Bo-Kyung Je

Immersion ultrasonography of excised nonpalpable breast lesion specimens after ultrasound-guided needle localization.

Objective Ultrasound-guided needle localization has been used prior to the surgical excision of nonpalpable breast lesions. The aim of the study was to assess the feasibility of the use of a saline immersion specimen ultrasound technique (immersion-US) to confirm the successful removal of breast lesions. Materials and Methods The devised immersion-US technique was used to examine the excised tissues of 72 ultrasound-guided needle localized breast lesions of 58 patients (34 benign lesions, 30 high-risk lesions and 8 malignant lesions). Freshly excised specimens were placed in a container filled with saline and one radiologist scanned the surgically excised specimens using a high-frequency linear transducer. We evaluated successful lesion removal and the qualities of the immersion-US images. Miss rates were determined by the use of postoperative ultrasound during follow-up. Results All 72 lesions were identified by the use of immersion-US and satisfactory or excellent quality images were obtained for most lesions (70/72, 97%). Five (7%) lesions were initially identified as incompletely excised, based on the immersion-US findings, and prompt re-excision was undertaken. Follow-up ultrasound examinations showed no residual mass in the surgical field in any patient. Conclusion The immersion-US technique was found straightforward and efficient to perform. Immersion-US was able to determine whether nonpalpable breast lesions had been successfully excised after ultrasound-guided needle localization.

Detailed nodal features of cervical tuberculous lymphadenitis on serial neck computed tomography before and after chemotherapy: focus on the relation between clinical outcomes and computed tomography features.

Objective: To investigate the relation between clinical outcomes and nodal features on computed tomography (CT) in cervical tuberculous lymphadenitis (CTBL) before and after antituberculous chemotherapy. Methods: Fifty-six patients with CTBL underwent CT before and after a 6- or 12-month course of standard chemotherapy. Three radiologists evaluated the nodal features on serial CT retrospectively, including calcification (no/punctuate/large), necrosis (no/eccentric/central), perinodal infiltrations (no/localized/extensive), and enhancing patterns (no/peripheral/homogeneous). The clinical outcome was defined as “favorable” (n = 33) or “unfavorable” (n = 23) at the completion of chemotherapy. Results: All the features on the initial CT scan did not show a statistically significant difference between the favorable and unfavorable groups. On the final CT scan, absence of necrosis (P < 0.005), no infiltration (P < 0.005), no enhancement (P < 0.008), and central enhancement (P < 0.014) were more common in the favorable group, whereas large necrosis (P < 0.005), localized and extensive infiltration (P = 0.005, P < 0.005), and peripheral enhancement were more common in the unfavorable group (P < 0.005, P = 0.009). Conclusions: Central necrosis, perinodal infiltration, and peripheral rim enhancement on the final CT scan showed differences between the 2 groups. These CT features reflecting inflammation can be useful findings for assessing treatment response.

Comparison of computed tomography findings between bacteremic and non-bacteremic acute pyelonephritis due to Escherichia coli.

AIM To identify computed tomography (CT) findings that are associated with the presence of bacteremia in patients with acute pyelonephritis (APN) due to Escherichia coli (E. coli). METHODS The clinical data and contrast-enhanced CT findings of 128 patients who were diagnosed with APN due to E. coli and showed renal abnormality on contrast-enhanced CT between January 2003 and November 2013 were retrospectively reviewed. The patients were divided into two groups according to the presence of bacteremia: The bacteremia group and the non-bacteremia group. The abnormality on contrast-enhanced CT were categorized into 5 renal and 4 extrarenal CT findings and compared between the two groups using the χ (2) test and multivariate logistic regression. RESULTS Among the 128 patients, 34 patients (26.6%) were classified into the bacteremia group and 94 patients (73.4%) into the non-bacteremia group. There was no statistically significant difference in gender between the two groups (P = 0.09), but the age of the patients in the bacteremia group was higher than that of the patients in the non-bacteremia group (P < 0.01). Compared to the non-bacteremia group, 1 renal CT finding such as urothelial thickening and 3 extrarenal CT findings such as diffuse peritoneal thickening, cystitis and pulmonary congestion were more frequently observed in the bacteremia group with statistical significance. The logistic regression analysis revealed that CT findings, including urothelial thickening, diffuse peritoneal thickening, cystitis and pulmonary congestion were suggested as the predictive CT findings of bacteremic APN. CONCLUSION On CT, urothelial thickening, diffuse peritoneal thickening, cystitis, and pulmonary congestion are more frequently observed in patients with bacteremic APN due to E. coli.

Unilateral occipital condylar dysplasia: 3‐dimensional multidetector CT and MR findings

Occipital condylar dysplasia is a rare congenital anomaly that is caused by failure to form lateral elements of the 4 occipital sclerotome from the 4 week of gestation (Tubbs et al. 2013). This flattened and underdeveloped condyle occurs as an isolated anomaly or as part of complex Atlanto-occipital abnormality (Shapiro and Robinson 1976). Although its clinical manifestations are headache, stiff neck, torticollis, ataxia, and neurological signs associated with cervicomedullary compression, this congenital anomaly is difficult to be recognized, due to late onset of symptoms that usually occurs no sooner than the second decades (Kruyff 1965; Shapiro and Robinson 1976). Therefore, imaging examination is mandatory for its diagnosis. A 6-year-old girl underwent brain magnetic resonance imaging (MRI) to evaluate a recent episode of lateral deviation of the left eyeball. Contrast-enhanced brain MR images showed displaced medulla oblongata and upper cervical cord by a bony protrusion into the foramen magnum (Fig. 1a,b). Multidetector computed tomography (CT) with three-dimensional reconstruction revealed that the left occipital condyle is asymmetrically small as compared with the right one, so the craniovertebral junction (CVJ) was tilted with the SchmidtFisher angle of 130° which is no more than 125° in normal CVJ. The bony protrusion on MR was the medial part of the left occipital condyle, which was due to the pressure by atlas, leading to displaced medulla, tilting of atlas and axis, and atlanto-axial subluxation (Fig. 1c–e). Due to the tilting atlas, the course of the left vertebral artery and the canal for the left hypoglossal nerve were aberrant and elongated, as compared with the normal contralateral ones (Fig. 1f). Considering the lateral displacement of brainstem and cervical cord, we are planning an operation to decompress the deformity in order to prevent cord compression and attain stability of CVJ. Craniovertebral junction is comprised of occiput, atlas, axis, and supporting ligaments (Smoker 1994). Anatomically, this articulation surrounds the cervicomedullary junction, including medulla oblongata, spinal cord, and lower cranial nerves (Smoker 1994; Tubbs et al. 2013). Functionally, CVJ keeps movement of the head on the neck and the stability of the vertebrae, thus protecting the spinal cord (David et al. 1998). As a part of CVJ, occipital condyles articulate with the superior faces of the atlas to form the atlanto-occipital joints that contribute to the flexion and extension of the head and neck (Tubbs et al. 2013). Thus, occipital condylar hypoplasia can lead to instability of CVJ and compression of the cervicomedullary junction as well as adjacent vascular structures, resulting in various neurological disorders such as ataxia, spastic quadriparesis and lower cranial nerve palsies (Kruyff 1965). However, symptoms usually begin insidiously and generally occur near adolescence when the axial growth is accelerated (Ryken & Menezes, 1993). In our case, the symptom that made the patient visit the hospital was lateral deviation of the left eye. In addition, she had developmental delay, dysarthria, and left leg disturbance for a while without being evaluated. However, we could not identify any relations between these symptoms and the cervicomedullary displacement due to occipital condylar anomaly. Physical examination revealed torticollis that was so subtle that her parents did not even notice it before. We concluded that the left occipital condylar dysplasia in this case was an incidental finding not associated with the seizure, developmental delay, dysarthria, and shuffled leg of the patient. Since Kruyff first introduced plain radiographs of occipital dysplasia in 1965, CT is considered as the best modality to evaluate the articulations of CVJ and to investigate occipital condylar hypoplasia (Kruyff 1965; Ilkko et al. 1998). Currently, with the widespread availability of multidetector CT, we can obtain state-of-the art 3D images of CVJ, as shown in this case. In addition, MR can reveal detailed features of brainstem, spinal cord, lower cranial nerves, and ligaments in multiple orthogonal planes. In conclusion, occipital condylar dysplasia is a rare congenital anomaly that can occur in CVJ as an isolated anomaly or as part of a syndrome. Since its symptoms are diverse with late manifestation, physicians should be aware of imaging features of congenital abnormalities in CVJ. 3D CT and MR features can demonstrate detailed articulation in CVJ. A visualization of neurovascular structures surrounding CVJ is essential for surgical planning.