Thoracoabdominal CT Scan Research Articles

Challenges in determining the benefits of restaging after chemoradiotherapy for locally advanced rectal cancer

Primary staging Primary staging in rectal cancer is essential for determining the optimal treatment strategy and consists of local staging and screening for distant metastases. Local staging is important to determine the surgical approach and to identify individual risk factors for recurrence, such as depth of extramural spread, lymph node involvement, mesorectal fascia (MRF) involvement and extramural vascular invasion [1–4]. Patients with a low risk for recurrence can be treated by surgery alone, whereas patients with a high risk for recurrence must be treated with neoadjuvant (chemo-) radio-therapy (CTxRTx) to decrease the chance of local recurrence [5,6]. Screening for distant metastases is important to identify metastasized patients who require a different treatment approach. Patients with resectable synchronous distant metastases should be treated with curative intent by resection of the distant metastases and primary tumor. Patients with unresectable distant metastases can be safely spared rectal surgery and treated with systemic chemotherapy, with a low chance of emergency surgery [7]. For primary local staging, MRI is superior compared with other imaging modalities currently available. Accuracies of tumor staging, nodal staging and MRF involvement by MRI are higher compared with the accuracies of CT scans and endoscopic ultrasound sonography [8–10]. Moreover, the multicenter Mercury study, with 12 colorectal units in four European countries, showed MRI to be highly accurate and reproducible [11]. Therefore, MRI is recommended in all guidelines as the preferred imaging modality in the preoperative assessment of rectal cancer [12–14]. For screening for distant metastases, most guidelines advise a thoracoabdominal CT scan [12,14].

Rupture d’un anévrisme de l’artère hépatique après chirurgie de canal lombaire étroit. Réflexions médico-légales

IntroductionDistinguishing between therapeutic contingency and surgical complication is sometimes not easy, especially when rare events occur. We report the case of a patient who presented with an intraperitoneal haemorrhage following laminectomy and discuss the implications of surgery in this complication. Case reportA 77-year-old woman, suffering from radiculopathy due to lumbar stenosis underwent a laminectomy in the prone position. On admission she presented with high blood pressure and obesity as significant comorbidities. A few hours after surgery, she collapsed and underwent a thoraco-abdominal CT-scan. The examination revealed a ruptured hepatic artery aneurysm. It is the first case published in the medical literature after lumbar surgery. The aim of this article was to discuss the responsibility of the surgeon and surgery, particularly the surgical positioning of the ruptured aneurysm. ConclusionAfter reviewing the literature we did not find any evidence to attribute the rupture of this hepatic artery aneurysm to lumbar surgery. This adverse event could be attributed to therapeutic contingency. In cases of patient complaint, this situation depends on national solidarity.

Esophageal metastasis of renal cancer 10years after nephrectomy.

The patient was a 65-year-old man, who had undergone right nephrectomy for renal cancer in 2002. At that time, histopathological examination revealed clear cell carcinoma (pT3a, pN0, M0, and pStage III). Postoperatively, he received natural interferon alpha (6 million units 3 times a week) from November 2002 to February 2005, and showed no evidence of recurrence. However, he noticed dysphagia in March 2012. Endoscopy revealed a pedunculated polypoid tumor in the mid-esophagus and biopsies were taken showing a clear cell carcinoma. Contrast-enhanced thoracoabdominal CT scanning identified a pedunculated polypoid tumor in the mid-thoracic esophagus and enlargement of a lymph node adjacent to the right main bronchus. With a diagnosis of esophageal and lymph node metastases of renal cancer, the patient underwent esophagectomy with right thoracotomy with reconstruction by a posterior mediastinal stomach tube. Postoperative histopathological examination revealed clear cell carcinoma. Because esophageal metastasis of renal cancer is extremely rare, this case is reported here together with discussions of the relevant literature.

Mucinous adenocarcinoma arising in chronic perianal fistula: good results with neoadjuvant chemoradiotherapy followed by surgery.

Chronic perianal fistulas are a common clinical condition. However, their evolution to adenocarcinoma is rare. We report the case of a 48-year-old man with perianal chronic fistulas, who developed two perianal ulcerated lesions near the external orifices of the fistulas, which extended proximally as a pararectal tumor. No intestinal lesion was seen at endoscopic examination. Histopathological biopsy indicated mucinous adenocarcinoma. Staging was performed by pelvic magnetic resonance imaging (MRI) and thoracoabdominal CT scan. The patient underwent a laparoscopic colostomy followed by neoadjuvant chemoradiotherapy and then laparoscopic abdominoperineal resection followed by adjuvant therapy. We have seen a favorable outcome with no recurrence at 3 years of follow-up.

Infectious Thoracic Aortitis: A Case Report

Aortitis is a term that refers to infectious or noninfectious conditions in which there is abnormal inflammation of the aortic wall. Here we report the case of a 32 years old woman who presented a diabetic Ketoacidosis. The thoraco abdominal CT scan showed endoluminal defect of the thoracic aorta with splenic and reanl infarction. Transesophageal echocardiogram showed a normal aortic and mitral valve and an obstructive vegetation linning the aortic wall. Blood culture were negative, Methicillin-resistant Staphylococcus aureus was isolated. The patient died after surgery (vegetectomy).

Augmented Reality-Guided Artery-First Pancreatico-Duodenectomy

BackgroundAugmented Reality (AR) in surgery consists in the fusion of synthetic computer-generated images (3D virtual model) obtained from medical imaging preoperative work-up and real-time patient images with the aim to visualize unapparent anatomical details. The potential of AR navigation as a tool to improve safety of the surgical dissection is presented in a case of pancreatico-duodenectomy (PD). MethodsA 77-year-old male patient underwent an AR-assisted PD. The 3D virtual anatomical model was obtained from thoraco-abdominal CT scan using customary software (VR-RENDER®, IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM®, Karl Storz, Tüttlingen, Germany) as well as different visible landmarks (inferior vena cava, left renal vein, aorta, superior mesenteric vein, inferior margin of the pancreas). A computer scientist manually registered virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time. Dissection of the superior mesenteric artery and the hanging maneuver were performed under AR guidance along the hanging plane. ResultsAR allowed for precise and safe recognition of all the important vascular structures. Operative time was 360 min. AR display and fine registration was performed within 6 min. The postoperative course was uneventful. The pathology was positive for ampullary adenocarcinoma; the final stage was pT1N0 (0/43 retrieved lymph nodes) with clear surgical margins. ConclusionsAR is a valuable navigation tool that can enhance the ability to achieve a safe surgical resection during PD.

Laparoscopic ampullectomy for an ampullarian adenoma

Lesions involving the ampulla of Vater are rare entities (0.1-0.2 %) with high malignant potential (90 %) [1]. As a treatment, the surgical procedure known as duodenopancreatectomy was the main option, whatever the tumor's stage or nature. Yet with improvements of endoscopic diagnostic and therapeutic techniques, management of these lesions has been modified, enabling endoscopic removal of adenoma and adenocarcinoma-in situ. Thus, when endoscopic treatment is not possible, surgical ampullectomy is still an alternative option to duodenopancreatectomy [1, 2]. The continuous improvements in surgical techniques and instruments now allow the safe realization of laparoscopic ampullectomy, despite the few cases described in the literature [3, 4]. Here we present a surgical technique in a 52-year-old patient with an ampulloma. The ampulloma was discovered during a gastroscopy for abdominal pain. The endoscopic ultrasound with biopsy revealed a 15-mm adenoma with moderate-grade dysplasia. The thoracoabdominal CT scan was normal. The procedure was performed as shown. The tumor histology showed a R0 resection (5-mm surgical margin) of an adenoma with focal high-grade dysplasia. At 3-year follow-up, outcomes were unremarkable, without any complications.

The use of routine thoracoabdominal CT scans in the polytrauma patient to estimate obesity

To utilize data from routine CT scans to quantify obesity in polytrauma patients without the need to obtain a height and weight. We utilized a comprehensive database including multidetector CT thoracoabdominal images of all polytrauma patients admitted to a Level 1 trauma center. One thousand one hundred seventy-four patients were reviewed from 2006 to 2008 and of these, 162 had previous documentation of Body Mass Index (BMI) or height and weight measurements as an outpatient within 6 months of trauma activation and with a truncal girth smaller than the scanning area of the CT machine. Truncal Adiposity Volume (TAV) was calculated from three dimensional reconstructions (3DRs) of the CT scans of the thorax and abdomen obtained in the emergency department. Statistical analysis yielded a fairly good correlation between TAV and BMI (correlation coefficient = 0.77; p-value < 0.0001). The intra-observer and inter-observer correlations in measuring TAV were high; 0.99 and 0.98 respectively. A linear regression equation of BMI on TAV was estimated and it had a form: 3DR BMI = 20.81+0.00064×TAV. In conclusion, TAV provides a reproducible means of evaluating obesity in trauma patients from routinely obtained CT scans. The TAV eliminates the often problematic task of obtaining a height and weight in a trauma patient and it correlates fairly well with the most commonly used clinical method of quantifying patient adiposity, BMI. This method may provide a more direct measurement of adiposity than does BMI, and holds promise for improving trauma care and research in the obese patient.

Fundoplication intrathoracic migration associated with gastric organoaxial volvulus

A 49-year-old man presented at the emergency department for severe epigastric pain and a 48-hour episode of vomiting with a greatly affected general state. This is a patient diagnosed with Behcet’s disease and ankylosing spondylitis, operated for a hiatal hernia two months before his admission, where a laparoscopic Nissen fundoplication and pillars closure were performed. During the immediate postoperative period, he manifested a picture of vomiting and dysphagia after waking up from the anesthetic procedure. Both disappeared with corticosteroid administration. At the admission to the hospital, the patient showed clear signs of difficulty breathing, paleness, sweating, tachypnea, and tachycardia. On examination, we found no breath sounds in the right hemithorax, and the abdominal exploration revealed signs of rigidity of abdominal wall. Chest X-ray (Fig. 1). Our differential diagnosis stated hiatal hernia recurrence vs. secondary acute esophageal perforation for abdominal overpressure due to persistent nausea (Boerhaave syndrome). A thoraco-abdominal CT scan was requested (Fig. 2). An urgent surgery was performed, where we found a complete transhiatal migration from stomach to chest and an associated organoaxial volvulus, as well as a partially disrupted fundoplication. Once the herniated viscera were reintroduced in the abdominal cavity, a proper vascularisation was showed. The fundoplication was rebuilt and the pillars were approached. An abdominal drainage was inserted and removed 4 days after the postoperative period.

655 ISOLATED PHAECHROMOCYTOMA

Introduction: Phaechromocytoma is a neuroendocrine tumor associated with a variety of genetic disorders wich include(VHL),multiple endocrine neoplasia type2,Neurofibromatosis type 1 and hereditary pargangliomas.These hereditary syndrome are respectively caused by respectively mutation in VHL tumor suppressor gene,RET protooncogene,NF1 gene and gene coding succinate deshydrogenase SDHB,SDHC and SDHD.It is currently estimated that 20% of phaechromacytoma are associated with germline mutation.VHL predispose affected individual to develop retinal and central nervous hemangioblastoma, renal celle carcinoma and phaechromocytoma. We report a novel VHL germ-line mutation in a family with occurrence of isolated phaechromocytoma. Case: The 38 years old, caucasian male was admitted in hospital for major weakness, sweating ; body loss,elevated pressure, moderate renal failure ;Hypokalaemia. Plasma renine aldosterone activity is high, plasma fractionnal free metanephrine is very high Proteinuria :3 gr/24 h, microscopic haematuria. urinary normetadrenaline was very high 15916ng/24 h (normal < 200). Radiologic test: Brain, spinal, abdominal and thoraco abdominal CT scan, showed bilateral surrenale mass, left measured 4.5*3.5*4 cm, right 4.5*4*4.4 cm .MIBG scintigraphy : cervical para ganglioma. Patient have had bilateral adrenalectomy. Genetic analysis: VHL germline mutation was identified in the patient and family members.The c.640T > A mutation detected in our reported family has not been previously described. Discussion: This patient had presented phaechromocytoma in association and without other manifestation of VHL disease. The association of this mutation (c.640 > A) with phaechromocytoma only, variant of VHL disease, might be considered. To confirm this suggestion it seems reasonnable to subject these patient to lifelong follow up.

Marginal zone lymphomas in HIV patients

Incidence of Non-Hodgkin’s Lymphoma (NHL) remains high in the context of HIV infection. High-grade NHL are the sub-types commonly seen. Indolent lymphomas have been rarely described although several cases of follicular or marginal zone lymphoma (MZL) have been published. Among MZL, MALT lymphomas are predominant. We describe 3 cases of MZL with leukemic presentation. In our on-going cohort of 580 HIV-patients, 3 cases of MZL were identified. The following characteristic were recorded: clinical exam, thoracoabdominal CT-scan, cytological aspect of the peripheral blood smear, immunologic and cytogenetic analysis. There were 2 male and 1 female. Duration of HIV infection was 8, 13 and 18 when MZL was diagnosed. HCV serology was positive in 2 cases with pcr negativity in one case. In all cases, MZL was diagnosed during the occurrence of a mild hyperlymphocytosis: 5000, 6000 and 9000/mm3 respectively while hemoglobin and platelets remained normal. All patients were received HAART for more than 8 years and all have CD4 above 500/mm3 and viral load under 50 copies/ml. All patients were asymptomatic without peripheral adenopathy neither hepatosplenomegaly. On thoracoabdominal CT scan, only infracentrimetric adenopathy were detected. On peripheral smears, several lymphocytes with a villous aspect were detected for each patient. In all cases, immunologic phenotype by FACS was consistent with the diagnosis of MZL. Karyotype of the peripheral lymphocytes was normal in one case, revealed an isochromosome 3 in the second case and showed 46, XX, der(1)t(1;?), t(8;14;18)(q24;q32;q21) in the last case. After a follow-up of 2, 2 and 5 years, all patients are alive with a stable disease without chemotherapy. These data suggest that, as for non-HIV infected patients, MZL have an indolent course in HIV patients.

Post-traumatic transdiaphragmatic intercostal hernia: report of two cases

Transdiaphragmatic intercostal hernias (TIH) are rare. Less than 40 cases of TIH have so far been reported, with only 8 cases involving herniation of the liver. This report presents the case of 2 patients with a right-sided abdominal lump following a fall. Thoracoabdominal CT-scan showed a TIH between the 9th and 10th ribs with liver and right colonic herniation in both patients. Both patients were successfully treated with mesh repair. The presentation, physiopathology and management of this rare occurrence are discussed.

PO-06 The value of thoraco-abdominal CT scanning for the detection of occult cancer in patients with unprovoked venous thromboembolism. A randomized study

PO-06 The value of thoraco-abdominal CT scanning for the detection of occult cancer in patients with unprovoked venous thromboembolism. A randomized study

Multiple duodenal stromal tumors revealing type 1 neurofibromatosis: An indication for pancreas-preserving duodenectomy

GASTROINTESTINAL STROMAL TUMORS (GISTS) are the most common mesenchymal tumors of the gastrointestinal tract. Type 1 neurofibromatosis (von Recklinghausen disease) is known to be associated with GIST. A 56-year-old man with no previous medical history presented with epigastric pain and anemia. The clinical examination showed multiple subcutaneous nodes in the trunk. The upper gastrointestinal endoscopy revealed two submucosal tumors of 20 and 8 mm in the second part of the duodenum, whichnarrowed the lumen andwas associatedwith 2 additional lesions of less than 1 cm in the third part of the duodenum. Endoscopic ultrasonography confirmed these multiple submucosal duodenal tumorswithout involvement of themucosa.Multiple nonspecific lymph nodes surrounded the duodenum.At biopsy, fusiformcells, suggestingGIST, were found. The colonoscopy was unremarkable, as was the thoracoabdominal CT scan.

Kyste hydatique primitif et isolé du diaphragme en Tunisie

The hydatid cyst of the diaphragm is defined as the development of a hydatid cyst in the diaphragm muscle. The purpose of this study is to identify the specific pathogenic, clinical and therapeutic aspects of this hydatid cyst. It is important to confirm the diagnosis of the location before surgery. We report the case of a patient aged 40 years, in whom the diagnosis of hydatid cyst of the diaphragm was made incidentally in the course of a gastric stromal tumour. The patient was operated by a midline laparotomy. Resection of the protruding dome of hydatid cyst of the diaphragm was carried out along with total gastrectomy. The postoperative course was uneventful. After 12 months, the results were negative. The diagnosis of hydatid cyst of the diaphragm is based on the thoraco-abdominal CT scan. The treatment is surgical based on the topographic features of the cyst.

Tumornachsorge nach potentiell kurativerResektion eines Karzinoms

Surveillance programs have been recommended for colorectal and breast cancer patients in several countries, and appropriate surveillance guidelines have been issued by various societies. The Swiss Society of Gastroenterology consensus paper recommends a surveillance program for patients after curative resection of colorectal cancer (CRC), and the respective guidelines are updated regularly. Early detection of recurrent disease from CRC allows treatment with intention to cure. Five year survival rates after treatment for recurrent CRC can reach up to 50 % or more. Therefore tumor surveillance in CRC is important, and there is compelling evidence that patients benefit from intensive surveillance. In addition to clinical controls, measurements of carcinoembryonal antigen, colonoscopies and thoraco-abdominal CT scans should be performed on a regular basis. For surveillance of breast cancer (BC) patients, a regular schedule is recommended as well. However, this surveillance program is more focussing on the detection of possible loco-regional tumor relapse, as curative therapy of BC metastases is much less frequently possible than in CRC patients. Irrespective of the underlying tumor entity, surveillance is an important and challenging process that should be coordinated by one single physician. It is crucial that all involved physicians are aware of their responsibility and that they are informed about the respective surveillance program and its benefit to the patient.

P2-09-11: Role of 18FDG-PET/CT in the Staging of Large Primary Operable Breast Cancer.

Abstract Background: Prospective evaluation of the role of 18FDG-PET/CT in patients with large primary operable breast cancer. Material and Methods: During 56 months, consecutive patients with large (&amp;gt;2cm) breast cancer and clinical stage IIA/IIB/IIIA (based on clinical examination, mammography, breast MRI and ultrasonography) underwent 18FDG-PET/CT. The nuclear physician was blind to the results of any other procedure (bone scan, chest X-ray, liver ultrasound, or thoraco-abdominal CT scan). Results: Out of the 131 examined patients, 36 had clinical stage IIA (34 T2 N0, 2 T1 N1), 48 stage IIB (20 T3 N0, 28 T2 N1), and 47 stage IIIA (29 T3 N1, 9 T2 N2, 9 T3 N2). 18FDG-PET/CT modified staging for 5.6% of stage IIA patients, for 14.6% of stage IIB patients, and for 27.6% of stage IIIA patients. However, within stage IIIA, the yield was specifically high among the 18 patients with N2 disease (56% stage modification). When considering stage IIB and primary operable IIIA (T3 N1) together, the yield of 18FDG-PET/CT was 13% (10/77); extra-axillary regional lymph nodes were detected in 5 and distant metastases in 7 patients. In this series, 18FDG-PET/CT outperformed bone scan with only 1 misclassification versus 8 for bone scan (p=0.036). Discussion: 18FDG-PET/CT provided useful information in 13% of patients with T3 N0 / T2 N1 / T3 N1 disease. The yield was more modest in patients with T2 N0 disease. The very high yield in the case of lymph nodes classified N2 demonstrates that stage IIIA comprises two quite distinct groups of patients. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-09-11.

Extreme acute anemia in an adult sickle cell disease patient: look at the spleen

Dear Editor, A 27-year-old male with known homozygous (HbSS) sickle cell disease (SCD) was admitted to our medical intensive care unit for coma and extreme anemia. He had suffered mild occasional painful osseous vasoocclusive crises and had never received a blood transfusion except for during hip osteonecrosis surgery at the age of 17. He started complaining of lower limb and back pain for a couple of days followed by an intense abdominal pain and several episodes of lipothymia, and was admitted to the emergency room for coma (Glasgow coma scale of 3/15). On admission, his temperature was 36.9 C, blood pressure 109/70 mmHg, heart rate 140/min; extreme conjunctival pallor was noted, as well as an enlarged spleen. Laboratory tests revealed an extremely low hemoglobin level (1.7 g/ dL), low reticulocyte (49 9 10/L) and platelet counts (95 9 10/L), increased white blood cell counts (23 9 10/L), arterial lactates (15 mmol/L), and plasma lactate dehydrogenase (LDH) (2,300 IU/L, N \ 200 IU/L) levels with a normal value of total bilirubin (14 lmol/L, N \ 17 lmol/L). The patient was immediately intubated and mechanically ventilated. A thoraco-abdominal CT scan excluded an internal hemorrhage but evidenced a splenomegaly (17 cm in the antero-posterior axis). Emergency packed erythrocyte transfusion (n = 5) and splenectomy were performed. The spleen was enlarged (19 9 14 9 10 cm), congestive, and hemorrhagic. Pathologic examination showed marked congestion and clogging of splenic cords by sickled red blood cells and Gamna–Gandy bodies (Fig. 1), compatible with an acute splenic sequestration (ASS). Blood cultures, Parvovirus B19 PCR, and serology tests were negative. The patient was successfully extubated 2 days after surgery and was discharged home 2 weeks later. He was asymptomatic 3 months after surgery.

The Yield of 18F-FDG PET/CT in Patients with Clinical Stage IIA, IIB, or IIIA Breast Cancer: A Prospective Study

The purpose of this study was to prospectively evaluate the role of (18)F-FDG PET/CT in patients with stage IIA, IIB, or IIIA breast cancer. During 56 mo, 131 consecutive patients with large (>2 cm) breast cancer and clinical stage IIA, IIB, or IIIA (based on clinical examination, mammography, breast MRI, and ultrasonography) underwent (18)F-FDG PET/CT. The nuclear physician was unaware of the results of any other procedure (bone scan, chest radiography, liver ultrasound, or thoracoabdominal CT scan). Of the 131 examined patients, 36 had clinical stage IIA (34 T2N0 and 2 T1N1), 48 stage IIB (20 T3N0 and 28 T2N1), and 47 stage IIIA (29 T3N1, 9 T2N2, and 9 T3N2). (18)F-FDG PET/CT modified staging for 5.6% of stage IIA patients, for 14.6% of stage IIB patients, and for 27.6% of stage IIIA patients. However, within stage IIIA, the yield was specifically high among the 18 patients with N2 disease (56% stage modification). When considering stage IIB and primary operable IIIA (T3N1) together, the yield of (18)F-FDG PET/CT was 13% (10/77); extraaxillary regional lymph nodes were detected in 5 and distant metastases in 7 patients. In this series, (18)F-FDG PET/CT outperformed bone scanning, with only 1 misclassification versus 8 for bone scanning (P = 0.036). (18)F-FDG PET/CT provided useful information in 13% of patients with clinical T3N0, T2N1, or T3N1 disease. The yield was more modest in patients with stage IIA. The high yield in the case of N2 disease demonstrates that stage IIIA comprises 2 quite distinct groups of patients.

Primary hydatid disease of diaphragm with subcutenous extension

While diaphragmatic hydatid disease is a rare condition, subcutaneous extension of the disease is very rare. A 33-year-old female visited our clinic due to swelling on the right upper quadrant of the abdomen. Thoraco-abdominal CT scan and MRI revealed a hydatid cyst (110 x 98 x 78 mm) located in the costal part of the hemidiaphragm extending into the preperitoneal space and protruding intercostally to a subcutaneous area. Total pericyst resection without opening the cyst, including a margin of normal diaphragm, was performed. The patient was started on albendazole for three months. Hydatid cyst in the diaphragm should be considered in patients with preoperative imaging data indicating cystic lesions adjacent to the diaphragm, especially for cystic lesions encountered in patients who live in or who have come from endemic regions.