Six-monthly MRI detects metastases from high-risk uveal melanoma before the onset of symptoms, enhancing any opportunities for early treatment of metastatic disease and clinical trial participation. Whether these actually result in prolongation of life, after taking lead-time bias into account, requires further investigation.
It remains unclear whether MRI is essential in all patients with suspected malignant spinal cord compression (MSCC), or whether some patients can be treated on the basis of plain radiographic findings and neurological examination. A prospective study was carried out of 280 consecutive patients with suspected MSCC, and the results of neurological examination plus plain radiographs were compared with MRI. 201 patients had MSCC (186 extradural, 5 intradural extramedullary and 10 intramedullary) and 11 patients had thecal sac compression without evidence of spinal cord compression. 25% of patients with MSCC had two or more levels of compression, 69% of these involving more than one region of the spine. A paraspinal mass was noted at the site of extradural spinal cord compression in 28%, and only one-third of these were detected on plain radiography. Focal radiographic changes and consistent neurology were present in 91 (33%) patients who had not had previous radiotherapy. MRI confirmed the presence of MSCC in 89/91 patients (specificity and positive predictive value of radiographic/clinical findings 98%) and the level of disease in all. MRI led to a change in the radiotherapy plan in 53% of patients (21% major change). The sensory level when present was four or more segments below the MRI level in 25/121 (21%) patients, and two or more levels above in 8/121 (7%) patients. Although focal radiographic abnormalities with consistent neurological findings, when present, accurately predicted the presence and level of MSCC, whole spine MRI is indicated in most patients with suspected MSCC because the additional information may alter the management plan. Treatment may be appropriately initiated on the basis of focal radiographic changes and consistent neurology if MRI is contraindicated or delayed, and in patients with a poor prognosis. In patients in whom there are no focal radiographic abnormalities and consistent neurological findings, urgent MRI is mandatory before radiotherapy is commenced.
Seven hundred chest radiographs taken in a general hospital were reviewed, 100 (50 men and 50 women) from each of seven decades (3rd to 9th). Each radiograph was examined to determine the site and extent of calcific changes. Prevalence of costal cartilage calcification increased from 6% in the 3rd decade to 45% in the 9th and was commoner in men. Aortic calcification was absent below age 50 and increased from 4% in the 6th decade to 57% in the 9th. Both these trends were statistically significant. Other sites of calcification were found only in patients aged over 70; these included pleural, pericardial, tracheal, myocardial and diaphragmatic calcification.
A 62-year-old man presented with frank haematuria; a 2.5 cm papillary lesion was seen on¯exible cystoscopy, close to the right ureteric ori®ce. The tumour was resected, together with partial-thickness loop biopsies of the underlying muscle; histology con®rmed pTa G2 TCC. After the intravesical administration of 40 mg mitomycin C 24 h later, the catheter was removed. The patient voided with no pain and was discharged. When seen the following week he complained of right testicular and groin discomfort, which developed into a severe and unremitting pain over the course of the next month. There was no response to antibiotics and IVU showed mild right hydronephrosis. Cystoscopy at 9 weeks revealed a normal right ureteric ori®ce with an adjacent ulcer at the resection site. A ureteric stent was inserted and the ulcer biopsied, revealing necrotic and in¯am-matory cells only. On bimanual examination there was a hard, ®xed mass in the right hemipelvis. Severe pain continued even after removing the stent and commencement of continuous antibiotics and oxybutynin, so a urinary diversion was contemplated. CT, performed 19 weeks after surgery, showed a focal defect in the right bladder wall with abnormal perivesical enhancement and a small extravesical¯uid collection (Fig. 1a) which ®lled with contrast medium on voiding cystography (Fig. 1b). A catheter was left in situ for one month and removed after a normal repeat cystogram. At cystoscopy the necrotic ulcer was smaller and only slight residual pelvic thickening was palpable bimanually. The pain then resolved, but complete re-epithelialization of the ulcer was not apparent until 18 months after the resection. The patient remains well 48 months after presentation, but an epithelialized crater is still visible endoscopically (Fig. 2). CommentPersistent asymptomatic ulceration after the administration of intravesical chemotherapy is well known [1]. Furthermore, the presence of transmural muscle necrosis and perivesical fat necrosis has recently been reported in a b Fig. 1. a, CT showing thickening of the right lateral bladder wall, a focal bladder wall defect (arrow) and an adjacent extra-vesical¯uid collection. The external surface of the bladder wall and the obturator internus muscle are thickened and show enhancement of their opposing surfaces consistent with in¯ammatory change. b, Right anterior oblique view of a micturating cystogram showing contrast medium passing through a bladder wall defect into a paravesical collection.
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