Primary Hepatic Lymphoma: A Rare Form of Diffuse Large B-Cell Lymphoma of the Liver.

Background: Primary hepatic lymphoma is a rare, malignant lymphoma of the liver unlike the predominant lymph nodal or splenic involvement associated with other types of lymphoma. It is commonly associated with nonspecific symptoms and usually detected incidentally on imaging examination. Case Presentation: An 84-year-old man was evaluated for upper back pain. Chest computed tomography showed multiple large lesions in the liver, leading to the diagnosis of primary diffuse large B-cell lymphoma of the liver. Within 2 weeks of detecting his liver mass, the patient developed hypercalcemia and hyperuricemia that led to rapid deterioration and admission for treatment. Further diagnostic testing was performed, and he was initiated on appropriate chemotherapy. Conclusions: Primary hepatic lymphoma, a form of diffuse large B-cell lymphoma of the liver is a rare disease without specific clinical manifestations, biochemical indicators, or radiologic features except for space-occupying liver lesions. However, patients' conditions can deteriorate rapidly at an advanced stage as demonstrated in this case, which highlights the importance of a high level of suspicion for early diagnosis and treatment.

Incidental Findings of Malignancy of the Chest by Single Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT-CT MPI): One Year Follow-Up Report.

INTRODUCTION: We recently reported six cases of pulmonary/hilar malignancies as the result of incidental findings (IF) on CT attenuation correction (CTAC) during Single Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT-CT MPI). In this study, clinical features, diagnostic procedures, and clinical outcomes were examined on all patients who had malignancies or significant IF that required further follow-up. METHODS: Of 1,098 consecutive patients who underwent cardiac SPECT-CT MPI from September 1, 2017 to August 31, 2018, their MPI and CTAC were reviewed contemporaneously. Patients with known history of prior pulmonary or chest malignancy were excluded. RESULTS: A total of 79 (7.2%) patients were identified to have significant IF on CTAC. After diagnostic CT, 47 patients had significant findings that warranted further follow-up and included in this study. Eight of 1,098 patients (0.73%) and 8/79 patients (10.1%) were found to have malignancy of the chest because of IF on the CTAC. There were no statistically significant differences in baseline characteristics and cancer risk factors among patients who had cancer versus those without. At the time of diagnosis, four patients had cancer at an advanced stage, resulting in death within 12 months. Three others had early stage lung cancer and one had mantle cell lymphoma; they were alive at a mean follow-up of 17.5+/-2.1 months. Biopsy for tissue diagnosis was performed safely with needle biopsy. Major complication occurred in one patient (1/9 or 11.1%) with needle biopsy; none with surgical biopsy. CONCLUSION: This study underscored the importance of reviewing CTAC images obtained during cardiac SPECT-CT MPI to detect clinically important IF.

Incidental Findings of Pulmonary and Hilar Malignancy by Low-Resolution Computed Tomography Used in Myocardial Perfusion Imaging.

BACKGROUND: Low dose, low-resolution computed tomography (CT) is used for attenuation correction to improve the quality of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). Because of its low resolution, these CT images are considered non-diagnostic and are not routinely or uniformly reviewed or interpreted by a cardiologist. On the other hand, low-dose CT has been used for lung cancer screening to reduce lung cancer mortality and is recommended for annual screening of high-risk patients by the US Preventive Services Task Force. METHODS: Siemens Symbia Intevo Excel SPECT/CT scanners, used primarily for cardiac MPI, were used in the study. The study was intended to report incidental findings of pulmonary and hilar malignancy detected by these CT images during cardiac evaluation. It included 1,098 consecutive patients who had SPECT MPI from September 1, 2017 to August 31, 2018. When suspicious pulmonary nodules or abnormalities were identified, primary care providers were notified of the findings and recommendations for further evaluation. RESULTS: Five patients were found to have lung cancer (all male with substantial smoking history, aged 64-75 years), 1 had mantle cell lymphoma. Six of 1,098 (0.55%) patients were found to have incidental pulmonary/hilar malignancy, which is comparable to the yield (0.65%/year) of detecting lung cancer using low-dose CT for screening in The National Lung Screening Trial. CONCLUSIONS: Routine review and report of incidental findings on low-resolution CT during cardiac MPI by physicians skilled in CT interpretation is necessary to identify incidental but clinically important findings, including malignancies.

Significance of New, Isolated T-wave Inversion in Multiple Electrocardiogram Leads with Regadenoson Injection in Patients with Normal Myocardial Perfusion Imaging: An Observational Report of 5 Consecutive Cases.

INTRODUCTION: The pharmacologic (regadenoson) stress myocardial perfusion imaging (MPI) is used widely in patients who cannot exercise for detecting coronary artery disease (CAD). The interpretation of these studies depends primarily on the imaging results because the sensitivity of electrocardiograms (ECG) in this setting is poor. Prior study showed that effects of regadenoson on ST-segment occurred infrequently and had low sensitivity for detecting CAD. The significance of T-wave inversion in multiple ECG leads without ST-segment depression with regadenoson injection in patients with normal MPI is described and reported. METHODS: ECGs were reviewed retrospectively in 64 patients who had regadenoson MPI and coronary angiography for evaluation of CAD from June 1, 2016 to August 31, 2018. Five cases were identified with new, isolated T-wave inversion in multiple ECG leads. RESULTS: All five cases had new and isolated T-wave inversion in multiple leads without ST segment depression with regadenoson injection and normal MPI. At coronary angiography, three of the five cases showed obstructive coronary artery disease who received coronary percutaneous intervention. One case had nonobstructive coronary artery disease and one had a normal coronary artery. CONCLUSIONS: Despite nonspecific ST-T changes on baseline ECGs and normal MPI in all patients, three of five cases had obstructive CAD by coronary angiography. New, isolated T-wave inversion in multiple ECG leads with regadenoson injection were observed in our patients with normal MPI. These ECG findings may be associated with false negative MPI. Therefore, careful observation and scrutiny of all ECG changes, especially new, isolated T-wave inversion in multiple ECG leads during regadenoson MPI is advisable to identify potential obstructive CAD despite normal MPI findings.

Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II).

This study examined the effects of beta blockers on (1) appropriate implantable cardioverter defibrillator (ICD) therapy for ventricular tachycardia (VT) or ventricular fibrillation (VF), (2) inappropriate ICD therapy for atrial fibrillation or supraventricular tachycardia, and (3) survival in 691 patients who received ICDs in the Multicenter Automatic Defibrillator Implantation Trial-II. The study population involved 258 patients who were not receiving beta blockers and 433 who were receiving metoprolol (n = 192), atenolol (n = 58), or carvedilol (n = 182). Patients receiving beta blockers were divided into the upper quartile and lower 3 quartiles of the drug doses they were taking. Patients receiving the higher doses of beta blockers (those in the top quartile of doses) had a significant reduction in the risk for VT or VF requiring ICD therapy compared with patients not receiving beta blockers (hazard ratio 0.48, p = 0.02). The frequency of inappropriate ICD therapy for supraventricular tachyarrhythmias was not significantly different among the 3 treatment groups (p = 0.32). Beta-blocker use at the 2 dosage levels was associated with significant improvement in survival compared with the nonuse of beta blockers (hazard ratios 0.42 to 0.44, p <0.01). In conclusion, beta blockers reduce the risk for VT or VF and improve survival in ICD-treated patients with ischemic cardiomyopathy.