Suman Bandhu

In Vivo Proton Spectroscopy of Giant Cell Tumor of the Bone

OBJECTIVE The proton MR spectroscopic finding of elevated choline has been reported to be useful in the differentiation of malignant from benign musculoskeletal tumors. This study was designed to evaluate the MR spectroscopy features of giant cell tumor (GCT) of the bone, primarily to determine whether the presence of choline is a frequent occurrence in these tumors and whether MR spectroscopy features can be correlated with clinical, radiologic, and histopathologic findings. SUBJECTS AND METHODS MRI, dynamic contrast-enhanced MRI, and proton MR spectroscopy were performed in 33 patients with bone tumors on a 1.5-T MR scanner. Of these, 12 patients who had GCT of the bone form the subject material for this study. Dynamic contrast-enhanced MRI and single-voxel proton MR spectroscopy were performed after preliminary evaluation with radiography. Patients were divided into two groups, those with elevated choline levels and those without a choline peak on MR spectroscopy. The clinical and radiologic features, including the Campanacci stage and dynamic MRI findings, were compared in these two groups. Core biopsy was performed in all patients, and in 10 of 12 patients, histopathologic evaluation of the postoperative resected specimen was also performed. RESULTS Although all 12 tumors were benign on histopathology, four had elevated choline levels. Of these, three (75%) had an aggressive radiographic appearance (Campanacci stage 3). As opposed to this, only three of the eight (37.5%) tumors without a choline peak had an aggressive radiographic appearance. Except for a single case, all tumors showed early enhancement and washout of contrast material on dynamic MRI. CONCLUSION The results of this study indicate that GCT of bone may show raised choline levels on proton MR spectroscopy. This finding is not an indicator of malignancy in these tumors.

Ulcerative colitis associated with Takayasu arteritis.

Takayasu arteritis is a chronic vasculitis involving the left upper limbs, respectively. Left carotid was mainly the aorta and its branches. It is often complifeeble as compared to the right carotid. Rectal and cated with other systemic manifestations. Renal proctoscopic examinations revealed blood mixed with involvement is commonly in the form of renovascular stools coming from above without any evidence of hypertension though mesangial proliferative glomerulocal pathology. A clinical diagnosis of Takayasu lonephritis, crescentic glomerulonephritis and arteritis with renal and mesenteric ischemia was amyloidosis can also occur [1]. Skin changes include made. erythema nodosum, facial lupus rash and erythema Routine investigations revealed hemoglobin of 9 3 induratum. Dilated cardiomyopathy, myocarditis and g/dl, total leukocyte counts 15 000/mm with 70% pericarditis have been reported. Rarely, ulcerative neutrophils and ESR 60 mm/1st hour. Renal funccolitis has been reported with Takayasu arteritis [2]. tions, electrolytes and liver functions were normal. We report a patient with Takayasu arteritis who Urine examination showed 15–20 red blood cells developed ulcerative colitis and renal involvement without any dysmorphic cells or casts. Ultrasound of nearly 1 year after the initial diagnosis. The HLA the abdomen documented healthy appearing kidneys type in this patient is also presented. with the right larger (11 cm) than the left (9 cm). A 15-year-old boy was diagnosed to have A repeat DSA showed subtle narrowing of proximTakayasu arteritis 1 year ago when he presented with al part of bilateral subclavian arteries and wavy a fever of 4 months duration. A digital subtraction contour of abdominal aorta. Left renal artery showed angiography (DSA) at that time revealed involvement a short stenotic segment at its origin along with of descending thoracic aorta, abdominal aorta, left stenosis of the branch arising from it. Only the upper common carotid and left brachial artery. He respondpart of the left kidney was seen on nephrogram ed to steroids which were tapered off in 8 months. suggesting that another artery was supplying the At this admission, he presented with complaints of lower part of the left kidney (Fig. 1). However, this fever for 3 months, and hematuria and hematochezia artery could not be visualized indicating a tight osteal for 3 days. On examination, blood pressure was stenosis or occlusion. Superior and inferior mesen146/100 mmHg and 124/94 mmHg in the right and teric arteries were normal. These findings were consistent with renal infarction as the cause of hematuria. A colonoscopy done at this point revealed *Corresponding author. Tel.: 191-11-653-1201; fax: 191-11-686an edematous and erythematous mucosa with multi2663. E-mail address: peekay 124@hotmail.com (P. Aggarwal). ple small superficial erosions throughout the length of ]

Extra-hepatic bile duct adenoma in a patient with a choledochal cyst

To the Editor, Choledochal cyst is an uncommon anomaly of the biliary system. Many complications have been reported including choledocholithiasis, cystolithiasis, pancreatitis, intrahepatic abscesses, biliary cirrhosis, portal hypertension, and hepatobiliary malignancy. Bile duct adenoma (BDA), which is a rare neoplasm of the extrahepatic biliary tree, however, has not been reported in a choledochal cyst. Although this tumor is benign, it is considered to have a malignant potential. We report one such case in a 55-year-old man who underwent a pancreaticoduodenectomy for a suspicious mass in the distal part of a type I choledochal cyst. The mass was a BDA on histopathological examination. A 55-year-old male patient was admitted with complaints of recurrent episodes of upper abdominal pain for the last 4 years. He had an episode of cholangitis 2 months earlier. An ultrasound of the abdomen at that time suggested a choledochal cyst with a large stone in the mid-part of the common bile duct (CBD). At admission, a magnetic resonance cholangiopancreatography (MRCP) was performed, which confirmed the presence of a type I choledochal cyst with a stone in its mid-part. It also revealed a fuzzy growth in the distal bile duct. However, the possibility of sludge could not be ruled out (Fig. 1). A side-viewing endoscopy revealed normal ampulla. Computed tomography (CT) scan of the abdomen revealed an ill-defined mass arising from the wall of the CBD. There was no lymphadenopathy at the porta hepatis. The liver function tests revealed elevated serum alkaline phosphatase (348 IU). However, the serum bilirubin was normal. At laparotomy, a soft mass was palpable in the lower CBD. As the possibility of this being sludge was retained based on clinical and radiological pictures, the CBD was opened. The stone was removed and a soft, friable mass was encountered. The mass was sessile. A frozen section of the mass was reported as a BDA with foci of dysplasia. Because malignancy could not be ruled out, Whipple’s operation was performed. The choledochal cyst was completely excised. Hepaticojejunostomy was performed at the normal confluence. The postoperative course was uneventful. The histological examination revealed an adenoma of the distal bile duct with foci of mild to moderate dysplasia (Fig. 2). There was no evidence of malignancy in the excised specimen. Sections from the fusiform dilated bile duct revealed thickening and fibrosis of the wall with focal areas of inflammation. The lining was a single layer of cuboidal to columnar epithelium that was ulcerated at places. Dysplastic changes were not seen. Benign tumors of the extrahepatic biliary tree are rare. They account for only 6% of all tumors of the extrahepatic biliary tree. 1 They have been classified as papilloma, adenoma, granular cell myoblastomas, adenomyoma, fibromas, leiomyomas, neurinoma and hamartoma. Of these, papillomas and adenomas constitute the majority. In a review of 84 cases of benign neoplasms of the extrahepatic biliary tree; 41 (48%) were papillomas and 39 (46%) were adenomas. 2 Chu has reported a series of 30 cases of benign neoplasms of the biliary tract; 26 (86%) of which were adenomas or papillomas. 3

Tuberculous pseudoaneurysm of gastroduodenal artery

We report a patient with Gastroduodenal artery (GDA) pseudoaneurysm of tuberculous aetiology, who presented with massive hematemesis and who was successfully managed with transarterial steel coil embolization. Pseudoaneurysms are a rare but potentially fatal complication of tuberculosis and hence early recognition and management of this complication is important. To the best of our knowledge this is the first report of a GDA pseudoaneurysm resulting from tuberculosis.

Extra-osseous fat fluid level: a specific sign for osteomyelitis.

Osteomyelitis may pose as a diagnostic dilemma on various imaging modalities and may be confused with neoplasms and other pathology. Although a rare finding, extra-osseous fat fluid level, especially when associated with spongy bone destruction, can be considered a specific sign of osteomyelitis. Previously, only two cases of extra-osseous fat fluid level in osteomyelitis have been reported, one on computed tomography (CT) and the other on magnetic resonance imaging (MRI). The former was a case of septic arthritis with intra-articular fat fluid level. A case of osteomyelitis is presented with the demonstration of extra-osseous fat fluid level. Our case is unique in providing exquisite CT and MRI correlation.

Intraosseous and intraarticular pneumatosis in anaerobic osteomyelitis.

A 14-year-old diabetic girl presented with fever and pain and swelling of the left hip for 1 week. There was no history of trauma or biopsy. Laboratory examination revealed leucocytosis with raised erythrocyte sedimentation rate and C-reactive protein. CT revealed gas within the femur, left hip joint and surrounding soft tissues (Figs. 1 and 2). There was marrow and soft-tissue oedema with multiple cortical breeches. Cultures from purulent material in the soft tissues yielded mixed skin flora and Bacteroides fragilis. Bone biopsy confirmed osteomyelitis. Intraosseous gas has been reported after biopsy, penetrating wounds and fractures. Very few cases of intraosseous and intraarticular pneumatosis have been reported in the setting of osteomyelitis [1, 2]. In the absence of direct communication of bone with air, it is highly suggestive of osteomyelitis, and the pathogens are usually anaerobic and/or polymicrobial. The presumed mechanism is anaerobic metabolism with production of hydrogen and carbon dioxide gases [1]. The presence of intraosseous gas usually signifies fulminant infection requiring aggressive treatment. The other rare causes of intraosseous gas are lymphangiomatosis of bone, necrosis and neoplasm [1].

The role of 99mTc mebrofenin hepatobiliary scanning in predicting common bile duct stones in patients with gallstone disease.

BackgroundA dilated common bile duct and/or elevated serum alkaline phosphatase, raises a suspicion of bile duct stone(s) in patients with gallstones. Cholangiography, either endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), is the best method for diagnosing bile duct stones. ERCP has the disadvantage of being invasive, and there is a risk of complications; while MRCP is costly and is not widely available. AimThe objective of the present study was to evaluate the role of hepatobiliary nuclear scanning in diagnosing bile duct stones. MethodsTwenty-five patients with suspected common bile duct (CBD) stones underwent hepatobiliary scintigraphy. The results of scintigraphy were compared with cholangiograms obtained by ERCP in 11 patients and MRCP in 14 patients, considering MRCP/ERCP as the ‘gold standard’. ResultsScintigraphy showed features suggestive of CBD stones in 11 of the 25 patients. The results of ERCP/MRCP confirmed that eight of them had stones. Scintigraphy showed no features of CBD stones in the remaining 14 patients. ERCP/MRCP showed CBD stones in two of these 14 patients. Thus, scintigraphy had a sensitivity of 80% and a specificity of 80%. ConclusionWe conclude that scintigraphy has good sensitivity and specificity in predicting CBD stones in patients with gallstone disease and a dilated CBD.