Tiny Nodules Research Articles

BIOPSY-PROVEN CENTRAL NERVOUS SYSTEM AND PULMONARY SARCOIDOSIS: FIRST REPORTED CASE IN HONG KONG

SESSION TITLE: Pulmonary SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Lung is the commonest organ to be involved by sarcoidosis. Nervous system is involved in around 5% of cases only. [1] Due to rarity, neurosarcoidosis has never been reported in Hong Kong Chinese patients. CASE PRESENTATION: A 34-year-old Chinese clerk lady presented with headache and personality changes. CT brain showed hydrocephalus and MRI showed ill-defined T2 hyper-intense lesion without enhancement at superior-dorsal aspect of pons. (Fig.1) Endoscopic third ventriculostomy with brain biopsy found granulomatous inflammation with negative mycobacterial tuberculosis polymerase chain reaction (MTB-PCR). CT thorax showed numerous tiny pulmonary nodules with extensive mediastinal lymphadenopathy. (Figs 2,3)She was managed as miliary tuberculosis (TB) with central nervous system (CNS) involvement. Cognitive symptoms persisted despite 8 months of TB treatment and interstitial involvement worsened on CT thorax. Further investigations with transbronchial biopsy and endobronchial ultrasound guided needle aspiration of station 7 lymph node confirmed granulomatous inflammation with negative MTB-PCR. After multi-disciplinary team discussion, diagnosis was revised to be sarcoidosis. TB medications were stopped and she was started on oral prednisolone. The cognitive problem improved and repeat CT 3 months after steroid treatment showed reduced extent of bilateral lung nodules and lymphadenopathy. DISCUSSION: Sarcoidosis was thought to be rare among Asians. The incidence rate ranged from 0.027 (Taiwan) to 2 (Japan) per 100000. Reports in Chinese patients were scarce. The epidemiology in Hong Kong is unknown but there were a number of case reports over last 30 years showing it is not that rare.Diagnosis remained by exclusion from compatible clinical and radiological picture with histology of noncaseating granuloma. [2] This highlighted the diagnostic challenge: TB notification rate was 58.27 per 100000 in Hong Kong; that is 50-2000 times more common than sarcoidosis. Two diseases can overlap, making it more complicated. [3] Many cases therefore received TB treatment during pursuit of diagnosis. Symptoms and signs are non-specific. Usually patients need to have symptoms for more than 3 months, and require three or more encounters with health care providers before arriving diagnosis.Nervous system sarcoidosis is even rarer but it can be first symptoms before systemic disease. Imaging findings are also non-specific. It is difficult to obtain biopsy and some can only be found in autopsy. It is one of the most fearful complications of sarcoidosis as it can carry mortality up to 18%. More aggressive immunomodulating treatment are needed. CONCLUSIONS: Sarcoidosis is still rare but is likely under-recognized. Diagnosis can be challenging in particular to exclude TB. We presented the first biopsy-proven case of central nervous system sarcoidosis in Hong Kong Chinese patient with successful treatment. Reference #1: 1. Dominique V, Antje P, Hilario N, et al. Sarcoidosis. Lancet 2014; 383: 1155–67 Reference #2: 2. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med 1999; 160: 736–55. Reference #3: 3. Wong CF et al. A case of concomitant tuberculosis and sarcoidosis with mycobacterial DNA present in the sarcoid lesion. Chest 1998; 114:2; 626-9 DISCLOSURES: No relevant relationships by Yu Hong Chan, source=Web Response no disclosure on file for Yiu Cheong Yeung

Thyroid Nodule Classification Using Steerable Pyramid–Based Features From Ultrasound Images

The most common endocrine cancer is thyroid cancer. The incidental rate of thyroid cancer has significantly increased during the past few decades. Timely identification and suitable treatment are essential for better outcome. High-resolution ultrasound is the preferred modality for the detection of thyroid nodules as it has the capability of locating tiny nodules. This article proposes a feature extraction method by integrating steerable pyramid decomposition and cooccurrence matrix features for the characterization of the thyroid nodule. Steerable pyramid decomposition is carried out both in time domain and frequency domain. Textural features are obtained from the pyramid at different levels and with different filters. ReliefF method is used for feature selection. Support vector machine is used to classify the thyroid nodule as benign or malignant, and its performance is evaluated using accuracy, sensitivity, specificity, positive predictive value, negative predictive value, false alarm rate, and F1_score. The proposed approaches are tested on a dataset containing 110 thyroid ultrasound images (benign, malignant, and borderline cases). A very high overall accuracy of 99.08% with 100% sensitivity (malignant nodule detected as malignant) and 98.16% specificity (benign nodule detected as benign) is obtained for features extracted from steerable pyramid coefficients through convolution using sp1 filter at level 3. Experimental results clearly indicate that steerable pyramid–based cooccurrence matrix features can effectively describe the distinctive nature of the thyroid nodule in ultrasound image.

Management of incidental lung nodules

Due to the increase of incidentally detected pulmonary nodules and the information obtained from several screening programs, updated guidelines with new recommendations for the management of small pulmonary nodules have been proposed. These international guidelines coincide in proposing periodic follow-up for small nodules, less than 8 mm of diameter. Fleischner and British Thoracic Society guidelines are the most recent and popular guidelines for incidental pulmonary nodules management. They have specific recommendations according to nodule characteristics (density and size) and cancer risk of the patient. Both guidelines separate recommendations for solid and subsolid nodules. Predictive risk models have been developed to improve the nodule management. In certain cases follow up may not be the best option. We discuss the scenarios and options to achieve a histologic diagnosis of these tiny pulmonary nodules.

Video-assisted thoracic surgery for tiny pulmonary nodules with real-time image guidance in the hybrid theatre: the initial experience.

Localization of tiny lung nodules during video-assisted thoracic surgery (VATS) resection can be challenging. Real-time image-guided hookwire localization of the target lesions immediately followed by VATS lung resection in the hybrid operating theatre setting is an emerging approach. We retrospectively reviewed our experience with this form of hybrid operating theatre image-guided VATS (iVATS) for lung nodules 1.5 cm or less, or soft in consistency. These patients were compared with matched cohort who received standard hookwire localization in the radiology department. From February 2014 to September 2017, lung nodules of indeterminate nature in 32 consecutive patients with mean size 9.1±4.6 mm underwent iVATS. All were accurately localized by hookwire and successfully resected. There was no postoperative mortality. There were 21 (66%) malignant lesions, all with adequate resection margins. Major outcomes were compared with a comparable cohort of 8 patients who received standard hookwire localization and VATS (sVATS) performed at separate departments operation suites. sVATS groups has significantly longer 'at-risk' period for pneumothorax progression and hookwire dislodgement (109.5±57.1 minutes for sVATS vs. 41.1±15.0 minutes for iVATS, P=0.011), and a higher risk of hookwire dislodgement (25% for sVATS vs. 0 for iVATS, P=0.036). Real-time image-guided hookwire localization in the hybrid theatre setting is an effective facilitator of VATS resection of tiny lung nodules in selected patients, and may have added advantages in terms of safety and localization accuracy over the conventional sVATS method.

Contrast-enhanced computed tomography combined with Chitosan-Fe3O4 nanoparticles targeting fibroblast growth factor receptor and vascular endothelial growth factor receptor in the screening of early esophageal cancer.

Esophageal cancer is a malignant tumor with a relatively high invasiveness, metastatic potential and worldwide incidence among human cancers. The majority of patients with esophageal cancer are diagnosed in a late tumor stage due to a lack of advanced and sensitive protocols for the diagnosis of patients with early-stage esophageal cancer. In the current study, contrast-enhanced computerized tomography (CECT) combined with Chitosan-Fe3O4 nanoparticles targeting fibroblast growth factor receptor (FGFR) and vascular endothelial growth factor receptor (VEGFR; CECT-CNFV) were used to diagnose patients with suspected esophageal cancer. A Chitosan-Fe3O4-parceled bispecific antibody targeting FGFR and VEGFR was produced and its affinity to esophageal cancer cells was determined both in vitro and in vivo. A total of 320 patients with suspected esophageal cancer were voluntarily recruited to evaluate the efficacy of CECT-CNFV in the diagnosis of early-stage esophageal cancer. All participants were subjected to CT and CECT-CNFV to detect whether tumors were present in the esophageal area. A Chitosan-Fe3O4 nanoparticles contrast agent was orally administered at 20 min prior to CT and CECT-CNFV. The results demonstrated that CECT-CNFV improved diagnostic sensitivity and provided a novel protocol for the diagnosis of tumors in patients with suspected gastric cancer at an early-stage. Furthermore, the resolution ratio of images was enhanced by CECT-CNFV, which enabled the visualization of tiny tumor nodules in esophageal tissue. Clinical data demonstrated that CECT-CNFV diagnosed 200 patients with suspected early-stage esophageal cancer and 120 patients as tumor free. In addition, CECT-CNFV exhibited higher signal enhancement of tumor nodules than CT, suggesting a higher accuracy and accumulation of nanoparticle contrast agent within the tumor nodules of esophageal tissue. Notably, the survival rate of patients with esophageal cancer diagnosed at an early-stage by CECT-CNFV was higher than the mean five-year survival rate (P<0.01). In conclusion, CECT-CNFV enhanced the sensitivity and accuracy of CT in the diagnosis of early-stage esophageal cancer. Thus, CECT-CNFV may improve the accuracy of CT in the diagnosis of mural enhancement in patients with esophageal cancer.

CAD system: a content based image retrieval approach for pulmonary nodule detection in CT images

This paper proposes Computerized Aided Detection System (CAD) which uses Content Based Image Retrieval (CBIR) to detect cancer nodules present in an image. The CAD system is concerned for the radiologists to identify lung cancer at premature stages, which are very tiny nodules that are not able to seen by naked eye. In modern years, Image processing techniques play a key role in predicting diseases at early stages in particular in various cancer types such as liver cancer, breast cancer etc. This paper comprises of four steps: i) preprocessing an image in order to lessen the noise level and the accuracy of the image is to be improved, so that the accuracy in detection will be higher. ii) The image is segmented based on Marker-Controlled Watershed Segmentation. iii) The features of the nodules present in the image are extracted using GLCM. iv) The nodules are classified based on the extracted features using KNN classifier. The Content Based Image Retrieval Technique is used which is used to redeem query based images in the database by combining feature extraction and similarity matching methods. For experimentation of proposed technique, CT images are used which are extracted from Lung Image Database Consortium database (LIDC).

Long-term survival with repeat resection for lung oligometastasis from pancreatic ductal adenocarcinoma: a case report

BackgroundLong-term survival after resection of metastases from pancreatic ductal adenocarcinoma is rare.Case presentationA 54-year-old man underwent pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) with UICC staging pT3N1M0 followed by adjuvant chemotherapy with gemcitabine (GEM). Three years after radical resection of the primary tumor, a tiny nodule was found in the lower lobe of the left lung. Despite treatment with GEM, it increased gradually, but no other metastases were found. Eighteen months after the first indication of the nodule, wedge resection was performed. Pathological examination of the nodule indicated a metastatic tumor from PDAC. Pulmonary metastasectomy was again performed for lung oligometastases at 77 and 101 months after PD. The patient has been asymptomatic without tumor recurrence for 4 years since the last pulmonary resection.ConclusionsIn PDAC, the treatment strategy for oligometastasis is controversial. However, a few cases of long-term survival after pulmonary metastasectomy for oligometastasis of PDAC have been reported. More such cases need to be studied to address this issue effectively.

Characterization of novel high-speed die attachment method at 225 °C using submicrometer Ag-coated Cu particles

A novel die-attaching technology, using the in-situ dewetting of Ag shells in submicrometer Ag-coated Cu (Cu@Ag) particles during heating in air, was suggested for power device packaging. The particle size-dependent dewetting of Ag induced the formation of tiny nodules and rapid sinter bonding via fast Ag transfer under external pressure. A die attached by thermal compression for 5min at 225°C using 200- or 350-nm Cu@Ag particles showed shear strengths approaching or surpassing that (18.0MPa) of a die attached using Pb-5Sb.

Adrenal venous sampling as used in a patient with primary pigmented nodular adrenocortical disease

Background: Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause for hypercortisolism, and it diagnosis is highly challenging as the symptoms are often mild and the patients usually visit doctors long after the onset of their symptoms. Methods: Present herein is a rare case of PPNAD which was diagnosed thanks to adrenal venous sampling. A 21-year-old woman presented with centripetalism lumbodynia, hypertension, osteoporosis, and amenorrhea. Plasma cortisol concentrations were elevated, and there was a loss of circadian rhythms. Laboratory reports indicated her plasma adrenocorticotropic hormone (ACTH) as normal and brain imaging showed no delayed enhancement in the saddle region of the pituitary gland, confirming a diagnosis of ACTH-independent Cushing’s syndrome. Enhancement CT scan showed tiny nodules on her left adrenal gland. Adrenal venous sampling (AVS) discoverer elevated plasma cortisol in left adrenal vein and the left part of the inferior vena cava mesial side, indicating increased cortisol secretion in the left adrenal. Results: Following an adrenalectomy taken on her left adrenal, immunohistochemistry revealed PPNAD on the left adrenal. Conclusions: Adrenal venous sampling contributes to the diagnosis of PPNAD and that of Cushing’s syndrome as well. Adrenal venous sampling, an effective diagnostic of PPNAD, proves useful in diagnosis of Cushing’s syndrome.

Size and Ultrasound Features Affecting Results of Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules.

Our goal was to assess the diagnostic efficacy of ultrasound (US)-guided fine-needle aspiration (FNA) of thyroid nodules according to size and US features. A retrospective correlation was made with 1745 whole thyroidectomy and hemithyroidectomy specimens with preoperative US-guided FNA results. All cases were divided into 5 groups according to nodule size (≤5, 5.1-10, 10.1-15, 15.1-20, and >20 mm). For target nodules, static images and cine clips of conventional US and color Doppler were obtained. Ultrasound images were reviewed and evaluated by two radiologists with at least 5 years US working experience without knowing the results of pathology, and then agreement was achieved. The Bethesda category I rate was higher in nodules larger than 15 mm (P < .05). The diagnostic accuracy was best in nodules of 5 to 10 mm in diameter. The sensitivity, accuracy, PPV, and LR for negative US-guided FNA results were better in nodules with a size range of 5 to 15 mm. The specificity, negative predictive value (NPV), and LR for positive results and the Youden index rose with increasing nodule size. Seventeen false-positive and 60 false-negative results were found in this study. The false-negative rate rose with increasing nodule size. However, the false-positive rate was highest in the group containing the smallest nodules. Nodules with circumscribed margins and those that were nonsolid and nonhypoechoic and had no microcalcifications correlated with Bethesda I FNA results. Nodules with circumscribed margins and those that were nonsolid, heterogeneous, and nonhypoechoic and had increased vascularity correlated with false-negative FNA results. Borders correlated with Bethesda I false-negative and false-positive FNA results. Tiny nodules (≤5 mm) with obscure borders tended to yield false-positive FNA results. Large nodules (>20 mm) with several US features tended to yield false-negative FNA results.

Application of novel targeting nanoparticles contrast agent combined with contrast-enhanced computed tomography during screening for early-phase gastric carcinoma.

Gastric cancer is one of the most common human tumors worldwide. The biggest bottleneck is a lack of advanced and sensitive protocols for the diagnosis of patients with early-stage gastric cancer. Therefore, more sensitive methods of diagnosing gastric cancer are urgently required to improve survival rates. In this clinical study, contrast-enhanced computed tomography (CECT) with targeting nanoparticles contrast agent (CECT-TNCA) was used to diagnose early-stage gastric cancer. The specific-targeted tyrosine kinase inhibitors of gastric cancer, including platelet-derived growth factor receptor-β, Ret and Kit, were used as TNCAs. A total of 484 patients with suspected gastric cancer were voluntarily recruited to investigate the efficacy of CECT-TNCA in the diagnosis of patients with early-stage gastric cancer. Patients with suspected gastric cancer were subjected CT and CECT-TNCA to detect whether gastric tumors existed. TNCA was orally administered before CT and CECT-TNCA (20 min). Our diagnostic data revealed that CECT-TNCA improved sensitivity and provided a new protocol to diagnose tumors in patients with suspected gastric cancer at the early stage. In addition, imaging using CECT-TNCA enabled the visualization of tiny nodules in the gastric area. CECT-TNCA diagnosed 182 patients with suspected gastric cancer as tumor-free. CECT-TNCA confirmed gastric cancer in 302 patients. Our novel diagnosis indicated significantly (P<0.01) differential signal enhancement in the gastric nodules via CECT-TNCA compared with CT, suggesting higher accuracy and the accumulation of TNCA in tumor nodules in the stomach. Furthermore, survival rates of patients detected by early-diagnosis of CECT-TNCA were significantly higher than the mean five-year survival (P<0.01). In conclusion, our investigations demonstrate that the sensibility and accuracy of CT is improved through combination with liposome-encapsulated nanoparticle contrast agent for the diagnosis of early stage gastric cancer when compared with single CT detection. CECT-TNCA improves the accuracy of CT and diagnostic confidence in assessing mural enhancement in patients with suspected gastric cancer.

Make visible palpable, a “double-insurance strategy” for nodule localization

Localization for tiny pulmonary nodule during video-assisted thoracoscopic surgery (VATS) approach to facilitate sublobar resection remains a challenge for thoracic surgeons. To look for a needle in a haystack, adjuvant techniques such as hookwire insertion, colour dye or radionuclide injection have been well reported (1). However, such traditional techniques require a patient being transferred from the radiographic suite for localization and the operation room for resection, which would lead to more substantial complications, for example, pleuritic pain, label or marking migration, and pneumothorax to mention just a few.

Effect of hydrochloric acid on grain size analysis of the Quaternary red clay rich in tiny ferromanganese nodules, Jiangxi province, southern China

There are many tiny ferromanganese nodules that cannot be found and eliminated easily in Quaternary red clay in southern China. The existence of these tiny ferromanganese nodules may influence grain size analysis results. Therefore, this paper focuses on the effects of the ferromanganese nodules on the grain size analysis and the effects of hydrochloric acid (HCl) on removing these nodules. The experimental results showed that the nodules clearly influenced the results of grain size analysis. The tiny ferromanganese nodules increased the coarse fraction and show a low peak in the coarse fraction of >100 μm on the frequency curves. The addition of HCl in the pretreatment process of grain size analysis can eliminate the effects of these tiny nodules effectively. Additionally, the HCl reacts with clay minerals and causes a reduction of the <4 μm fraction.

Co-relation of human height with hand length, foot length and head length in Indian students

Tuberous sclerosis complex (TSC) is a rare autosomal disorder that typically affects children. The manifestations of TSC include development of benign lesions in various organs, primarily in the brain, skin, kidneys, heart, and lungs. TSC management often involves multidisciplinary specialties. Herein, we present a case of a 5-year-old male patient who presented with a headache, vomiting and fever. Radiological assessment demonstrated a lobulated enhancing tumor in the right lateral ventricle near the foramen of Monro for which he underwent craniotomy (total tumor resection), which turned out to be subependymal giant cell astrocytomas upon histopathological examination. A follow-up MRI after 10 months showed cortical dysplasias, with tiny subependymal nodules. Dermatology examination revealed hypomelanotic macules, angiofibromas and shagreen patch. At his one-year follow-up, the patient exhibited normal mental and physical growth. Therefore, calling attention to TSC diagnosis and management depending upon the particular presentation may improve the quality of life of TSC patients.

Managing Incidentalomas Safely: Do Computed Tomography Requisitions Tell Us What We Need to Know?

PurposeTechnological advancements and the ever-increasing use of computed tomography (CT) have greatly increased the detection of incidental findings, including tiny pulmonary nodules. The management of many “incidentalomas” is significantly influenced by a patient's history of cancer. The study aim is to determine if CT requisitions include prior history of malignancy. MethodsRequisitions for chest CTs performed at our adult tertiary care hospital during April 2012 were compared to a cancer history questionnaire, administered to patients at the time of CT scan. Patients were excluded from the study if the patient questionnaire was incomplete or if the purpose of the CT was for cancer staging or cancer follow-up. ResultsA total of 569 CTs of the chest were performed. Of the 327 patients that met inclusion criteria, 79 reported a history of cancer. After excluding patients for whom a history of malignancy could not be confirmed through a chart review and excluding nonmelanoma skin cancer, dysplasia, and in situ neoplasm, 68 patients were identified as having a history of malignancy. We found 44% (95% confidence interval [0.32-0.57]) of the chest CT requisitions for these 68 patients did not include the patient's history of cancer. Of the malignancies that were identified by patient questionnaire but omitted from the clinical history provided on the requisitions, 47% were malignancies that commonly metastasize to the lung. ConclusionsA significant number of requisitions failed to disclose a history of cancer. Without knowledge of prior malignancy, radiologists cannot comply with current guidelines regarding the reporting and management of incidental findings.

The “cluster of black pearls” sign of sarcoid lymphadenopathy: a new sign on thin-section contrast-enhanced multidetector CT

To identify a specific diagnostic sign for sarcoid adenopathy on contrast-enhanced multidetector computed tomography (MDCT) based on nodal morphology. A prospective study was performed on 105 patients with 1654 nodes. Of this, 18 patients with sarcoidosis formed the study group. The control group consisted of the remaining 87 patients with other proven disease entities of metastatic adenocarcinoma, lymphoma, tuberculosis, and reactive adenopathy for comparison. CT examinations were undertaken using a 64-section helical mode in the arterial and venous phases with a 0.5-mm section thickness. The lymph nodes were evaluated for various morphological criteria and the presence of the "cluster of black pearls" (CBP) sign. The CBP sign was considered present when tiny round nodules each measuring 1-2mm were seen distributed uniformly within the whole or part of the lymph node. The CBP sign had a significance of p<0.001, 83% sensitivity, 98% specificity, 91% positive predictive value, and 96% negative predictive value on a per node basis and a sensitivity of 100% on a per patient basis. The CBP sign is an accurate morphological sign differentiating sarcoid from other adenopathy.

Patient-specific image denoising for ultra-low-dose CT-guided lung biopsies.

Low-dose CT screening of the lungs is becoming a reality, triggering many more CT-guided lung biopsies. During these biopsies, the patient is submitted to repeated guiding scans with substantial cumulated radiation dose. Extension of the dose reduction to the biopsy procedure is therefore necessary. We propose an image denoising algorithm that specifically addresses the setup of CT-guided lung biopsies. It minimizes radiation exposure while keeping the image quality appropriate for navigation to the target lesion. A database of high-SNR CT patches is used to filter noisy pixels in a non-local means framework, while explicitly enforcing local spatial consistency in order to preserve fine image details and structures. The patch database may be created from a multi-patient set of high-SNR lung scans. Alternatively, the first scan, acquired at high-SNR right before the needle insertion, can provide a convenient patient-specific patch database. The proposed algorithm is compared to state-of-the-art denoising algorithms for a dataset of 43 real CT-guided biopsy scans. Ultra-low-dose scans were simulated by synthetic noise addition to the sinogram, equivalent to a 96% reduction in radiation dose. The feature similarity score for the proposed algorithm outperformed the compared methods for all the scans in the dataset. The benefit of the patient-specific patch database over the multi-patient one is demonstrated in terms of recovered contrast for a tiny porcine lung nodule, following denoising with both approaches. The proposed method provides a promising approach to the denoising of ultra-low-dose CT-guided biopsy images.

Recurrent Pneumonia: The Answer Is in the Esophagus

Laparoscopic adjustable gastric banding (LAGB) can impair esophageal peristalsis and relaxation of the lower esophageal sphincter, possibly leading to esophageal dilation. Stomach and esophagus dilation are rare; both are occasional complications of LAGB. Bronchoaspiration can occur as a late complication of gastric band placement, a serious complication that can be prevented by immediate deflation of the gastric band. We describe a case of a 44 year-old male patient who was treated for recurrent respiratory infections for several months and was subsequently found to have megaesophagus on further evaluation. A 44 year-old male with history of laparoscopic adjustable gastric band placement 4 years prior, presented to pulmonary clinic as a consultation for frequent respiratory infections requiring at least 7 courses of antibiotics over few months. He complained of persistent productive cough, exertional dyspnea and chest pain. Rest of review of systems was negative. His physical examination was normal. CT chest showed multiple tiny lung nodules representing a manifestation of recurrent and chronic aspiration and substantially dilated esophagus with fluid in the lumen (image 1). The patient was referred to GI clinic and after thorough evaluation, EGD was done that showed fluid in the lower third of the esophagus, dilated lumen of the lower third of the esophagus with no stenosis or stricture in the entire esophagus. It also showed a 4 cm gastric pouch in the stomach with fluid content proximal to the constriction from the lap band (EGD views are shown in images 2 and 3). Removal of the gastric band was performed with subsequent resolution of his symptoms. LAGB is approved for treatment of morbid obesity with successful outcomes by many bariatric surgeons worldwide. It is preferred due to ease of implementation and low rate of perioperative mortality. Megaesophagus with dysphagia can occur as a long term sequelae of LAGB. The preoperative manometry results cannot predict for its occurrence. The management of megaesophagus caused by LAGB requires band removal in most cases. Clinicians should be made aware of this rare entity when they encounter patients with frequent aspiration who had bariatric procedures. Inquiry about detailed relevant surgical history is also recommended.Figure 1Figure 2Figure 3

Novel Hexosaminidase-Targeting Fluorescence Probe for Visualizing Human Colorectal Cancer

Precise tumor diagnosis and evaluation of disease extent are crucial for treatment of solid cancers. In order to complement the limited ability of the unaided human eye to discriminate tumor tissue and normal tissue, we have developed a series of fluorescence probes activatable specifically in cancer tissues. Here, we describe the design, synthesis, and application of a new fluorescence probe targeting hexosaminidase (HMRef-βGlcNAc), which is located in lysosomes and is overexpressed in several carcinomas, including colorectal cancer. This probe could sensitively detect intracellular hexosaminidase activity in human colorectal cancer cell lines, and could visualize tiny metastatic nodules (smaller than 1 mm) in a mouse model of disseminated human peritoneal colorectal cancer (HCT116). In human colorectal cancer specimens obtained at surgery, the probe showed high tumor sensitivity/specificity, together with a high tumor-to-normal signal ratio. HMRef-βGlcNAc is a promising candidate for clinical application during surgical or endoscopic procedures to treat colorectal cancer.

A Case of Nongerminomatous Germ Cell Tumor with Fulminant Course Concomitant Leptomeningeal Metastasis.

We present the case of a 9-year-old boy with a non-germinomatous germ cell tumor (NGGCT) in the pineal gland that exhibited a fulminant course following chemo- and radiotherapy. After the detection of the tiny cerebellar enhancing nodule at the end of chemo- and radiotherapy, tumor seeding progressed rapidly into the entire cisternal space. We herein report a rare case of NGGCT with fulminant clinical course of concomitant cerebellar seeding, with review of literature.