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OBJECTIVE: The purpose of this study was to determine the frequency with which sonographic detection of a normal separate ipsilateral ovary enables the diagnosis of paraovarian cysts. MATERIALS AND METHODS: We reviewed the initial sonographic reports, sonograms, and medical records of 42 patients with surgically proved paraovarian cysts. All sonograms were obtained with a 3.5-MHz transabdominal probe. The location, size, shape, wall thickness, internal echoes of the cyst, and visualization or nonvisualization of the ipsilateral ovaries were recorded during sonographic examination. RESULTS: Forty-six paraovarian cysts were identified in 42 patients. One patient had bilateral cysts, and one had multiple (four) unilateral cysts. A teratoma in one patient and an ovarian cyst in another coexisted with a paraovarian cyst in the same adnexa. With the exception of these two, 31 (76%) of 41 ovaries abutted by cysts were detected. All detectable ovaries were normal. With one exception, all cysts were thin walled and unilocular, and 43 of 46 were anechoic. During surgery, two patients were found to have cyst torsion, two were found to have papillary serous cystadenoma, and one was found to have both. CONCLUSION: Unlike the findings of previous reports, our results indicate that most patients with paraovarian cysts have a separate, normal ipsilateral ovary that can be detected easily by means of transabdominal sonography, thus aiding in distinguishing paraovarian from true ovarian cysts.

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RATIONALE AND OBJECTIVES: The purpose of this study is three-fold: 1) to quantify the cardiorespiratory responses to rapid right atrial injections of meglumine/sodium diatrizoate, ioxaglate, iotrolan, and iopamidol; 2) to compare the effects of each contrast medium to that of its corresponding vehicle and saline; and 3) to evaluate the role of the vagus nerve in the cardiorespiratory responses. METHODS: Seventeen anesthetized dogs, breathing spontaneously, were used. Injections of 2.0 mL/kg were given into the right atrium in 2 seconds. Each contrast medium, along with its vehicle and saline, was tested on 4 dogs (5 dogs for diatrizoate). Blood pressure, air flow, tidal volume, upper airway pressure, esophageal pressure, mean arterial pressure and heart rate, breathing frequency, dynamic lung compliance, upper airway resistance, and total lung resistance were recorded or calculated. RESULTS: Diatrizoate and its vehicle caused a significant increase in blood pressure, tidal volume, esophageal pressure, and a decrease in mean arterial pressure with an increase in heart rate. These responses were not mediated by vagal afferents. Ioxaglate and iotrolan, but not their vehicles, increased breathing frequency; this response was abolished by vagal block. Ioxaglate decreased mean arterial pressure and increased heart rate; the decrease in mean arterial pressure was still present during vagal block. Iopamidol and its vehicle did not alter respiratory parameters. Iopamidol, but not its vehicle, caused only a minimal and transient increase in mean arterial pressure before and during vagal block. None of the contrast media changed upper airway resistance, total lung resistance, and dynamic lung compliance. CONCLUSION: Both diatrizoate and its vehicle elicited the largest changes in respiratory and cardiovascular functions, not mediated by vagal afferents and caused by osmolality of the solution. Ioxaglate, iotrolan, and iopamidol induced smaller cardiorespiratory changes, mediated by vagal afferents. Their respective vehicles did not cause any effects, which suggests that the chemical structure plays a role. Nonionic contrast media elicited only minor and transient cardiorespiratory alterations.

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The author's approach and technique in the treatment of complex liver abscesses that persisted or recurred following percutaneous drainage are described. Six patients were treated by percutaneous debridement using an instrument specially designed for that purpose. Four patients were chronically ill but stable, while the other two were septic, hypotensive and considered to be life threatened. All patients had primary pyogenic abscesses. Four had demonstrated mixed bacterial flora consisting of E. coli, Klebsiella, Proteus and gram-positive cocci and two were caused by E. coli only. Contrast enhanced CT of the abdomen in all cases revealed multiloculated or septated abscesses containing large central debris and peripheral shell or halo of compromised hepatic parenchyma. Debridement was successful in all cases, resulting in complete healing within 12 days. Follow-up for 1-4.5 years revealed no recurrences. Three cases of infected tumors of the liver were referred for treatment. CT findings in these cases demonstrated a well developed external capsule and internal septations, and the absence of a surrounding halo of compromised parenchyma distinguishes them from primary abscesses. This preliminary experience makes the authors to conclude that percutaneous debridement of pyogenic liver abscesses is a safe and curative procedure in selected cases of life-threatening chronic liver abscesses.

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Safe angioplasty of a portacaval shunt requires particular knowledge of the tissue characteristics of an anastomosis and the behavior of a balloon during inflation. The nature and true diameter of a portacaval shunt anastomosis are more difficult to evaluate than those of a peripheral arterial lesion, and complications are potentially more hazardous than those related to peripheral arterial angioplasty. We suggest that in some instances low pressure and incomplete balloon inflation are all that is necessary to yield safe and satisfactory results.

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Three cases of pancreatic carcinoma that arose in the tail and extended into the adjacent left kidney are presented. Because of misleading symptoms and radiographic features, the tumors were misdiagnosed as primary renal tumor. In most cases, computed tomography (CT) provides the correct diagnosis and prevents unnecessary surgery.

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Two cases of fibrolamellar carcinoma (FLC) of the liver reported here illustrate that this rare neoplasm is a distinct variant of the usual hepatocellular carcinoma (HCC). It occurs in younger individuals, is unrelated to liver cirrhosis and has a remarkably better prognosis due to a higher surgical resectability rate. It is sonographically hyperechoic and demonstrates angiographic and computed tomographic features of a very vascular tumor. The differential diagnosis includes focal nodular hyperplasia, hepatic adenoma, hepatocellular carcinoma and hemangioma.

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A technique for the biopsy of abdominal masses consisting of the simultaneous insertion of multiple needles is described. This technique was employed in 45 patients. The results were compared with the author's preceding experience with 32 cases performed with a conventional technique of sequential biopsies. Adequate specimens were obtained in 42 (93.3%) cases with the multiple simultaneous percutaneous needle biopsy (MSPNB) technique. This compares with a diagnostic adequacy yield of 84.3% for the sequential technique. In 25 cases performed under CT guidance, the average CT utilization time was 12 minutes, and the average number of slices was 3, as compared to 45 minutes and 12 slices with the conventional sequential technique. No complications were encountered. We conclude that the MSPNB technique is a safe time- and cost-effective technique with a high yield of adequate and diagnostic specimens.

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With the widespread acceptance of ultrasonography and computed tomography for the evaluation of renal masses, the role of guided renal cyst puncture in the evaluation of a suspected renal cyst has undergone revision in recent years. In this article, the authors review the technique, interpretation, and complications of diagnostic cyst puncture and attempt to define its current diagnostic and therapeutic indications.

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A case of an asymptomatic posterior mediastinal thoracic duct cyst diagnosed with fluoroscopically guided needle aspiration is reported. Previously, the diagnosis of thoracic duct cyst was established surgically and more recently was established by lymphangiography. To the authors' knowledge, diagnosis using needle aspiration has not been reported.

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Isolated segments of the right jugular veins of six mongrel dogs were exposed to solutions of 60% diatrizoate (3 dogs) and 60% iopamidol (3 dogs) in vivo. Normal blood flow was re-established after 3 minutes of exposure to the contrast material. The left jugular veins served as controls. Veins were harvested at 1, 24, and 48 hours and studied by light and scanning electron microscopy. Changes consisting of cellular swelling, denudation, platelet aggregation and fibrin deposition were uniform and prominent with diatrizoate. Response to iopamidol was minimal consisting only of cellular swelling. The study suggests that post-phlebographic thrombophlebitis may be reduced by the use of nonionic contrast materials.

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The clinical and radiographic features of Wilms' tumor in 4 adult patients are described. Wilms' tumors in adults are usually bulky and contain numerous areas of necrosis and hemorrhage, imparting a complex appearance to the lesion on sonography and computed tomography. Angiography reveals the tumor to be hypovascular with some neovascularity. No specific features of the lesion differentiate it from hypernephroma. In contrast to the childhood variety, Wilms' tumors in adults have ill-defined margins and frequently extend into the retroperitoneum. Their treatment is the subject of debate and prognosis is poor.

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The sciatic artery is a persistent fetal vessel that usually constitutes the end arterial supply to the lower extremity and replaces the femoral artery, which is usually present but hypoplastic. It is prone to vascular disease, such as aneurysm and arteriosclerosis. The artery can be demonstrated angiographically by transfemoral catheterization or translumbar aortogram with peripheral studies. Bilateral aortoperipheral studies are necessary because the anomaly is often bilateral. Surgical therapy was carried out on ten of 18 patients. The recommended technique is a femoropopliteal vein bypass. When an aneurysm is present, either ligation of the aneurysm or aneurysmorrhaphy accompanied by femoral popliteal bypass is the recommended procedure.

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It is well known that inflammatory diseases of the kidney may involve the perirenal space and spread contiguously to other organs, such as the stomach, colon, gallbladder and duodenum. It is less well known that fistulas may develop between the kidney and the lung. Presenting symptoms may suggest either renal or pulmonary disease. Two cases are reported. Familiarity with this entity should help to avoid misdiagnosis, especially when presenting symptoms are related to the respiratory system.

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A case is described of thyroid carcinoma presenting as renal metastases 37 years after initial resection of the primary. Thyroid carcinoma metastatic to the kidney detected during life is rare, only 2 cases having been reported to date. An additional feature of this case is that the patient had donated the contralateral kidney for transplantation before discovery of the metastases. Metastatic thyroid carcinoma is reviewed and the implication of organ donation in patients with thyroid carcinoma is discussed.

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Two cases of small peripheral papillary renal carcinoma causing large spontaneous perirenal hemorrhages are presented. The value and limitations of computerized tomography, ultrasonography, arteriography, and percutaneous aspiration biopsy in these cases are discussed. The need for careful explorative surgery and dissection of the specimen is emphasized. Excretory urography should be the first examination in all patients with renal pain and signs of internal bleeding. Arteriography should be done when the diagnosis is not evident.

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In 2 patients with the malignant carcinoid syndrome, a Swam-Ganz balloon tip, flow-directed catheter was used to occlude hepatic arterial flow and perfuse hepatic metastases with 5-fluorouracil. The first patient, symptomatic for 16 months, was rendered asymptomatic for 14 months after treatment. The second patient was relieved of severe diarrhea and generalized urticaria, but progression of the cardiac manifestations were unaffected. Symptoms of the carcinoid syndrome are usually the most debilitating aspect of this illness. When more conservative measures cannot alleviate their symptoms, hepatic artery occlusion with chemotherapeutic perfusion of metastases should be considered.

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