Cross-Sectional Imaging and Thoracoscopic Resection of Functional Intrathoracic Paraganglioma of the Aortic Body.

Paragangliomas are extra-adrenal tumors that are derived from neuroendocrine chromaffin cells. The rare disease has a variable presentation depending upon its anatomic location and functionality. We describe the case of a 56-year-old female patient who had an incidental mass found on imaging. The patient underwent biochemical testing and a mediastinal biopsy due to the nonspecific imaging findings. The mediastinal mass was resected through hemisternotomy and found to be a functional paraganglioma. This case highlights the importance of radiologists to consider the prospect of paragangliomas in the differential diagnosis of an intra-thoracic mass.

Epipericardial fat necrosis: Uncommon cause of acute pleuritic chest pain.

Epipericardial fat necrosis (EPFN) is a rare cause for acute chest. We describe the case of a previously healthy 25-year-old man who presented with sudden onset of left-sided chest pain. Laboratory values showed only mildly elevated d-dimer and electrocardiogram was normal. However, subsequent CT angiogram of the chest revealed fat necrosis in the epipericardial fat, characteristic for EPFN, for which the patient was treated with nonsteroidal anti-inflammatory drug. This case highlights the importance of radiologists to consider the prospect of EPFN in the differential diagnosis of acute chest pain as correct diagnosis allows for conservative management and avoidance of more aggressive techniques in symptomatic patients.

Incidence of aortic arch anomalies in patients with thoracic aortic dissections.

BACKGROUND AND AIM OF STUDY: Traditionally aortic arch anomalies have been viewed as a "normal" and clinically insignificant; therefore, they are often overlooked by radiologists and go unreported. Arch anomalies have been reported to occur in 7% to 15% of patients without thoracic aortic aneurysm or dissection. This study aims to define the incidence of aortic arch anomalies in patients with a thoracic aortic dissection (TAD). METHODS: We retrospectively reviewed all patients from 2006 to 2010 with a TAD admitted to a single institution. Thoracic computed tomography images of 176 patients with dissected thoracic aortas and 179 consecutive, unselected age-matched patients without dissection as controls were reviewed to determine the incidence of bovine arch and other arch anomalies. Statistical analysis of demographic data and clinical outcomes was performed to evaluate significant differences between the groups. RESULTS: Arch anomalies occurred in 34% of patients with TAD compared to controls (19%, p = 0.0017). The most common variant was a common origin of the innominate and left common carotid arteries ("bovine" arch) found in 31% of dissection patients compared to 15% in the control group (p = 0.0004). Overall arch anomalies occurred in 27% of all Type A dissections and 39% (p = 0.1409) of all Type B dissections. The association was statistically significant in patients ages 50 to 79 with TAD (36.4%, p = 0.0011) and in African Americans collectively (43.2%, p = 0.0033). CONCLUSIONS: Aortic arch anomalies occur frequently in patients with TAD and therefore may represent a proclivity for this life threatening condition.

Impact of resident call eligibility on major discrepancy rate.

RATIONALE AND OBJECTIVES: The Resident Review Committee (RRC) recently changed the policy concerning first-year resident call. Our study is intended to evaluate whether the additional 6 months of training before a resident's first call made a significant difference in the resident's ability to provide patient care. To evaluate this, we assessed the discrepancy rates between preliminary interpretations made by residents and final reports by attendings. MATERIALS AND METHODS: All cross-sectional imaging interpreted by on-call residents (5 PM to 8 AM) during the first 6 months of call duties was reviewed for discrepant findings between the preliminary resident report and the final interpretation by an attending. Only major discrepancies were evaluated. A major discrepancy was defined as a change made to the resident preliminary report by an attending radiologist where a delay in communicating that finding had the potential to negatively affect clinical outcomes. Major discrepancy rates between groups were then compared. RESULTS: During the second 6 months of the 2008-2009 academic year, first-year residents interpreted 3331 studies. Fifty-nine of those were declared to be discrepancies after an attending over-read, a rate of 1.8%. During the first 6 months of the 2009-2010 academic year, second-year residents interpreted 4649 studies with 49 discrepancies, a rate of 1.0%. This difference is statistically significant (P = .008). CONCLUSIONS: The recent RRC policy change requiring 6 additional months of training before assuming independent on-call responsibilities has significantly decreased the major discrepancy rate at our institution.

Axillary lymph nodes suspicious for breast cancer metastasis: sampling with US-guided 14-gauge core-needle biopsy--clinical experience in 100 patients.

PURPOSE: To study the clinical usefulness of ultrasonography (US)-guided core-needle biopsy (CNB) of axillary lymph nodes and the US-depicted abnormalities that may be used to predict nodal metastases. MATERIALS AND METHODS: This retrospective study was HIPAA compliant and institutional review board approved; the requirement for informed patient consent was waived. US-guided 14-gauge CNB of abnormal axillary lymph nodes was performed in 100 of 144 patients with primary breast cancer who underwent US assessment of axillary lymph nodes. A biopsy needle with controllable action rather than a traditional throw-type needle was used. US findings were considered suspicious for metastasis if cortical thickening and/or nonhilar blood flow (NHBF) to the lymph node cortex was present. The absence of any discernible fatty hilum was also noted. RESULTS: Nodal metastases were documented at CNB in 64 (64%) of the 100 patients. All 36 patients with negative biopsy results underwent subsequent sentinel lymph node biopsy (SLNB), which yielded negative findings in 32 (89%) patients and revealed metastasis in four (11%). All 44 patients who did not undergo CNB because of negative US results subsequently underwent SLNB, which revealed lymph node metastasis in 12 (27%) patients. Cortical thickening was found in 63 (79%) of the total of 80 metastatic nodes, but only a minority (n = 26 [32%]) of the nodes had an absent fatty hilum. NHBF to the cortex was detected in 52 (65%) metastatic nodes. Both absence of a fatty hilum (metastasis detected in 26 [93%] of 28 nodes) and cortical thickening combined with NHBF (metastasis detected in 52 [81%] of 64 nodes) had a high positive predictive value. No clinically important complications were encountered with the biopsy procedures. CONCLUSION: Axillary lymph nodes with abnormal US findings can be sampled with high accuracy and without major complications by using a modified 14-gauge CNB technique.

Value of rapid assessment cytology in the surgical management of head and neck tumors in a Nigerian mission hospital.

BACKGROUND: Fine-needle aspiration (FNA) or touch preparation with rapid assessment is a valuable diagnostic tool with a reported accuracy of diagnosis similar to intraoperative frozen section consultation. The Nigeria Christian Hospital partners with health care professionals from the United States to provide surgical care for rural residents of Aba, Nigeria. Frozen section diagnosis is impractical in this setting because of very limited resources. Therefore, intraoperative rapid assessment FNA or touch preparation to guide surgical management was performed on all mass lesions, and the results were evaluated. METHODS: FNA was performed just before surgery using a 22-gauge needle attached to a 10-mL syringe and/or an intraoperative touch preparation was performed on biopsies of lesions that failed to yield cellular aspirates. Smears were prepared and stained with hematoxylin and eosin, and an immediate diagnosis was rendered. Tissue samples from the same resected/biopsied cases were fixed in 10% formalin and later transported to Vanderbilt University Medical Center Department of Pathology for processing. Cytologic and histologic correlations were then performed. RESULTS AND CONCLUSIONS: More than 100 patients underwent surgery for head and/or neck masses during the 2-week periods between November 2002 and November 2003. Of these patients, 98 had either preoperative FNA and/or intraoperative touch preparation performed. Twenty-seven patients were male and 71 were female; the ages ranged from 2 months to 70 years. Sites sampled included the following: thyroid (n = 40); facial/jaw area (n = 19); parotid/submandibular gland (n = 13); scalp/skull region (n = 7); cervical lymph nodes (n = 5); neck (n = 5); other (n = 4); supraclavicular lymph nodes (n = 3); and oral cavity (n = 2). On cytologic analysis, there were 79 benign diagnoses, 17 malignant diagnoses, and 2 nondiagnostic samples. A benign versus malignant cytologic diagnosis was accurate in 97 of 98 cases. In conclusion, rapid assessment cytology was invaluable in the surgical treatment of many of the patients.

Differentiating the pathologies of cerebral malaria by postmortem parasite counts.

To study the pathogenesis of fatal cerebral malaria, we conducted autopsies in 31 children with this clinical diagnosis. We found that 23% of the children had actually died from other causes. The remaining patients had parasites sequestered in cerebral capillaries, and 75% of those had additional intra- and perivascular pathology. Retinopathy was the only clinical sign distinguishing malarial from nonmalarial coma. These data have implications for treating malaria patients, designing clinical trials and assessing malaria-specific disease associations.