Fine needle aspiration cytology and core biopsy in the diagnosis of alveolar soft part sarcoma presenting with lung metastases. A case report

BACKGROUND

Alveolar soft part sarcoma is a rare soft tissue tumor of uncertain origin usually affecting young adults. This neoplasm has early metastatic potential. Its cytologic features, particularly when presenting with metastases, have rarely been described.

CASE

A 23-year-old male presented with shortness of breath and scapular pain. Routine chest roentgenograms revealed multiple lung nodules. Malignancy was established by percutaneous fluoroscopically guided fine needle aspiration on a lung nodule. Possible metastatic alveolar soft part sarcoma was suggested by cytology among few considerations in the differential diagnosis. Alveolar soft part sarcoma was confirmed by lung core biopsy and further supported by immunohistochemistry and electron microscopy. Tumor cells expressed muscle-specific actin and myoglobin, and contained diastase-resistant inclusions with periodic acid-Schiff stain. Ultrastructurally, peculiar, elongated intracytoplasmic crystalline bodies typical of this neoplasm were identified. A meticulous clinical search led to finding the primary tumor deeply located in the right posterior thigh.

CONCLUSION

Aspiration cytology is a reliable, cost-efficient technique in the diagnostic workup of masses suspicious for malignancy.

The Bird's Nest inferior vena caval filter: review of a single-center experience

PURPOSE

To examine a large single-center experience with Bird's Nest vena caval filters for indications, clinically evident recurrent thromboembolic disease, and other filter-related complications.

MATERIALS AND METHODS

During a 6-year period, 308 patients underwent percutaneous placement of an inferior vena caval filter. The 267 patients who received a Bird's Nest filter are the subject of this retrospective review. The series included 162 men and 105 women who ranged in age from 16 to 88 years (mean, 57.1 +/- 17.0 standard deviation).

RESULTS

Indications for filter placement included contraindication to anticoagulation (n = 141), complication of anticoagulation (n = 23), failure of anticoagulation (n = 30), failure of previously placed filter (n = 1), and prophylaxis (n = 82). Ten patients had more than one indication. Acute lower extremity deep venous thrombosis was confirmed in 133 patients, pulmonary embolism (PE) was found in 44 patients, and both were positively diagnosed in 37 other patients. Fifty-three patients had no documented acute thromboembolic disease at the time of insertion. Mean follow-up was 13 months. Thirty-day mortality was 9.7%, including one death from recurrent PE and one major puncture-site bleeding episode that may have contributed to death. Recurrent PE was found at radionuclide scanning or autopsy in three patients (1.1%), whereas another eight patients (3.0%) had suspected recurrent PE without confirmatory studies. Eight patients (3.0%) developed early venous access site thrombosis, including two who progressed to phlegmasia cerulea dolens with fatal complications. Significant nonthromboembolic problems were encountered in 1.9% of patients.

CONCLUSIONS

The Bird's Nest filter is a safe and effective device for patients with complicated venous thromboembolic disease.

Portal hypertension: surgical management in the 1990s

BACKGROUND

Although liver transplantation offers definitive treatment for portal hypertension with end-stage liver failure, surgical portosystemic shunts avoid the risks of transplantation and immunosuppressive therapy, and transjugular intrahepatic portosystemic shunt (TIPS) creates a portosystemic shunt with minimal operative risk. The appropriate applications of these modalities are discussed.

METHODS

All adults undergoing primary liver transplantation alone (PLT, n = 265), PLT after TIPS (n = 34), PLT after surgical shunts (n = 12), surgical shunt alone (n = 13), TIPS alone (n = 35), or surgical shunt after PLT (n = 5) served as the basis of this study.

RESULTS

In contrast to surgical shunts before PLT, TIPS before PLT increased the 1-year graft survival. Surgical shunts alone were done in 18 patients with normal or near normal liver function with 100% survival. TIPS alone offered effective symptomatic relief to most patients, all of whom were judged not to be surgical candidates.

CONCLUSIONS

TIPS, surgical shunts, and liver transplantation each have a logical role in management of portal hypertension. Surgical candidates with Child's B or C liver failure should be treated with liver transplantation, and TIPS offers effective treatment for nonsurgical candidates. Surgical shunts can be performed with excellent results in patients with Child's A liver disease. Portal vein occlusion with normal liver function can be successfully treated with surgical shunts.

MR angiography of the pelvis with variable velocity encoding and a phased-array coil

PURPOSE

To evaluate the feasibility of an automated variable velocity-encoding sequence and improve the signal-to-noise ratio (S/N) on magnetic resonance angiograms with use of phase contrast and a pelvic phased-array coil.

MATERIALS AND METHODS

Three cardiac-gated, two-dimensional (2D), phase-contrast (PC) sequences were evaluated in 10 healthy subjects. A 2D gated PC sequence with variable velocity encoding (velocity-optimized phase contrast [VOPC]) was compared with gated 2D PC sequences performed with high or low constant velocity encoding. S/Ns in VOPC images obtained with a pelvic phased-array coil were compared with those in VOPC images obtained with a body coil.

RESULTS

Two blinded readers preferred VOPC for simultaneous display of large and small blood vessels in one acquisition compared with constant low (P = .0105) and high (P = .0067) velocity encoding and for overall image interpretation. VOPC images obtained with the pelvic coil had a 68%-100% better S/N compared with those obtained with the body coil.

CONCLUSION

Use of a phased-array coil and variable velocity encoding improves depiction of segmental vascular anatomic structures of the pelvis.

Pneumatoceles causing respiratory compromise. Treatment by percutaneous decompression

Pulmonary pneumatoceles are uncommon but generally benign, thin-walled parenchymal air collections arising in association with acute pneumonia. Rarely, they may attain such size as to severely affect respiration. We describe the percutaneous placement of multiple drains in a patient with pneumonia due to atypical measles and large pneumatoceles. Decompression via tubes resulted in improved ventilation and acceleration of recovery.

Peripheral MR angiography with variable velocity encoding. Work in progress

An electrocardiographically triggered two-dimensional phase-contrast (PC) magnetic resonance angiographic pulse sequence was developed in which velocity encoding (VENC) was varied throughout an acquisition in response to changes in blood velocity during the cardiac cycle. This was done to better capture signal in the peripheral vasculature, where pulsatile flow degrades images. After reconstruction, a matched filter addition technique was applied to the cardiac phase images to obtain a single high-quality static image. Images were obtained of six healthy volunteers--with and without varying VENC--and contrast-to-noise ratio (C/N) calculations were performed for the added images. Varying VENC significantly improved vascular signal from small and large vessels (P less than .02), but it was most helpful for small vessels, for which the C/N increased by as much as 260% (average increase, 149%). These preliminary findings suggest that variable VENC can enhance the signal from the small and large peripheral blood vessels in cardiac-gated PC acquisitions.

Abdominal abscesses associated with enteric fistulas: percutaneous management

For many years, surgical dictum stated abdominal fistulas should be treated by means of surgical excision. Recent advances in percutaneous techniques have altered this. The authors reviewed 150 consecutive abdominal abscesses drained percutaneously over a 36-month period. Among these, 24 patients were found to have 26 fistulous communications to bowel, the pancreatic duct, or the biliary system. Initial drainage of their abscesses was performed in the hospital, but 17 of 24 patients were discharged with a tube in place and were followed up as outpatients. The duration of drainage ranged from 4 days to 3 months. Fistulas healed in 21 of 24 patients (88%) without surgical intervention. Complications were few and included inadvertent dislodgment requiring tube replacement (two patients) and inadvertent puncture of the transverse colon (one patient). Treatment of abdominal abscesses with fistulas by means of percutaneous methods is reliable and safe. Hospital stay may be minimized with outpatient management after drainage.

CT findings after uncomplicated percutaneous gastrostomy

CT scans of the upper abdomen were obtained 1 hr to 9 days after percutaneous placement of feeding gastrostomy in 18 patients in order to establish a range of normal postprocedural findings. A majority of patients (56%) had pneumoperitoneum. Additional findings included abdominal wall hematomas in six patients (33%) and gastric hematomas in three patients (17%). Except for one case of mild ascites in an individual with large hepatic metastases, no abdominal fluid collections were discovered. After percutaneous gastrostomy, pneumoperitoneum and abdominal wall or gastric hematomas are commonly present. Presence of subcutaneous emphysema, free peritoneal fluid, or a loculated abdominal fluid collection should alert one to a possible complication.

Effects of improved contrast on lung-nodule detection. A clinical ROC study

We evaluated the effects of unsharp masking and highly efficient scatter rejection on film-screen chest radiographs of cancer patients. Unsharp masking significantly improved the detectability of lung nodules and visibility of anatomic structures in poorly penetrated areas of the chest. Highly efficient scatter rejection by an improved antiscatter grid provided only modest additional benefits. The study supports the conclusion that nodule detection in poorly penetrated areas on conventional chest radiographs is limited primarily by display contrast, whereas in the well-penetrated lung fields it is limited primarily by confusing background structures, rather than inadequate contrast. A method for analyzing clinical nodule detection data by transforming the FROC data to ROC coordinates also is demonstrated.

Tomographic digital subtraction angiography: initial clinical studies using tomosynthesis. Work in progress

We have developed a method for acquiring multiple tomographic subtraction images using a rapid, repetitive, circular tomographic motion. The method combines the principles of digital subtraction angiography (DSA) and electronic tomosynthesis. Fifteen patients were examined with the technique using single intravenous bolus injections of contrast material. The image sequence obtained during each injection was first processed with a nontomographic mask subtraction, and the result was then compared with the tomographic DSA scans synthesized from the same sequence. The effective section thickness was approximately 0.5 cm, with each section being 0.5-1.0 cm apart. Twelve of the intravenous DSA scans provided the necessary diagnostic or clinically useful information. Two of the three nondiagnostic scans were caused by avoidable technical reasons. In eight cases, the tomographic DSA scans were superior in quality to the nontomographic scans, exhibited significantly less artifact from patient motion and overlying bowel gas, and were effective in separating overlapping vessels. Tomosynthesis permits multiple electronic imaging of the area of interest without reinjection of contrast material and appears to be more informative than nontomographic intravenous DSA imaging.

Intramural esophageal pseudodiverticulosis. A report in a child with a sixteen-year follow up

A case of intramural esophageal pseudodiverticulosis in a five-year-old with a 16-year follow up is presented.

Digital video subtraction angiography for evaluation of peripheral vascular disease

Digital video subtraction angiography (DVSA) has been employed to study a variety of peripheral vascular problems, using equipment developed at the University of Wisconsin. The technique is relatively simple and safe and has good patient acceptance. Experience indicates that in selected patients it is a satisfactory alternative to standard arteriography for screening and for definitive evaluation and on occasion may yield information not obtainable with conventional methods. It can aid in the performance of transluminal angioplasty and is suitable for serial evaluation of atherosclerotic vessels and bypass grafts.