Arye Blachar

Preoperative localization of parathyroid adenoma in patients with concomitant thyroid nodular disease

We have previously demonstrated the role of high-resolution ultrasonography (US) in preoperative localization of parathyroid adenoma in patients with primary hyperparathyroidism (PHPT) and no thyroid abnormalities. The present study prospectively evaluated the possible additional value of 99mTc-sestamibi (MIBI) in patients with PHPT and concomitant multinodular thyroid disease (MND). Patients with PHPT underwent US and MIBI scintigraphy prior to neck exploration. Imaging data were correlated with the site and pathology of the parathyroid tissue removed and were analyzed separately for patients with MND and those with a normal thyroid gland. Among 77 patients with a solitary parathyroid adenoma at surgery, 40 had concomitant MND, whereas 37 patients had no morphologic changes in the thyroid gland, on US or at surgery. Prior to surgery, MIBI scintigraphy depicted 58 of the 77 adenomas (75%) and US localized 51 (66%); the combined sensitivity was 87% (67/77). Among the 37 patients with no thyroid nodules, MIBI located 29 (78%) and US identified 30 (81%) of the adenomas; the combined sensitivity was 89%. In the 40 patients with MND, MIBI identified 29 adenomas (73%) and US localized only 53% (21/40); the combined sensitivity was 85%. Overall, the positive predictive value (PPV) of MIBI for detecting a solitary parathyroid adenoma was 94%, for US it was 88%, and with the two tests combined it was 97%. In patients with no thyroid abnormalities, the PPV of MIBI and US was 97%, but it decreased to 91% and 78%, respectively, in patients with MND. Two patients with false-positive findings on both MIBI and US had associated thyroid disease. Hence MIBI scintigraphy contributes to localization of a solitary parathyroid adenoma mainly in patients with concomitant MND. The combined MIBI and US modalities result in sparing these patients bilateral neck exploration.

Radiologists’ performance in the diagnosis of acute intestinal ischemia, using MDCT and specific CT findings, using a variety of CT protocols

The aim of this study was to evaluate the performance of radiologists in the diagnosis of acute intestinal ischemia using specific multi-detector CT findings. The abdominal CT scans of 90 patients were retrospectively reviewed by three radiologists: an abdominal imaging specialist, an experienced general radiologist, and a senior resident. Forty-seven patients had surgically proven intestinal ischemia and comprised the case group, while 43 patients had no evidence of intestinal ischemia at surgery and comprised the control group. Images were reviewed in a random and blinded fashion. Radiologists’ performance in diagnosing bowel ischemia from other bowel pathologies was evaluated. The sensitivity, specificity, and accuracy for diagnosing bowel ischemia were 89%, 67%, and 79% for the abdominal imager; 83%, 67%, and 76% for the general radiologist; and 66%, 83%, and 74% for the senior resident, respectively. The calculated kappa value for inter-observer agreement regarding the presence of bowel ischemia was 0.79. CT findings that significantly distinguished bowel ischemia from other bowel pathologies were decreased or absent bowel wall enhancement, filling defect in the superior mesenteric artery, small bowel pneumatosis, and gas in the portal veins or superior mesenteric vein. For most of these signs, there was good inter-observer agreement. Radiologists’ performance in diagnosing bowel ischemia is good, but lower than previously reported since a significant amount of cases are evaluated using a suboptimal CT technique. Radiologists’ experience and expertise have an important impact on their performance.

Pre-operative sonographic diagnosis of incarcerated neonatal Spigelian hernia containing the testis

BackgroundSpigelian hernia (SH) is a ventral hernia that occurs along the semilunar line formed by the fibrous union of the rectus sheath and the anterior abdominal wall muscles, usually containing small bowel segments, omental fat or both. Spigelian hernias are rare in adults and exceedingly rare in children. A few case reports describing SH in the paediatric population have been published and an association with cryptorchidism has been very rarely reported.ObjectiveTo report three examples of SH.ResultsWe describe three examples of SH containing incarcerated testis in two neonates. These were diagnosed preoperatively with US. Ultrasound-guided reduction of the hernia contents was performed successfully in one case.ConclusionsUltrasound plays an important role in the diagnosis and management of these hernias.

Response to Temozolomide in Patients With Metastatic Colorectal Cancer With Loss of MGMT Expression: A New Approach in the Era of Personalized Medicine?

Introduction Treatment of metastatic colorectal cancer (mCRC) has been revolutionized in the last two decades by the introduction of new chemotherapeutic agents and target-specific therapies. Despite this progress, time to progression of disease during first-line treatment is 9 to 11 months and 3 to 4 months in second line. After resistance is acquired to two to three line treatments, patients can’t be offered any treatment known to additionally benefit them. In search for alternative effective treatments, we appeal occasionally to the Target Now examination, which examines tumor mutations known to be responsive to chemotherapy or biologic agents by advanced molecular biology profiling method. The tissue is analyzed by immunohistochemistry, fluorescence in situ hybridization, quantitative polymerase chain reaction, gene sequencing, and microarray analysis. We report two consecutiveoccasions,inwhichadecreasedexpressionofO-methylguanineDNA-methyl transferase (MGMT) was noted, and the use of temozolomide was recommended as treatment for metastatic colon cancer. To our surprise, both patients responded to single agent temozolomide with an impressive clinical response and partial tumor regression. We report these patients along with the rationale for alkylating agents administration as treatment for patients who exhausted other therapeutic options for their metastatic disease. This report may open the door to an effectivelinetreatmentforpatientswithcoloncancerdeficientinMGMT.

Real-time Sonography of Killian-Jamieson Diverticulum and Its Differentiation From Thyroid Nodules

Killian-Jamieson and Zenker diverticula are both rare pharyngoesophageal diverticula. Both are outpouching of the mucosal and submucosal layers of the esophageal wall, which protrude through a muscular gap at the level ofthe pharyngoesophageal esophagus. When these diverticula are large enough, they can be in proximity to the thyroid gland and may mimic a thyroid nodule. 1 , 2 Thyroid nodules, although shown well by high-resolution sonography, cannot be finally diagnosed by imaging modalities; therefore, most of them are further investigated with fine-needle aspiration (FNA). To our knowledge, 7 previous case reports of Zenker diverticulum diagnosed by sonography are reported in the literature. 3 - 6 There is no report regarding the sonographic diagnosis of Killian-Jamieson diverticulum. Both can be mistaken for a thyroid nodule. Our purpose is to focus radiologists attention on the possibility of a pseudo thyroid lesion originating in the esophagus and to describe the sonographic findings and advantages of real-time sonography in examining the thyroid to reach the correct diagnosis and avoid unnecessary invasive and possible dangerous procedures.

Clinical presentation can predict disease course in patients with intraductal papillary mucinous neoplasm of the pancreas.

BackgroundPreoperative diagnosis of malignancy within intraductal papillary mucinous neoplasm of the pancreas (IPMN) solely by clinical or radiological findings is not always possible. We sought a correlation between preoperative clinico-radiological findings and outcome.MethodsA prospective database of pancreatic resections for IPMN (2002–2008) and a retrospective pathological revision of all pancreatic cancer specimens (1995–2001) were analyzed. The patients were grouped into asymptomatic with preoperative diagnosis of IPMN (group 1), symptomatic with a preoperative diagnosis of IPMN (group 2), and those with a preoperative diagnosis of pancreatic cancer whose specimen revealed a background of IPMN (group 3). The groups were compared for demographics, clinical presentation, pathological findings, and outcome.ResultsOf the 62 patients with IPMN, 19 were in group 1, 23 in group 2, and 20 in group 3. Their median age (range) was 65.6 (46–80), 67 (50–84), and 73.4 (57–86) years, respectively. The clinical presentation for groups 2 and 3 included abdominal pain (56% vs. 32 %), weight loss (8% vs. 52%), obstructive jaundice (4% vs. 57%), pancreatitis (22% and 5%), and new onset of diabetes (14% and 44%). Invasive cancer was found in one patient in group 1 (5.2%), two patients in group 2 (8.7%), and all patients in group 3. IPMN was present in 23 of 217 (10.6%) of all resected pancreatic cancer specimens. Five year survival for patients with invasive disease was 47% and 92% for patients with noninvasive disease (mean follow-up 37.6 months).ConclusionsBenign IPMN can usually be differentiated from adenocarcinoma preoperatively. The clinical presentation is highly indicative of disease course.

Mass at the Splenic Hilum A Clue to Torsion of a Wandering Spleen Located in a Normal Left Upper Quadrant Position

Wandering spleen is an extremely rare condition in which the spleen is lacking its normal ligamentous attachments and therefore can move to an ectopic position in the abdomen or pelvis. Wandering spleen predisposes the patient to life-threatening complications due to torsion of the spleens vascular pedicle, with resulting splenic infarction, portal hypertension, and bleeding. Because of the nonspecific symptoms, imaging plays an important role. To our knowledge, only a few case reports describing wandering spleen in the pediatric population have been published, including 2 cases in infancy. We report a case of splenic torsion in an infant with a preoperative diagnosis made on the basis of color and power Doppler sonography. The diagnosis was confirmed by contrast-enhanced helical computed tomography (CT) and proved at surgery. On sonography, a diffusely hypoechoic spleen and a mass at the splenic hilum representing the torsed splenic pedicle were shown. The splenic hilar mass correlates with the CT whirl sign indicative of torsion.

Non-contrast Computed Tomography After Percutaneous Nephrolithotomy: Findings and Clinical Significance

OBJECTIVEnTo describe the post-percutaneous nephrolithotomy (PNL) non-contrast-enhanced computed tomography (NCCT) findings and assessed their clinical significance. NCCT evaluates stone clearance after PNL and also reveals procedure-related changes.nnnMETHODSnOne hundred consecutive patients who underwent PNL were evaluated by NCCT one day post-procedure. Two radiologists analyzed the type and severity of the NCCT findings, which were then statistically analyzed in relation to the patients clinical course.nnnRESULTSnThe patients mean age was 54 years (range 18-82) and the mean maximal stone diameter was 37 mm (range 15-70). The median operative time was 110 minutes for an immediate stone-free rate of 83%, changing to 94% (P = .073) after a second-look PNL in 11 patients. The post-PNL NCCT findings were hydronephrosis (70%), atelectasis (54%), ipsilateral pleural effusion (52%), paracolic gutter fluid (44%), perinephric hematoma (40%), perinephric fluid (32%), ureteronephrosis (31%), renal swelling (23%), contralateral pleural effusion (22%), residual fragments (RFs) (17%), subcapsular hematoma (10%), and flank hematoma (6%). Univariate analysis revealed a significant association with clinical variables for all NCCT findings except for atelectasis, ureteronephrosis, contralateral pleural effusion, RFs, and flank hematoma. In multivariate analysis, only perinephric fluid (P = .007) and ipsilateral pleural effusion (P = .034) were associated with longer hospitalization, and perinephric fluid with longer recovery (P = .004). The complication rate was 12%, but none were linked with the radiological findings.nnnCONCLUSIONnThis work describes the post-PNL NCCT findings and their clinical significance. Perinephric fluid and ipsilateral pleural effusion were found to independently predict longer hospitalization and recovery time.

One stop screening for multiple cancers: The experience of an integrated cancer prevention center

BACKGROUNDnCancer is a leading cause of mortality worldwide. Screening is a key strategy for reducing cancer morbidity and mortality.nnnMETHODSnWe aimed to describe the experience of an integrated cancer prevention center in screening an asymptomatic population for the presence of neoplasia. One-thousand consecutive asymptomatic, apparently healthy adults, aged 20-80 years, were screened for early detection of 11 common cancers that account for 70-80% of cancer mortality.nnnRESULTSnMalignant and benign lesions were found in 2.4% and 7.1% of the screenees, respectively. The most common malignant lesions were in the gastrointestinal tract and breast followed by gynecological and skin. The compliance rate for the different screening procedures was considerably higher than the actual screening rate in the general Israeli population - 78% compared to 60% for mammography (p<0.001) and 39% compared to 16% for colonoscopy (p<0.001). Advanced age, family history of cancer and certain lifestyle parameters were associated with increased risk. Moreover, polymorphisms in the APC and CD24 genes indicated high cancer risk. When two of the polymorphisms existed in an individual, the risk for a neoplastic lesion was extremely high (OR 2.3 [95% CI 0.94-5.9]).nnnCONCLUSIONSnOne stop shop screening for 11 common cancers in the setting of a multidisciplinary outpatient clinic is feasible and can detect cancer at an early stage.

Femoral head density on CT scans of patients following hip fracture fixation by expandable proximal peg or dynamic screw

Computed tomography (CT) is currently considered to be an accurate method for evaluating bone density. We evaluated the CT measurements of bone density using the Hounsfield units (HUs) in 23 patients who had been operated in the past for an extra-capsular hip fracture. Twelve patients were treated with a dynamic hip screw and 11 with a proximal femoral expandable hip nail. All the CTs had been performed for non-orthopedic purposes. Bone density with a region of interest (ROI) could be assessed for both hips. We compared the bone density between the operated versus the non-operated sides as well as between the two surgical groups. Bone density was higher in the hip peg (the femoral component of the expandable nail) side 262.5 (range, 169-351) HU, compared to the opposite non-operated side and to the hip screw group 194 (range, 99-283) HU. The hip screw side had decreased bone density compared to the opposite non-operated side. We were able to define a density index and a difference index: both were higher in the hip peg group. These findings persisted over time. It would be interesting to speculate that increased bone density around an expandable peg provides better fracture stabilization and probably faster healing than a dynamic hip screw.