Nikunj Rashmikant Chauhan

Solitary fibrous tumors of the thorax: Nomenclature, epidemiology, radiologic and pathologic findings, differential diagnoses, and management

AJR:200, March 2013 Epidemiology It is difficult to ascertain the true incidence and prevalence of solitary fibrous tumors because the majority of patients with these masses are asymptomatic. Solitary fibrous tumors arising from the pleura, however, have been estimated to occur with a frequency of 2.8 per 100,000 individuals, with only eight hundred cases reported between 1931 and 2002 [4]. Moreover, these tumors account for less than 5% of all tumors arising from the pleura [5]. Overall, solitary fibrous tumors account for less than 2% of all softtissue tumors [6]. These tumors occur equally in both men and women, most frequently in the 6th and 7th decades of life [7]. There is no known association with tobacco, asbestos, or any other toxicant.

Demystifying NUT Midline Carcinoma: Radiologic and Pathologic Correlations of an Aggressive Malignancy

OBJECTIVE NUT midline carcinoma is a rare poorly differentiated aggressive subtype of squamous cell carcinoma. To date, fewer than 100 total cases have been reported. CONCLUSION Given the rarity of this disease process and lack of pathognomonic imaging findings, a definitive diagnosis based solely on imaging findings alone is untenable. Select cases are used to emphasize the particularly infiltrative and aggressive nature of NUT midline carcinoma, which shows a complete disregard for normal tissue boundaries and rapid progression during brief intervals.

Artificial ascites and pneumoperitoneum to facilitate thermal ablation of liver tumors: a pictorial essay

Image-guided percutaneous thermal ablation is increasingly utilized in the treatment of hepatic malignancies. Peripherally located hepatic tumors can be difficult to access or located adjacent to critical structures that can be injured. As a result, ablation of peripheral tumors may be avoided or may be performed too cautiously, leading to inadequate ablation coverage. In these cases, separating the tumor from adjacent critical structures can increase the efficacy and safety of procedures. Artificial ascites and artificial pneumoperitoneum are techniques that utilize fluid and gas, respectively, to insulate critical structures from the thermal ablation zone. Induction of artificial ascites and artificial pneumoperitoneum can enable complete ablation of otherwise inaccessible hepatic tumors, improve tumor visualization, minimize unintended thermal injury to surrounding organs, and reduce post-procedural pain. This pictorial essay illustrates and discusses the proper technique and clinical considerations for successful artificial ascites and pneumoperitoneum creation to facilitate safe peripheral hepatic tumor ablation.

Teaching NeuroImages: massive abdominal CSFoma.

A 31-year-old woman with congenital hydrocephalus status post ventriculoperitoneal shunt placement 23 years earlier presented with abdominal distention. The patient denied fever, headache, or sensory or motor abnormalities. Examination was notable for a tense abdomen. CT of the abdomen and pelvis demonstrated a massive, loculated, CSFoma, or CSF pseudocyst (figure). Ventriculoperitoneal shunts are associated with a variety of complications including disruption of the tube, obstruction of the tip, infection, intestinal perforation, tip migration, and CSFoma development.1 CSFoma is a rare complication, thought to be caused by low-grade shunt infection, chronic inflammation, increased CSF protein, or peritoneal adhesions, and is estimated to occur in 1.0% to 4.5% of cases, with a typical occurrence within 3 weeks to 5 years of shunt placement.2,3 Treatment consists of external drainage or surgical excision followed by reconstruction of the shunt system.4

Traffic Jam in the Duodenum: Imaging and Pathogenesis of Bouveret Syndrome

A 90-year-old woman with a history of cholelithiasis and chronic cholecystitis presented to the hospital with nausea, bilious vomiting, and anorexia for 3 days. The patient denied fevers, chills, hematemesis, hematochezia, or melena. Physical examination was notable for an uncomfortable woman with epigastric tenderness. An abdominal radiograph was obtained and demonstrated pneumobilia and an enlarged gastric bubble (Figure 1). Subsequent computed tomography with intravenous contrast material was obtained and demonstrated a gallstone in the proximal duodenum causing gastric distention, consistent with Bouveret syndrome (Figure 2). The patient underwent endoscopic-guided lithotripsy with resolution of symptoms.

Incarcerated Morgagni hernia mimicking acute cholecystitis

A 64-year-old man presented with sharp, constant right upper quadrant pain, nausea, and constipation for 2 days. The patient reported intermittent right upper quadrant pain for the prior 6 years, which was exacerbated by eating, but noted that over the past 2 days the pain had become more severe. The patient had previously undergone three right upper quadrant ultrasound studies that were all negative for acute cholecystitis. On presentation, examination was notable for focal tenderness to palpation over the xiphoid process. A right upper quadrant ultrasound study was completed, and demonstrated a single hepatic cyst and gallbladder sludge without evidence of gallstones, gallbladder wall thickening, pericholecystic fluid, or a sonographic Murphy’s sign (Fig. 1). A chest radiograph was obtained, and demonstrated elevation of the right hemidiaphragm with colonic interposition in the right upper quadrant (Fig. 2). Computed tomography of the abdomen and pelvis with intravenous and oral contrast was performed, and demonstrated a large right-sided anterior diaphragmatic hernia containing distended loops of colon with short segment narrowing at the entrance as well as soft tissue stranding and simple fluid within the herniation sac, consistent with an incarcerated Morgagni hernia (Fig. 3). The patient underwent laparoscopic diaphragmatic hernia repair with mesh, which was complicated by postoperative development of a right pneumothorax, but with eventual normalization of the chest radiograph (Fig. 4) and resolution of the right upper quadrant pain.

The Lady Windermere Syndrome

A 78-year-old woman with bronchiectasis, numerous prior admissions for bacterial pneumonia, and mitral valve prolapse presented to this hospital with fever and cough for 6 days. The patient reported developing a nagging, persistent cough described as ‘‘inhaling cake crumbs,’’ without sputum production 6 days prior. Concomitantly, the patient experienced low-grade temperatures ranging from 37.8–38.6 C. On presentation to this hospital, the patient reported worsening ‘‘coughing attacks,’’ complicated by diffuse myalgias and generalized weakness. The patient, however, denied recent illnesses or travel. Physical examination was notable for a temperature of 38.9 C, respirations of 29 breaths per minute, an oxygen saturation of 90 % while breathing ambient air, and diffuse wheezing and rhonchi throughout all the lung fields. A chest radiograph showed widespread bronchiectasis bilaterally, but no consolidative opacities, pleural effusions, pulmonary edema, or pneumothoraces (Fig. 1). Computed tomography of the chest without intravenous contrast material demonstrated moderate bilateral bronchiectasis as well as tree-in-bud nodularity throughout the right, middle and lingular segments, suggestive of mycobacterium avium–intracellulare infection (Fig. 2). Two separate sputum samples were obtained, and were subsequently positive for mycobacterium avium–intracellulare. Human immunodeficiency virus testing was negative. The patient was initially prescribed ceftazidime and levofloxacin with transition to clarithromycin, rifampin, and ethambutol for 1 year, with complete resolution of her symptoms. Repeated computed tomography of the chest without intravenous contrast material completed 6 months later demonstrated persistent, moderate bilateral bronchiectasis with near complete resolution of the previously seen tree-in-bud nodularity, suggestive of resolving mycobacterium avium–intracellulare infection (Fig. 3).

Pulmonary cement emboli after kyphoplasty

CaseA 37-year-old woman with estrogen/progesterone receptorpositive breast cancer with metastases to the lungs, liver,and lumbar spine, being treated with vinorelbine, initiallypresented to this hospital with severe lower back pain. Atthe time of presentation, multiplanar magnetic resonanceimaging of the spine after the administration of intravenousgadolinium demonstrated anterior wedge compressiondeformities of the L1 and L2 vertebral bodies (Fig. 1). Thepatient underwent bilateral transpedicular kyphoplasty,without evidence of cement extravasation (Fig. 2). Onemonth later, after an uneventful recovery, the patientreturned to this hospital with pleuritic chest pain, shortnessof breath, and generalized weakness for 4 days. On phys-ical examination, the patient was tachycardic with a heartrate of 115 beats per min, with diffuse chest wall tender-ness and diminished breath sounds at the bilateral lungbases. Laboratory testing demonstrated an elevatedD-dimer of 1,700 ng/mL (normal reference range less than250 ng/mL). A portable chest radiograph demonstrated apossible serpiginous linear density within the left lung,without evidence of pneumonia, pleural effusions, orpneumothorax (Fig. 3). Given the patient’s pleuritic chestpain, shortness of breath, and tachycardia, history of met-astatic disease, and elevated D-dimer, computed tomogra-phy of the chest with pulmonary angiography protocol wascompleted to evaluate for pulmonary emboli. Analysis ofthe study demonstrated numerous linear hyperdensitiesthroughout the arterial tree, consistent with pulmonarycement emboli from the prior kyphoplasty as well asmultiple hypodense filling defects representing associatedthrombi (Fig. 4). The patient was admitted to the MedicalOncology Service, where she was started on enoxaparin,and eventually discharged with plans to continue vinorel-bine treatments. On return clinic visits 1 month later, thepatient reported complete resolution of chest pain, short-ness of breath, and weakness, with mild improvement inback pain.DiscussionVertebral body compression fractures are common,occurring at a rate of 500 per 100,000 in patients aged50–54 and 2,960 per 100,000 in patients older than 85, andprompting numerous emergency department visits per year[1]. Initial treatment consists of conservative measuresincluding analgesia, bed rest, and bracing. Further man-agement of intractable pain from vertebral compressionfractures may be undertaken with vertebroplasty and kyp-hoplasty, although these procedures remain somewhatcontroversial. Vertebroplasty and kyphoplasty are associ-ated with a variety of complications including infection,

The many faces of Hereditary Hemorrhagic Telangiectasia: median arcuate ligament syndrome, arteriovenous malformations, and cerebral aneurysms.

A 60-year-old woman was seen for episodes of recurrent epistaxis over a seven-to-eight year period. The patient reported a history of fatigue and anemia, but denied personal or family history of coagulopathies, genetic diseases, or anticoagulant use. The patient underwent fiberoptic nasopharyngoscopy with cauterization of prominent vessels in the right-anterior septum and left-posterior septum, but continued to experience recurrent epistaxis. On repeat examination, the patient was noted to have multiple millimeter blanching facial telangiectasias, a 3-cm blanching lesion on her right index finger, and a 4-cm, pulsatile mass located in her central abdomen. Abdominal ultrasound was completed and demonstrated an enlarged and tortuous hepatic artery. Computed tomographic angiography of the abdomen with intravenous contrast was performed, and demonstrated severe narrowing of the proximal celiac artery by the median arcuate ligament of the diaphragm as well post-stenotic dilatation of the celiac artery, a tortuously dilated proper/common hepatic artery, numerous vascular malformations throughout the liver, and hepatic artery to hepatic vein anastomoses (Figs. 1, 2). In the setting of epistaxis, mucocutaneous telangiectasias, and abdominal arteriovenous malformations, the patient was clinically diagnosed with Hereditary Hemorrhagic Telangiectasia (Osler–Weber–Rendu Syndrome). Genetic testing was completed, and identified a pathologic substitution in the ACVRL1 gene, confirming the diagnosis of Hereditary Hemorrhagic Telangiectasia. Out of concern for systemic arteriovenous malformations, brain magnetic resonance angiography with intravenous contrast was completed, and demonstrated numerous cerebral aneurysms including: a 5-mm saccular aneurysm of the left internal carotid artery, a 3-mm saccular aneurysm of the left middle cerebral artery, and a 2-mm aneurysm of the right posterior communicating artery (Fig. 3). Chest computed tomography, echocardiography, endoscopy, and colonoscopy were recommended, but the patient refused these studies.

Emergency management of puerperal breast abscess

A 38-year-old woman, who was 1 month postpartum, presented with left breast pain. The patient reported a 5-day history of stabbing left breast pain, erythema, and tenderness. She had been breast feeding and pumping breast milk without difficulty, but recently noted blood, mucous, and purulent material within the pumped milk. The patient denied fevers, chills, breast trauma, a palpable mass, or right breast abnormalities. Ultrasound of the left breast demonstrated a 4.7 9 2.1 cm complex fluid collection with associated skin thickening, consistent with left breast cellulitis, mastitis, and a breast abscess (Fig. 1). Surgical consultation was obtained, and a trial of ultrasound-guided aspiration of the left breast abscess was completed (Fig. 2) that yielded 12 ml of purulent fluid. Aspirated samples were evaluated by microbiology with cultures positive for methicillin-resistant Staphylococcus aureus. Trimethoprim and sulfamethoxazole were initiated for 7 days. Repeat ultrasound of the left breast demonstrated complete resolution of the left breast abscess (Fig. 3). On return visit, the patient reported decreased pain, swelling, and drainage from the left breast, and has subsequently been able to resume left breast feeding and pumping. Discussion