Javier Casillas

Diabetic muscle infarction after simultaneous pancreas-kidney transplant

Diabetic muscle infarction (DMI) is a rare entity that occurs in patients with long‐standing type 1 insulin dependent diabetes mellitus (IDDM). We describe DMI occurring on an average of 5 months after SPK in four patients with IDDM and end stage renal disease (ESRD). These patients had evidence of other long‐term diabetic complications including retinopathy and neuropathy, as well as microangiopathy and hypercoagulability, both of which are pre‐disposing factors for DMI. The etiology of DMI is not well understood. Despite establishment of normoglycemia after kidney–pancreas transplantation, DMI may occur as a result of tissue damage/fragility secondary to the pre‐existing long‐term labile glycemic control and hypertension. This may be exacerbated by the pro‐coagulant effects of the calcineurin‐inhibitors and the use of steroids as part of the immunosuppressive regimen.

Large Esophageal Liposarcoma: A Case Report and Review of the Literature

Liposarcoma is one of the most common neoplasms of adulthood. However, it is exceedingly rare in the gastrointestinal tract. To our knowledge, only 12 cases occurring in the esophagus have been reported in the world literature to date. We report the case of a 42-year-old man with a pleomorphic liposarcoma arising in the esophageal wall. The morphologic, immunophenotypic, and ultrastructural characteristics are presented, as well as the results of literature review.

Concurrent infantile hemangioendothelioma and mesenchymal hamartoma in a developmentally arrested liver of an infant requiring hepatic transplantation.

A newborn female underwent a surgical resection for a hepatic mass discovered prenatally by ultrasonography, and diagnosed pathologically as a mesenchymal hamartoma. Within 4 months after surgery, multiple cutaneous hemangiomas developed and a multinodular mass was detected in the liver. A liver biopsy showed an infantile hemangioendothelioma with type I features. An orthotopic liver transplant was performed due to the extensive nature of the hepatic involvement and progressive respiratory compromise. Virtually the entire liver was involved by a large infantile hemangioendothelioma. A multicystic mesenchymal hamartoma was also found on the left side. In addition, the uninvolved hepatic parenchyma had features recapitulating the fetal liver. This simultaneous involvement of the liver by a mesenchymal hamartoma and infantile hemangioendothelioma is unique. A review of the literature revealed only one incompletely characterized case with similar findings.

Retrocaval ureter: Computed tomography and ultrasound appearance

The computed tomography and sonography appearance of retrocaval ureter is correlated with findings on intravenous urography. Computed tomography is recommended as the imaging procedure of choice to confirm the diagnosis of retrocaval ureter.

Role of magnetic resonance cholangiopancreatography in diagnosing choledochal cysts: Case series and review

AIM To determine the merits of magnetic resonance cholangiopancreatography (MRCP) as the primary diagnostic test for choledochal cysts (CCs). METHODS Between 2009 and 2012, patients who underwent MRCP for perioperative diagnosis were identified. Demographic information, clinical characteristics, and radiographic findings were recorded. MRCP results were compared with intraoperative findings. A PubMed search identified studies published between 1996-2012, employing MRCP as the primary preoperative imaging and comparing results with either endoscopic retrograde cholangiopancreatography (ERCP) or operative findings. Detection rates for CCs and abnormal pancreaticobiliary junction (APBJ) were calculated. In addition detection rates for clinically related biliary pathology like choledocholithiasis and cholangiocarcinomas in patients diagnosed with CCs were also evaluated. RESULTS Eight patients were identified with CCs. Six patients out of them had type IV CCs, 1 had type I and 1 had a new variant of choledochal cyst with confluent dilatation of the common bile duct (CBD) and cystic duct. Seven patients had an APBJ and 3 of those had a long common-channel. Gallstones were found in 2 patients, 1 had a CBD stone, and 1 pancreatic-duct stone was also detected. In all cases, MRCP successfully identified the type of CCs, as well as APBJ with ductal stones. From analyzing the literature, we found that MRCP has 96%-100% detection rate for CCs. Additionally, we found that the range for sensitivity, specificity, and diagnostic accuracy was 53%-100%, 90%-100% and 56%-100% in diagnosing APBJ. MRCPs detection rate was 100% for choledocholithiasis and 87% for cholangiocarcinomas with concurrent CCs. CONCLUSION After initial ultrasound and computed tomography scan, MRCP should be the next diagnostic test in both adult and pediatric patients. ERCP should be reserved for patients where therapeutic intervention is needed.

Sonographic diagnosis of aneurysm of the right portal vein.

The rarity of portal vein aneurysms (PV As) has been emphasized in the world literature with most reported cases occurring in the extrahepatic portal circulation. ]n 1950, Barzilai and Kleckner first reported this entity in a patient with postnecrotic cirhosis.l Reports of similar lesions followed.27 Intrahepatic PYAs are exceedingly rare. Ohnishi et al described two patients with right PYAs confinned by angiography.8 We report a case of intrahepatic PV A initially detected by CT and con~ finned by pulsed Doppler ultrasound.

Focal nodular hyperplasia in identical twins.

A unique case of a focal nodular hyperplasia (FNH) in identical twins is presented. The computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen demonstrated in both twins a mass of identical size in the same segment of their liver. Histopathologic examination of both masses confirmed the diagnosis of focal nodular hyperplasia. This case report strongly supports the theory of a congenital vascular anomaly playing a major role in the etiology of focal nodular hyperplasia.

Hepatic artery aneurysm simulating a cystic mass of the pancreas

Aneurysms of the hepatic artery are the second most common visceral aneurysm found in the abdomen, following those of the splenic artery (1, 2). Owing to the close relationship between the common hepatic artery and the head of the pancreas, aneurysms of this vessel may be confused with pancreatic masses during radiologic imaging. This is a case report of a patient with an hepatic artery aneurysm, the only one found in approximately 15,600 consecutive CT examinations of the upper abdomen performed at our institution in a 5-year period. He was initially misdiagnosed as having a pancreatic pseudocyst.

Multiparametric-MRI and Targeted Biopsies in the Management of Prostate Cancer Patients on Active Surveillance.

An important key to clinical management of prostate cancer patients is to determine early those who will benefit from primary treatment and are not good candidates for active surveillance (AS). We describe a 67-year-old gentleman with a long history of stable prostate-specific antigen (PSA) levels and a negative biopsy. After slight PSA rise and low volume Gleason score 6 biopsy, the patient was considered for primary treatment or AS. A multiparametric (MP)-MRI exam revealed a suspicious lesion in the anterior apex of the prostate. Biopsies were carried out on a 3D-ultrasound prostate biopsy system with MRI-fusion. The location of the target area was challenging and could have been missed using standard 12-core biopsy template. The pathology determined Gleason 3 + 4 disease in 30% of the core from this region. Consequently, the patient underwent radiotherapy (RT). MP-MRI was also used to follow the changes from pre- to post-RT.

Mucoepidermoid carcinoma of the intrapancreatic common bile duct: immunohistochemical profile, prognosis, and review of the literature.

Mucoepidermoid carcinoma of the bile duct is a rare entity. Only one mucoepidermoid carcinoma from the common bile duct has been reported in the Korean literature. Herein, we present the first in the English literature. The tumor arose in the intrapancreatic (distal) common bile duct in an 83-year-old woman who presented with obstructive jaundice and elevated liver enzymes. The tumor invaded the underlying pancreas and peripancreatic adipose tissue and showed pagetoid spread into the extrapancreatic common bile duct and cystic duct. The tumor exhibited nests of malignant cells with diffuse CK7 and MUC1 positivity. The basal cells were p63 and CK5/6 positive. The luminal cells were stained with carcinoembryonic antigen, MUC5, and mucicarmine and were focally positive for CK20. There was focal MUC4 staining on the apical luminal border. The neoplastic cells were negative for MUC2 and HER2-neu. We discuss the clinical presentation, diagnostic features, immunohistochemical profile, and prognosis of mucoepidermoid carcinoma of the common bile duct. The features of this neoplasm are further compared with mucoepidermoid carcinoma of the hepatobiliary system, adenosquamous carcinoma, and mucoepidermoid carcinoma of other organs.