A Case of Renal Cell Carcinoma Presented with Chest Wall Metastasis / 결핵

The appearance of a tumor in the chest wall is rare compared to that in any other part of the body. It can be classified into benign and malignant types and can be located in the rib, clavicle, sternum, cartilage and soft tissues. Tumors that are metastatic are commonly located in the lung, breast, bone and pleura. But, the soft tissue mass of anterior chest wall is rarely metastasized from a distant organ that is not confined to the thoracic cavity. This and thus has rarely been described. A 68-year-old man was admitted to our hospital with a chief complaint of resting dyspnea. A huge non-tender mass of about 10*15 cm in size was visible on his left lower anterior chest wall. We pathologically confirmed that the mass was a metastatic renal cell carcinoma of clear cell type by incision biopsy. Through an incision biopsy, the mass was pathologically confirmed as a metastatic renal cell carcinoma of the clear cell type.

A Case of Endobronchial Granular Cell Tumor Associated with Malignant Mediastinal Tumor / 결핵

Granular Cell Tumors(GCT) were originally described as myoblastic myomas. Subsequent scientific investigations elucidated the origin of this tumor as Schwann cells . Usually they have a predilection for head and neck, but also can occur in many other organs. This tumor is believed to originate from Schwann cells based on subsequent scientific investigations. Although it usually appears in the head and neck, it can also appear in other organs, as well. Endobronchial granular cell tumors are rather rare and should be differentiated from other common diseases of endobronchial location endobronchial diseases such as bronchogenic carcinoma and endobronchial tuberculosis, especially in Korea . We report a A case of a patient with an extremely rare condition of endobronchial granular cell tumor concurrent with malignant mediastinal tumor in a patient (delete) is reported.

A case of spontaneous pneumomediastinum and subcutaneous emphysema in dermatomyositis: Including analysis of cases with dermatomyositis and pneumomediastinum in the literature / 대한내과학회지

Spontaneous pneumomediastnum is a very rare complication of systemic autoimmune diseases. The precise mechanism of pneumomediastinum in dermatomyositis is not well known. Pulmonary alveoli rupture secondary to interstitial pneumonitis or pulmonary infarctions consequent upon vasculitis are the suggested mechanisms. Among the idiopathic inflammatory myopathies, dermatomyositis and polymyositis show similar clinical manifestations except skin lesions. But pneumomediastinum occurs exclusively in cases with dermatomyositis, not in case with polymyositis. In a literature review, patients with dermatomyositis and pneumomediastinum had some characteristic features. As compared with dermatomyositis without pneumomediastinum, CK level was normal in about half and concomitance of interstitial lung disease and cutaneous vasculitis were very frequent. We experienced a case of dermatomyositis with spontaneous pneumomediastinum and subcutaneous emphysema. Thus we report that with a review of the literature and analysis of reported cases.

Intracranial CT Angiography with Spiral CT: Preliminary Report

PURPOSE: The purpose of this study was to assess the usefulness of CT angiography(CTA) with spiral CT in evaluation of intracranial vascular lesions. MATERIALS AND METHODS: CTA and conventional angiography(CA) were performed in 22 patients with suspected intracranial vascular lesion. Nine patients had 10 aneurysms and 2 patients had arteriovenous malformation(AVM)s, while the remaining 11 patients had no vascular lesion. Twenty seconds after beginning injection of contrast media(100 mL with use of a power injector at the rate of 3 mL/sec), CT scanning(30-second continuous exposure and 60-mm length) was performed with a table speed of 2mm/sec and a section thickness of 2mm. The starting point was selected at the floor of the sella turcica. The resulting data were reformatted by MIP and SSD after reconstruction of 1 mm interval. For aneurysm, its size, shape, direction, neck and the relationship to adjacent vessels were compared to CA. RESULTS: The aneurysm diameter was ranged between 3mm and 20mm and all aneurysms were clearly visualized with CTA. CTA findings of the size, shape, direction, and neck of aneurysms and the relationship between aneurysm and adjacent vessels were well correlated with CA. In one case of aneurysm, calcification of the aneurysm wall was demonstrated on CTA. In one case of AVM, the nidus and its arterial supply and venous drainage were well visualized. In the other case of AVM, however, the feeding artery of AVM was not demonstrated on CTA(it was also unclear on CA). CONCLUSION: CTA with spiral CT may be useful in the evaluation of intracranial vascular lesion and valuable as a screening test for intracranial aneurysm.

Gastric Wall Shortening in Early Gastric Cancer: Upper Gastrointestinal Series and Pathologic Correlation

PURPOSE: To investigate the causes of gastric wall shortening in early gastric cancer, upper gastrointestinal study was correlated with pathologic findings. MATERIALS AND METHODS: We evaluated 41 cases(M :F=1.7:1, average age=49) of early gastric cancer, retrospectively. The gastric wall shortening were classified as Grade I; none, Grade II ;intermediate, and Grade III; prominent. Pathologic findings such as size of lesions, depth of tumor invasion, degree of the submucosal fibrosis, degree of thickness of the submucosa and muscularis propria, and morphologic patterns of lesions including conversing mucosal folds were correlated with the degree of gastric wall shortening on upper gastrointestinal series. RESULTS: Submucosal fibrosis was present in 4 cases in Grade I (n=21), 4 cases in Grade II (n=6) and 8 cases in Grade III (n=10). Positive conversing mucosal folds were seen in 5 cases in Grade I (n=17), 0 case in Grade II (n=2) and 9 cases in Grade III (n=9). Gastric wall shortening was significantly associated with submucosal fibrosis and conversing mucosal folds of early gastric cancer. (p=.0001 and p=.002, respectively) CONCLUSION: Upper gastrointestinal finding of gastric wall protrusion in patients with early gastric cancer should not misinterprete as advanced gastric cancer since the finding could be a result of submucosal fibrosis.

Gastric Wall Shortening in Early Gastric Cancer: Upper Gastrointestinal Series and Pathologic Correlation

PURPOSE: To investigate the causes of gastric wall shortening in early gastric cancer, upper gastrointestinal study was correlated with pathologic findings. MATERIALS AND METHODS: We evaluated 41 cases(M :F=1.7:1, average age=49) of early gastric cancer, retrospectively. The gastric wall shortening were classified as Grade I; none, Grade II ;intermediate, and Grade III; prominent. Pathologic findings such as size of lesions, depth of tumor invasion, degree of the submucosal fibrosis, degree of thickness of the submucosa and muscularis propria, and morphologic patterns of lesions including conversing mucosal folds were correlated with the degree of gastric wall shortening on upper gastrointestinal series. RESULTS: Submucosal fibrosis was present in 4 cases in Grade I (n=21), 4 cases in Grade II (n=6) and 8 cases in Grade III (n=10). Positive conversing mucosal folds were seen in 5 cases in Grade I (n=17), 0 case in Grade II (n=2) and 9 cases in Grade III (n=9). Gastric wall shortening was significantly associated with submucosal fibrosis and conversing mucosal folds of early gastric cancer. (p=.0001 and p=.002, respectively) CONCLUSION: Upper gastrointestinal finding of gastric wall protrusion in patients with early gastric cancer should not misinterprete as advanced gastric cancer since the finding could be a result of submucosal fibrosis.

Role of IVIR in Limb Fracture

PURPOSE: In evaluation of the limb fracture, MR scan has been used in limited roles as evaluating the associated soft tissue injury not the fracture itself. This study aims at understanding the possible role of MR in fracture. METHODS AND MATERIALS: thirty three sets of MR scans in twenty nine patients were retrospectively analyzed. They included twelve tibial plateau fractures, four pateliar fractures, four distal femur fractures, five epiphyseal fractures and four others. RESULTS: All MRs except two showed better image and more information about the extent of the injury (93.9%). Evaluation of cartilage (which was impossible on other modalities) was possible in 28 MR scans (84.8%). Surrounding marrow change associated with fracture was also able to be evaluated. Associated soft tissue injury or other abnormality could be evaluated-cruciate or collateral ligament injury, meniscus tear, chodromalacia or osteonecrosis. In epiphyseal injury, direct demonstrability of premature bony fusion on MR took a critical role in making a management plan. CONCLUSION: MR scan in fracture has its value in evaluating the extent and degree of the injury and it is especially advantageous in detecting cartilage injury and early complication of growth plate injury.

Detectability of Extrahepatic Duct Stones: A Comparison between Nonenhanced and Enhanced CT

PURPOSE: A study was performed to compare the detectability of extrahepatic duct stones between nonenhanced and enhanced computed tomography(CT). MATERIALS AND METHODS: Consecutive 30 patients with extrahepatic duct stones were analyzed with special attention to the detectability of stones between nonenhanced and enhanced CT. The extrahepatic duct was further divided into two segments, one above(suprapancereatic) and the other in(intrapancreatic) the head of the pancreas. Conspicuity of the stone was graded as "visible", "suspicious", and "invisible". Three radiologists reviewed the CT images without prior information and determined the location of stone and grade of their conspicuity. RESULTS: The stones were located at the suprapancreatic common duct in 5 patients, intrapancreatic common duct, in 15 patients and both portion of the duct in 10 patients. There was no difference in the detection rate of stones between the two images at suprapancreatic common duct, and was 93%, However, the rate at intrapancreatic common duct was 95% and 64% on nonenhanced and enhanced CT scans, respectively. The overall detection rate was 95% on nonenhance CT and 75% on enhanced CT. CONCLUSION: We concluded that nonenhanced CT was prerequisite to evaluate the extrahepatic duct stones in addition to enhanced CT.

Comparisons of MR Findings of the Spinal Metastasis and the Spinal Tuberculosis

PURPOSE: MR findings of the spinal metastasis and the tuberculosis are well known, but sometimes it might be difficult to differentiate these lesions. Therefore we reviewed and analyzed the MR findings which would be useful for the differentiation. MATERIALS AND METHODS: T1- and T2-weighted spin echo images and gadolinium-enhanced Tl-weighted images were obtained with 1. 5T and 1. 0T superconductive MR imager. We reviewed MR findings in 16 cases of spinal metastases and 24 cases of spinal tuberculosis in terms of signal intensity, contrast enhancement pattern, disc space involvement, spinal canal compressing feature and paraspinal soft tissue mass. RESULTS: The signal intensities of both lesions were hypointense on T1WI and hyperintense on T2WI except those of the metastatic lesions from the prostatic carcinoma. Heterogeneous enhancement was noted in 63% of metastasis, whereas peripheral rim enhancement was noted in 83% of spinal tuberculosis(p (.001). Spinal canal compression by collapsed vertebra was only noted in spinal metastasis, and that by paraspinal soft tissue was noted in both spinal metastasis and tuberculosis(p (.001). Disc space invasion was noted in 19% of spinal metastasis and 88% of spinal tuberculosis. Spinal tuberculosis was common at lower thoracic spine(T10) and typically involved two or more adjacent vertebral bodies(96%). CONCLUSION: The important differential point between spinal metastasis and tuberculosis was the enhancement pattern, involvement of two or more contiguous vertebral bodies and the feature of spinal canal compressing. The secondary importance was the disc space involvement pattern.

Differential Diagnosis of Hepatic Malignant Tumors and Hemangiomas by Using Dynamic Magnetic Resonance Imaging

PURPOSE: The purpose of this study is to assess the usefulness of dynamic MR imaging after contrast enhancement with Gd-DTPA in the differential diagnosis of hepatic focal lesions. MATERIALS AND METHODS: The population consists of 22 cases of hepatocellular carcinoma, 44 cases of hemangioma, and five cases of metastasis. Diagnosis of hepatocellular carcinoma was made by surgery, fine needle biopsy, ultrasonography, CT and conventional angiography. Hemangioma was diagnosed on the basis of ultrasonography, CT, conventional spin-echo MRI and clinical data. Diagnosis of metastasis was done by fine needle aspiration biopsy. Dynamic and delayed images were obtained using 1.5T superconductive magnetom after Gd-DTPA(0.1mmol/kg) intravenous injection. Quantitative and qualitative evaluation was done for each lesion. RESULTS: Early contrast enhancement with rapid or gradual washout was noted in 15 lesions of hepatocellular carcinoma(68.2%) ;on the delayed images, no contrast enhancement was noted in 18 lesions(81. 8%). Peripheral contrast enhancement pattern was predominantly(86.4%) observed in hemangiomas during dynamic phase. On the delayed images, homogeneous and persistent contrast enhancement of masses were noted in all hemangiomas. Characteristic centripetal fill-in pattern was observed in 32 lesions of hemangioma (72.7%). Contrast inversion of masses during contrast enhancement study was noted in all hemangiomas, while continuous negative contrast was noted in hepatocellular carcinomas and metastases. CONCLUSION: Dynamic MR imaging after contrast enhancement with Gd-DTPA is an useful method in the differential diagnosis of hepatic focal lesions.

MR Cholangiography: Usefulness in Obstructive Jaundice

PURPOSE: Three-dimensional(3D) magnetic resonance(MR) projection imaging was evaluated as a noninvasive alternative to direct cholangiography for the assessment of its reliability in patients with obsructive jaundice. METHODS AND MATERIALS: A heavily T2-weighted gradient-echo sequence(PSIF) was used for 3D MR projecion imaging of the biliary system in five healthy volunteers and 25 patients with obstructive jaundice. The 3D images of the bile ducts were formed by stacking consecutive coronal MR images obtained with a fast imaging method to a maximum-intensity projection algorithm. RESULTS: In the volunteers, MR cholangiography could demonstrate the anatomy of the biliary tract in only two subjects. The extrahepatic and intraheparic bile ducts were well visualized in 23 patients with obstructive jaundice. The leve of obstruction and the grade of dilatation were dipicted with MR cholangiography in all cases. And the cause of obstruction could be determined with MR cholangiography in 18 cases, MR cholangiography was successful in two patients in whom ERCP failed. The gallbladder or dilated pancreatic duct not demonstrated by means of direct cholangiography was demonstrated with MR cholangiography in six cases.

Reduction of Intussusception by Air Insufflation in Children: Recent Three-year Experience

PURPOSE: This study was conducted to evaluate success and perforation rates of pneumatic reduction and to find the predictors of reduction failure. METHODS AND MATERIALS: We reviewed 224 cases of pediatric intussusception diagnosed by air-enema between July, 1989 and June, 1992. The mean age was 9.8 months(range, 1 month to 3 years). Logistic regression analysis was used to find predictors of reduction failure. RESULTS: Successful reduction was achieved in 197 cases(87.9% of success rate). Bowel perforation occurred in two cases(0.9% of perforation rate). There were two statistically significant predictors of failure;(1) ileoileocolic intussusception(p<.001), (2) long duration of symptom(p<.001). Surgery was performed in 26 cases (11.6%), of which seven required bowel resection. CONCLUSION: Pneumatic reduction is a useful means in the management of pediatric intussusception with a high success rate and no mortality.

Experimental Embolization Using Histoacryl Blue (N-butyl 2-cyanoacrylate) in Pig Rete Mirabile

PURPOSE: This study was performed to evaluate any difference in the penetration of the acrylic glue into the pig rete mirabile according to the difference of the concentration of the glue mixture. MATERIALS AND METHODS: Three domestic pigs (12-15kg) were used. After obtaining a normal angiography, two different concentrations of 1:1 and 0.5:1 of Histoacryl Blue mixture with Lipiodol were administrated into pig rete mirabile and then anglographic and pathologic findings were analyzed after taking a postembolization angiography. RESULTS: The degree of the penetration of the glue mixture into the pig rete was different in the anglographic and pathologic findings according to the glue mixture ratio. In case of using 0.5:1 mixture of glue and Lipiodol, glue penetrated into the smaller vessels with size of about 80 micro rn than in case of using 1:1 mixture of glue and Lipiodol. CONCLUSION: Because the polymerization time of glue mixture will be different according to the concentration of glue mixture, a mixture with thin glue concentration seemed to penetrate deeply into the pig rete.

Image-Guided Percutaneous Biopsies with a Biopsy Gun

PURPOSE:We report the results of image-guided percutaneous biopsies with a biopsy gun and evaluate the clinical usefullness. MATERIALS AND METHODS: One hundred and five biopsies under ultrasonographic or fiuoroscopic guidance were performed. Various anatomic sites were targeted (liver;50, chest;22, kidney;12, pancreas;8, intraperitoneum;7, retroperitoneum; ). RESULTS:Obtained tissue was diagnostic in 98 of the 105 biopsies(93%). In each instance, representative core tissue specimens were obtained. Evaluation of the core tissue by pathologist revealed consistent, uniform specimens that contained significant crush artifact in no case. Five biopsies yielded inadeguate tissues which were too small for histopathologic interpretation or were composed of necrotic debris. Two biopsies yielded adequate tissues, but tissues were not of the target. The diagnoses were malignancy in 77 biopsies and benign disease in 21 biopsies. No complications other than mild, localized discomfort were encountered except a transient hemoptysis and pneumothorax which was observed in two patients. CONCLUSION:Cutting biopsy with a biopsy gun provided sufficient amount of target tissue for an accurate diagnosis of malignant and benign disease. It was a safe and useful procedure for percutaneous biopsy.

Is There Any Indicator to Predict the Difficulty of PTBD?

PURPOSE: A retrospective study was performed to find any indicator to predict the difficulty of percutaneous transhepatic biliary drainage(PTBD) before the procedure and to evaluate correlationship between the chronological change of fluoroscopic time and the operator's experience. MATERIALS AND METHODS: The materials included the consecutive 138 cases of PTBD of 120 patients with obstructive jaundice. Under the presumption that the difficulty of procedure would be reflected on fluoroscopic time, the correlation between fluoroscopic time and eight factors(i. e. ;sex, age, disease, approach, degree of IHD dilatation, total bilirubin, alkaline phosphatase, and operator) were analysed. Also chronological change of fluoroscopic time in three operators, who performed more than 25 procedures, were evaluated. RESULTS: Statistically significant factors were operator (P=0.000), sex (P:0.028), approach(P=0.048), and total billrubin (P=0.021). Good correlation between the chronological change of fluoroscopic time and the operator's experience was found. CONCLUSION: The significant factors could be used as an indicator to predict the difficulty before PTBD procedure. The chronological change of fluoroscopic time could be used as an indirect estimate in the stabilization of the operator fechnigue.

MR angiography of the renal arteries

We reviewed MR angiograms to evaluate its efficacy for visualizing the renal arteries and detecting renovascular disease. 41 renal arteries in 19 patients were examined by MR angiography. 3-D time-of-flight technique was used as routine examination method for MR angiography and 2-D time-of-flight technique was added in some particular cases to visualize venous flow. Within two weeks after MR angiography was performed, 23 renal arteries in 10 patients were additionally examined by conventional angiography or intraarterial DSA. The success rates of vessel visualization on MR angiography in normal renal arteries were 100% in main 67.7% in segmental, and 11.8% in intrarenal arteries. As a result of comparative study in normal main renal arteries with MR angiograms and conventional angiograms, overall correspondence in the number and the shape was noted and the caliber discrepancy between two examination did not exceed 3.0 mm. one arteriovenous fistula with aneurysm, one stenotic artery and two occluded arteries were well evaluated One arteriovenous fistula with aneurysm, and two occluded arteries were well evaluated by MR angiography. However three stenotic lesions were misdiagnosed as occlusions on MR angiography. and the overall accuracy was 87%. We conclude that MR angiography has the potential to be a noninvasive and useful screening method for determining the number of renal arteries and for detection of abnormalities of main renal arteries.

Diagnosis and follow-up of a case of nutcracker syndrome with MR angiography

A case of nutcracker syndrome which was initially diagnosed by magnetic resonance angiography (MRA) is reported. On preoperative MRA in an 18-year-old male patient with gross hematuria, left renal vein was obliterated at the level of superior mesenteric artery and there was no connection with inferior vena cava. The follow-up MRA after surgical correction with external prosthesis demonstrated entire course of left renal vein without evidence of obstruction which might suggest a possible usage of MRA for a non-invasive diagnosis of nutcracker syndrome.

Diagnosis and follow-up of a case of nutcracker syndrome with MR angiography

A case of nutcracker syndrome which was initially diagnosed by magnetic resonance angiography (MRA) is reported. On preoperative MRA in an 18-year-old male patient with gross hematuria, left renal vein was obliterated at the level of superior mesenteric artery and there was no connection with inferior vena cava. The follow-up MRA after surgical correction with external prosthesis demonstrated entire course of left renal vein without evidence of obstruction which might suggest a possible usage of MRA for a non-invasive diagnosis of nutcracker syndrome.

Pseudocapsule of hepatocellular carcinoma: CT and US versus pathologic correlation

The encapsulated hepatocellular (HCC) is a pathologic subtype of HCC. It is a well defined tumor that tends to grow slowly, and has a better prognosis than any other gross forms of HCC. Twenty surgically resected HCC were evaluated retropectively to correlate the thickness of pseudocapsules in pathology with those in computed tomography and ultrasound. At a histologic examination, pseudocapsules of seven cases were composed of two layers, an inner compact fibrous zone and outer loose fibrous zone interlaced with compressed liver parenchyma containing small vessels and newly formed bile ducts. Sonographic thickness and pathologic measurements of pseudocapsule relatively well correlated, but the former slightly overestimated the thickness of pathologic pseudocapsule (r=0.825, y=2.56x-1.23, P<0.05). On the other hand, thickness in CT and pathologic measurement did not correlate well. Thirteen cases showed one layer of pseudocapsule in which two cases were composed of thin layer of compact fibrosis and eleven cases composed of loose fibrosis. There were poor correlations in this group between thickness of pseudocapsules in pathology and those in images. Image overtly overestimated the thickness of the pseudocapsules in pathology. In conclusion, radiologic pseudocapsule of HCC may represent the compressed liver parenchyma as well as the fibrous pseudocapsule.

Pseudocapsule of hepatocellular carcinoma: CT and US versus pathologic correlation

The encapsulated hepatocellular (HCC) is a pathologic subtype of HCC. It is a well defined tumor that tends to grow slowly, and has a better prognosis than any other gross forms of HCC. Twenty surgically resected HCC were evaluated retropectively to correlate the thickness of pseudocapsules in pathology with those in computed tomography and ultrasound. At a histologic examination, pseudocapsules of seven cases were composed of two layers, an inner compact fibrous zone and outer loose fibrous zone interlaced with compressed liver parenchyma containing small vessels and newly formed bile ducts. Sonographic thickness and pathologic measurements of pseudocapsule relatively well correlated, but the former slightly overestimated the thickness of pathologic pseudocapsule (r=0.825, y=2.56x-1.23, P<0.05). On the other hand, thickness in CT and pathologic measurement did not correlate well. Thirteen cases showed one layer of pseudocapsule in which two cases were composed of thin layer of compact fibrosis and eleven cases composed of loose fibrosis. There were poor correlations in this group between thickness of pseudocapsules in pathology and those in images. Image overtly overestimated the thickness of the pseudocapsules in pathology. In conclusion, radiologic pseudocapsule of HCC may represent the compressed liver parenchyma as well as the fibrous pseudocapsule.