abnormalities in 1 case. The study also included 17 cases of unilateral external auditory canal atresia, 5 cases of bilateral atresia, and 1 normal external auditory canal. There were 8 cases of unilateral and 2 cases of bilateral bony atresia. There were 9 unilateral and 1 bilateral cases of membranous atresia. Two cases had bony atresia on one side, with contralateral membranous atresia on the other. Nine unilateral and 2 bilateral cases were positioned superiorly and posteriorly of the mandibular condyle. Thick atresic plate were found in 10 unilateral and 2 bilateral cases. Small tympanic cavities were found in 12 unilateral and 2 bilateral patients; 7 unilateral and 2 bilateral cases had acellular and hypoplastic mastoids. Ossicular deformities were seen in 14 unilateral and 2 bilateral patients. One patient had no ossicle. Anteriorly located descending facial nerve canal was noted in 9 unilateral and 2 bilateral cases. Congenital cholesteatoma was identified in 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)