Intraoperative Frozen Cytology of Central Nervous System Neoplasms: An Ancillary Tool for Frozen Diagnosis

BACKGROUND: Pathologic diagnosis of central nervous system (CNS) neoplasms is made by comparing light microscopic, immunohistochemical, and molecular cytogenetic findings with clinicoradiologic observations. Intraoperative frozen cytology smears can improve the diagnostic accuracy for CNS neoplasms. Here, we evaluate the diagnostic value of cytology in frozen diagnoses of CNS neoplasms. METHODS: Cases were selected from patients undergoing both frozen cytology and frozen sections. Diagnostic accuracy was evaluated. RESULTS: Four hundred and fifty-four cases were included in this retrospective single-center review study covering a span of 10 years. Five discrepant cases (1.1%) were found after excluding 53 deferred cases (31 cases of tentative diagnosis, 22 cases of inadequate frozen sampling). A total of 346 cases of complete concordance and 50 cases of partial concordance were classified as not discordant cases in the present study. Diagnostic accuracy of intraoperative frozen diagnosis was 87.2%, and the accuracy was 98.8% after excluding deferred cases. Discrepancies between frozen and permanent diagnoses (n = 5, 1.1%) were found in cases of nonrepresentative sampling (n = 2) and misinterpretation (n = 3). High concordance was observed more frequently in meningeal tumors (97/98, 99%), metastatic brain tumors (51/52, 98.1%), pituitary adenomas (86/89, 96.6%), schwannomas (45/47, 95.8%), high-grade astrocytic tumors (47/58, 81%), low grade astrocytic tumors (10/13, 76.9%), non-neoplastic lesions (23/36, 63.9%), in decreasing frequency. CONCLUSIONS: Using intraoperative cytology and frozen sections of CNS tumors is a highly accurate diagnostic ancillary method, providing subtyping of CNS neoplasms, especially in frequently encountered entities.

Comparison of Endoscopic Submucosal Dissection and Surgery for Differentiated Type Early Gastric Cancer within the Expanded Criteria

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) is a novel alternative treatment for differentiated early gastric cancer (EGC) without lymph node metastasis. We conducted this study to verify the therapeutic usefulness of ESD for treating differentiated EGC compared to that of surgery. METHODS: This is a retrospective cohort study of 382 patients treated with differentiated EGC from March 2006 to May 2010. The propensity score yielded 275 matched patients. They were divided into an ESD group of 175 people and a gastrectomy group of 100 people. The patient demographics, pathologic characteristics, length of hospital stay, complication rate and survival rate were compared. RESULTS: The complication rate was higher for the gastrectomy group than for the ESD group (15.0% vs. 5.1%, p=0.007). The average length of patient hospitalization was longer after gastrectomy than after ESD (8.6 days vs. 2.4 days, p<0.001). There were two cases of mortality in the surgery group within 30 days of procedure. The 5-year survival rates of the two groups did not show a statistically significant difference (92.0% vs. 93.3%, p=0.496). CONCLUSIONS: The long-term survival rates of ESD and gastrectomy were not significantly different. The complication rate was lower for ESD than for gastrectomy, and the length of hospital stay was shorter after ESD than after gastrectomy.

Comparison of Outcomes after Device Closure and Medication Alone in Patients with Patent Foramen Ovale and Cryptogenic Stroke in Korean Population

PURPOSE: To compare the effectiveness of device closure and medical therapy in prevention of recurrent embolic event in the Korean population with cryptogenic stroke and patent foramen ovale (PFO). MATERIALS AND METHODS: Consecutive 164 patients (men: 126 patients, mean age: 48.1 years, closure group: 72 patients, medical group: 92 patients) were enrolled. The primary end point was a composite of death, stroke, transient ischemic attack (TIA), or peripheral embolism. RESULTS: Baseline characteristics were similar in the two groups, except age, which was higher in the medical group (45.3±9.8 vs. 50.2±6.1, p<0.0001), and risk of paradoxical embolism score, which was higher in the closure group (6.2±1.6 vs. 5.7±1.3, p=0.026). On echocardiography, large right-to-left shunt (81.9% vs. 63.0%, p=0.009) and shunt at rest/septal hypermobility (61.1% vs. 23.9%, p<0.0001) were more common in the closure group. The device was successfully implanted in 71 (98.6%) patients. The primary end point occurred in 2 patients (2 TIA, 2.8%) in the closure group and in 2 (1 death, 1 stroke, 2.2%) in the medical group. Event-free survival rate did not differ between the two groups. CONCLUSION: Compared to medical therapy, device closure of PFO in patients with cryptogenic stroke did not show difference in reduction of recurrent embolic events in the real world's setting. However, considering high risk of echocardiographic findings in the closure group, further investigation of the role of PFO closure in the Asian population is needed.

Cephalometric Variables Significantly Associated with Apnea Hypopnea Index in Suspected Obstructive Sleep Apnea Patients : A Preliminary Study

OBJECTIVES: The purpose of this study is to find the cephalometric variables which are significantly correlated with the apnea-hypopnea index (AHI) in suspected Korean obstructive sleep apnea (OSA) patients. METHODS: We examined lateral cephalogram and attended-full night laboratory polysomnography of the 40 participants who complained of OSA symptoms. The correlation analysis was conducted to find the cephalometric variables which are significantly correlated with the AHI. RESULTS: The correlation analysis showed that the higher AHI was associated with the longer distance between hyoid and mandibular plane (p = 0.023), the longer distance between C3 and hyoid (p = 0.014), the longer tongue length (p = 0.003), the larger inferior tongue area (p = 0.008), the larger anterior displacement of the hyoid bone (p = 0.024), the longer distance between posterior nasal spine and the tip of the soft palate (p = 0.021), and the larger cross-sectional area of soft palate (p = 0.001) of cephalogram in erect position. The higher AHI was correlated with the longer distance between hyoid and mandibular plane (p = 0.008), the longer tongue length (p = 0.037), the larger inferior tongue area (p = 0.013), the thicker uvula (p = 0.004), the longer distance between retrognathion and hyoid (p = 0.025), and larger cross-sectional area of soft palate (p = 0.001) of cephalogram in supine position. CONCLUSIONS: The present preliminary results showed the candidate measurements of cephalogram which are significantly correlated with the AHI in suspected OSA.

Personality Characteristics of Patients with Obstructive Sleep Apnea and Simple Snoring : A Preliminary Study / 수면정신생리

OBJECTIVE: Few studies have evaluated the personality characteristics of patients with obstructive sleep apnea (OSA) and simple snoring. We investigated the personality characteristics of OSA and simple snoring patients and compared differences in personality between the two groups using the Eysenck Personality Questionnaire (EPQ). MATERIALS AND METHODS: Two hundred and thirty-seven patients who were suspected to have OSA or simple snoring participated in this study. A self-questionnaire which included the EPQ was administered to all participants. All subjects underwent polysomnography in a sleep laboratory and those with an apnea-hypopnea index (AHI) > or =5 were included in the OSA group, while those with an AHI <5 were included in the simple snoring group. RESULTS: OSA patients had significantly lower scores for Psychoticism (F=4.563, p=0.034) than simple snorers. There were no significant differences in Extraversion (F=3.029, p=0.083), Lie (F=0.398, p=0.529), or Neuroticism (F=3.367, p=0.068) scores between the two groups. In the correlation analysis of the OSA group, AHI was positively correlated with Extraversion score (r=0.16, p=0.029) and negatively correlated with Lie score (B=-0.31, p<0.001). Using multiple stepwise linear regression analysis with the four EPQ parameter scores as dependent variables, Lie score was associated with older age (B=0.14, p<0.001) and lower AHI (B=-0.05, p<0.001), Psychoticism score was associated with higher Pittsburgh Sleep Quality Index (PSQI ; B=0.14, p<0.001), Neuroticism score was associated with higher PSQI (B=0.34, p=0.001) and female sex (B=3.15, p=0.003), and Extraversion score was associated with younger age (B=-0.08, p=0.020) and higher body mass index (B=0.26, p=0.023). CONCLUSION: This study suggests that patients with OSA are significantly less prone to psychotic personality characteristics than those with simple snoring. Among OSA patients, higher AHI was correlated with low falsehood and high extraversion tendencies.

Regression of Colonic Adenomas After Treatment With Sulindac in Familial Adenomatous Polyposis: A Case With a 2-Year Follow-up Without a Prophylactic Colectomy

Familial adenomatous polyposis (FAP) is an autosomal dominant disorder characterized by hundreds of colorectal adenomatous polyps that progress to colorectal cancer. Management of patients with FAP is with a total colectomy. Chemopreventive strategies have been studied in FAP patients in an effort to delay the development of adenomas in the upper and the lower gastrointestinal tract and to prevent recurrence of adenomas in the retained rectum of patients after prophylactic surgery. Sulindac, a nonsteroidal anti-inflammatory drug, causes regression of colorectal adenomas in the retained rectal segment of FAP patients. However, evidence regarding long-term use of this therapy and its effect on the intact colon has been insufficient. We report a case in which the long-term use of sulindac was effective in reducing the size and the number of colonic polyps in patients with FAP without a prophylactic colectomy and polypectomy; we also present a review of the literature.

A Case of Successful Treatment for Obstructive Jaundice in Hepatocellular Carcinoma with A Biliary Invasion by Transcatheter Arterial Chemoembolization after Biliary Drainage / 대한췌담도학회지

Biliary invasion by hepatocellular carcinoma (HCC) is much less common. Patients manifest obstructive jaundice as the initial complaint, but most of them are inoperable. We report a case of completely improved biliary invasion in HCC after transcatheter arterial chemoembolization (TACE). A 61-year-old woman was referred for evaluation of jaundice. A biliary invasion of huge HCC was confirmed by image of abdominal computerized tomography (CT) and biopsy specimen. After improvement of jaundice by endoscopic retrograde biliary drainage and percutaneous transhepatic biliary drainage, she underwent TACE as a palliative treatment. Follow-up CT showed partial lipiodol uptake in hepatic tumor and its bile duct invasion. In follow-up endoscopic retrograde cholangiopancreatography, occluded cholangiogram showed neither luminal obstruction nor filling defect after removal of biliary stent. Our case suggests that obstructive jaundice, caused by inoperable huge HCC with biliary invasion, may be expected to resolve successfully biliary obstruction by a choice of TACE.

Clinical and Physical Characteristics That Affect Apnea-Hypopnea Index in Suspected Obstructive Sleep Apnea Patients : The Preliminary Study

OBJECTIVES: The purpose of this study is to find the influential clinical and physical characteristics which affect apnea-hypopnea index (AHI) in suspected obstructive sleep apnea (OSA) patients. METHODS: We evaluated the comprehensive factors including sleep related symptoms, clinical scales, medical history, substance use, and anthropometric data of the 119 participants who complained of the symptoms of OSA. All the participants underwent attended-full night laboratory polysomnography. The correlation and multiple regression analysis were conducted to find the influential and predictive factors of AHI. RESULTS: A multiple linear regression model 1 showed that higher AHI was associated with higher body mass index (BMI)(p < 0.001) and higher frequency of observed apnea (p = 0.002). In multiple linear regression model 2, AHI was associated with higher BMI (p < 0.001) and loudness of snoring (p = 0.018). CONCLUSIONS: The present preliminary results suggest that BMI and observed apnea are most influential factors that affect AHI in suspected OSA patients. In the future study we will design the prediction formula for the OSA and AHI, which is useful in the clinical medical field.

Patterns of Collateral Pathway on Transfemoral Cerebral Angiography in Patients with Internal Carotid Artery Stenosis / 대한뇌졸중학회지

BACKGROUND: In recent studies, by utilizing single photon emission computed tomography (SPECT) and magnetic resonance angiography (MRA), anatomical and functional evaluation became possible. Although MRA is increasingly being used to evaluate vascular status, conventional angiography is still gold standard for investigating anatomical structures. We studied the correlation between internal carotid artery (ICA) stenosis, patterns of collateral pathway, and cerebrovascular reserve using transfemoral cerebral angiography (TFCA) and SPECT. METHODS: We studied 54 patients with symptomatic ICA stenosis who were visit to our hospital between Sep 2009 and May 2011. Forms of collateral pathway were classified into primary and secondary pathway group. Severity of ICA stenosis was divided into 4 stages. Vascular reserve on SPECT was classified into favorable and poor groups. RESULTS: As a result of TFCA, collateral pathways were observed in 44 of 54 patients. Collateral flow via anterior communicating artery (AcoA) pattern occupied the highest proportion and other major patterns were collaterals via posterior cerebral artery-middle cerebral artery (PCA-MCA) and via posterior communicating artery (PCoA) pattern. Twenty-eight patients were primary pathway group and 16 patients were secondary pathway group. In both groups, most patients had moderate or severe ICA stenosis. As a result of SPECT, favorable vascular reserves were observed in 17 of 54 patients. Most of them had mild ICA stenosis and/or primary collateral pathway. Contrarily, most of secondary pathway group had poor vascular reserve even if their ICA stenosis severity was mild. CONCLUSION: In patients with symptomatic ICA stenosis with collateral pathways, rate of primary collateral pathways was higher than secondary collateral pathways. Secondary collateral pathways had insufficient compensatory effect about reduced cerebral blood perfusion.

A case of esophagitis caused by co-infection of cytomegalovirus and candida / 대한내과학회지

A 72-year-old man with end-stage renal disease who was taking oral steroids and immunosuppressive agents to control rheumatoid arthritis was admitted with complaints of anorexia and general weakness. Based on endoscopic findings and a histologic examination, the patient was diagnosed with infective esophagitis caused by Candida spp. and cytomegalovirus co-infection. Cytomegalovirus and Candida spp. are common causes of opportunistic infections; however, cytomegalovirus and Candida spp. co-infection is very rare. The patient was treated with ganciclovir and fluconazole. Endoscopic examination after 3 weeks showed improvement of the esophagitis. When endoscopy examination shows typical white spots that are indicative of Candida esophagitis, histologic and microbiologic studies should be encouraged for cytomegalovirus and Candida co-infection, especially in immunocompromised patients.

MRI of Neurosyphilis Presenting as Mesiotemporal Abnormalities: a Case Report

The high signal intensities in bilateral mesiotemporal lobes on T2-weighted images are typical findings of herpes encephalitis or paraneoplastic limbic encephalitis. We report a case of neurosyphilis with mesiotemporal involvement on MRI. Positive antibodies in the cerebrospinal fluid confirmed the diagnosis. The results suggest that neurosyphilis should be considered when MRI results indicate mesiotemporal abnormalities.

A case of gastrointestinal Kaposi sarcoma in a patient with AIDS / 대한내과학회지

Kaposi sarcoma in acquired immunodeficiency syndrome (AIDS) is rarely seen in Korea and the incidence has declined in the era of highly active antiretroviral therapy (HAART). Visceral involvement in patients having AIDS with Kaposi sarcoma is more common than in patients infected with non-human immunodeficiency virus. Visceral involvement may be asymptomatic and usuallydoes not require specific therapy. Chemotherapy is usually used in symptomatic or rapidly progressive disease, and interferon- alpha can be applied as an alternative treatment option. Compared to cutaneous Kaposi sarcoma in AIDS, only three cases of gastrointestinal Kaposi sarcoma in patients with AIDS have been reported in Korea, and no experience with interferon therapy for AIDS-associated visceral Kaposi sarcoma has been reported. We report a case of gastrointestinal Kaposi sarcoma in a patient with AIDS who had combined treatment with interferon-alpha and HAART.

Arterivenous Fistula Complicated by Popliteal Venous Access for Endovascular Thrombolytic Therapy of Deep Vein Thrombosis

We report a case of an iatrogenic arteriovenous fistula complicated by catheter-directed thrombolytic therapy in a patient with acute deep vein thrombosis of a lower extremity. To the best of our knowledge, this is the first report of an arteriovenous fistula between the sural artery and popliteal vein in that situation. As the vessels have a close anatomical relationship, the arteriovenous fistula seems to be a potential complication after endovascular thrombolytic therapy of acute deep vein thrombosis.

Evaluation of Atherosclerotic Plaque in Patients without Coronary Artery Calcification Using Multidetector Row Computed Tomography: A Preliminary Report of 110 patients

PURPOSE: We analyzed the frequency and characteristics of atherosclerotic plaques in the patients without coronary artery calcification (CAC) by the use of multidetector row CT (MDCT). In addition, we analyzed patients with negative CAC to guarantee the absence of coronary artery disease (CAD). MATERIALS AND METHODS: One hundred-ten patients with a suspicion of CAD and no CAC as detected on 16-slice and 64-slice MDCT were enrolled in this retrospective study. We analyzed the frequency of atherosclerotic plaques. For characterizing the atherosclerotic plaques, location, attenuation, volume, the degree of stenosis, and the remodeling index (RI) were analyzed. RESULTS: Atherosclerotic plaques were detected in 8 patients (7.3%). The plaques were located in the right coronary artery (n=3), left anterior descending artery (n=3), and left main coronary artery (n=2). Attenuation, volume, stenosis and RI were 41.4+/-16.6 HU (range, 20.2 - 69.9 HU), 55+/-55 mm3 (range, 15-179 mm3), 40.7+/-16.3% (range,16.0-68.0%) and 1.35+/-0.13 (range, 1.16-1.50). Lipid rich plaque and significant stenosis were detected in 6 patients and in 2 patients, respectively. CONCLUSION: Despite negative CAC as detected on MDCT, atherosclerotic plaque might have significant stenosis or lipid rich plaque. Therefore, negative CAC does not seem to guarantee the absence of CAD. Coronary CT angiography was recommended for patients with negative CAC.

The Relationship between Aortic Calcification Volume and Obstructive Coronary Artery Disease: Comparison with Coronary Calcification Volume

PURPOSE: We compared the diagnostic performance of aortic calcification volume with that of coronary artery calcification volume at CT in diagnosing obstructive coronary artery disease (OCAD). MATERIALS AND METHODS: A total of 308 patients (M: F=141:167) underwent coronary CT angiography using a 64-slice MDCT. We measured the calcification volume (mm3) of coronary artery (CAC), thoracic aorta (TAC), abdominal aorta (AAC), and whole aorta (AC) at unenhanced CT. OCAD was defined as the significant stenosis (>=50%) in any coronary artery at CT angiography. The diagnostic performance for OCAD was evaluated by calculating the area under the receiver operating characteristic (ROC) curve. RESULTS: Among the 308 patients studied, 45 patients were diagnosed with OCAD. The mean volumes of TAC, AAC, AC, and CAC were 518.8 mm3, 551.5 mm3, 1069.9 mm3, 57.6 mm3, respectively. The areas under the ROC curve of TAC, AAC, AC, and CAC for OCAD were 0.766 (0.694<95% confidence interval <0.838), 0.837 (0.784<95% confidence interval <0.892), 0.814 (0.755<95% confidence interval <0.873), 0.871 (0.812<95% confidence interval<0.930), respectively. CONCLUSION: The volume of aortic calcification as well as coronary artery calcification is associated with obstructive coronary artery disease.

Retrospective Study of Magnetic Resonance Imaging & Vestibular Function Testing in Patients Suggestive of Central Vestibular Disorders

BACKGROUND AND OBJECTIVES:There were many tools to evaluate dizzy patients with various causes. Our aim was to find the relationship between the magnetic resonance imaging(MRI) and vestibular function testing(VFT) in patients who are supposed of central vestibular disorders and to evaluate their effects. MATERIALS AND METHODS:We selected 183 patients retrospectively by standardized questionnaires, physical examinations, chart reviews from 3,825 patients who visited otorhinolaryngology via department of emergency and out patient clinic with chief complaints of dizziness. Among them, 13 patients were supposed to have MRI in relation to dizziness. We analyzed the result of VFT, MRI findings and then classified them in according to lesion locations, pathologic findings in MRI & optokinetic tests, caloric tests, step velocity tests, vestibulo-ocular tests, visual fixation tests in VFT. RESULTS:There were 9 ischemic findings, 1 hemorrhagic finding, 3 neoplasms in pathologic findings. There were 5 pons lesions, 4 cerebellum lesions, 3 thalamus lesions, 2 medulla lesions, 2 pituitary lesions and 1 caudate nucleus lesions in locations. CONCLUSIONS:Dizzy patients visiting otorhinolaryngology OPD had 0.34%(13/3825) central origin vertigo, and vascular disease is most common. Therefore we supported that careful readings of VFT findings in identifying central vestibular disorders were valuable and might well represent the gold standard. MRI was an important tool for evaluating the central nervous system, and we should use MRI to assess central vestibular dysfunction. We concluded MRI correlated well with VFT findings of central vestibular dysfunction.

One Case of Downbeat Nystagmus with Compression of Vestibulocochlear Nerve by Vertebral Arteries

A case is reported of downbeat nystagmus associated with compression of the root of vestibulocochlear nerve by vertebral arteries, which was revealed by magnetic resonance imaging. Chief complain of the patient was positional vertigo, which aggrevated at left decubitus position. Downbeat nystagmus was increased in left Dix-hall pike test. Tetsuo et al, reported downbeat nystagmus with compression of dolichoectatic vertebral arteries to the medulla oblongata and surgical neurovascular decompression of the dolichoectasia reverses the progression of symptoms if permanent neurologic damage has not already occurred.

Utility of MR Cholangiography for Follow-up Examination after Metallic Stent Placement in the Bile Duct

PURPOSE: To evaluate the efficacy of MR cholangiography for follow-up examination after metallic stent placement in the bile duct. MATERIALS AND METHODS: Between December 1999 and June 2000, 15 patients with biliary obstruction in whom metallic biliary stents had been placed underwent MR cholangiography during follow-up examination. The causes of obstruction were hilar cholangiocarcinoma (n=6), common bile duct cancer (n=5), gall bladder cancer (n=1) and pancreatic cancer (n=3). The types of self-expandable metallic stent employed were the nitinol stent (n=2), the Endocoil nitinol stent (n=3), the Ultraflexed Diamond stent (n=5), and the Wallstent (n=5). Using MR cholangiography, we measured the diameter of that part of the biliary stent which showed high signal intensity, assigning one point if this was less than one third of the stent diameter, two points if between one third and two thirds, and three points if more than two thirds. We decided that a higher score indicated fewer artifacts. RESULTS: The score was 1.7-3 (mean, 2.3) points for the Endocoil nitinol stent, 1.7-2.3 (mean, 2) for the nitinot stent, and 1-3 (mean, 1.7) for the Ultraflex Diamond stant. In most cases, two thirds of the stent diameter was observed. For the Wallstent, the score was 1-1.7 (mean, 1.3) points and the inner portion of the stent was almost invisible. CONCLUSION: MR cholangiography is not useful for follow-up examination after the placement of Wallstents and three other types of nitinol stent in the bile duct.

Nasal Tooth: Case Report

Ectopic tooth is not uncommon and usually occurs in the palate and maxillary sinus. We report a case of ectopic tooth located in the nasal cavity, a rare site. The mass depicted by CT was highly attenuated, and central lucency was observed.

Percutaneous Vertebroplasty in Osteoporotic Vertebral Body Compression Fracture

PURPOSE: To determine the clinical efficacy of percutaneous vertebroplasty in cases of painful and medically intractable osteoporotic vertebral compression fracture. MATERIALS AND METHODS: Ninety-eight patients (20 men and 78 women; mean age, 69 years) underwent 122 per-cutaneous vertebroplasty procedures for the treatment of osteoporotic vertical compression fracture. For the evaluation of bone mass, bone densitometry was performed in 45 patients, and to assess the recent evolution of the fracture, all 98 underwent MRI. Percutaneous vertebroplasty involves percutaneous transpedicular puncture of the involved vertebrae followed by the injection of a Polymethylmethacrylate(PMMA)-Barium mixture into the vertebral body. To assess leakage of the mixture into the epidural tissue, neural foramina, venous plexus and paravertebral tissue, we then immediately obtained a computerized tomographic (CT) scan, assessing the clinical efficacy of the procedure on the basis of time required for pain relief (defined as more than 60% reduction of initial pain), and time required for ambulation without significant pain. RESULTS: Percutaneous vertebroplasty was successful in all patients. Pain relief was accomplished within 1-5(mean, 1.8) days and early ambulation without significant pain was possible within 2 -15 (mean, 3.3) days. Post-procedural CT scanning revealed leakage of the PMMA-barium mixture into Paravertebral tissue(n=41), the paravertebral venous plexus (n=34) and epidural tissue (n=4). No neural foraminal leakage was identified, and no procedure-related complication requiring surgical treatment occurred. CONCLUSION: Percutaneous vertebroplasty is an effective new interventional procedure for the treatment of osteoporotic vertebral compression fracture. It relieves pain, provides early mobilization, and strengthens involved vertebral bodies.