D. Masulovic

The Utility of 18F-FDG PET/CT for Diagnosis and Adjustment of Therapy in Patients with Active Chronic Sarcoidosis

The purpose of this study was to assess the utility of 18F-FDG PET/CT for detection of inflammation in granulomatous sites and management of patients with chronic sarcoidosis. The 3 specific aims were to assess differences between 18F-FDG PET/CT and multidetector CT (MDCT) findings, to compare 18F-FDG PET/CT results with serum levels of angiotensin-converting enzyme (ACE), and to determine whether 18F-FDG PET/CT findings are associated with the decision to change therapy. Methods: We studied 90 sarcoidosis patients (mean age ± SD, 47 ± 12 y; 32 men and 58 women) with persistent symptoms who were referred for 18F-FDG PET/CT evaluation to assess the extent of inflammation. They also underwent MDCT and measurement of serum ACE level. After the follow-up (12 ± 5 mo after 18F-FDG PET/CT), the clinical status and changes in therapy were analyzed. Results: 18F-FDG PET/CT detected inflammation in 74 patients (82%) (maximum standardized uptake value, 8.1 ± 3.9). MDCT was positive for sarcoidosis in 6 additional patients (80, 89%). The difference between the 2 methods was not significant (P = 0.238, McNemar test), and their agreement was fair (κ = 0.198). Although ACE levels were significantly higher in patients with positive than negative 18F-FDG PET/CT results (P = 0.002, Mann–Whitney test), 38 patients (51%) with positive 18F-FDG PET/CT results had normal ACE levels. The therapy was initiated or changed in 73 out of 90 patients (81%). Both univariate and multivariate logistic regression analyses indicated that positive 18F-FDG PET/CT results were significantly (P < 0.001) associated with changes in therapy, with no contribution from age, sex, ACE level, CT results, or previous therapy. Conclusion: Our results indicate that 18F-FDG PET/CT is a useful adjunct to other diagnostic methods for detecting active inflammatory sites in chronic sarcoidosis patients with persistent symptoms, especially those with normal ACE levels. 18F-FDG PET/CT proved advantageous for determining the spread of active disease throughout the body and influenced the decision to adjust the therapy.

The accuracy of ultrasonography in classification of groin hernias according to the criteria of the unified classification system

BackgroundThe modern concept of type-related individualized groin hernia surgery imposes a demand for precise and accurate preoperative determination of the type of groin hernia. The aim of this prospective study was to evaluate the accuracy of ultrasonography in classification of groin hernias, according to the criteria of the unified classification system. Unified classification divides groin hernias into nine types (grades): type I (indirect, small), II (indirect, medium), III (indirect, large), IV (direct, small), V (direct, medium), VI (direct, large), VII (combined-pantaloon), VIII (femoral), and O (other).Patients and methodsOne hundred and twenty-five adult patients with clinically diagnosed or suspected groin hernias were examined. Ultrasonography of both groins was performed with a 5 to 10-MHz linear-array transducer. Preoperative ultrasonographic findings of type of groin hernia were compared with the intraoperative findings, which were considered the gold standard.ResultsTotal accuracy of ultrasonography in determination of type of groin hernia was 96% (119 of 124 correct predictions of type of groin hernia compared with surgical explorations). All hernias of types I, IV, V, VII, and VIII were correctly identified with ultrasonography (sensitivity and specificity 100%). In the remaining five cases of the 124 (4%), hernia was incorrectly classified with ultrasonography: type VI (direct, large) was misdiagnosed as type III (indirect, large) in three cases, type III as type VI in one case, and type III as type II (indirect, medium) in one case. The sensitivity and the specificity of ultrasonography in classifying type II were 100 and 99%, respectively, for type III, 85 and 97%, and for type VI, 90 and 99%.ConclusionUltrasonography of the groin regions could be used with great accuracy for precise classification of groin hernias in adults. Each type of groin hernia, according to the unified classification system that we used for classification, has a characteristic ultrasonographic presentation, which is demonstrated in this study.

Planned staged reoperative necrosectomy using an abdominal zipper in the treatment of necrotizing pancreatitis

PurposeThe optimal operative treatment for severe necrotizing pancreatitis (SNP) still remains controversial. This article describes the operative approach with a planned staged necrosectomy using the “zipper” technique.MethodsBetween 1996 and 2000, 35 patients with SNP were treated with this approach. The patient demographics, etiology and severity of SNP, hospital course, and outcome were recorded and comparisons of several parameters were made between the patients who survived and those who died.ResultsHospital mortality was 34%. A total of 16 fistulae developed in 11 patients (31%), recurrent intra-abdominal abscesses in 4 (11%), and hemorrhaging in 5 (14%). The patients who died compared with those who survived had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-II score on admission (14.5 vs 9, P < 0.001), extrapancreatic extension of necrosis more often (100% vs 65%, P = 0.02), and developed postoperative hemorrhaging more often (33% vs 4%, P = 0.038). A multivariate logistic analysis revealed an APACHE-II score of >13 on admission (P = 0.018) and an extension of necrosis behind both paracolic gutters (P < 0.001) to both be prognostic factors for mortality.ConclusionsSevere necrotizing pancreatitis still carries significant morbidity and mortality. This surgical approach facilitates the removal of all devitalized tissue and seems to decrease the incidence of recurrent intra-abdominal infection requiring reoperation. An APACHE-II score of ≥13 and an extension of necrosis behind both paracolic gutters was thus found to signify a worse outcome.

Invasive Lobular Breast Cancer Presenting an Unusual Metastatic Pattern in the Form of Peritoneal and Rectal Metastases: A Case Report

Gastrointestinal metastases from invasive lobular breast cancer are uncommon with the stomach and small intestines being the most common metastatic sites. Peritoneal and rectal metastases are very rare and only rarely occur as the first manifestation of disease. We herein report the case of a 47-year-old woman who presented with abdominal carcinomatosis as a first sign of invasive lobular breast carcinoma (ILC). Identifying the most important immunohistochemical markers for ILC: gross cystic disease fluid protein 15, estrogen and progesterone receptors enabled a correct diagnosis. After a six year disease-free period, relapse occurred with severe obstruction due to rectal metastasis from lobular breast carcinoma. Since there was no widespread metastatic disease, surgery with concomitant hormonal therapy was performed.

Gastrointestinal: the role of multidetector computer tomography in diagnosis of pneumatosis cystoides intestinalis

A 46-year old woman presented to our hospital with abdominal pain, diarrhea and bloody stools. She had no previous clinical history of asthma, diabetes, connective tissue diseases, endoscopic examinations and surgery. Laboratory and abdominal ultrasound examination revealed no abnormalities. Barium enema disclosed multiple round filling defects with smooth margins in the sigmoid and descending colon. Further colonoscopy evaluation showed multiple sessile soft, polypoid lesions with normal overlying mucosa. The results of histopathological examination were nonspecific and inconclusive. The patient underwent multidetector computer tomography (MDCT) examination in order to determine the nature and extent of detected polypoid lesions. Multiplanar reformation images with a lung window setting (Figure 1) showed numerous air filled cysts within the wall of sigmoid and ascending colon. Virtual CT colonoscopy (Figure 2) also revealed multiple gas cysts. MDCT findings were consistent with the diagnosis of pneumatosis cystoides intestinalis (PCI). Pneumatosis cystoides intestinalis is a rare condition characterized by multiple air filled cysts within submucosa or subserosa of the intestinal wall. The etiology of PCI is still unclear although many theories have been proposed. PCI can develop as a primary idiopathic condition, or secondary to different bronchopulmonary and gastrointestinal diseases. Association of PCI with raised intraabdominal pressure has already been reported. PCI is usually benign condition, but can present with serious complications such as obstruction, intussusception and intestinal perforation. Different diagnostic modalities are used in the diagnosis of PCI. Colonoscopy findings of multiple, round submucosal protrusions usually with normal overlying mucosa are not conclusive and include lymphoid hyperplasia, hyperplastic polyposis or colitis cystica profunda in differential diagnosis. Barium enema reveals smooth protrusions but can not exclude multiple polypoid lesions. MDCT evaluation with multiplanar reformations and virtual colonoscopy resolves the diagnostic problem, revealing gas filled cysts in colonic wall. Moreover, MDCT can exclude or detect complications and other pathological conditions such as polyposis, diverticulosis, and tumors.

Education and imaging. Gastrointestinal: the role of multidetector computer tomography in diagnosis of pneumatosis cystoides intestinalis.

A 46-year old woman presented to our hospital with abdominal pain, diarrhea and bloody stools. She had no previous clinical history of asthma, diabetes, connective tissue diseases, endoscopic examinations and surgery. Laboratory and abdominal ultrasound examination revealed no abnormalities. Barium enema disclosed multiple round filling defects with smooth margins in the sigmoid and descending colon. Further colonoscopy evaluation showed multiple sessile soft, polypoid lesions with normal overlying mucosa. The results of histopathological examination were nonspecific and inconclusive. The patient underwent multidetector computer tomography (MDCT) examination in order to determine the nature and extent of detected polypoid lesions. Multiplanar reformation images with a lung window setting (Figure 1) showed numerous air filled cysts within the wall of sigmoid and ascending colon. Virtual CT colonoscopy (Figure 2) also revealed multiple gas cysts. MDCT findings were consistent with the diagnosis of pneumatosis cystoides intestinalis (PCI). Pneumatosis cystoides intestinalis is a rare condition characterized by multiple air filled cysts within submucosa or subserosa of the intestinal wall. The etiology of PCI is still unclear although many theories have been proposed. PCI can develop as a primary idiopathic condition, or secondary to different bronchopulmonary and gastrointestinal diseases. Association of PCI with raised intraabdominal pressure has already been reported. PCI is usually benign condition, but can present with serious complications such as obstruction, intussusception and intestinal perforation. Different diagnostic modalities are used in the diagnosis of PCI. Colonoscopy findings of multiple, round submucosal protrusions usually with normal overlying mucosa are not conclusive and include lymphoid hyperplasia, hyperplastic polyposis or colitis cystica profunda in differential diagnosis. Barium enema reveals smooth protrusions but can not exclude multiple polypoid lesions. MDCT evaluation with multiplanar reformations and virtual colonoscopy resolves the diagnostic problem, revealing gas filled cysts in colonic wall. Moreover, MDCT can exclude or detect complications and other pathological conditions such as polyposis, diverticulosis, and tumors.

Double-Barreled Wet Colostomy: Urinary and Fecal Diversion

PURPOSE Double-barreled wet colostomy represents simultaneous urinary and fecal surgical diversion performed most commonly after pelvic exenteration as a palliative procedure or after actinic damage. We report the structural and functional results of double-barreled wet colostomy with special attention to surgical technique, morbidity and functional results compared to those described in the available literature. MATERIALS AND METHODS We retrospectively followed 38 patients who underwent double-barreled wet colostomy at our institution from April 2003 to November 2007. The parameters were patient age and gender, the indication for double-barreled wet colostomy, postoperative morbidity and mortality, length of hospital stay and functional assessment by excreting excretory urography. RESULTS A total of 38 double-barreled wet colostomies were performed at our institution, including 24 following total pelvic exenteration, 14 without resection, 9 in inoperable tumor cases and 5 in actinic damage cases. The postoperative morbidity rate was 15.7% with no treatment related mortality. Two patients had late postoperative complications, including stenosis of the ureterocolonic anastomosis and conduit necrosis, respectively. CONCLUSIONS In our experience double-barreled wet colostomy has an acceptable morbidity and mortality rate, is performed without technical difficulties and does not require prolonged operative time. Double-barreled wet colostomy represents the procedure of choice in patients who require concurrent urinary and fecal diversion.

Hepatobiliary and pancreatic: Juxtapapillary duodenal diverticulum causing cholestasis

Duodenal diverticula are outpouchings from the duodenum that represent herniation of the mucosa and submucosa through the muscular wall. Diverticula are uncommon before the age of 50 years but can be demonstrated in 10–15% of the population by the age of 80 years. At least 75% of diverticula are located within 2 cm of the ampulla of Vater and have been called juxtapapillary diverticula. The remainder occur at the accessory ampulla or elsewhere in the duodenum. There is now persuasive evidence for an association between bile duct stones and duodenal diverticula, particularly bile duct stones in the absence of gallbladder stones (primary bile duct stones). This association is likely to reflect a degree of bile stasis that is often accompanied by bacterial contamination of bile. Diverticula have also been associated with idiopathic pancreatitis. Diverticula are best demonstrated by duodenal endoscopy using a side-viewing endoscope or by barium meal radiographs. With computed tomography (CT) scans and magnetic resonance imaging scans, larger diverticula are seen as lesions on the medial wall of the second part of the duodenum that typically contains gas. The patient illustrated below was a 70-year-old woman who was investigated because of intermittent pain in the upper abdomen, particularly after meals. Blood tests revealed a mild elevation of bilirubin, a minor elevation of alanine aminotransferase and amylase and a moderate elevation of alkaline phosphatase (359 u/l). On an upper abdominal ultrasound study, intrahepatic and extrahepatic bile ducts were mildly dilated and she had a distended gallbladder without gallbladder stones. A contrast-enhanced CT scan after oral contrast showed a hypodense lesion, 3 cm in diameter (arrow), in the region of the head of the pancreas (Figure 1). Small amounts of gas were demonstrated within the lesion on some slices. She also had dilatation of the bile duct and main pancreatic duct and distension of the gallbladder. A barium radiograph showed only partial filling of a diverticulum on the medial wall of the second part of the duodenum (Figure 2). At endoscopy, the diverticulum was filled with impacted food residue. Following endoscopic extraction, her symptoms resolved and liver function tests returned to normal. Impacted food residue within a diverticulum is a rare cause of cholestasis as duodenal diverticula have a relatively wide orifice.

Sclerosing Mesenteritis Presenting as a Pseudotumor of the Greater Omentum

Objective: The aim was to demonstrate a diagnostic challenge of sclerosing mesenteritis initially considered as liposarcoma. Clinical Presentation and Intervention: A 45-year-old man was admitted with a painful abdominal mass. Abdominal computed tomography demonstrated a well- demarcated tumor in his left hemiabdomen, with a large fat component and areas of soft tissue attenuation suggestive of liposarcoma. Intraoperative findings showed a tumor arising from the greater omentum. The tumor was completely removed, and histopathology confirmed a pseudotumorous type of sclerosing mesenteritis with dominant mesenteric lipodystrophy. Conclusion: This case showed that a pseudotumorous type of sclerosing mesenteritis should be considered in the differential diagnosis of the mesenteric tumors.

Standardized perfusion value of the esophageal carcinoma and its correlation with quantitative CT perfusion parameter values.

PURPOSE Standardized perfusion value (SPV) is a universal indicator of tissue perfusion, normalized to the whole-body perfusion, which was proposed to simplify, unify and allow the interchangeability among the perfusion measurements and comparison between the tumor perfusion and metabolism. The aims of our study were to assess the standardized perfusion value (SPV) of the esophageal carcinoma, and its correlation with quantitative CT perfusion measurements: blood flow (BF), blood volume (BV), mean transit time (MTT) and permeability surface area product (PS) of the same tumor volume samples, which were obtained by deconvolution-based CT perfusion analysis. METHODS Forty CT perfusion studies of the esophageal cancer were analyzed, using the commercial deconvolution-based CT perfusion software (Perfusion 3.0, GE Healthcare). The SPV of the esophageal tumor and neighboring skeletal muscle were correlated with the corresponding mean tumor and muscle quantitative CT perfusion parameter values, using Spearmans rank correlation coefficient (rS). RESULTS Median SPV of the esophageal carcinoma (7.1; range: 2.8-13.4) significantly differed from the SPV of the skeletal muscle (median: 1.0; range: 0.4-2.4), (Z=-5.511, p<0.001). The cut-off value of the SPV of 2.5 enabled discrimination of esophageal cancer from the skeletal muscle with sensitivity and specificity of 100%. SPV of the esophageal carcinoma significantly correlated with corresponding tumor BF (rS=0.484, p=0.002), BV (rS=0.637, p<0.001) and PS (rS=0.432, p=0.005), and SPV of the skeletal muscle significantly correlated with corresponding muscle BF (rS=0.573, p<0.001), BV (rS=0.849, p<0.001) and PS (rS=0.761, p<0.001). CONCLUSIONS We presented a database of the SPV for the esophageal cancer and proved that SPV of the esophageal neoplasm significantly differs from the SPV of the skeletal muscle, which represented a sample of healthy tissue. The SPV was validated against quantitative CT perfusion measurements and statistically significant correlation was proved.