A case of primary bilateral adrenal non-Hodgkin's lymphoma / 대한내과학회지

Primary adrenal lymphoma is extremely uncommon. The tumor is accidentally discovered by abdominal ultrasonography(USG), computed tomography(CT) or magnetic resonance imaging (MRI) in patients with nonspecific symptoms and diagnosed at operation or autopsy. In this case, a 60-year-old man was admitted for the evaluation of mild left frank discomfort for two months before admission. The abdominal USG was performed and showed the dense masses in both adrenal glands. The laboratory tests including blood count, chemistry and hormonal tests showed the normal levels except for the basal ACTH level of 108 pg/ml(normal range: 9~52 pg/ml). The 123I MIBG scan was normal. The bilateral adrenalectomy was done. The tumor was diagnosed as diffuse large B-cell non-Hodgkin's lymphoma(NHL) according to the Revised European-American lymphoma(REAL) classification. He was treated with the adjuvant combination chemotherapy of CHOP(cyclophosphamide, adriamycin, vincristine and prednisolone) but expired due to sepsis after the second chemotherapy. We describe the first case of primary bilateral adrenal NHL in Korea. Primary adrenal lymphoma should be included in the differential diagnosis of suprarenal mass.

Diagnostic Ability of Arm Exercise Thallium-201 SPECT in Detecting Coronary Artery Disease

BACKGROUND: Exercise testing is a standard noninvasive method used in the evaluation and management of patients with suspected coronary artery disease. However, patients with lower limb impairment are unable to undergo a standard bicycle or treadmill test. Alternative methods of exercise testing are needed for patients with vascular, orthopedic or neurologic conditions who cannot perform leg exercise. This study was aimed to determine the diagnostic accuracy of arm exercise thallium-201 SPECT for evaluating chest pain in patients unable to perform leg exercise. METHOD: Twenty-five anginal patients performed arm ergometry testing in conjunction with thallium-201 SPECT. Thereafter all underwent coronary angiography. RESULT: Significant coronary artery disease (> or =50% stenosis) in at least one vessel was present in 22 (88%) of the 25 patients. The sensitivity of thallium-201 SPECT for detecting coronary artery disease was 91%, which was significantly higher than the 32% sensitivity found with the electrocardiographic response alone (p <0.001). Thallium-201 SPECT yielded a sensitivity of 88, 86 and 100% for one, two, and three vessel diseases, respectively, and an 84% sensitivity and 81% specificity for detecting individual vessel stenosis. CONCLUSION: Arm exercise thallium-201 SPECT is useful for detecting coronary artery disease in patients unable to perform leg exercise. In addition, it provides an information regarding exercise tolerance. Therefore, this test appears to be reliable and useful and should be considered in the detection of coronary artery disease in nonambulatory patients.

Evaluation of Confocal Laser Scanning Indocyanine Green Angiography Images of Occult Choroidal Neovascularization

For the interpretation of the confocal laser scanning indocyanine green angiography(Heidelberg Retina Angiograph, HRA) in patients with choroidal neovascularization(CNV) secondary to age-related macular degeneration(AMD), we analyzed the early and the late phase images comparatively. HRA was carried out in 41 eyes of 36 patients that revealed occult CNV or undetectable CNV on fluorescein angiograms. In all patients, the image qualitites of HRA was excellent in the early as well as in the late phase studies and CNV was detected in 38 eyes(93%). In 25 eyes(66%), we could get all the possible information of CNV with the early phase images which revealed CNV as fine neovascular networks or vascular structures of lnear or dot pattern usually surrounded by hypofluorescent margins. And when the hypofluorescent margin surrounded the neovascular structure completely, a well-defined CNV could be diagnosed. In 9 eyes(24%), more accurate evaluation of the nature, size and geometry of CNV could be made with the help of more late phase images. In these cases, as the initially identified neovascular structures were stained in the late phase, more intensely leaking portions or more widespread minimally stained areas could be detected. In remaining 4 eyes(10%), CNV could b detected in the late phase without apparent evidence of vascular structure in the early phase. Our study suggests that careful reading of the whole sequence of ICG angiograms and comparative analysis of the early and late phase images are required to get the clinically useful information from HRA.

The Evaluation of Anterior Segment Ischemia in Pigmented Rabbits Using Indocyanine Green (ICG) Iris Angiography

To evaluate the usefulness of indocyanine green (ICG) iris angiography in darkly pigmented iris and to investigate whether the anterior segment ischemia can be produced by tenotomies of two or more rectus muscles in rabbits, twenty one eyes of 21 pigmented rabbits wer divided into four groups according to the surgical procedures. Group I (2 eyes) underwent only conjunctival peritomy as a control. Group II (6 eyes), Group III (9 eyes), Group IV (4 eyes) underwent tenotomies of two, three and four rectus muscles, respectively. All these eyes underwent ICG iris angiography at pre-op, post-op 10 housrs, 3 days, 7 days and 14 days. In eight eyes of Group I and Group II, fluorescein iris angiography was taken simultaneously. The quality of fluorescein iris angiography was much lower in the pigmented iris and the interpretation was more difficult compared to ICG iris angiography. The peritomy (Group I) or tenotomies of two rectus muscles (Group II) produced no circulatory defect of the iris even after 10 hours postoperatively. After tenotomies of three rectus muscles (Group III) there were transient mild filling defects in superior or inferior sector of iris in 7 of 9 eyes. These defects lasted for 1 to 3 days. Tenotomies of four rectus muscles (Group IV) produced transient filling defects which lasted for 1 to 7 days. ICG iris angiography was suitable for the evaluation of anterior segment circulation in darkly pigmented iris, thus, it can be applied to the coriental brown iris. And in contrast to the previous concept that the rabbits iris arteries derive solely from the long posterior ciliary arteries, circulatory disturbance of iris, even though transient, could be produced by severance of rectus muscles.

Two Cases of Retinoblastoma Diagnosed by Fine needle Aspiration Biopsy

Retinoblastoma is a highly malignant intraocular tumor of childhood that requires accurate diagnosis and prompt treatment. The diagnosis of retinoblastoma is based on the fundus finding and noninvasive radiologic evaluation, but sometimes retinoblastoma is clinically misdiagnosed as nonneoplastic lesion such as Coats' disease, persistent hyperplastic primary vitreous, toxocariasis and old retinal detachment and sometimes vice versa. We performed fine needle aspiration biopsies in two cases, in whom retinoblastoma or Coats' disease was suspected but there was diagnostic uncertainty on fundus finding, orbit CT or MRI. The cytologic diagnosis of two cases was retinoblastoma. And after enucleation final histopathologic diagnosis correlated with the cytodiagnosis. We think that fine needle aspiration biopsy may be helpful in establishing the diagnosis in difficult cases of childhood leukocoria including retionblastoma.