SCREENING MAMMOGRAPHY OF BREAST IMPLANTS im a long or short Breast surgery by benbenzhou


SCREENING MAMMOGRAPHY OF BREAST IMPLANTS im a long or short Breast surgery

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									AJA:159,      November        1992                        SCREENING         MAMMOGRAPHY          OF BREAST            IMPLANTS                                                        977

    Fig. 6.-A,         Coned-down         mam-
mogram       of a ruptured      subglandular
implant shows coalescence                of nu-
merous        silicone     granulomas        (ar-
row) and fine, linear calcification            of
periprosthetic           capsule        (arrow
    B, Coned-down           mammogram          of
same patient with long-standing               im-
plant rupture shows opacification              of
numerous     axillary lymph nodes              by
uptake of silicone gel (arrows).

    Fig. 7.-Craniocaudal                mammo-
gram      of both   breasts     shows      intact
silicone     gel implants        with     combi-
nation of plaquelike      (arrows)      and
sawtooth     (arrowheads)       calcifica-
tions in periprosthetic    capsule.

implant  diverticula                 (herniations)       [1 2-1   41, and ruptured      im-    of the vigorous compression                  used for mammography.                 Implant
plants [15-18].                                                                                rupture may be associated                  with progression            of existing     her-
   The prevalence              of a periprosthetic           rim was similar    in women       niation of the sac. The degree of compression                               used during
with       a long or short              history      of implantation.     This suggests        mammography             of an augmented             breast is approximately             half
that in the subglandular                   position     this rim occurs     in the imme-       that used for a nonaugmented                    breast. Although          the compres-
diate postoperative                  period and persists.         A similar observation        sion used during mammography                          could potentially          result in
was made with respect to the prevalence             of herniation     found                   disruption        of the fibrous          capsule       or actual rupture            of the
in 1 7% of patients.     This also suggests    that hemiation        occurs                    implant, an informed             consent is not obtained             from the patient
quickly and persists.      There was a statistically     significant    cor-                   before     the examination             is performed.          In our practice           one
relation    between    the presence     of a periprosthetic        rim and                     patient had sudden               softening      of one previously            firm breast
implant     hemiation.    This supports    the theory      that capsular                      during mammography.                   However,      the patient had a diagnostic
contracture      may correlate   with a periprosthetic       rim and that                     mammogram              and was not in the study group. The patient
closed capsulotomy         could result in hemiation      of the implant                       underwent        implant revision as a result of the difference                      in the
envelope     through   a fissure created during capsulotomy.             The                  shape of her breasts.                At surgery,      both implants          were intact.
degree of implant               hemiation           may be exaggerated         as a result    To our knowledge,              there is no report in the literature of implant
                                                                                              rupture incurred as a result of mammography.
                                                                                                  Implant failure was shown in 5% of patients,                          although      only
                                                                                              seven of the 1 8 ruptures               in five of the 1 6 patients             have been
                                                                                              surgically       confirmed.         This figure of 5% may not accurately
                                                                                              reflect the prevalence               of implant failure in the asymptomatic
                                                                                              population.        Factors       that may detract           from the study as an
                                                                                              accurate        representation          of the asymptomatic                 women       with
                                                                                              breast implants           include the possibility          that these women may
                                                                                              have self-selected             themselves         to have screening             mammog-
                                                                                              raphy. Inquiry as to whether                  they may have had a history of
                                                                                              trauma or closed capsulotomy                      was not made. Bias from the
                                                                                              fact that this is a regional subpopulation                     may be operative.
                                                                                                  The prevalence            of implant failure in 5% of patients                 may be
                                                                                              an underestimate             of the actual failure rate of breast implants
                                                                                              in the women studied.                 As implant rupture            may occur at any
                                                                                              point around           the periphery          of the implant,          the radiodense
                                                                                              implant may obscure                 the extravasated           silicone.     Even when
   Fig.     8.-Mediolateral             oblique                                               multiple      views are available,              1 00% of the periphery               is not
mammogram          of intact subglandular                                                     visualized.       Although        it is more likely that larger leaks would
implant    in patient       with no history
of implant revision shows a 5-mm-
                                                                                              be radiographically              discernible,       a small leak could be ob-
thick    periprosthetic         rim of soft                                                   scured, thus resulting              in an underestimate            of the actual prey-
tissue (arrows)        adjacent      to antero-                                               alence of failed implants.
inferior   aspect      of envelope.        Note
benign     calcifications         within   peri-                                                 Of the three       women       with mammographic              abnormalities        who
capsular fibrosis (arrowheads).                                                               underwent       surgical     biopsy, carcinoma           was found in two cases
978                                                                              DESTOUET        ET AL.                                                                    AJR:159,    November      1992

and lobular neoplasia (lobular carcinoma   in situ) was diag-                                          for augmentation               or reconstructive          mammoplasty.         Radiology     1989;
nosed in the third. Of the two cancers, one was stage 0 and
                                                                                                 7. Mitnick JS, Harris MN, Roses DF. Mammographic detection of carcinoma
the other was stage II.                                                                             of the breast in patients with augmentation prostheses. Surg Gynecol
  This study         determined       the prevalence           of certain   abnormal-                  Obstet 1989;168:30-32
ities specific      to implantation        of breast      prostheses           in asymp-         8. Leibman AJ, Kruse B. Breast cancer: mammographic                                  and sonographic
tomatic  women.   Women                 with subglandular            implants had a                    findings     after    augmentation         mammoplasty.        Radiology    1990;1 74:1 95-1 98
                                                                                                 9. Eklund          GW, Busby           RC, Miller SH, Job JS. Improved                 imaging of the
higher rate of sequelae               than did women             with submuscular
                                                                                                    augmented   breast.               AJR 1988;151       :469-473
implants. Overall, it appears that the submuscular      implants                                10. Gylbert L, Asplund        0, Jurell G, Olenius M. Results of subglandular breast
offer significant benefits, including improved visualization    of                                     augmentation    using a new classification  method: 18-year follow-up. Scand
the breast parenchyma on mammography.                                                                  J Plast Reconstr Surg Hand Surg 1989;23:133-136
                                                                                                11 .   Young VL, Bartell T, Destouet JM, Monsees B, Logan SE. Calcification of
                                                                                                       breast implant capsule. South Med J 1989;82:1 171-1173
                                                                                                12.    Smith DS. False-positive radiographic diagnosis of breast implant rupture:
ACKNOWLEDGMENTS                                                                                        report of two cases. Ann Plast Surg 1985;14:166-167
                                                                                                13.    Grant EG, Cigtay OS, Mascatello vJ. Irregularity of Silastic breast implants
  We thank Vicki Gardner for assistance in data collection                             and             mimicking   a soft tissue mass. AJR 1978:130:461-462
Sharon Keathley and Linda Macker for manuscript preparation.                                    14.    Destouet JM. Mammography of the altered breast. In: Syllabus for the
                                                                                                       Categorical    Course on Breast Imaging. Aeston,    VA: American   College                       of
                                                                                                       Radiology,    1990:77-84
REFERENCES                                                                                      15.    Monsees     BS, Destouet JM. Mammography     in aesthetic and reconstructive
                                                                                                       breast surgery. Perspect Plast Surg 1991;1 :103-119
 1 . Marik PE, Kark AL, Zambakides          A. Scleroderma  after silicone augmenta-            16. Andersen B, Hawtof D, Alani H, Kepetansky                           D. The diagnosis of ruptured
      tion mammoplasty:    a report    of 2 cases. S Afr Med J 1990;77:212-213                         implants.     Plast Reconstr         Surg    1989;84:903-907
 2. Silverstein MJ, Handel N, Gamagami P, et al. Breast cancer in women                         17. Shermis RB, Adler DD, Smith DD Jr, Hall JD. Intraductal silicone secondary
    after augmentation mammoplasty. Arch Surg 1988;123:681-685                                      to breast implant rupture: an unusual mammographic presentation. Breast
 3. Young VL, Lund H, Destouet JM, Pidgeon L, Ueda K. Effect of breast                                 Dis 1990;3:17-20
      implants   on mammography.       South   Med J 1991;84:707-714                            18. Jensen         SA, Mackey JK. Xeromammography                       after augmentation        mammo-
 4. Douglas KP, Bluth El, Sauter ER, et al. Roentgenographic        evaluation of                      plasty.     AJR 1985;144:629-633
    the augmented    breast. South Med J 1991;84:49-54                                          19. Hayes H Jr., Vandergrift                J, Diner WC. Mammography              and breast implants.
 5. Gumucio CA, Pin P, Young LV, Destouet JD, Monsees B, Eichling J. The                               Plast Reconstr          Surg    1988;82:    1-6
    effect of breast implants on the radiographic detection of microcalcification              20. Silverstein MJ, Gamagami P, Handel N. Missed breast cancer in an
    and soft-tissue masses. Plast Reconstr Surg 1989;84:772-778                                    augmented woman using implant displacement mammography. Ann Plast
 6. Dershaw DD, Chaglassian           TA. Mammography       after prosthesis     placement         Surg 1990;25:210-213

F                The reader’s      attention     is directed      to the commentary          on this article,               which     appears        on the following             pages.


Considerations                                               When               Imaging                       Women                   with Breast                   Implants
Lawrence                 W. Bassett1’2           and A. James               Brenner1’3

    Destouet et al. [1] report their experience                               in the interpre-                recommendation           supported      by the American    College of Ra-
tation of screening mammograms         obtained                               in 350 women                    diology (ACR).        Destouet    et al. [1 ] detected two breast cancers
with         breast        implants-the            largest      published        series      in the           among the 350 asymptomatic             women they examined.
literature. This report should                      be of interest to all radiologists                           It is important to emphasize that the examination of women
who interpret mammograms.                           An estimated one to two million                           with silicone gel implants requires special expertise by the
women in the United States                          have undergone augmentation                               mammography        technologist.     For screening mammography       of
mammoplasty,     most of these                      with silicone gel implants. Com-                          women with silicone gel or saline bag implants, four views,
plications           related     to silicone      breast     implants       include    fibrous     or         rather than two, should be taken whenever possible. At our
calcific capsular contracture,    rupture and leakage, localized                                              facilities, the examination       of a patient with implants begins
pain, and paresthesias.    In addition, it has been reported that                                             with mediolateral      oblique and craniocaudal      views of each
silicone         gel       implants       may    possibly       be associated             with   the          breast to include as much of the implant and surrounding
development     of generalized autoimmune   disorders [2]. Con-                                               breast tissue as possible. These views are taken with only
cern about the potential dangers of silicone gel-filled    breast                                             moderate compression,         intended to hold the breast still, with-
implants    has reached      the Food and Drug Administration                                                 out applying undue force on the implant. Additionally,            two
(FDA). On April 16, 1992, the agency announced          it would                                              “implant-displaced”         (modified   compression      or   push-back)
allow silicone gel implants to be available only under special                                                views are usually taken, as described         by Eklund et al. [5].
conditions [3]. Owing to the desire for implants on the part of                                               These additional views allow for taut compression         of breast
patients who have lost a breast because of cancer or trauma,                                                  tissue anterior to the displaced implant. Both implant-included
the devices will be available for women enrolled in clinical                                                  and implant-displaced    views are recommended,        since either
studies.                                                                                                      method used alone might result in a cancer being missed.
                                                                                                              Because    the technical requirements      are more complex than
                                                                                                              for a screening examination     of a patient without implants, we
Implants             and     Screening          Mammography                                                   believe the mammograms         should be reviewed for technical
                                                                                                              quality before the patient leaves the mammography         facility. In
          who have silicone breast implants are not at in-                                                    view of recent media coverage, patients with implants are
creasedrisk for breast cancer [4], but the FDA does recom-                                                    often anxious at the time of their mammographic       examination.
mend that women with implants have screening       mammo-                                                     For this reason, it is suggested that a radiologist be available
grams at regular guideline intervals, according  to age-a                                                     to answer questions that the patient may have.

      This article
                is a commentary    on the preceding article by Destouet et al.
     The Iris Cantor Center for Breast Imaging, Department
      I                                                            of Radiological Sciences, University of Califomia, Los Angeles, Medical Center, 165-49 200 UCLA
Medical Plaza, 10833 Le Conte Ave., Los Angeles, CA 90024-1721           . Address reprint requests to L. W. Bassett.
   2 University  of California, Los Angeles-Jonsson     Comprehensive     Cancer Center,   University of Calhfomia, Los Angeles, School of Medicine, Los Angeles, CA
      3   Tower Breast Imaging        Center,    Los Angeles,    CA 90024.
AJR       159:979-981,        November     1992 0361-803X/92/1595-0979                C American       Roentgen   Ray Society
980                                                                                BASSETT             AND    BRENNER                                                          AJA:159,     November      1992

Encapsulation               of Silicone         Gel     Implants                                             compression             approaches        that of a closed capsulotomy,                     then
                                                                                                             new      and    more     difficult     questions        must     be investigated           in the
    As reported in the article by Destouet et al. [1], fibrous                                               discussion        regarding          the propriety       of informed         consent.
tissue encapsulation  is a frequent complication of silicone gel
breast implants. The capsular membrane that forms around
breast implants may be soft and impalpable        or hard and                                                Informed        Consent
resistant.                     fibrous
                  It is uncertain          encapsulation
                                           why                 occurs
                                                                                                                The possibility  of implant rupture from mammographic
around implants, but it has been postulated            that capsule
                                                                                                             compression     has led some professional      liability carriers to
formation is due to a reaction   to silicone droplets       diffusing
                                                                                                             suggest, as a risk management       tool, that a signed consent
(“bleeding”) through the implant envelope or a result of low-
                                                                                                             form be obtained      prior to mammography         of women with
grade subclinical infection [6]. When a hard capsule forms,
                                                                                                             breast implants. Radiologists    have voiced concern over the
the breast may have an undesirable       contour and feel. In
                                                                                                             need for signed consents      as there are few state statutes,
addition,     a hard, fixed capsule precludes   the use of implant-
                                                                                                             regulations, or case laws mandating       employment      of such a
displaced      views during mammography.      ClOSed capsulotomy,
                                                                                                             practice,       and      considerable         anxiety      could      be generated             by
a procedure              by which the surgeon                      uses vigorous manual
                                                                                                             requiring such consent. Informed consent is generally consid-
compression              to disrupt the fibrous                    capsule, can result in
                                                                                                             ered a standard of care issue subject to potential negligence.
significant  hemiation of the implant,     resulting                              in mammo-
                                                                                                             These standards for disclosure and consent vary from state
graphic findings that are illustrated in the article                              by Destouet
                                                                                                             to state with respect to necessary information required, that
et al.
                                                                                                             is, what a “reasonable      physician” should tell a patient, as
                                                                                                             opposed     to what a “reasonable      patient” should expect to
                                                                                                             hear. Such subtle differences have far-reaching implications,
Implant      Rupture
                                                                                                             and radiologists should be familiar with the parameters used
    Rupture implies breakage of the implant envelope that                                                    in their own jurisdiction. Leading legal commentary     prescribes
surrounds the silicone gel. Recent unpublished     results have                                              that the standard of care for any action be related to the
suggested an increased prevalence of rupture in patients with                                                probability of an adverse event and the severity of such an
silicone gel implants who have undergone closed capsuloto-                                                   event. To the extent that such an adverse event has a
mies (De Camara DL et al., presented at the American Society                                                 reasonable    likelihood of occurring,    “material” or significant
of Plastic and Reconstructive    Surgery meeting, September                                                  complications     should be discussed. Such complications       have
1991). The potential for rupture of silicone gel implants from                                               already        been      mentioned.        The     product         of probability          times
mammographic                 compression              is not     known.      As Destouet          et         severity       approaches            zero if indeed            the probability          of such
al. indicate, there are no documented     cases of rupture due to                                            adverse        events      itself    approaches         an infinitely        small     number.
mammography        in the American literature. However, we areS                                              Thus, in the absence                 of documented             and reported          complica-
aware of unsubstantiated    cases of rupture attributed   to mam-                                            tions,      a general      requirement        to obtain          signed      consent      forms
mography,          including        one from          an individual       radiologic   practice              for the mammographic       procedure lacks a compelling indica-
listed among a compilation      of complications    reviewed at a                                            tion. No scientific evidence currently available indicates that
problem case conference      [7]. While new, nonimplanted      sill-                                         the appropriate    standard of care in imaging patients with
cone gel bags can withstand      considerable    compression, it is                                          silicone breast implants requires the use of signed consent
suspected that over time implanted silicone gel bags may be                                                  forms. At this time, the ACR does not recommend        obtaining
subject to fatigue and trauma that make them more vulnera-                                                   consent forms. Instead, attention to technical experience and
ble. Therefore, radiologists   should at least be aware of the                                               expertise, as mentioned earlier, should be the focus of atten-
potential         for     implant      rupture          during        mammography,           and             tion for the imaging facility.
should have a protocol within their facilities to deal with any
complications  that may arise on site. Clinical signs of implant
                                                                                                             Other       Imaging       Techniques
rupture include palpable silicone nodules, decreased breast
size,     asymmetry,              tenderness,           and      softer    texture.    It is of                 The limitations          of mammography               in the evaluation             of breast
interest that Destouet et al. encountered      a 5% prevalence of                                            implants   had led to interest                     in the use of other imaging
presumed     unsuspected     silicone extravasation   in their pa-                                           techniques   for these patients.                   Hams et al. [8] found sonog-
tients, suggesting a significant rate of asymptomatic      rupture.                                          raphy to be more sensitive than mammography               in the detec-
    Implants surrounded     by an intact fibrous capsule can                                                 tion of silicone leakage. Of 22 patients with 28 rupture sites,
undergo       rupture        of the implant            envelope       without     leakage    into            14 ruptures were missed on physical examination,            seven were
surrounding             tissues,      resulting         in an intracapsular            rupture.              missed with mammography,          and only one was missed with
Manual        capsulotomy     can convert   a contained  intracapsular                                       sonography.     Our own experience       with sonography        has not
rupture      into an extracapsular   rupture with leakage of silicone.                                       been as rewarding,       yet we are convinced that more investi-
The     fibrous         capsule     can    also       break      as a result       of mammo-                 gation of the use of sonography       is justified, particularly if the
graphic compression, an event that may be accompanied    by                                                  results can be correlated with findings at surgical removal. At
an audible popping sound. Thus, mammographic     compres-                                                    the University of California, Los Angeles, MR imaging exami-
sion could potentially   convert  an intracapsular                             rupture to an                 nations have been performed         in 1 40 symptomatic         women
extracapsular   rupture.    If the force     from                            mammographic                    with silicone    implants.   When   a combination        of pulse se-
AJR:159,       November     1992                       IMAGING      OF      WOMEN           WITH        BREAST          IMPLANTS                                                     981

quences,        including     water-suppression          techniques,     was used,                      lence and findings of implant complications.      AJR     1992;159:973-978
                                                                                                   2. Weiner SR. Silicone augmentation mammoplasty and rheumatic disease.
silicone leakage          into surrounding         breast tissue was identified
                                                                                                      In: Stratmeyer ME, ed. Silicone in medical devices: proceedings of a
in approximately           75% of patients         with this complication   [9].                        conference held in Baltimore,    MD,    Feb 1-2, 1991. BetheSda, MD: Depart-
                                                                                                        ment of Health and Human         Services   (Publication FDA 92-4249), 1991:
Conclusions                                                                                        3. Kessler DA. The basis of the FDA’s decision on breast implants. N EnglJ
                                                                                                      Med 1992;326:1713-1715
   The subject of silicone implant complications    has received                                   4. Berkel H, Birdsell DC, Jenkins H. Breast augmentation: a risk factor for
so much recent publicity that radiologists       are tempted to                                       breast cancer? N EngI J Med 1992:326:1649-1653
respond with approaches      lacking sufficient scientific docu-                                   5. Eklund GW, Busby RC, Miller SH, Job JS. Improved imaging of the
                                                                                                      augmented   breast. AJR 1988;151 :469-473
mentation.   The article by Destouet et al. is an important
                                                                                                   6. Mclnnis WD. Plastic surgery of the breast. In: Mitchell GW, Bassett LW,
contribution        to the investigations          required   to develop      appro-                  eds. The female breast and its disorders.   Baltimore: Williams & Wilkins,
priate understanding               of the imaging        and natural      history     of                1990:196-201
silicone implants.                                                                                 7. Renfrew      DL, Franken EA, Berbaum        KS, Weigelt MA, Abu-Yousef         MM.
                                                                                                      Errors in radiology: classification and lessons in 182 cases presented at a
                                                                                                      problem case conference. Radiology       1992;183:145-150
REFERENCES                                                                                         8. Harris KM, Ganott MA, Shestak K, Losken W, Tobon H. Detection            of
                                                                                                      silicone leaks: a new sonographic    sign. Radiology     1991;181(P):134
 1 . Destouet JM, Monsees BS, Oser RF, Nemecek JR, Young VL, Pilgram                               9. Gorcyzca DP, Sinha 5, Ahn C, et al. MR imaging of patients with silicone
     TK. Screening mammography in 350 women with breast uiplants: eva-                                breast implants. Radiology (in press)

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                                                                                                                                            Robert     N. Berk
        Radiologic-Pathologic                                        Conferences                           of the Massachusetts                                                     General                Hospital

Meckel’s                       Diverticulum
Felix    S. Chew1        and       Domenic          A. Zarnbuto

   A 30-year-old         woman            presented         with acute             periumbilical                 tion [2]. The              most        sensitive        methods           of radiologic          detection
abdominal    pain and low-grade      fever. No fl-human chorionic                                                are enteroclysis                   [3] and, if ectopic              gastric     mucosa         is present,
gonadotropin     was detected   in the serum and the WBC count                                                   99mTc-pertechnetate                     scintigraphy              [4].
was 8800/mm3;            however, the erythrocyte  sedimentation rate                                               Acute diverticulitis                  in a Meckel’s               diverticulum         may develop
was 51 mm/hr.           Transvaginal  sonography  showed a complex                                               in a manner      similar to idiopathic     acute appendicitis.      Intralu-
mass posterior          to the uterus with a target appearance   and                                             minal occlusion       without compromise        of the vascular      supply
acoustic       shadowing         (Fig.      1). The      uterus         and    ovaries         were              results in acute inflammation         that may progress        to necrosis
separately       identified    as normal. Findings                   on a supine abdom-                          and perforation.       When the inflammation         is confined     to the
inal    radiograph      were        normal.       The      differential            diagnosis       in-           mucosa           and submucosa,                 the gross appearance                     of the serosal
cluded bowel, appendiceal,                     or tubal lesions containing                    gas or             surface shows mildly                      dilated vessels. With progression     of the
calcium.     At surgery,         an inflamed        diverticulum        containing        a                      inflammatory process                      into and through the muscularis    propria,
fecolith but without          perforation      was found in the distal ileum.                                    the surface becomes                        red and hemorrhagic;   with further pro-
The final pathologic            diagnosis       was acute diverticulitis             in a                        gression,          the color darkens                 and ultimately              may become                black
Meckel’s      diverticulum.                                                                                      and     gangrenous.                  Perforation               occurs     as a late           event.        This
    Meckel’s      diverticulum       is a persistent          remnant      of the om-                            process           is different           from colonic               diverticulitis,       in which            the
phalomesenteric           duct (vitelline duct), a structure              that is nor-                           diverticula  are outpouchings                        of mucosa and submucosa     with-
mally obliterated         by the fifth week of gestation.               These struc-                             out a muscularis       propria,                    and perforation occurs early. The
tures occur in the distal ileum, about 1 m proximal                              to the                          treatment   is surgical.
ileocecal     valve, usually on the antimesenteric                     border.      Their
morphology         ranges from a broad-based                   saccule to an elon-                               REFERENCES
gated tubular         structure.      Heterotopic        gastric     mucosa       is fre-                         1 . Lewin        KJ, Riddell       RH, Weinstein         WM.      Gastrointestinal     pathology          and its
quently     present.      Meckel’s      diverticulum        is the most common                                         dllnical                New York: Igaku-Shoin, 1992:737-739
anomaly       of the gastrointestinal            tract, with a prevalence               of                        2. Weinstein EC, Cain JC, ReMine WH. Meckel’s diverticulum: 55 years of
about 2% in the general population                     [1]. Approximately           22%                              clinical and surgical experience. JAMA 1962;1 82:251-253
                                                                                                                  3. Maglinte DD, Elmore MF, lsenberg M, Dolan PA. Meckel diverticulum:
may be symptomatic;                the most frequently             treated     surgical
                                                                                                                     radiologic  demonstration     by enteroclysis. AJR 1980:134:925-932
complications         are bleeding              from     ulceration           of the gastric                      4. Sfakianakis GN, Haase GM. Abdominal scintigraphy for ectopic gastric
mucosa,        obstruction         due     to intussusception,                and      inflamma-                     mucosa: a retrospective      analysis of 143 studies. AJR 1982:138:7-12

   Fig. 1.-Acute    diverticulitis   in a Meckel’s diverticulum.
   A, Transvaginal   sonogram       shows a 3.7 x 2.8 cm rounded                      lesion (arrow)       posterior     to the uterus with a hyperechoic,  shadowing     central region.
   B and f, Gross specimen         shows an inflamed,    hemorrhagic                   diverticulum,      containing      a fecolith and extending  from the antimesentenc      border of the ileum
(m = mesentery,    i = ileum, d = diverticulum).

   From the weekly     radiologic-pathologic        correlation      conferences       conducted      by Jack     Wittenberg.         Pathology       editor:   Andrew          E. Rosenberg.      Radiology     editors:     Felix
S. Chew, William E. Palmer, Daniel P. Barboriak,                  Daniel I. Rosenthal.
    1 Both  authors:  Department         of Radiology,     Massachusetts            General    Hospital    and    Harvard         Medical     School,      32 Fruit      St.,    Boston,    MA 021 1 4. Address             reprint
requests   to F. S. Chew.
AJR 159:982,     November      1992 0361-803X/92/1            595-0982        C American       Roentgen      Ray Society

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