Pseudoaneurysm formation or dural arteriovenous fistula formation at the middle meningeal artery following revascularization surgery in Moyamoya disease

Moyamoya disease (MMD) is a rare progressive steno-occlusive cerebrovascular disorder. Currently, revascularization surgery is used as optimal treatment to overcome MMD. However, revascularization for MMD has reported several complications. Also, iatrogenic complications such as pseudoaneurysms formation or dural arteriovenous fistulas (dAVFs) formation—has been identified in rare cases after the surgical intervention for revascularizations.We describe two cases. In first case, the patency of the anastomosis site was good and saccular type pseudoaneurysm formation was found at parietal branch of posterior middle meningeal artery (MMA) in transfemoral cerebral angiography (TFCA) performed on the twelfth day after surgery. We decided to treat pseudoaneurysm by endovascular embolization the next day, but the patient was shown unconsciousness and anisocoria during sleep at that day. Computed tomography showed massive subdural hemorrhage at the ipsilateral side, thus we performed decompressive craniectomy and hematoma evacuation.In second case, the patency of the anastomosis site was good and dAVF formation at right MMA was found in TFCA performed on the sixth day after surgery. We performed endovascular obliteration of the arteriovenous fistula under local anesthesia.Pseudoaneurysm formation or dAVF formation after revascularization surgery is an exceptional case. If patients have such complications, practioner should carefully screen the patients by implementing digital subtraction angiogram to identify anatomic features; as well as consider immediate treatment in any way, including embolization or other surgery

Efficacy of Acetylcysteine and Selenium in Aneurysmal Subarachnoid Hemorrhage Patients: A Prospective, Multicenter, Single Blind Randomized Controlled Trial

Background@#Subarachnoid hemorrhage (SAH) patients have oxidative stress results in inflammation, tissue degeneration and neuronal damage. These deleterious effects cause aggravation of the perihematomal edema (PHE), vasospasm, and even hydrocephalus. We hypothesized that antioxidants may have a neuroprotective role in acute aneurysmal SAH (aSAH) patients. @*Methods@#We conducted a prospective, multicenter randomized (single blind) trial between January 2017 and October 2019, investigating whether antioxidants (acetylcysteine and selenium) have the potential to improve the neurologic outcome in aSAH patients. The antioxidant patient group received antioxidants of acetylcysteine (2,000 mg/day) and selenium (1,600 µg/day) intravenously (IV) for 14 days. These drugs were administrated within 24 hours of admission. The non-antioxidant patient group received a placebo IV. @*Results@#In total, 293 patients were enrolled with 103 patients remaining after applying the inclusion and exclusion criteria. No significant differences were observed in the baseline characteristics between the antioxidant (n = 53) and non-antioxidant (n = 50) groups. Among clinical factors, the duration of intensive care unit (ICU) stay was significantly shortened in patients who received antioxidants (11.2, 95% confidence interval [CI], 9.7–14.5 vs. 8.3, 95% CI, 6.2–10.2 days, P = 0.008). However, no beneficial effects were observed on radiological outcomes. @*Conclusion@#In conclusion, antioxidant treatment failed to show the reduction of PHE volume, mid-line shifting, vasospasm and hydrocephalus in acute SAH patients. A significant reduction in ICU stay was observed but need more optimal dosing schedule and precise outcome targets are required to clarify the clinical impacts of antioxidants in these patients.

Ruptured Medullary Hemangioblastoma Mimicking a Craniocervical Junction Dural Arteriovenous Fistula with a Pseudoaneurysm / 신경중재치료의학

Hemangioblastomas (HBMs) are rare vascular tumors commonly located in the posterior fossa of adults. A mid-50s patient presented with sudden unconsciousness. Computed tomography scans revealed acute hemorrhages around the posterior fossa, predominantly in the subarachnoid space. Digital subtraction angiography (DSA) revealed an 8-mm round lesion filled with contrast agent, fed by the C1 segmental artery of the left vertebral artery (VA), showing early venous drainage to the spinal cord and brainstem. Emergent embolization was attempted under suspicion of a ruptured dural arteriovenous fistula, resulting in parent artery occlusion due to feeder selection failure. Follow-up DSA after a month depicted a persistent aneurysm via collaterals from both VAs. Consequently, the decision was made to proceed with surgical intervention, leading to the resection of the lesion, confirming its diagnosis as a HBM through histological examination. This case underscores the potential for misdiagnosis when HBMs with an intratumoral shunt mimic vascular shunt lesions.

Scrub typhus infection in a kidney transplant recipient: a case report / 고신대학교의과대학학술지

Scrub typhus is a febrile disease that is endemic to Asia and the Pacific region. Its clinical manifestations include fever, myalgia, lymphadenopathy, and a characteristic eschar. The main manifestations of this disease are difficult to differentiate from those of other febrile illnesses; thus, a careful clinical examination and a high index of suspicion are crucial for an early diagnosis. Our case involved a 55-year-old female renal transplant recipient who presented with fever and sore throat in November. Her clinical symptoms did not improve after oral amoxicillin/clavulanate administration for 7 days, after which proteinuria and acute kidney injury were identified. After hospitalization, an eschar was found and immunoglobulin M antibodies against Orientia tsutsugamushi were detected by indirect immunofluorescence. She received oral doxycycline for 7 days and showed improvement in renal function and proteinuria. This is the first case report of scrub typhus infection in a kidney transplant patient in Korea. It is meaningful to report that the renal abnormalities associated with scrub typhus improved in a renal transplant patient through treatment of the disease. This case highlights the importance of examining the social history and symptoms of patients suspected of having scrub typhus in endemic areas. Early diagnosis and treatment are crucial in kidney transplant patients to preserve graft function and prevent fatal complications.

Efficacy of intraoperative neuromonitoring (IONM) and intraoperative indocyanine green videoangiography (ICG-VA) during unruptured anterior choroidal artery aneurysm clipping surgery

Objective@#The aim of this study was to investigate the efficacy of intraoperative indocyanine green videoangiography (ICG-VA) and intraoperative neuromonitoring (IONM) to prevent postoperative ischemic complications during microsurgical clipping of unruptured anterior choroidal artery (AChA) aneurysms. @*Methods@#We retrospectively reviewed the clinical and radiological records of all patients who had undergone microsurgical clipping for unruptured AChA aneurysms at our institution between April 2001 and December 2019. We compared the postoperative complication rate of the group for which intraoperative ICG-VA and IONM were utilized (group B; n=324) with that of the group for which intraoperative ICG-VA and IONM were not utilized (group A; n=72). @*Results@#There were no statistically significant differences in demographic data between the two groups. Statistically significant differences were observed in the rate of overall complications (p=0.014) and postoperative ischemic complications related to AChA territory (p=0.039). All the cases (n=4) in group B who had postoperative infarctions related to AChA territory showed false-negative results of intraoperative ICG-VA and IONM. @*Conclusions@#Preserving the patency of the AChA is essential to minimize postoperative complications. Intraoperative monitoring tools including ICG-VA and IONM can greatly contribute to lowering complication rates. However, their pitfalls and false-negative results should always be considered.

Microsurgical treatment of lateral cavernous sinus wall dural arteriovenous fistula with large venous aneurysm: A case report

We report a case of lateral cavernous sinus wall dural arteriovenous fistula (DAVF) accompanied large venous aneurysm which is presented intracerebral hemorrhage (ICH). A 58-year-old male patient came to emergency department for acute onset of headache and dysarthria. In brain computed tomography scan, large left temporal lobe ICH was noted. In transfemoral cerebral angiography, multiple arteries from external carotid artery and left internal carotid artery (ICA) fed arteriovenous shunt. This shunt was drained through cavernous sinus with enlarged multiple cortical veins. One large venous aneurysm was estimated as bleeding focus for ICH. Considering ICH and high flow shunt, we planned urgent treatment to reduce flow of arteriovenous shunt. However, transvenous embolization was failed due to tortuous venous anatomy. Therefore, we planned craniotomy and microsurgical treatment. There was engorged small vessel in lateral wall of cavernous sinus and vascular trunk which is fistulous connection was noted. Fistula connection was obliterated and disconnected after coagulation. In postoperative image, fistula was completely disappeared and there was no cortical venous reflux, also large venous aneurysm was disappeared. Patient recovered very well without new neurological deficits. We reported successfully treated lateral cavernous sinus wall DAVF by combined endovascular and transcranial-microsurgical treatment.

Microsurgical treatment of lateral cavernous sinus wall dural arteriovenous fistula with large venous aneurysm: A case report

We report a case of lateral cavernous sinus wall dural arteriovenous fistula (DAVF) accompanied large venous aneurysm which is presented intracerebral hemorrhage (ICH). A 58-year-old male patient came to emergency department for acute onset of headache and dysarthria. In brain computed tomography scan, large left temporal lobe ICH was noted. In transfemoral cerebral angiography, multiple arteries from external carotid artery and left internal carotid artery (ICA) fed arteriovenous shunt. This shunt was drained through cavernous sinus with enlarged multiple cortical veins. One large venous aneurysm was estimated as bleeding focus for ICH. Considering ICH and high flow shunt, we planned urgent treatment to reduce flow of arteriovenous shunt. However, transvenous embolization was failed due to tortuous venous anatomy. Therefore, we planned craniotomy and microsurgical treatment. There was engorged small vessel in lateral wall of cavernous sinus and vascular trunk which is fistulous connection was noted. Fistula connection was obliterated and disconnected after coagulation. In postoperative image, fistula was completely disappeared and there was no cortical venous reflux, also large venous aneurysm was disappeared. Patient recovered very well without new neurological deficits. We reported successfully treated lateral cavernous sinus wall DAVF by combined endovascular and transcranial-microsurgical treatment.

Clinical Outcomes of Large (>10 mm) Unruptured Posterior Circulation Aneurysms and Their Predictors

Objective@#: The treatment of large aneurysms of the posterior circulation is complicated and remains challenging. We here analyzed our institutional clinical outcomes of large unruptured aneurysms of the posterior circulation. @*Methods@#: This study included 56 patients who presented with a large (>10 mm) unruptured aneurysm of the posterior circulation between 2002 and 2018. @*Results@#: There were 18 (32.1%) male and 38 (67.9%) female patients, with a mean age of 53.4 years. The most common location was the vertebral artery, followed by the basilar tip and posterior cerebral artery. The median follow-up duration was 29 months. Eighteen patients (32.1%) were treated by transcranial surgery and 38 (67.9%) were treated by endovascular treatment (EVT). Posttreatment complications occurred in 16 patients (28.6%), with there being no significant difference between the transcranial surgery and EVT groups. Complete obliteration was achieved in 30 patients (53.6%), with there being no statistically significant difference between the transcranial surgery and EVT groups. Recurrence occurred in 17 patients (30.4%), and the rate of recurrence was higher in the EVT group than in the transcranial surgery group (39.5% vs. 11.1%, p=0.03). Forty-four (84%) of 56 patients showed a favorable functional outcome. In saccular aneurysm, EVT was negative predictor of worsening of functional status. @*Conclusion@#: Treatment of these aneurysms harbors an inherent high risk of morbidity. No superiority was found between transcranial surgery and EVT in terms of complications and complete obliteration, but transcranial surgery showed a higher treatment durability than EVT.

Role of microsurgery for treatment of posterior circulation aneurysms in the endovascular era

Objective@#Several studies have reported that the outcomes of endovascular treatment were superior to those of microsurgical treatment for posterior circulation aneurysms. Thus, this study compared outcomes of endovascular and microsurgical treatment for posterior circulation aneurysms and assess the usefulness of microsurgery in these patients. @*Methods@#Outcomes were retrospectively evaluated after endovascular and microsurgical treatment of 621 posterior circulation aneurysms. The 621 aneurysms included 187 treated by surgical clipping and 434 treated by endovascular coiling. @*Results@#In patients with unruptured aneurysms the rates of residual lesions and retreatment were significantly lower in those who underwent microsurgical than endovascular treatment. However immediate postoperative and 6 month follow-up Glasgow outcome scale (GOS) scores did not differ significantly in the two groups. In patients with ruptured aneurysms, the rates of residual lesions and retreatment were significantly lower in the microsurgery than in the endovascular treatment group. Even so immediate postoperative and 6 month follow-up GOS scores did not differ significantly in the two groups. @*Conclusions@#Endovascular treatment has increasingly become an alternative modality for microsurgery in posterior circulation aneurysm, whereas the indication for microsurgery is greatly reduced. However, the absolute number of microsurgery is maintained showing that it is a still valuable technique, as advances in endovascular or stent-assisted coiling have not solved many of the challenges inherent in the management of complex aneurysms. Hence, the advantages and limitations of both modalities must be carefully concerned in posterior circulation aneurysm to obtain favorable outcome.

Unusual presentation of infectious intracranial aneurysm with sequential hemorrhagic and ischemic components

Infectious intracranial aneurysm (IIA), a rare type of cerebral aneurysm, is often observed in patients with infective endocarditis. Hemorrhage or infarction often occurs; however, the presentation of both hemorrhagic and ischemic components is rare. A 41-year-old man with progressive motor weakness, dysarthria, and severe headache was admitted to our hospital. Brain computed tomography scan revealed a scanty subarachnoid hemorrhage (SAH), and diffusion magnetic resonance imaging confirmed acute cerebral infarction around the external capsule and insular lobe. A digital subtraction cerebral angiogram revealed an obstruction in the middle cerebral artery (MCA). The patient’s neurological symptoms improved remarkably on the fifth day, and a follow-up angiogram revealed recanalized MCA with pseudoaneurysm, which was not observed on the previous angiogram. A blood culture result confirmed bacteremia, and the patient was then diagnosed with infective endocarditis. The pseudoaneurysm was treated with anastomosis of the superficial temporal artery and MCA with trapping of the parent artery. He was discharged with no neurological deficits. Herein, we present a patient with IIA, who sequentially developed SAH and cerebral infarction, and underwent extracranial-intracranial bypass with trapping of the parent artery. Although the treatment strategy for IIA is controversial, the treatment plan should be cautiously discussed with the patient. In addition, the assessment of an underlying infectious disease is required.

Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM

Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80–90% complete obliteration rate with a 2–3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30–40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.

Corrigendum: Elucidation of Bacterial Pneumonia-Causing Pathogens in Patients with Respiratory Viral Infection / 결핵및호흡기질환

In this article, the ethical statement was missing.

Vertebral Body Fracture after Oblique Lumbar Interbody Fusion in 2 Patients: A Case Report

OBJECTIVES@#We aimed to report 2 cases of coronal vertebral fracture after an OLIF procedure in non-osteoporotic patients without significant trauma, and to review the complications of OLIF.SUMMARY OF LITERATURE REVIEW: There is a growing but limited literature describing early postoperative complications after OLIF.@*MATERIALS AND METHODS@#Patient 1 was an obese woman who underwent 2-level OLIF with posterior instrumentation procedures and subsequently experienced 2-level coronal plane fractures. Patient 2 was an elderly man who underwent 3-level OLIF without posterior instrumentation and experienced 1 coronal vertebral fracture. We report vertebral body fracture as a complication of OLIF through these 2 cases.@*RESULTS@#Patient 1 was treated nonsurgically after the fractures. The fractures healed uneventfully. However, patient 2 underwent posterior instrumented fusion and had a solid bridging bone above and below the fracture. Factors potentially contributing to these fractures are discussed.@*CONCLUSIONS@#OLIF is an effective procedure for several spinal diseases. However, fracture can occur after OLIF even in non-osteoporotic patients. Factors such as intraoperative end-plate breach, subsidence, cage rolling, and inadequate posterior instrumentation could contribute to the development of fractures after oblique interbody fusion.

Analgesic Efficacy and Safety of Prolonged-Release Oxycodone/Naloxone in Korean Patients with Chronic Pain from Spinal Disorders

BACKGROUND: A prolonged-release formulation of oxycodone/naloxone has been shown to be effective in European populations for the management of chronic moderate to severe pain. However, no clinical data exist for its use in Korean patients. The objective of this study was to assess efficacy and safety of prolonged-release oxycodone/naloxone in Korean patients for management of chronic moderate-to-severe pain. METHODS: In this multicenter, single-arm, open-label, phase IV study, Korean adults with moderate-to-severe spinal disorder-related pain that was not satisfactorily controlled with weak opioids and nonsteroidal anti-inflammatory drugs received prolonged-release oral oxycodone/naloxone at a starting dose of 10/5 mg/day (maximum 80/40 mg/day) for 8 weeks. Changes in pain intensity and quality of life (QoL) were measured using a numeric rating scale (NRS, 0–10) and the Korean-language EuroQol-five dimensions questionnaire, respectively. RESULTS: Among 209 patients assessed for efficacy, the mean NRS pain score was reduced by 25.9% between baseline and week 8 of treatment (p < 0.0001). There was also a significant improvement in QoL from baseline to week 8 (p < 0.0001). The incidence of adverse drug reactions was 27.7%, the most common being nausea, constipation, and dizziness; 77.9% of these adverse drug reactions had resolved or were resolving at the end of the study. CONCLUSIONS: Prolonged-release oxycodone/naloxone provided significant and clinically relevant reductions in pain intensity and improved QoL in Korean patients with chronic spinal disorders. (ClinicalTrials.gov identifier: NCT01811238)

Vertebral Body Fracture after Oblique Lumbar Interbody Fusion in 2 Patients: A Case Report / 대한척추외과학회지

STUDY DESIGN: Although the frequency of the oblique lumbar interbody fusion (OLIF) procedure has increased in recent years, reports on its complications remain rare. We report 2 cases of vertebral fracture after OLIF. OBJECTIVES: We aimed to report 2 cases of coronal vertebral fracture after an OLIF procedure in non-osteoporotic patients without significant trauma, and to review the complications of OLIF. SUMMARY OF LITERATURE REVIEW: There is a growing but limited literature describing early postoperative complications after OLIF. MATERIALS AND METHODS: Patient 1 was an obese woman who underwent 2-level OLIF with posterior instrumentation procedures and subsequently experienced 2-level coronal plane fractures. Patient 2 was an elderly man who underwent 3-level OLIF without posterior instrumentation and experienced 1 coronal vertebral fracture. We report vertebral body fracture as a complication of OLIF through these 2 cases. RESULTS: Patient 1 was treated nonsurgically after the fractures. The fractures healed uneventfully. However, patient 2 underwent posterior instrumented fusion and had a solid bridging bone above and below the fracture. Factors potentially contributing to these fractures are discussed. CONCLUSIONS: OLIF is an effective procedure for several spinal diseases. However, fracture can occur after OLIF even in non-osteoporotic patients. Factors such as intraoperative end-plate breach, subsidence, cage rolling, and inadequate posterior instrumentation could contribute to the development of fractures after oblique interbody fusion.

The potential theragnostic (diagnostic+therapeutic) application of exosomes in diverse biomedical fields

Exosomes are membranous vesicles of 30-150 nm in diameter that are derived from the exocytosis of the intraluminal vesicles of many cell types including immune cells, stem cells, cardiovascular cells and tumor cells. Exosomes participate in intercellular communication by delivering their contents to recipient cells, with or without direct contact between cells, and thereby influence physiological and pathological processes. They are present in various body fluids and contain proteins, nucleic acids, lipids, and microRNAs that can be transported to surrounding cells. Theragnosis is a concept in next-generation medicine that simultaneously combines accurate diagnostics with therapeutic effects. Molecular components in exosomes have been found to be related to certain diseases and treatment responses, indicating that they may have applications in diagnosis via molecular imaging and biomarker detection. In addition, recent studies have reported that exosomes have immunotherapeutic applications or can act as a drug delivery system for targeted therapies with drugs and biomolecules. In this review, we describe the formation, structure, and physiological roles of exosomes. We also discuss their roles in the pathogenesis and progression of diseases including neurodegenerative diseases, cardiovascular diseases, and cancer. The potential applications of exosomes for theragnostic purposes in various diseases are also discussed. This review summarizes the current knowledge about the physiological and pathological roles of exosomes as well as their diagnostic and therapeutic uses, including emerging exosome-based therapies that could not be applied until now.

Efficacy of tenofovir-based rescue therapy for chronic hepatitis B patients with resistance to lamivudine and entecavir

BACKGROUND/AIMS: Tenofovir disoproxil fumarate (TDF) monotherapy for 48 weeks provided a virological response comparable to that of TDF and entecavir (ETV) combination therapy in patients infected with ETV-resistant hepatitis B virus (HBV). Little long-term data in routine clinical practice are available regarding the optimal treatment of patients with ETV-resistant HBV. METHODS: We investigated the long-term antiviral efficacy of combination therapy of TDF+lamivudine (LAM) or TDF+ETV compared to that of TDF monotherapy in 73 patients with resistance to both LAM and ETV. RESULTS: Patients were treated with TDF monotherapy (n=12), TDF+LAM (n=19), or TDF+ETV (n=42) for more than 6 months. The median duration of TDF-based rescue therapy was 37 months. Virologic response (VR) was found in 63 patients (86.3%). The rates of VR among the three groups (TDF monotherapy, TDF+LAM, and TDF+ETV) were not statistically different (log-rank P=0.200) at 12 months (59.3%, 78.9%, and 51.8%, respectively) or at 24 months (88.4%, 94.7%, and 84.2%). In addition, treatment efficacy of TDF-based combination or TDF monotherapy was not statistically different with ETV-resistant strains or exposure to other antiviral agents. In multivariate analysis, only lower baseline HBV DNA level was an independent predictor for VR (hazard ratio, 0.723; 95% confidence interval, 0.627-0.834; P<0.001). CONCLUSIONS: TDF monotherapy was as effective as combination therapy of TDF+LAM or TDF+ETV in maintaining long-term viral suppression in chronic hepatitis B patients with resistance to both LAM and ETV. HBV DNA level at the start of TDF rescue therapy was the only independent predictor of subsequent VR.

Clinical Outcomes and Contributors in Contemporary Kidney Transplantation: Single Center Experience / 대한이식학회지

BACKGROUND: In recent years, introduction of novel immunosuppressive agents and its proper implementation for clinical practice have contributed to improving clinical outcomes of kidney transplantation (KT). Here, we report clinical outcomes of KTs and related risk factors. METHODS: From July 1998 to June 2016, 354 KTs (182 from living and 172 from deceased donors) have been performed at Ulsan University Hospital. We retrospectively reviewed the clinical characteristics and outcomes of KT recipients, then estimated graft and patient survival rate were estimated and analyzed risk factors using Cox-regression. RESULTS: The median follow-up period was 53 months (range; 3 to 220 months). The mean ages of recipients and donors were 45.0 years (SD, 12.5) and 44.7 years (SD, 13.6) years, respectively. During follow-up, 18 grafts were lost and 5- and 10-year death-censored graft survival was 96.7% and 91.5%, respectively. Biopsy-proven acute rejection (BPAR) occurred in 71 patients (55 cases of acute cellular rejection and 16 of antibody-mediated rejection). Cox-regression analysis showed that BPAR was a risk factor related to graft loss (hazard ratio [HR], 14.38; 95% confidence interval [CI], 3.79 to 54.53; P < 0.001). In addition, 15 patients died, and the 5- and 10-year patient survival was 97.2% and 91.9%, respectively. Age ≥60 years (HR, 6.03; 95% CI, 1.12 to 32.61; P=0.037) and diabetes (HR, 6.18; 95% CI, 1.35 to 28.22; P=0.019) were significantly related to patient survival. CONCLUSIONS: We experienced excellent clinical outcomes of KT in terms of graft failure and patient survival despite the relatively high proportion of deceased donors. Long-term and short-term clinical outcomes have improved in the last two decades.

Pancreatic Neuroendocrine Tumor Presenting with Arthritis and Panniculitis

Pancreatic neoplasm is complicated and can be preceded by extra-pancreatic manifestations, such as cutaneous and musculoskeletal symptoms. Awareness of these associations is important for timely diagnosis and appropriate treatment. We report a case of pancreatic neuroendocrine tumor (NET) presenting with arthritis and panniculitis. The patient had a two month history of right knee pain and subcutaneous nodules in both legs. Synovial fluid analysis from the right knee joint revealed a mildly increased white blood cell count without crystallization. A skin biopsy of a subcutaneous nodule revealed lobular panniculitis. The initial treatment with empirical antibiotics did not alleviate the symptoms; however, the right knee arthritis and skin nodules improved with steroid treatment. On the eighth day of hospitalization, the patient complained of abdominal discomfort. Abdominopelvic computed tomography scanning revealed a 14-cm sized pancreatic mass with peritoneal metastasis. Percutaneous needle biopsy confirmed the diagnosis of pancreatic NET.

Pancreatic Metastasis from Invasive Ductal Carcinoma of the Breast / 대한내과학회지

Pancreatic metastases from primary breast cancer are very rare. We report a case of pancreatic metastasis from invasive ductal carcinoma 13 years after the initial diagnosis of breast cancer. When the pancreatic mass was discovered, it was believed to be a primary pancreatic cancer due to the long interval from the initial diagnosis of breast cancer to metastasis. However, it was confirmed as metastatic breast cancer based on the pathology after surgical removal. Follow-up imaging has shown no recurrence.