Su Lim Lee

Comprehensive reviews of the interfascial plane of the retroperitoneum: normal anatomy and pathologic entities

The retroperitoneum is conventionally divided into three distinct compartments: posterior pararenal space, anterior pararenal space, and perirenal space, bounded by the posterior parietal peritoneum, transversalis fascia, and perirenal fascia. But more recent work has demonstrated that the perirenal fascia is not made up of distinct unilaminated fascia, but a single multilaminated structure with potential space. These potential spaces are represented by retromesenteric plane, retrorenal plane, lateral conal plane, and combined fascial plane. The purpose of this review was to demonstrate embryogenesis, anatomy of interfascial plane, and spreading pathways of various pathologic entities with computed tomography imaging.

Small Bowel Volvulus Induced by Mesenteric Lymphangioma in an Adult: a Case Report

Mesenteric lymphangiomas are rare abdominal masses that are seldom associated with small bowel volvulus, and especially in adult patients. We report here on an unusual case of small bowel volvulus that was induced by a mesenteric lymphangioma in a 43-year-old man who suffered from repeated bouts of abdominal pain. At multidetector CT, we noticed whirling of the cystic mesenteric mass and the adjacent small bowel around the superior mesenteric artery. Small bowel volvulus induced by the rotation of the mesenteric lymphangioma was found on exploratory laparotomy. Lymphangioma should be considered as a rare cause of small bowel volvulus in adult patients.

Pseudocirrhosis of Breast Cancer Metastases to the Liver Treated by Chemotherapy

Pseudocirrhosis refers to a condition that shows changes in hepatic contour that mimic cirrhosis radiographically in the absence of the typical histopathological findings of cirrhosis. This condition has been observed in patients with cancer metastatic to the liver, both in those who have undergone prior systemic chemotherapy and those who have not. Pseudocirrhosis may cause difficulty in interpretation of the response to chemotherapy and hepatic decompression and complication of portal hypertension have a negative effect on the prognosis. We report on a case of breast cancer with liver metastases that showed cirrhotic changes during disease progression. Progression of liver metastases was confirmed by F18 fluorodeoxyglucose positron emission tomography/computed tomography (PET-CT). We also performed ultrasound-guided liver biopsy and confirmed tumor infiltration with severe desmoplastic fibrosis. This case suggests the pathogenesis of pseudocirrhosis through histopathological findings and the role of PET-CT in evaluation of the response to chemotherapy in patients with pseudocirrhosis.

Multidetector-row computed tomography (MDCT) features of small bowel obstruction (SBO) caused by Meckel's diverticulum.

OBJECTIVES To report the multidetector-row computed tomography (MDCT) findings of small bowel obstruction (SBO) caused by Meckels diverticulum. MATERIALS AND METHODS Ten patients (9 men and 1 woman; age range, 2-44 years; median age, 21years) with surgical proven Meckels diverticulum who presented SBO on the preoperative MDCT were included in the study. RESULTS On MDCT, all patients presented with SBO, either high-grade (n=6) or low-grade obstruction (n=4). Meckels diverticulum was identified in five patients (n=5, 50%) on preoperative MDCT. In the five patients in whom a diverticulum was not seen on preoperative MDCT, MDCT showed a transition site on ileum with dilated proximal loops (n=3), pneumoperitoneum (n=1), jejuno-jejunal intussusception (n=1). Transition zone was located near midline in four patients (4/5, 80%). CONCLUSION The diagnosis of Meckels diverticulum complicated SBO can be made with certainty when the diverticulum is visualized on preoperative MDCT. However, the preoperative diagnosis is difficult if the Meckels diverticulum is not noted on the MDCT. When the obstructive processes are visualized in the lower abdomen or pelvis, particularly near the midline, one should keep in mind that SBO may be caused by Meckels diverticulum without prior surgical history.

Clinical effect of double coaxial self-expandable metallic stent in management of malignant colon obstruction

PURPOSE We aimed to evaluate the clinical effectiveness and safety of double coaxial self-expandable metallic stent (DCSEMS) in management of malignant colonic obstruction as a bridge to surgery or palliation for inoperable patients. METHODS Between April 2006 and December 2012, 49 patients (27 males and 22 females; median age, 68 years; age range, 38-91 years) were selected to receive decompressive therapy for malignant colonic obstruction by implanting a DCSEMS. Application of DCSEMS was attempted in 49 patients under fluoroscopic guidance. The obstruction was located in the transverse colon (n=2), descending colon (n=7), sigmoid colon (n=24), rectosigmoid junction (n=6), and the rectum (n=10). The intended use of DCSEMS was as a bridge to elective surgery in 23 patients and palliation in 26 patients. RESULTS Clinical success, defined as >50% dilatation of the stent with subsequent symptomatic improvement, was achieved in 48 of 49 patients (98%). The stent was properly inserted in all patients. No immediate major procedure-related complications occurred. One patient in the bridge-to-surgery group had colon perforation three days after DCSEMS application. Four patients had late migrations of the double stent. CONCLUSION Application of DCSEMS is safe and effective in management of malignant colonic obstruction; it prevents stent migration and tumor ingrowth and lowers perforation rate during the stent application.

Cholangiocarcinoma with a paraneoplastic leukemoid reaction mimicking a pyogenic liver abscess

To the Editor, In rare cases, cholangiocellular carcinoma (CCC) is associated with a paraneoplastic leukemoid reaction (PLR), but on presentation, it also occasionally mimics a pyogenic liver abscess with pyrexia and leukocytosis [1]. Consequently, potential pitfalls exist in the diagnosis of a PLR as the first manifestation of CCC. Here we present a case of CCC with a PLR mimicking an abscess in a patient who presented with pyrexia and leukocytosis. A 63-year-old man was admitted to the hospital with intermittent fever occurring over the past 1 month. He also complained of anorexia and progressive generalized weakness. His body temperature was 39℃. Laboratory tests showed a white blood cell (WBC) count of 22,800/µL, with 78.3% neutrophils. The blood chemistry profile was as follows: total bilirubin 0.26 mg/dL, aspartate aminotransferase 27 U/L, alanine aminotransferase 15 U/L, total protein 6.7 g/dL, and albumin 2.5 g/dL. C-reactive protein was 20.2 mg/dL (normal range < 0.3). The coagulation profile was within normal limits. Tests for serum tumor markers showed normal levels of α-fetoprotein (2.8 ng/mL), protein induced by the absence of vitamin K or antagonist II (12 mAU/mL), carbohydrate antigenic determinant (CA19-9; 35.5 U/mL), and carcinoembryonic antigen (6.2 ng/mL). Serologic tests for hepatitis B and C were negative. Computed tomography (CT) of the chest and abdomen did not demonstrate lesions in the lungs but did show a 3.8-cm centrally hypodense lesion with rim enhancement in segment 4 of the liver (Fig. 1). Figure 1 Arterial-phase helical computed tomography showed a 3.8-cm rim-enhancing, centrally hypodense lesion in segment 4 of the liver. Initially, an early liver abscess was suspected. However, ultrasonography-guided aspiration or drainage was impossible due to its immature appearance. Accordingly, the patient was given antibiotics intravenously for 14 days, but the fever did not subside, and the WBC count increased to 33,000/µL. Blood cultures were negative for bacteria and fungi. Follow-up liver ultrasonography still failed to show the features of a mature liver abscess, leading us to question our initial diagnosis. We therefore re-evaluated the rim-enhancing centrally hypodense liver lesion and the extreme leukocytosis. Gadoxetate-disodium-enhanced magnetic resonance imaging 10 days after hospitalization showed low T1 and high T2 signal intensities, rim-like arterial enhancement, and a washout lesion in the left lobe of the liver (Fig. 2). An ultrasonography-guided biopsy was performed after 2 weeks of hospitalization. Microscopic examination showed poorly differentiated malignant cells positive for cytokeratin (CK) 7 and CK19 and negative for CK20 and hepatocyte-specific antigen (Fig. 3), suggestive of CCC. Even though infection including a pyogenic liver abscess was excluded, neither the extreme leukocytosis, up to 33,000/µL with 94% segmented neutrophils, nor the fever subsided. Because both may be caused by leukemia, bone marrow examination was performed. The possibility of leukemia was excluded by the bone marrow examination. Based on the above, we concluded that the extreme leukocytosis with pyrexia was a PLR of the CCC. Figure 2 Magnetic resonance imaging findings in the liver showed a round nodule with a low signal intensity (arrow) on T1-weighted images (A) and a high signal intensity (arrow) on T2-weighted images (B) in the left hepatic lobe. Figure 3 Microscopic findings of the tumor. Hematoxylin and eosin staining showed poorly differentiated malignant cells suggestive of adenocarcinoma (A, ×100; B, ×400). Positive staining of the tumor cells for (C) cytokeratin 7 (×100) and ... Surgical resection of the liver mass was suggested after 3 weeks of hospitalization. However, it was refused initially by the family because of the patients deteriorating condition; 2 months after his initial hospitalization, the family was finally persuaded by the doctor to allow surgery. Preoperative chest CT revealed multiple new metastatic lung nodules (Fig. 4), which had not been seen 2 months earlier, and surgery was therefore postponed. The patients condition deteriorated progressively despite supportive management, and his WBC count increased to 62,000/µL (Fig. 5). He rapidly became hypoxic and hypotensive. On day 71 after admission, he died due to cardiorespiratory failure. Rapid progression of CCC with a PLR was presumed to be the cause of death based on negative blood and urine cultures and the absence of signs of pneumonia on chest X-ray. Figure 4 Computed tomography of the chest showed newly developed multiple pulmonary nodules (black arrows) suggestive of metastasis. Figure 5 The clinical course of body temperature and white blood cell (WBC) counts beginning from initial hospitalization. CT, computed tomography; MRI, magnetic resonance imaging. A leukemoid reaction refers to a neutrophil-dominant leukocytosis > 50,000/µL, which excludes leukemia. A PLR is a leukemoid reaction that occurs in association with cancer and is thought to be induced by paracrine molecules released from tumor cells. Lung, gastrointestinal, and genitourinary cancers, hepatocellular carcinoma, melanoma, and sarcoma may be associated with a PLR. However, it remains a diagnosis of exclusion, because severe infections or certain drugs can also cause extreme leukocytosis [2]. A PLR is rarely reported in CCC, which on its own has a poor prognosis. To our knowledge, only two cases of a PLR in patients with CCC have been documented [3,4]. The differentiation of CCC from a pyogenic liver abscess can be challenging, because the radiographic findings of a liver abscess can vary depending on the degree of maturation and internal contents. Hepatic abscesses mimicking CCC have often been reported. In most cases, those that mimic a malignant hepatic tumor can usually be identified as true liver abscesses based on the laboratory findings and clinical symptoms [1]. In our patient, radiographic findings, leukocytosis, fever, and a normal CA19-9 level suggested an early liver abscess, but the abscess-mimicking mass-like lesion was unresponsive to antibiotics, thus favoring a diagnosis of malignancy. Our difficulty in differentiating CCC with a PLR from a liver abscess was largely due to the overlapping radiological, clinical, and laboratory findings. Malignant tumors with a PLR are aggressive with a poor prognosis usually. Management of patients with a PLR involves treating the underlying condition, although a PLR usually manifests during the late stages of cancer [5]. It has been suggested that the degree of leukocytosis is associated with tumor burden in malignant tumors with a PLR. In our case, the patient presented at an early stage, based on the tumor size and WBC count. However, his CCC with a PLR was fatal, because the diagnosis was delayed due to radiological, clinical, and laboratory findings overlapping those of a hepatic abscess, thus resulting in deterioration of the patients condition and delayed treatment. As evidenced by our case, even if the clinical and laboratory findings suggest a liver abscess, an abscess-mimicking liver lesion should also be considered and differentiated from CCC with a PLR. In patients with an abscess-mimicking hepatic nodule, pyrexia, and extreme leukocytosis, a prompt diagnostic approach to identify the underlying cause and thus the most effective treatment might result in a better prognosis.

Gastric ectopic pancreas complicated by formation of a pseudocyst.

a Department of Radiology, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Uijeongbu 480717, South Korea b Department of General Surgery, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Uijeongbu 480717, South Korea c Department of Gastroenterology, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 271, Cheonbo-ro, Uijeongbu 480717, South Korea

MDCT Findings of Right Circumaortic Renal Vein with Ectopic Kidney

Anomalies of renal vasculature combined with ectopic kidneys were found on a multi-detector CT scan. Knowledge of renal vascular variation is very important for surgical exploration, radiologic intervention and staging for urologic cancer. We present an extremely rare case of a right circumaortic renal vein combined with a right ectopic kidney. The right kidney was located at the level between the third and fifth lumbar vertebra. The right circumaortic renal vein crossed the aorta and returned to the inferior vena cava behind the aorta.

Spontaneous aortic pseudoaneurysm rupture into the sigmoid colon in Behçet’s disease patient

Behçets disease (BD) is a multisystem autoimmune disorder characterized by recurrent orogenital ulcers, uveitis, and skin lesions. The vascular manifestations include thrombophlebitis, stenosis, occlusion, and pseudoaneurysm. BD infrequently precipitates aortic pseudoaneurysm rupture into the sigmoid mesocolon and lumen of the adjacent colon. Here we report an extremely rare case of spontaneous abdominal aortic pseudoaneurysm rupture via the sigmoid mesocolon into the lumen of the sigmoid colon in a 37-year-old patient with BD.

Gastroenteropancreatic—origin neuroendocrine carcinomas: Three case reports with favorable responses following localized radiotherapy and a review of literature

Rationale: The radiotherapy (RT) responses of gastroenteropancreatic (GEP)-origin neuroendocrine tumors remain unclear. We report cases of favorable response after localized RT of GEP-origin neuroendocrine carcinomas (GEP-NECs). Patient concerns: 1. An 82-year-old male presented with a lower esophageal mass. Positron emission tomography computed tomography (PET-CT) scan showed a lower esophageal mass and gastrohepatic lymph nodes. 2. A 52-year-old female presented with abdominal discomfort. CT scan showed a 9.8 cm-sized enhancing mass in the lesser sac abutting the stomach, pancreas and liver. 3. A 54-year-old male patient presented with anal pain and bleeding. CT scan showed a remnant mass in the perirectal area after trans-anal excision. Diagnoses: The diagnoses of GEP-NECs were pathologically confirmed by biopsy or excision, and immunohistochemical stainings of Ki-67, CD56, synaptophysin and chromogranin-A. Interventions: 1. The patient was treated with definitive RT. 2. The patient was treated with RT after two cycles of etoposide-cisplatin chemotherapy. 3. The patient was treated with adjuvant RT. Outcomes: 1. Complete remission was achieved based on CT scan four months after RT. 2. CT scan showed partial regression of the mass with a 5 cm-diameter at six months after RT. Adjuvant chemotherapy was administered after RT. 3. The residual mass was almost completely regressed at CT scan four months after RT. Lessons: In cases of GEP-NECs, RT can be a useful treatment modality with favorable tumor response for patients with inoperable conditions or those suffering from bulky tumor masses.