Contrast-enhanced postmortem computed tomography in clinical pathology: enhanced value of 20 clinical autopsies.

Postmortem computed tomography (PMCT) is a modern tool that complements autopsy diagnostics. In clinical autopsies, a major cause of death is cardiovascular disease. To improve the performance of PMCT in cardiovascular disease, full body angiography was developed (PMCT angiography [PMCTA]). Twenty PMCTA scans generated before autopsy were compared with native PMCT and clinical autopsy. The objective of the study was to quantify the additional diagnostic value of adding angiography to native imaging and to compare PMCT and PMCTA findings to autopsy findings. The diagnosis of the cause of death was identical or overlapped in 80% of the cases that used PMCTA and 70% that used PMCT. The additional diagnostic yield given by PMCT and PMCTA in combination with autopsy was 55%. PMCT yielded additional diagnoses in the musculoskeletal system. The greatest additional diagnostic value of PMCTA was in association with cardiovascular diagnoses. The accuracy of PMCTA for cardiac causes of death was 80%, and the positive predictive value was 90%. The findings indicate that native PMCT cannot display the cardiovascular system sufficiently clearly for high-quality diagnostic assessment. However, PMCTA is a powerful tool in autopsy cases with a history of cardiovascular disease and/or a suspected cardiovascular cause of death. The combination of PMCTA and clinical autopsy enhances diagnostic quality and completeness of the autopsy report. Furthermore, in cases without consent or with a restricted consent for clinical autopsy, PMCTA has the potential to provide information on cardiovascular causes of death.

The use of contrast-enhanced post Mortem CT in the detection of cardiovascular deaths.

OBJECTIVES: To evaluate the diagnostic value of contrast enhanced post mortem computed tomography (PMCT) in comparison to non-enhanced post mortem CT in the detection of cardiovascular causes of death (COD). BACKGROUND: As autopsy rates decline, new methods to determine CODs are necessary. So contrast enhanced PMCT shall be evaluated in comparison to established non-enhanced PMCT in order to further improve the method. METHODS: In a prospective study, 20 corpses were examined using a 64-row multisclice CT (MSCT) before and after intraarterial perfusion with a newly developed, barium-bearing contrast agent and ventilation of the lungs. The cause of death was determined in enhanced and unenhanced scans and a level of confidence (LOC) was given by three experienced radiologists on a scale between 0 and 4. Results were compared to autopsy results as gold standard. Autopsy was performed blinded to PMCT-findings. RESULTS: The method allowed visualization of different types of cause of death. There was a significant improvement in LOC in enhanced scans compared to unenhanced scans as well as an improvement in the detection of COD. The cause of death could be determined in 19 out of 20 patients. CONCLUSIONS: PMCT is feasible and appears to be robust for diagnosing cardiovascular causes of death. When compared with unenhanced post-mortem CT intraarterial perfusion and pulmonary ventilation significantly improve visualization and diagnostic accuracy. These promising results warrant further studies.

Fulminant puerperal sepsis due to anaplastic large-cell lymphoma (ALCL) with therapy-refractory cerebral edema.

INTRODUCTION: Lymphoma is among the five most frequent malignancies during pregnancy while anaplastic large-cell lymphoma (ALCL) is rare, accounting only for 2-3 % of all adult-onset non-Hodgkin lymphomas. CASE REPORT: A 23-year-old gravida 1, para 1 presented with puerperal mastitis and septicemia following secondary cesarean section. Mastitis had been present for a week prior to delivery. A CT scan for further diagnostics revealed numerous prominent lymph nodes. Cerebrospinal fluid testing, bone marrow and lymph node biopsy confirmed diagnosis of ALCL. Systemic and intrathecal chemotherapy was initiated, stabilizing the patient's clinical situation. 30 days postpartum (pp.), a cerebral edema was diagnosed responsible for cerebro-venous hypoperfusion. Immediate ventricle drainage and further therapeutic measures revealed no improvement. The patient died 33 days pp. CONCLUSION: Puerperal septicemia seemingly caused by mastitis still needs rapid further evaluation if the patient's clinical presentation quickly declines despite antibiotic therapy. Immediate initiation of chemotherapy after confirmation of ALCL is required to increase the therapeutic benefit due to the poor prognosis of ALCL.

Chronic kidney disease is associated with high abdominal incisional hernia rates and wound healing disturbances.

BACKGROUND AND OBJECTIVES: Incisional hernias are among the most frequent complications following abdominal surgery with impact on morbidity and mortality rates. Elevated uremia toxins may inhibit granulation tissue formation and impair wound healing, thereby promoting incisional hernia development. Here, we quantified the hazard ratio for incisional hernia prevalence in patients at risk undergoing abdominal reoperations with interrelationship to kidney function. In the same cohort, incidence rates for de novo wound healing disturbances within a4-month follow-up period were determined. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: Upon hospitalization for elective abdominal surgery in a university hospital (tertiary medical center), past medical histories were recorded in 251 patients and incisional hernia prevalence rates were calculated. Known modifiers for hernia formation as well as laboratory values for estimated glomerular filtration rate (eGFR) were recorded. The status of wound healing was assessed by a blinded investigator 4 months postoperatively. Chronic kidney disease(CKD) was defined as eGFR <60 ml/min/1.73 m2. To identify independent risk factors for incisional hernia or postoperative wound healing disorder, multivariate regression analyses were performed. RESULTS: The incisional hernia prevalence was 24.3 % in the overall cohort. Patients with CKD (32/251; 12.8 %)were more likely to suffer from incisional hernias with an odds ratio (OR) of 2.8 ([95 % CI 1.2-6.1]; p = 0.014) than patients with eGFR >60 ml/min (219/251; 88.2 %). In multivariate analyses, CKD proved to be an independent risk factor for incisional hernia development with an OR similar to obesity (BMI>25; OR 2.6 [95 % CI 1.3-5.1];p = 0.007). In the prospective analysis, disturbed wound healing occurred in 32 of 251 (12.8 %) patients undergoing abdominal operations. Frequency of wound healing was increased when CKD was present (8/32; 25 %; OR 2.3[95 % CI 1.1­6.7]; p = 0.026) compared to patients with eGFR>60 ml/min (24/219; 11 %). CONCLUSIONS: Chronic kidney disease is associated with impaired wound healing and constitutes an independent risk factor for incisional hernia development.

Efficacy of antegrade pyeloperfusion to protect the renal pelvis in kidney microwave ablation using an in vivo swine model.

PURPOSE: The purpose of this study was to evaluate the efficacy of antegrade pyeloperfusion with cooled 5% of glucose solution to protect the renal collecting system during microwave ablation (MWA). MATERIALS AND METHODS: Computed tomographically guided nephrostomy was performed in 1 kidney in each of 14 female pigs by placing a 6F nephrostomy catheter. Pyeloperfusion was performed through infusion of cooled 5% of glucose solution via the nephrostomy catheter (4°C; 10 mL/min). Microwave ablation (915 MHz) was performed at 45 W for 10 minutes in the irrigated and the non-irrigated kidneys creating a central lesion and a peripheral lesion in each kidney. Maximum ablation diameters were measured and ablation volumes were calculated after the animals were killed. The extent of thermal injury of the renal pyelon was assessed histopathologically in the slice of maximal thermal injury on a 10-point scale ranging from 0 (none) to 10 (complete). RESULTS: Pyeloperfusion did not impact the ablation volume or the degree of thermal injury to the collecting system for the central or peripheral MWA procedures: The mean (SD) volume of the MWA zones was equivalent for the irrigated versus non-irrigated kidneys for the peripheral (3.07 [2.39] mL vs 3.87 [3.08] mL) and central MWA procedures (2.26 [1.55] mL vs 2.40 [1.60] mL). The mean (SD) histologic scores of the thermal damage of the pyelon were similar for the irrigated versus non-irrigated kidneys in the peripheral MWA (1.0 [2.7] vs 0.2 [0.6]) and in the central MWA (1.6 [2.7] vs 3.4 [3.4]). CONCLUSIONS: In MWA, cooled antegrade pyeloperfusion is not useful to modulate the ablation volume in peripheral or central locations. Accordingly, pyeloperfusion may not be useful as a protective measure to avoid thermal damage in MWA of the kidney. Therefore, MWA of central renal tumors does not seem advisable.

Superselective particle embolization enhances efficacy of radiofrequency ablation: effects of particle size and sequence of action.

PURPOSE: To evaluate the effects of particle size and course of action of superselective bland transcatheter arterial embolization (TAE) on the efficacy of radiofrequency ablation (RFA). METHODS: Twenty pigs were divided into five groups: group 1a, 40-µm bland TAE before RFA; group 1b, 40-µm bland TAE after RFA; group 2a, 250-µm bland TAE before RFA; group 2b, 250-µm bland TAE after RFA and group 3, RFA alone. A total of 40 treatments were performed with a combined CT and angiography system. The sizes of the treated zones were measured from contrast-enhanced CTs on days 1 and 28. Animals were humanely killed, and the treated zones were examined pathologically. RESULTS: There were no complications during procedures and follow-up. The short-axis diameter of the ablation zone in group 1a (mean ± standard deviation, 3.19 ± 0.39 cm) was significantly larger than in group 1b (2.44 ± 0.52 cm; P = 0.021), group 2a (2.51 ± 0.32 cm; P = 0.048), group 2b (2.19 ± 0.44 cm; P = 0.02), and group 3 (1.91 ± 0.55 cm; P < 0.001). The greatest volume of ablation was achieved by performing embolization with 40-µm particles before RFA (group 1a; 20.97 ± 9.65 cm(3)). At histology, 40-µm microspheres were observed to occlude smaller and more distal arteries than 250-µm microspheres. CONCLUSION: Bland TAE is more effective before RFA than postablation embolization. The use of very small 40-µm microspheres enhances the efficacy of RFA more than the use of larger particles.

Novel insights into osteogenesis and matrix remodelling associated with calcific uraemic arteriolopathy.

BACKGROUND: Calcific uraemic arteriolopathy (CUA) or calciphylaxis is a rare, life-threatening disease predominantly occurring in patients with end-stage renal disease. Its pathogenesis has been suggested to include ectopic osteogenesis in soft tissue and the vasculature associated with extracellular matrix (ECM) remodelling. METHODS: To gain further insights into the pathogenesis of CUA, we performed systematic analyses of skin specimens obtained from seven CUA patients including histology, immunohistochemistry, electron microscopy, electron dispersive X-ray analysis (EDX) and quantitative real-time RT-PCR. Skin specimens of (i) seven patients without chronic kidney disease and without CUA and (ii) seven dialysis patients without CUA served as controls. RESULTS: In the CUA skin lesions, we observed a significant upregulation of bone morphogenic protein 2 (BMP-2), its target gene Runx2 and its indirect antagonist sclerostin. Furthermore, we detected an increased expression of inactive uncarboxylated matrix Gla protein (Glu-MGP). The upregulation of osteogenesis-associated markers was accompanied by an increased expression of osteopontin, fibronectin, laminin and collagen I indicating an extensive remodelling of the subcutaneous ECM. EDX analysis revealed calcium/phosphate accumulations in the subcutis of all CUA patients with a molar ratio of 1.68 ± 0.06 matching that of hydroxyapatite mineral. Widespread media calcification in cutaneous arterioles was associated with destruction of the endothelial layer and partial exfoliation of the endothelial cells (ECs). CD31 immunostaining revealed aggregates of ECs contributing to intraluminal obstruction and consecutive malperfusion resulting in the clinical picture of ulcerative necrosis in all seven patients. CONCLUSIONS: Our data indicate that CUA is an active osteogenic process including the upregulation of BMP-2 signalling, hydroxyapatite deposition and extensive matrix remodelling of the subcutis.

Virtual CT autopsy in clinical pathology: feasibility in clinical autopsies.

For the past century, autopsy techniques in clinical pathology have not changed significantly, while autopsy rates are declining. Modern imaging techniques offer interesting prospects of supportive post-mortem diagnostic investigation. In a prospective study of 29 autopsy cases, complimentary virtual autopsy using unenhanced post-mortem computed tomography (pmCT) was performed. We analysed in a prospective cohort study 29 unenhanced pmCT scans, generated prior to autopsy. Clinical information regarding clinical history and circumstances of death were provided. The objective of the study was to find consistency and/or discrepancy between virtual autopsy and conventional autopsy findings regarding cause of death and death-related diagnoses, reconstruction of the pathogenetic mechanisms involved, side diagnoses and CPR (cardiopulmonary resuscitation)- or death-related post-mortem changes. Accuracy of pmCT for cause of death was 68 % and the positive predictive value (PPV) was 75 %. Regarding the pathogenetic mechanisms, accuracy of pmCT was 21 % and PPV was 29 %. The combined diagnostic yield of autopsy and pmCT was 133 % compared to autopsy only. Modern imaging techniques give an opportunity for post-mortem diagnostics to complete but not yet replace traditional autopsy. We could show that in two out of three cases, the cause of death found by pmCT matched the diagnosis from classical autopsy. While both disciplines, pathology and radiology, will profit from the mutual exchange of data, it seems a realistic aim to strive for virtual autopsy possibly further supported by biopsies and contrast-enhanced pmCT as an alternative to the classical clinical autopsy. A combination of both methods enhances diagnostic quality and completeness of the autopsy report.

Macrophage activation syndrome in a patient with pulmonary inflammatory myofibroblastic tumour.

We describe for the first time a case of macrophage activation syndrome (MAS) in a patient with a history of inflammatory myofibroblastic tumour (inflammatory pseudotumour, IPT) of the lung and thoracic spine. The patient was admitted to the intensive care unit with a history of prolonged remitting fever, hepatosplenomegaly, bilaterally enlarged thoracic lymph nodes and an acute severe inflammatory response syndrome (SIRS). Up-regulated cytokine production (e.g. IL-1ß and IL-6), increased levels of ferritin and circulating soluble interleukin-2 receptor (sIL-2R, sCD25) led to the differential diagnosis of MAS. Bone marrow aspiration, the main tool for a definite diagnosis, revealed macrophages phagocytosing haematopoietic cells. Immunosuppressive therapy with corticosteroids and cyclosporine was an effective treatment in this patient.

Microwave ablation compared with radiofrequency ablation for breast tissue in an ex vivo bovine udder model.

PURPOSE: To compare the effectiveness of microwave (MW) ablation with radiofrequency (RF) ablation for treating breast tissue in a nonperfused ex vivo model of healthy bovine udder tissue. MATERIALS AND METHODS: MW ablations were performed at power outputs of 25W, 35W, and 45W using a 915-MHz frequency generator and a 2-cm active tip antenna. RF ablations were performed with a bipolar RF system with 2- and 3-cm active tip electrodes. Tissue temperatures were continuously monitored during ablation. RESULTS: The mean short-axis diameters of the coagulation zones were 1.34 ± 0.14, 1.45 ± 0.13, and 1.74 ± 0.11 cm for MW ablation at outputs of 25W, 35W, and 45W. For RF ablation, the corresponding values were 1.16 ± 0.09 and 1.26 ± 0.14 cm with electrodes having 2- and 3-cm active tips, respectively. The mean coagulation volumes were 2.27 ± 0.65, 2.85 ± 0.72, and 4.45 ± 0.47 cm(3) for MW ablation at outputs of 25W, 35W, and 45W and 1.18 ± 0.30 and 2.29 ± 0.55 cm(3) got RF ablation with 2- and 3-cm electrodes, respectively. MW ablations at 35W and 45W achieved significantly longer short-axis diameters than RF ablations (P < 0.05). The highest tissue temperature was achieved with MW ablation at 45W (P < 0.05). On histological examination, the extent of the ablation zone in MW ablations was less affected by tissue heterogeneity than that in RF ablations. CONCLUSION: MW ablation appears to be advantageous with respect to the volume of ablation and the shape of the margin of necrosis compared with RF ablation in an ex vivo bovine udder.