Nikos Courcoutsakis

CT Findings of Primary Pigmented Nodular Adrenocortical Disease: Rare Cause of ACTH-Independent Cushing Syndrome

AJR 2010; 194:W541 0361–803X/10/1946–W541

Perfusion parameters analysis of the vertebral bone marrow in patients with Ph1− chronic myeloproliferative neoplasms (PhnegMPN): A dynamic contrast‐enhanced MRI (DCE‐MRI) study

To evaluate perfusion parameters of the vertebral bone marrow in patients with Philadelphia negative chronic myeloproliferative neoplasms (PhnegMPN) using dynamic contrast‐enhanced MRI (DCE‐MRI).

Hepatoid Adenocarcinoma of the Gallbladder Case Report and Literature Review

Hepatoid adenocarcinoma (HAC) is a rare tumor consisting of three distinct patters, solid, tubular and trabecular, with morphological and functional features resembling hepatocellular carcinoma (HCC). The tumor is found most frequently in the stomach [1, 2], where it was originally described by Ishikura et al. [3] as a specific subtype of primary gastric carcinoma, with occasional reports describing locations in other organs such as the lung [4, 5], kidney [6], female reproductive tract [7–11], pancreas [12–14], and gallbladder [15, 16]. In this report, we present a case of HAC of the gallbladder. Case Report

Single-incision assisted laparoscopic surgery (SILS) in the treatment of an intussusception induced by a solitary hamartomatous polyp: a case report and review of the literature

IntroductionIn this case report, we describe the successful treatment of a small-bowel intussusception, which was caused by a 3cm solitary hamartomatous polyp, with single-incision laparoscopic surgery. Single-incision laparoscopic surgery is a minimally invasive surgical procedure with important advantages that allows the reduction of the intussusception and the resection of the polyp. This case report contributes to the medical literature by describing the advantages of this surgical technique that warrant its consideration as a treatment of choice in similar cases.Case presentationWe report a case of a 19-year-old Greek woman who complained about intermittent, non-specific abdominal pain in her left lateral abdomen. She had been admitted to the hospital because of incomplete obstructive ileus. Ultrasound and computed tomography were carried out, which revealed an intussusception of the small bowel. This pathogenic situation was treated by single-incision laparoscopic surgery. Her pathology report revealed a benign, hamartomatous excised polyp of the Peutz-Jeghers type. The patient had a quick recovery without any post-operative complications.ConclusionWe recommend single-incision laparoscopic surgery for the safe excision of solitary hamartomatous polyps and the management of their complications, as it represents a potential advance in minimally invasive approaches.

Common Bile Duct Obstruction Secondary to a Periampullary Diverticulum

Periampullary duodenal diverticula are not uncommon and are usually asymptomatic although complications may occasionally occur. Here, we report the case of a 72-year-old woman who presented with painless obstructive jaundice. Laboratory tests showed abnormally elevated serum concentrations of total and direct bilirubin, of alkaline phosphatase, of γ-glutamyl transpeptidase, and of aspartate and alanine aminotransferases. Serum concentrations of the tumor markers carbohydrate antigen 19-9 and carcinoembryonic antigen were normal. Abdominal ultrasonography showed dilatation of the common bile duct (CBD), but no gallstones were found either in the gallbladder or in the CBD. The gallbladder wall was normal. Computed tomography failed to detect the cause of CBD obstruction. Magnetic resonance imaging and magnetic resonance cholangiopancreatography revealed a periampullary diverticulum measuring 2 cm in diameter and compressing the CBD. The pancreatic duct was normal. Hypotonic duodenography demonstrated a periampullary diverticulum with a filling defect corresponding to the papilla. CBD compression by the diverticulum was considered as the cause of jaundice. The patient was successfully treated by surgical excision of the diverticulum. In conclusion, the presence of a periampullary diverticulum should be considered in elderly patients presenting with obstructive jaundice in the absence of CBD gallstones or of a tumor mass. Non-interventional imaging studies should be preferred for diagnosis of this condition, and surgical or endoscopic interventions should be used judiciously for the effective and safe treatment of these patients.

Sister Mary Joseph’s Nodule as the First Sign of Pancreatic Carcinoma

IntroductionMetastasis to the umbilicus from intra-abdominal malignantsolid tumors is not common, occurring mostly in patientswith advanced gastrointestinal and gynecologic carcinomasalthough it may sometimes be the first presentation of anoccult, underlying adenocarcinoma [1–4]. This condition isalso known as Sister Mary Josephs nodule or sign, namedafter Sister Mary Joseph (1856–1939), the superintendentnurse and surgical assistant of Dr. William Mayo at St.Marys Hospital in Rochester, Minnesota, USA, who no-ticed the association between umbilical nodules observedduring skin preparation for surgery and advanced intra-abdominal cancer found at surgery [5, 6]. Her name wasaccredited to this clinical feature in 1949 by Sir HamiltonBailey in his book “Physical Signs in Clinical Surgery”.Pancreatic carcinoma usually metastasizes to regionallymph nodes, liver, and peritoneum. However, 10 % ofumbilical metastases originate from a pancreatic carcinoma[7, 8] and sometimes they are the first sign of the disease [9,10]. In this report, we present a patient who had a previouslymesh-repaired umbilical hernia and presented with a SisterMary Josephs nodule associated with an advanced, meta-static adenocarcinoma of the pancreas before diagnosing theprimary tumor.Case ReportA 64-year-old woman was admitted because of painlessobstructive jaundice of 3-days duration when she noticedyellow-colored scleras and dark-colored urine. Threemonths before presentation she noticed a gradually enlarg-ing, progressively painful and inflamed skin nodule in theumbilicus. She also reported loss of appetite and a 10-kgweight loss over this time period. She had no history of liverdisease and she denied having fever, gastrointestinal com-plaints, or any systemic symptoms. Her past medical historyincluded an umbilical hernia repair by using a prostheticmesh 3 years before.On physical examination the scleras and the skinappeared yellow. An abdominal scar of a midline surgicalincision was present above and below the umbilicus. Awell-circumscribed reddish mass measuring approximately 2 cmin diameter, with a slightly ulcerated surface, hard, andpainful on palpation, and fixed to the underlying tissueswas noted in the umbilicus (Fig. 1). Abdominal examinationrevealed mild tenderness localized in the right upper abdom-inal quadrant and the epigastrium, but no mass was palpa-ble. There were no enlarged cervical, axillary, or inguinallymph nodes.

Gastrointestinal: Gallbladder Carcinoma and Cholelithiasis: A Radiologic—Pathologic Correlation

A 82-year-old female presented with right upper quadrant pain and fever. Anorexia and weight loss of 5Kg over six months was reported. On MRCP, multiple round and ovoid gallbladder filling defects were demonstrated suggestive of gallstones. An irregular lesion attached to the slightly thickened gallbladder wall was also demonstrated (Figure 1). Cholecystectomy was performed and histology diagnosed a gallbladder adenocarcinoma and cholelithiasis. (Figure 2). Primary gallbladder carcinoma (GBC) is an uncommon malignancy, three times more common in women than in men, often presenting with vague symptoms. GBC median survival is only 6 months as anatomical factors promote early local spread. The majority of patients present with advance disease. Cholelithiasis is an important risk factor for the development of GBC, probably due to chronic irritation and inflammation of the gallbladder leading to mucosal dysplasia and then carcinoma. Other risk factors include age, postmenopausal status and cigarette smoking. GBC is usually unsuspected; symptoms are not specific and may include abdominal pain, fever, weight loss and jaundice. Jaundice occurs more frequently as a result of malignant obstruction of the biliary tree rather than hepatic metastasis or coexistent choledocholethiasis. The cross-sectional imaging patterns of GBC consist of a mass replacing the gallbladder (40%–65% of cases) [pattern A], focal or diffuse wall thickening (20%–30%) [pattern B]. In pattern C (15%–25%)—as in the present case—GBC is manifested as a polypoid lesion (usually larger than 1 cm in diameter) with a thickened implantation base. The differential diagnosis should include adenomatous or cholesterol polyps, carcinoid or melanoma metastasis. It has been reported that conventional MRI with associated Magnetic Resonance Angiography (MRA) and MRCP can disclose the disease and simultaneously detect liver or vascular invasion, biliary tract and/or lymph node involvement.

Education and imaging. Gastrointestinal: gallbladder carcinoma and cholelithiasis: a radiologic--pathologic correlation.

A 82-year-old female presented with right upper quadrant pain and fever. Anorexia and weight loss of 5Kg over six months was reported. On MRCP, multiple round and ovoid gallbladder filling defects were demonstrated suggestive of gallstones. An irregular lesion attached to the slightly thickened gallbladder wall was also demonstrated (Figure 1). Cholecystectomy was performed and histology diagnosed a gallbladder adenocarcinoma and cholelithiasis. (Figure 2). Primary gallbladder carcinoma (GBC) is an uncommon malignancy, three times more common in women than in men, often presenting with vague symptoms. GBC median survival is only 6 months as anatomical factors promote early local spread. The majority of patients present with advance disease. Cholelithiasis is an important risk factor for the development of GBC, probably due to chronic irritation and inflammation of the gallbladder leading to mucosal dysplasia and then carcinoma. Other risk factors include age, postmenopausal status and cigarette smoking. GBC is usually unsuspected; symptoms are not specific and may include abdominal pain, fever, weight loss and jaundice. Jaundice occurs more frequently as a result of malignant obstruction of the biliary tree rather than hepatic metastasis or coexistent choledocholethiasis. The cross-sectional imaging patterns of GBC consist of a mass replacing the gallbladder (40%–65% of cases) [pattern A], focal or diffuse wall thickening (20%–30%) [pattern B]. In pattern C (15%–25%)—as in the present case—GBC is manifested as a polypoid lesion (usually larger than 1 cm in diameter) with a thickened implantation base. The differential diagnosis should include adenomatous or cholesterol polyps, carcinoid or melanoma metastasis. It has been reported that conventional MRI with associated Magnetic Resonance Angiography (MRA) and MRCP can disclose the disease and simultaneously detect liver or vascular invasion, biliary tract and/or lymph node involvement.

Is laparoscopic resection the appropriate management of a jejunal gastrointestinal stromal tumor (GIST)? Report of a case.

A 51-year-old female patient presented with iron deficiency anemia. Upper and lower gastrointestinal endoscopy were unremarkable. Computed tomography enteroclysis showed an ovoid 3×4-cm jejunal tumor with intraluminal protrusion and exophytic growth pattern, without lymphadenopathy or metastatic disease. Laparoscopic resection of the tumor was successfully carried out. Histologically, a mesenchymal tumor composed of spindle cells with an interlacing bundle pattern and high-mitotic activity greater than10 mitoses/50 high-power fields were observed. The immunohistochemistry showed that the tumor was KIT (CD117)-, vimentin-, smooth muscle actin-, and S-100-positive, whereas it was CD34-negative. These findings were consistent with the features of a gastrointestinal stromal tumor. The patient had an uneventful postoperative course, and after 10 months of follow-up, she is well without any evidence of tumor recurrence.

Hepatobiliary and pancreatic: Duplication of the gallbladder

Congenital anomalies of the gallbladder can be categorized as anomalies of number, anomalies of form and anomalies of position. Anomalies of number include congenital absence of the gallbladder, duplication of the gallbladder and perhaps hypoplasia of the gallbladder. Abnormalities of form include the presence of septa or abnormal folding of the gallbladder that results in a bilobed gallbladder, hourglass deformity or a phrygian cap deformity. This category can also include diverticula of the gallbladder. Anomalies of position include an intrahepatic gallbladder, leftsided gallbladder and a floating gallbladder that is susceptible to torsion. Of the above, the most common are anomalies of form that result in a phrygian cap deformity or a bilobed deformity. In relation to anomalies of number, congenital absence of the gallbladder is rare but duplication of the gallbladder has an estimated prevalence of 1–3 per 10 000 individuals. The patient illustrated below was a 30-year-old white woman who was referred for investigation because of discomfort in the upper abdomen and episodes of pain in the epigastrium and right upper quadrant. On examination, the only abnormality was mild tenderness on palpation over the right upper quadrant. Routine blood tests including liver function tests were within the reference range. An ultrasound study of the upper abdomen revealed two cystic structures in the gallbladder fossa lying side by side (Fig. 1). The structure on the left had the appearance of a normal gallbladder while the structure on the right had minor thickening of the wall and contained echogenic material. Magnetic resonance cholangiopancreatography revealed a true duplication of the gallbladder and showed that the two cystic ducts converged to form a common cystic duct prior to entry into the bile duct (Fig. 2). The presence of duplication of the gallbladder was confirmed at the time of laparoscopic cholecystectomy. Although a common cystic duct was demonstrated in the above patient, the majority of patients have separate cystic ducts that enter the bile duct. There are also reports of duplication where the second gallbladder is in an anomalous position such as within the liver or under the left lobe of the liver. There is no persuasive evidence that duplication of the gallbladder is associated with increased risks for gallbladder stones or gallbladder neoplasia.