Intrathoracic Abnormalities Research Articles

Preoperative imaging of clinically relevant intrathoracic abnormalities in pectus excavatum patients.

Preoperative radiological imaging in pectus excavatum sometimes coincidentally yields additional intrathoracic abnormalities. In the context of a larger research project investigating replacement of CT scans by 3D-surface scanning as routine preoperative work-up for pectus excavatum, this study aims to quantify the incidence of clinically relevant intrathoracic abnormalities found incidentally using conventional CT in pectus excavatum patients. A single-center retrospective cohort study was conducted including pectus excavatum patients, receiving CT between 2012 and 2021 as part of their preoperative evaluation. Radiology reports were reviewed for additional intrathoracic abnormalities and scored into three subclasses: non-clinically relevant, potentially clinically relevant or clinically relevant findings. Also, two-view plain chest radiographs reports, if available, were evaluated for those patients with a clinically relevant finding. Subgroup analysis was performed to compare adolescents and adults. In total, 382 patients were included, of whom 117 were adolescents. Although in 41 patients (11%) an additional intrathoracic abnormality was found, only two patients (0.5%) presented with a clinically relevant abnormality requiring additional diagnostics, postponing surgical correction. In only one of the two patients, plain chest radiographs were available, which did not show the abnormality. Subgroup analyses revealed no differences in (potentially) clinically relevant abnormalities between adolescents and adults. The prevalence of clinically relevant intrathoracic abnormalities in pectus excavatum patients was low, supporting the notion that CT and plain radiographs can be safely replaced by 3D-surface scanning in the preoperative work-up for pectus excavatum repair.

Cannabinoid hyperemesis syndrome complicated by pneumomediastinum: implications for pediatrics

Background. Cannabinoid hyperemesis syndrome / CHS (prolonged and frequent use of high-dose cannabis) in the pediatric population has been increasingly reported over the last decade. CHS can lead to life-threatening complications such as pneumomediastinum, which warrant careful consideration for surgical intervention. Case Presentation. A 17-year-old female with no significant past medical history presented to the emergency department with abdominal, chest and back pain (worse with deep inspiration), nausea, and vomiting for 24 hours. Upon further history, the patient reported a similar episode six months ago, being a cannabis smoker (at least once a day) in the last two years. Chest X-ray revealed a subtle abnormal lucency along the anteroposterior window and anterior mediastinum, consistent with a small amount of pneumomediastinum without any other acute intrathoracic abnormalities. Follow-up chest computed tomography with contrast showed multiple foci of air within the anterior and posterior mediastinum tracking up to the thoracic inlet. There was no evidence of contrast extravasation; however, small esophageal perforation could not be excluded. Given uncomplicated pneumomediastinum (without frank contrast extravasation) the patient was treated medically with piperacillin-tazobactam, metronidazole, and micafungin for microbial prophylaxis; hydromorphone for pain control; as well as with pantoprazole, ondansetron, and promethazine. Nutrition was provided via total parenteral nutrition. The evolution was favorable (no signs of occult esophageal perforation occurred), being advanced to a soft diet on hospital day eight, solid food diet on day nine, at which point antibiotics were discontinued, and the patient was subsequently discharged. Conclusion. CHS in increasingly encountered in the pediatric setting due to rising prevalence of cannabis use. The management of CHS and potentially life-threatening complications such as pneumomediastinum should be given careful consideration. Pneumomediastinum can be a harbinger of esophageal perforation that may warrant urgent surgical intervention.

Role of Multidetector Computed Tomography in Evaluation of Cardiac and Extracardiac Intrathoracic Abnormalities in Pediatric Patients

Role of Multidetector Computed Tomography in Evaluation of Cardiac and Extracardiac Intrathoracic Abnormalities in Pediatric Patients

Nodules and masses are associated with malignant pleural effusion in dogs and cats but many other intrathoracic CT features are poor predictors of the effusion type.

Thoracic CT may be used in the workup of patients with pleural effusion. In humans, certain pleural features on CT aid in diagnosing an underlying cause for pleural effusion, whereas this is not well studied in veterinary medicine. This retrospective cross-sectional analytical study assessed pleural and other intrathoracic abnormalities on CT in dogs and cats with pleural effusion and explored potential discriminatory features between effusion types. Eighty-nine dogs and 32 cats with pleural cytology and/or histopathology were categorized into malignant pleural disease (15 dogs and 11 cats), pyothorax (34 dogs and 7 cats), chylothorax (20 dogs and 11 cats), transudative (11 dogs and 2 cats), and hemorrhagic effusion (9 dogs and 1 cat). Multivariable logistic regression analysis comparing malignancy to other effusions found that older patient age (dogs: odds ratio 1.28, P=0.015; cats: odds ratio 1.53, P=0.005), nodular diaphragmatic pleural thickening (dogs: odds ratio 7.64, P=0.021; cats: odds ratio 13.67, P=0.031), costal pleural masses (dogs: odds ratio 21.50, P=0.018; cats: odds ratio 32.74, P=0.019), and pulmonary masses (dogs: odds ratio 44.67, P=0.002; cats: odds ratio 18.26, P=0.077) were associated with malignancy. In dogs, any costal pleural abnormality (odds ratio 47.55, P=0.002) and pulmonary masses (odds ratio 10.05, P=0.004) were associated with malignancy/pyothorax, whereas any costal pleural abnormality (odds ratio 0.14, P=0.006) and sternal lymphadenopathy (odds ratio 0.22, P=0.040) were inversely associated with transudates. There were, however, many overlapping abnormalities between effusion types, so further diagnostic testing remains important for diagnosis.

Endoscopic ultrasound fine-needle aspiration by experienced pulmonologists: a cusum analysis

Endobronchial ultrasound transbronchial needle aspiration (EBUS TBNA) is an established, minimally invasive way to sample intrathoracic abnormalities. The EBUS scope can be passed into the oesophagus to perform endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA). In cases of suspected lung cancer, a combination of the two techniques is now recommended by consensus guidelines. EBUS TBNA is usually performed by pulmonologists; however, the learning curve for EUS-B-FNA, which may be performed during the same procedure, has not been described.A multicentre, observational Australian study, using prospectively collected data from three experienced pulmonologists was conducted. Cumulative sum (cusum) analysis was used to generate visual learning curves.A total of 152 target lesions were sampled in 137 patients, with an overall sensitivity for malignancy of 94.8%. The sensitivity for malignant lesions outside of the 2009 International Association for the Study of Lung Cancer lymph node map (largely intraparenchymal lesions) was 92.9%. All three operators were competent by conventional cusum criteria. There was one case of pneumothorax, and no episodes of mediastinitis or oesophageal perforation were observed.Our data suggest that experienced pulmonologists can safely and accurately perform EUS-B-FNA, with a high diagnostic sensitivity for both lymph node and non-nodal lesions.

Diffuse Pulmonary Lymphangiomatosis: MDCT Findings After Direct Lymphangiography.

The aim of this study was to analyze the findings of MDCT performed after direct lymphangiography in patients with diffuse pulmonary lymphangiomatosis. Twenty-three patients (13 male and 10 female patients) diagnosed with diffuse pulmonary lymphangiomatosis on the basis of clinical features and findings from imaging, bronchoscopy, and pathologic analysis were retrospectively evaluated. All patients underwent pulmonary MDCT after direct lymphangiography, surgical operation or open lung biopsy, and histopathologic examination. MDCT images were analyzed by two experienced radiologists independently. MDCT after direct lymphangiography revealed numerous intrathoracic abnormalities, including abnormal distribution of contrast medium, dilatation of lymphatic channels, mediastinal soft-tissue infiltration, and peribronchovascular thickening. Nineteen patients had interlobular septal thickening, 18 had diffuse ground-glass opacities, 22 had pleural effusion, 14 had extrapleural soft-tissue thickening, 20 had pericardial effusion and thickened pericardium, 10 had multiple lymphadenopathy in mediastinum, and five had mediastinal, pericardial, and thoracic aeroceles. MDCT performed after direct lymphangiography is well suited to clarify the characteristics of intrathoracic disorders and is an excellent tool in the diagnosis of diffuse pulmonary lymphangiomatosis.

Low dose chest CT protocol (50 mAs) as a routine protocol for comprehensive assessment of intrathoracic abnormality

PurposeTo determine the diagnostic capability of low-dose CT (50mAs) in comparison to standard-dose CT (150mAs). Materials and methodsFifty-nine consecutive patients underwent two non-contrast chest CT scans with different current-time products (50 and 150mAs at 120kVp) on a 64-detector row CT scanner. Three board certified chest radiologists independently reviewed 118 series of 2mm-thick images (2 series for each of 59 patients) in a random order. The readers assessed abnormal findings including emphysema, ground-glass opacity, reticular opacity, micronodules, bronchiectasis, honeycomb, nodules (>5mm), aortic aneurysm, coronary artery calcification, pericardial and pleural effusion, pleural thickening, mediastinal tumor and lymph node enlargement. Five-point scale from 1 (definitely absent) to 5 (definitely present) was used to record the results. The rates of score agreement between two images were calculated. Deviation of one observer's score from other two observers was compared between low dose CT and standard dose CT. ResultsMean agreement rate of the lung parenchymal findings between low dose CT and standard dose CT images was 0.836 (range, 0.746–0.926). Mean agreement rates for mediastinal and pleural findings were 0.920 (range, 0.735–1.000). There was no statistically significant difference in the deviation of the observers' scores between low-dose CT and standard-dose CT. ConclusionLow dose CT protocol at 50mAs can produce the screening results consistent with standard dose CT protocol (150mAs), supporting routine use of low dose chest CT protocol.

Acute contained ruptured aortic aneurysm presenting as left vocal fold immobility.

Objective. To recognize intrathoracic abnormalities, including expansion or rupture of aortic aneurysms, as a source of acute onset vocal fold immobility. Methods. A case report and review of the literature. Results. An 85-year-old female with prior history of an aortic aneurysm presented to a tertiary care facility with sudden onset hoarseness. On laryngoscopy, the left vocal fold was immobile in the paramedian position. A CT scan obtained that day revealed a new, large hematoma surrounding the upper descending aortic stent graft consistent with an acute contained ruptured aortic aneurysm. She was referred to the emergency department for evaluation and treatment by vascular surgery. She was counseled regarding surgical options and ultimately decided not to pursue further treatment. Her vocal fold immobility was subsequently treated via office-based injection medialization two weeks after presentation and again 5 months after the initial injection which dramatically improved her voice. Follow-up CT scan at 8 months demonstrated a reduction of the hematoma. The left vocal cord remains immobile to date. Conclusion. Ortner's syndrome, or cardiovocal syndrome, is hoarseness secondary to left recurrent laryngeal nerve palsy caused by cardiovascular pathology. It is a rare condition and, while typically presenting gradually, may also present with acute symptomatology.

Acute Contained Ruptured Aortic Aneurysm Presenting as Left Vocal Cord Paralysis

Objectives: Recognize intrathoracic abnormalities, including expansion or rupture of aortic aneurysms, as a source of acute onset vocal cord paralysis. Methods: Case report and review of the literature. Results: An 85-year-old female with prior history of an aortic aneurysm status post-endovascular repair presented to a tertiary care laryngology clinic with a history of sudden onset hoarseness that began two months prior with no subsequent improvement. On laryngoscopy, the left vocal cord was seen in the midline position. A computed tomography (CT) scan obtained that day revealed a new, large acute 4.6 cm hematoma surrounding the upper descending aortic stent graft consistent with an acute contained ruptured aortic aneurysm. She was subsequently referred to the Emergency Department for further evaluation and treatment by the vascular surgery team. She was counseled regarding surgical options and ultimately decided not to pursue further treatment. Her vocal cord paralysis was subsequently treated via office-based injection medialization two weeks after presentation and again 5 months after the initial injection which dramatically improved her voice. Follow-up CT scan at 8 months after diagnosis demonstrated a slight decrease in the size of the hematoma and the development of a pseudoaneurysm within it. The left vocal cord remains immobile to date. Conclusions: Ortner’s syndrome, or cardiovocal syndrome, is hoarseness secondary to left recurrent laryngeal nerve palsy caused by cardiovascular pathology. It is a rare condition, and while typically presenting gradually, may also present with acute symptomatology.

Low-Dose Chest Computed Tomography as a Screening Tool: Findings in 536 Aircrews

Plain chest radiographs and pulmonary function tests have been used for pulmonary screening for flight duties of aircrews of the Republic of Korea Air Force. However, the screening accuracy of plain chest radiographs is controversial. Chest CT imaging with low-dose protocol (LDCT) improves detection of intra-thoracic abnormalities compared to plain chest radiographs. The aim of this study was to assess the influence of LDCT on flight duties of aircrews and to investigate their radiologic findings. From June 2009 to May 2011, the Aerospace Medical Center screened asymptomatic subjects 40 yr of age or older to evaluate intra-thoracic abnormalities using LDCT. The abnormal findings, including types and frequency, were recorded and the aircrew's flight duties were also recorded. This study included 536 subjects. No abnormal findings were found in 387 (72.2%) subjects. Abnormal findings related to pulmonary nodules were detected in 123 (23.00%) subjects. Air-trapping lesions were found in 33 (6.1%) subjects. One subject had a mediastinal tumor. Changes of flight duty were made in 26 (4.9%) subjects on the basis of LDCT findings. No subject was permanently disqualified for flight duty. Pulmonary screening with LDCT could detect many intra-thoracic abnormalities. LDCT was especially useful in the detection of bullae and bleb, and the flight duties of all subjects with bullae and bleb were changed.

An Approach To Imaging Adult Congenital Heart Disease : Pitfals And Pearls

Noninvasive cardiovascular evaluation of an adult congenital heart disease (ACHD) patient is a multimodality endeavor that can include chest roentgenograms, electrocardiograms, echocardiography (including stress, three-dimensional, intravascular and intracardiac ultrasound, and transesophageal), cardiac magnetic resonance imaging (CMR), computed tomography angiography (CTA), single photon emission computed tomographic (SPECT) perfusion imaging, and positron emission tomography (PET). The cost-benefit ratio and limitations of each modality should always be considered (Table 1). Adults with ACHD often need repetitive imaging, making them vulnerable to radiation-induced cancer; hence, modalities using ionizing radiation should be minimized. A transthoracic echocardiogram remains the initial noninvasive modality of choice due to its real-time imaging capability with excellent temporal resolution and its ability to quickly assess hemodynamics along with anatomic delineation. A transesophageal echocardiogram is extremely helpful in further defining intracardiac anatomy and guiding surgical and interventional procedures. Cardiac magnetic resonance imaging is an adjunctive modality to an echocardiogram because ACHD patients frequently have intra-thoracic abnormalities (e.g., adhesions from multiple cardiac operations and lung disease) that can limit the resolution of the ultrasound beam. A CMR is especially helpful in periodic evaluation of the right ventricle, visceral situs, extracardiac anatomy, lesions of the pericardium, pulmonary veins, systemic veins, pulmonary arteries, and aorta. For real-time CMR, special techniques such as echo planar can be used; for hemodynamic evaluation by CMR, techniques like velocity-vector mapping, myocardial tagging, echo planar, and fast gradient echo can be used. Besides excellent spatial resolution, the advantage of CTA over other techniques is an extremely fast acquisition time. Furthermore, CTA can replace an invasive procedure such as catheterization and angiography for anatomical diagnosis where hemodynamics is not required, such as the diagnosis of arch or coronary artery anomalies. Nuclear scans such as lung perfusion scans and splenic scans are very helpful in determining differential pulmonary blood flow and splenic function, respectively. Both SPECT and PET are valuable in assessing tissue perfusion and metabolism and help to determine viable versus nonviable myocardium after surgery for hypoplastic left heart syndrome and coronary artery anomaly, after arterial switch operation for d-transposition of great arteries, and in acquired illness such as Kawasaki disease. When considering imaging a patient with ACHD, and overall evaluation strategy should include the aspects found in Table 2.

What is the Value of CT Angiography for Patients with Acute Chest Pain?

Coronary CT angiography (CCTA) is an innovative technique to visualize the coronary arteries in patients with suspected coronary artery disease. CCTA has been validated in patients with non acute symptoms. Because of its high negative predictive value in this population, some have advocated using it in patients admitted to the emergency department with chest pain to determine the presence of coronary artery disease and acute coronary syndrome (ACS). With current CCTA protocols, adequate evaluation of the coronary arteries is feasible using radiation doses similar to, and even lower than, those for single-photon emission CT, which is commonly used to stratify these patients. In addition to its unique capability of visualizing the coronary tree in a noninvasive fashion, CCTA evaluates extracardiac pathologic conditions, which are part of the differential diagnosis in patients with chest pain, such as pulmonary embolism and acute aortic syndrome. These conditions, although less common than ACS, are also life threatening and their timely diagnosis and treatment may have a positive impact on survival. Other less frequent conditions, such as coronary artery anomalies, also are easily detected with CCTA. Overall, CCTA has an excellent negative predictive value and sensitivity for ACS in patients presenting with chest pain and simultaneously can aid in the diagnoses of other relevant intrathoracic abnormalities.

Ultrasound-guided Transthoracic Forceps Biopsy of a Peripheral Lung Mass

Interventional pulmonologists are often called upon to diagnose a variety of intrathoracic abnormalities. Linear array endobronchial ultrasound has greatly increased the diagnostic accuracy of transbronchial needle aspiration for centrally located lesions in the chest, and radial endobronchial ultrasound and electromagnetic navigation have markedly increased the diagnostic yield for biopsies of peripheral pulmonary lesions. Image-guided transthoracic biopsies of peripheral pulmonary lesions that approximate the pleural surface have been successfully performed using the "core" biopsy devices, though these may be less successful for smaller pleural-based lesions given their design. In this case study, we describe a novel technique for the biopsy of a peripheral lung mass using ultrasound guidance and biopsy forceps.

Occult pneumomediastinum in blunt chest trauma: Clinical significance

Introduction Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or “overt pneumomediastinum”, raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or “occult pneumomediastinum”. Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population. Methods A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated. Results Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest ( p < 0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common ( p < 0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0–0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam. Conclusion Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.

A suggested curriculum in echocardiography for critical care physicians

Echocardiography is a powerful diagnostic and monitoring tool of cardiac performance, cardiac pathology, and extracardiac intrathoracic abnormalities. Numerous investigations in intensive care have shown its merit, being efficacious and safe. Because many obvious and/or unsuspected conditions can impact the hemodynamic status of critically ill patients, echocardiography is becoming an integral part of an intensivist's diagnostic and monitoring armamentarium. However, significant background information, cognitive, and technical skills are required to properly perform and interpret echocardiography images. Some education and training guidelines for echocardiography have been developed while others remain "in progress." This manuscript suggests a core curriculum and necessary training elements for intensivists. This curriculum does not segregate portable handheld surface echocardiography from the typical platforms of transthoracic echocardiography and transesophageal echocardiography, because hardware and software developments have bridged these technologies.

3095: Advantages of ultrasonography over mammography as a follow-up imaging modality in patients with breast cancer underwent surgical treatment

The purpose of this study is to illustrate the superiority of ultrasonography (US) to mammography for detecting a recurrent tumor after surgery for breast cancer. Although it provides the limited objectivity and reproducibility, US is useful for detecting and evaluating the abnormalities that often excluded on mammography due to technical difficulty such as far upper, lower, inner, or outer portion of breast and in case of mastectomy site (chest wall) recurrence. US sometimes easily demonstrates the intra-thoracic abnormalities like pericardial effusion or pleural metastasis and regional lymph nodes. In addition, US-guided interventions are readily applied to the suspicious lesions for pathological diagnosis. In conclusion, in many cases, US is superior or complementary to mammography to monitor intramammary recurrence after breast surgery. The purpose of this study is to illustrate the superiority of ultrasonography (US) to mammography for detecting a recurrent tumor after surgery for breast cancer. Although it provides the limited objectivity and reproducibility, US is useful for detecting and evaluating the abnormalities that often excluded on mammography due to technical difficulty such as far upper, lower, inner, or outer portion of breast and in case of mastectomy site (chest wall) recurrence. US sometimes easily demonstrates the intra-thoracic abnormalities like pericardial effusion or pleural metastasis and regional lymph nodes. In addition, US-guided interventions are readily applied to the suspicious lesions for pathological diagnosis. In conclusion, in many cases, US is superior or complementary to mammography to monitor intramammary recurrence after breast surgery.

Transmissão do glioma de um doador de múltiplos órgãos para o enxerto pancreático

INTRODUÇÃO: A disparidade entre a oferta e a demanda de órgãos para transplanteimpulsiona a inclusão de doadores com tumores primários do sistema nervosocentral (SNC) no programa de transplantes. OBJETIVO: reportar um caso de um paciente que desenvolveu um glioma no enxerto pancreático proveniente de um doador de múltiplos órgãos cuja causa mortis foi um glioma maligno. RELATO DE CASO: paciente, branca, 11anos de idade, portadora de glioma maligno evolui a morte encefálica, sendo doadora de múltiplos órgãos. Havia sido submetida a 4 craniotomias com a finalidade de ressecar a massa tumoral. Sem sucesso, apresentou hipertensão intra-crâniana. No entanto, a derivação ventrículo-peritoneal não foi empregada em nenhum momento de sua evolução.Durante a captação do órgão, anormalidades intra-torácicas ou intra-abdominais não foram encontradas. Coração, fígado, pâncreas e um rim foram utilizados para transplante em diferentes receptores. Um rim não foi utilizado devido a problemas anatômicos. Um transplante de pâncreas isolado foi realizado um paciente masculino, 21 anos de idade, diabético tipo I há 19 anos. Não ocorreram complicações pós-operatórias e o paciente teve alta hospitalar livre de insulina. No quarto mês pós-operatório, foi encontrada uma tumoração na cabeça do pâncreas transplantado em exames de imagem. Optou-se, então, pela pancreatectomia. À histologia, demonstrou-se o mesmo tipo histológico do glioma malignodo doador. Atualmente, o paciente tem sido rigorosamente acompanhado, estando no 12ºmês pós-transplante, numa boa evolução clínica, sem imunossupressão, fazendo, novamente,uso de insulina e sem sinais de recidiva tumoral.

Solitary Pulmonary Metastasis Presenting 20 Years After Primary Resection of Wilms Tumor

Wilms tumor is the most common renal malignancy of childhood. Relapse occurs most often within 4 years of initial diagnosis, and the most common site of metastasis is the lung. We describe a 22-year-old man who presented with hemoptysis and a solitary pulmonary lesion 20 years after primary resection of Wilms tumor. Computed tomography of the chest showed an indeterminate pulmonary mass of heterogeneous attenuation with no other intrathoracic abnormalities. Surgical resection revealed a solitary pulmonary metastasis from Wilms tumor. Further evaluation yielded no evidence of extrathoracic metastases. This case shows that late relapse in the form of a solitary pulmonary mass can occur in patients with Wilms tumor.

Illustrations of abdominal abnormalities on 99mTc tetrofosmin gated cardiac SPECT

99mTc tetrofosmin is predominantly cleared by the hepatobiliary system and its scan is analogous to a cholescintigraphy. The radiopharmaceutical may be localized in the bone marrow. During cardiac acquisition, when the area being viewed includes the lower thorax and abdomen, abnormalities of the liver, gallbladder and kidneys, and the radioactivity in the oesophagus, stomach and bowel, as well as bone marrow uptake, can be depicted by routine raw data cine images. Excluding the intrathoracic abnormalities, these abdominal abnormalities are illustrated in this paper. Retrospectively, we reviewed the raw data cine images from 566 patients. These images were 180 degrees or 360 degrees rotation and showed the abdominal organs and thoracic cage, including the ribs, sternum and spine. We found 234 abnormalities, which were correlated with radiography, laboratory and clinical findings. Intra-abdominal abnormalities included bone marrow visualization, 93 occurrences (39.7%); duodeno-gastric (DG) and entero-gastric (EG) reflux, 47 (20.1%); non-visualization of the gallbladder, including possible causes of cholelithiasis, acute cholecystitis, or cholecystectomy, 31 (13.2%); elevation of the right diaphragm and depression of diaphragm, 30 (12.8%); renal abnormalities, including absent kidney, renal atrophy and cyst, 12 (5.1%); splenomegaly, 10 (4.3%); liver, including hepatomegaly and cirrhosis of the liver, eight (3.4%); and breast attenuation resulting in photopenia in the liver, three (1.2%). (1) The bone marrow uptake of the vertebrae accounts for almost 40% of the abdominal abnormalities, and is usually concordant with anaemia; (2) DG and EG refluxes represent 20% of abdominal abnormalities; they may have a clinical impact and may or may not interfere with SPECT processes and result in artifacts of the inferior wall of the left ventricle; (3) non-visualization of the gallbladder should prompt a search for cholelithiasis; and (4) benign renal cyst or cirrhosis of the liver could also be demonstrated. These coincidental findings may be included in routine cardiac SPECT reports that may have clinical impact because they give the referring physician the chance to pursue further clinical investigation.

Bow-shaped tracheal rings: the lesson learnt from an endotracheal intubation

Tracheal abnormalities are extremely rare and can occur as a single congenital anomaly, as part of a wider spectrum of abnormalities [such as the syndrome of vertebral defects, anal atresia, tracheoesphageal fistula and/or oesophageal atresia, radial dysplasia, and renal defects (VATER), and the syndrome of vertebral defects, anal atresia, cardiovascular defects, tracheoesphageal fistula and/or oesophageal atresia, radial dysplasia, and renal and limb defects (VACTERL)] or in tracheomalacia. Congenital complete and near-complete tracheal rings are the more common morphological abnormalities that occur. A case of a long segment of bow-shaped, as opposed to horseshoe-shaped, tracheal rings is presented, along with a review of tracheal anatomy and embryology. This abnormality presented when, during repeated attempts at endotracheal intubation, the anaesthetist was consistently unable to ventilate the patient, whereas they were able to do so with a facemask. Bronchoscopy showed the posterior tracheal wall prolapsing into the airway, and radiology demonstrated this to be due to wide tracheal rings without any intrathoracic abnormality.