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Long Island Radiological Society Interesting Case Panel Tuesday, March 12 th, 2013 Nassau University Medical Center East Meadow, NY.

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Presentation on theme: "Long Island Radiological Society Interesting Case Panel Tuesday, March 12 th, 2013 Nassau University Medical Center East Meadow, NY."— Presentation transcript:

1 Long Island Radiological Society Interesting Case Panel Tuesday, March 12 th, 2013 Nassau University Medical Center East Meadow, NY

2 Case 1 40 year-old Hispanic female with left upper quadrant pain and weight loss; left upper quadrant mass palpable on exam Submitted by Judy Atallah, DO PGY4


4 STOP Proceed to next slide for diagnosis

5 Leiomyosarcoma Uncommon malignancy of smooth muscle origin arising from alimentary tract, retroperitoneum, urogenital tract, or soft tissues Most commonly metastasizes to liver, lung, peritoneal surfaces; may also spread to soft tissues, bone, spleen, or cause ascites Represent 11% of retroperitoneal malignancies 16% 2 year survival when in retroperitoneum

6 Leiomyosarcoma Imaging features are nonspecific Usually large and necrotic mass, without calcification When large, primary tumor and metastases may demonstrate moderate peripheral enhancement Otherwise, contrast enhancement is not a prominent feature

7 Reference Leiomyosarcoma: computed tomographic findings. A J McLeod, J Zornoza, A Shirkhoda. July 1984 Radiology, 152, 133-136. Primary Retroperitoneal Neoplasms: CT and MR Imaging Findings with Anatomic and Pathologic Diagnostic Clues. M. Nishino, K.Hayakawa, M. Minami, A. Yamamoto, H. Ueda, K. Takasu. January 2003 RadioGraphics, 23, 45-57. RadioGraphics,

8 Case 2 72 year-old male with cough productive for blood tinged sputum for one month as well as weight loss and decreased appetite Submitted by Sofiya Greenberg, MD PGY3

9 STOP Proceed to next slides for diagnosis

10 Clinical Findings AFB culture positive for mycobacterium tuberculosis Patient and department of health were notified Patient was placed on respiratory isolation Treatment for TB was administered, patient was instructed to follow up with ID for long term treatment

11 Empyema Necessitans Extension of a pleural infection out of the thoracic cavity and into neighboring structures. Most commonly due to TB or fungal infections Can occur following necrotizing pneumonia or lung abscess Treatment is with antibiotics plus closed or open drainage of the pleural space

12 References Heffner JE, Klein JS, Hampson C. Diagnostic utility and clinical application of imaging for pleural space infections. Chest. 2010;137 (2): 467-79. Glicklich M, Mendelson DS, Gendal ES et-al. Tuberculous empyema necessitatis. Computed tomography findings. Clin Imaging. 1990;14 (1): 23-5. Haddad CJ, Sim WK. Empyema necessitatis. Am Fam Physician. 1989;40 (4): 149-52

13 Case 3 19 year-old male presents after MVA with blunt abdominal trauma and diffuse non- specific abdominal pain Submitted by Brian Goodman, MD PGY2

14 Do you see any vascular abnormality?

15 STOP Proceed to next slide for diagnosis

16 Celiac Artery Injury after Blunt Abdominal Trauma Approximately 90-95% of injuries to abdominal visceral vasculature are caused by penetrating trauma, only 5-10% are attributed to blunt trauma Injury to the celiac axis is extremely rare, only case reports in the literature Mortality can be as high as 75%

17 Celiac Artery Injury after Blunt Abdominal Trauma Initial evaluation is usually with arterial phase CT angiography If suspicious, confirm with conventional angiography MR angiography less commonly used Imaging findings: Luminal disruption/filling defect Intimal flap suggestive of dissection Superimposed thrombosis Look for evidence of abdominal visceral ischemia

18 References Gorra AS, Mittleider D, Clark DE, Gibbs M. Arch Surg. Asymptomatic isolated celiac artery dissection after a fall. 2009 Mar;144(3):279-81. doi: 10.1001/archsurg.2009.22. Kirchhoff C, Stegmaier J, Krotz M, Muetzel Rauch E, Mutschler W, Kanz KG, Heindl B. Celiac dissection after blunt abdominal trauma complicated by acute hepatic failure: case report and review of literature. J Vasc Surg. 2007 Sep;46(3):576-80. Suchak AA, Reich D, Ritchie W. Traumatic isolated dissection of the celiac artery. AJR Am J Roentgenol. 2007 Dec;189(6):W373-4.

19 Case 4 54 year-old female with hypertension and palpitations; clinical concern for pheochromocytoma Submitted by Allison Rubin, MD PGY2

20 Axial T2W images of the abdomen at the level of the adrenal glands

21 Indium-111 labeled octreotide scan of abdomen and pelvis

22 Axial T2W, T1W, and T1W FS post gadolinium administration images of the pelvis

23 Sagittal T2W image of the pelvis STOP Proceed to next slide for diagnosis

24 Extra-adrenal Paraganglioma: Organ of Zuckerkandl Rare catecholamine secreting tumor that arises from the neural crest chromaffin cells May occur at any site where sympathetic nervous tissue is located –Adrenal pheochromocytomas  90% –Extra-adrenal paragangliomas  10% The most common site for extra-adrenal paragangliomas is the Organ of Zuckerkandl (Chromaffin tissue near the origin of the IMA) Signs and Symptoms: episodic headache, sweating, hypertension, palpitations Paragangliomas are associated with a number of inherited syndromes, e.g. MEN 2A/B, NF1, VHL, Carney’s Triad, and Familial Paragangliomas

25 Imaging Findings CT Findings –Para-aortic soft tissue mass with homogenous enhancement –May have central areas of low attenuation –Punctate calcifications –Acute hemorrhage may cause areas of high attenuation Nuclear Imaging – 121 I- or 131 I-MIBG imaging used in the evaluation of pheochromoctyoma, however, it is less sensitive in the diagnosis of extra-adrenal paraganglioma – 99m Tc- labeled hydrazinonicotinyl-Tyr3-octreotide scintigraphy was shown to have 96% sensitivity as compared to 72% sensitivity for 131 I-MIBG imaging in the diagnosis of extra-adrenal paragangliomas (Chen et al., 2009) MR Imaging –T1: isointense or hypointense to liver –T2: hyperintense –Enhances with gadolinium administration

26 References Chen L et al. 99mTc-HYNIC-TOC Scintigraphy Is Superior to 131I-MIBG Imaging in the Evaluation of Extraadrenal Pheochromocytoma. J Nuc Med 2009; 50:397-400 Kahraman D et al. Extra-adrenal Pheochromocytoma in the Organ of Zuckerkandl: Diagnosis and treatment strategies. Exp Clin Endocrinol Diabetes 2011; 119: 436-9 Lee KY et al. Imaging Extraadrenal Paragangliomas of the Body: Imaging features. AJR 2006; 187: 492-504 Sahdev et al. CT and MR Imaging of Unusual Locations of Extra-adrenal Paragangliomas (Pheochromocytomas). Eur Radiol 2005; 15: 85-92 van Gils APG et al. MR Imaging and MIBG Scintigraphy of Pheochromocytomas and Extraadrenal Functioning Paragangliomas. Radiographics 1991; 11: 37-57

27 Case 5 45 year-old female with shortness of breath Submitted by Toshimasa Clark, MD PGY5



30 STOP Proceed to next slide for diagnosis

31 Partial Anomalous Pulmonary Venous Return Congenital right to left shunt wherein one or more pulmonary veins return anomalously to the superior or the inferior vena cava, the right atrium, or the coronary sinus. Upper lobe PAPVR may drain to the brachiocephalic vein via a vertical vein, while in this case a lower lobe PAPVR drains to the IVC Mechanism is thought to be involution of a portion of the common pulmonary vein on the affected side at an embryological stage when there remain connections between the pulmonary veins, omphalomesenteric veins, and primitive IVC

32 References Kalke B, Carlson R, Ferrlici R, et al. Partial pulmonary anomalous venous connection. Am J Cardiol 1967; 20:91- 101. Zwetsch B, et al. Three-Dimensional Image Reconstruction of Partial Anomalous Pulmonary Venous Return to the Superior Vena Cava. Chest 1995; 108(6):1743-1745. Kaiser LR, et al. Mastery of Cardiothoracic Surgery. Philadelphia: Lippincott and Williams, 2007. Print.

33 Case 6 48 year-old female with chronic left ankle pain Submitted by Kory Byrns, MD PGY3



36 STOP Proceed to next slide for diagnosis

37 Fibrous Talocalcaneal Coalition Abnormal bridging, usually related to failure of embryological segmentation May be asymptomatic or present as progressive ankle pain/stiffness, lateral leg pain, or, uncommonly, with tarsal sinus or tarsal tunnel symptoms 25% bilateral, though may present with only unilateral symptoms May be osseous, cartilaginous, or fibrous Radiographs are relatively insensitive and nonspecific, but may note “C sign” of calcaneal sclerosis along the medial subtalar joint

38 Fibrous Talocalcaneal Coalition In fibrous coalition, CT reveals sclerosis and irregularity at the articulation with narrowing and broadening of the joint space Subchondral cysts may develop MR reveals sclerosis as low signal on all pulse sequences With motion, marrow edema develops, demonstrating diminished T1 and elevated T2 signal, as in this case If present, marrow and trabecular continuity indicate osseous rather than fibrous coalition

39 Reference Crim J: Imaging of tarsal coalition. Radiol Clin North Am. 46(6):1017-26, vi, 2008

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