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109Contents

124 Original ArticleMetastatic Oral Cancer

niCole Hsu et al.

128 Original ArticleDuodenoileal Fistula

PrasHant naPHade et al.

130 Original ArticleMeckel's Diverticulitis

MattHew Mullen et al.

134 Original ArticleMononucleosis-Like Syndrome

PatHik desai et al.

114 Original ArticleOccult Breast Cancer

Freya sCHnabel et al.

120 Original ArticleAcute Mesenteric Ischemia

Marlin wayne Causey et al.

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110 editors | July 2013

Journal of Surgical Radiology

Executive EditorSapan Desai

Surgisphere Corporation

Science EditorThomas KoenigsbergerSurgisphere Corporation

Staff EditorCarol Fisher

Surgisphere Corporation

Editor-in-ChiefCynthia Shortell

Duke University Medical Center, Durham, North Carolina

Managing EditorMark Shapiro Duke University Medical Center, Durham, North Carolina

Journal EditorsHasan Alam Massachusetts General Hospital, Boston, MassachusettsAli Azizzadeh University of Texas at Houston, Houston, TexasStanley Ashley Brigham and Women’s Hospital, Boston, MassachusettsAnthony Atala Wake Forest Baptist Health, Winston-Salem, North CarolinaDavid Bentrem Northwestern University, Chicago, IllinoisGavin Britz Duke University Medical Center, Durham, North CarolinaAlasdair Conn Massachusetts General Hospital, Boston, MassachusettsJames Cusack Jr. Massachusetts General Hospital, Boston, MassachusettsDaniel Dent University of Texas Health Sciences Center, San Antonio, TexasCelia Divino Mount Sinai School of Medicine, New York, New YorkAnahita Dua University of Texas at Houston, Houston, TexasN. Joseph Espat Roger Williams Medical Center, Providence, Rhode IslandSteven Evans Georgetown University Medical Center, Washington, DCThomas Fahey III Weill Cornell Medical College, New York City, New YorkAllan Friedman Duke University Medical Center, Durham, North CarolinaRichard Gray Mayo Clinic, Phoenix, ArizonaRalph Greco Stanford University, Stanford, CaliforniaRajan Gupta Duke University Medical Center, Durham, North CarolinaTimothy Hall Stamford Hospital, Stamford, ConnecticutW. Scott Helton Hospital of Saint Raphael, New Haven, ConnecticutG. Chad Hughes Duke University Medical Center, Durham, North CarolinaRonald C. Jones Baylor University Medical Center, Dallas, TexasCharles Kim Duke University Medical Center, Durham, North CarolinaDavid King Massachusetts General Hospital, Boston, MassachusettsChristopher J. Kwolek Massachusetts General Hospital, Boston, MassachusettsMichael Leitman Beth Israel Medical Center, New York City, New YorkMatthew Menard Brigham and Women’s Hospital, Boston, MassachusettsMichael Miller Duke University Medical Center, Durham, North CarolinaStephen Milner Johns Hopkins University, Baltimore, MarylandEugene Moretti Duke University Medical Center, Durham, North CarolinaTheodore Pappas Duke University Medical Center, Durham, North CarolinaJeff Pruitt UT Southwestern Medical Center, Dallas, TexasScott Pruitt Duke University Medical Center, Durham, North CarolinaHazim Safi University of Texas at Houston, Houston, TexasRanjan Sudan Duke University Medical Center, Durham, North CarolinaGilbert upchurch, Jr University of Virginia, Charlottesville, Virginia

Advisor to the JournalDanny O. Jacobs Duke University Medical Center, Durham, North Carolina

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Citation Schnabel et al. Mammographically Occult Breast Cancers in Women Older Than 70 Years. J Surg Radiol. 2013 Jul 1;4(3).

CorrespondenCe Freya Schnabel, MD E-mail Freya.Schnabel@nyumc.org.

reCeived January 30, 2013. aCCepted May 1, 2013. epub July 1, 2013.

Mammographically Occult Breast Cancers in Women Older Than 70 years Freya Schnabel MD,1 Jessica Billig BA,2 Jennifer Chun MPH,1 Cristina Checka MD,1 Amber Guth MD,1 Deborah Axelrod MD1

1 Department of Surgery, New York University Langone Medical Center, NYU Cancer Institute, New York, NY.2 School of Medicine, New York University Langone Medical Center, New York, NY.

Abstractpurpose Mammography, the most widely used screening tool for breast cancer, has a false negative rate of 10-15%. Increased breast density reduces the sensitivity of mammography. Recent data suggests a correlation between mammographically-occult breast cancer (MOBC) and increas-ing breast density. The purpose of this study was to investigate the incidence of MOBC in women over 70 years and to examine the association of MOBC with breast density and other factors.Methods The NYU Langone Medical Center (NYULMC) pathology database was queried for all women older than 70 diagnosed with breast cancer between 2002-2009. A retrospective chart review collected variables including age, method of presentation, histology, stage, mammographic density, and other risk factors. Statistical analyses were performed using Pearson’s Chi-Square Test and descriptive analyses.results A total of 461 women comprised our study cohort. The majority (70%) had been screened with annual mammography prior to diagnosis. In this cohort, 20 women presented with MOBC. Sixty percent of the women with MOBC had heterogeneously or extremely dense breasts. Women with MOBC had an increased rate of invasive lobular histology when compared with the group of women with mammographically-evident disease.ConClusion Women with denser breasts are at a higher risk of MOBC than women with lesser breast density. This may be due to the decreased sensitivity of mammography in this group. The in-crease in cases of lobular histology may play a role. Breast density and risk for breast cancer should be taken into account when developing screening protocols, for women of all ages.

Keywords mammography, MRI, ultrasound, breast density, older women, screening

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IntroductionMammography is currently the foundation of breast cancer screening and is the only imaging modality that has been demonstrated to reduce mortality from breast cancer. How-ever, mammography continues to have a significant false nega-tive rate which is highest among women with dense breasts. The sensitivity of mammography in women with predomi-nantly fatty breasts is 80% as compared to a sensitivity of 30% in women with extremely dense breasts (1). This decrease in sensitivity is related to the proportion of dense tissue, which masks the presence of mass lesions (2-4). Mammographic density has also been established as an independent risk fac-tor for breast cancer (5-6). Women with heterogeneously dense or extremely dense breasts have a 4- to 6-fold increase in risk for the development of breast cancer (6-8). Thus, women with dense breasts may be at an increased risk of mammographi-cally occult breast cancer (MOBC) both due to the reduction in mammographic sensitivity and their risk to develop the disease. Breast cancer that is not detected by standard screen-ing methods exposes the patient to the risk of a delay in di-agnosis, which may impact on survival and treatment-related morbidities.

In general, mammographic density decreases with age with a larger proportion of the breast parenchyma and stroma re-placed by radiolucent, fatty tissue. However, a significant pop-ulation of older women manifests persistently dense breast tissue on mammography (9). This may be due to an abnor-mal process of involution of breast tissue (10). Moreover, in both premenopausal and postmenopausal women with dense breasts, there is an increased risk of breast cancer (11-12).

Therefore, older women with persistently dense breast tissue may be at an inherent increased risk to develop breast cancer, while at the same time being at risk for a delay in diagnosis because of the lack of sensitivity of mammographic screening.

The purpose of this study was to investigate the incidence of MOBC in women older than 70 years at a single institution. We also aimed to characterize the clinical factors that may be associated with MOBC in this population.

MethodsThe NYU pathology database was queried for all cases of breast cancer in women older than 70 years diagnosed be-tween 2002 and 2009. An IRB-approved retrospective chart review was conducted for this group of patients. The follow-ing variables of interest were collected: patient age, method of presentation (i.e. palpable mass vs. non-palpable abnormal-ity), tumor histology, stage, mammographic density, and his-tory of other known risk factors (i.e. use of post-menopausal hormone replacement therapy and family history). The study cohort consisted of patients who had mammographically-occult breast cancer, defined as cancer that had no associated findings on mammography performed at the time of diagno-sis. These cancers presented either by palpable mass, or a non-palpable abnormality detected on other imaging modalities: screening ultrasound or screening magnetic resonance imag-ing (MRI). We compared this cohort to patients who presented initially with suspicious findings on screening mammography, which we defined as mammographically evident breast cancer (MEBC).

Table 1. Clinical Characteristics of MO + ME (n=461)

VARIABLE MO* (n=20) ME† (n=441) p-valueAGE (median) 79 yrs 78 yrs 0.32

Positive FHBC 7 (35%) 132 (30%) 0.63

Previous HRT use 4 (20%) 71 (16%) 0.64

Breast Cancer StageStage 0 3 (15%) 82 (18%)

0.91Stage1 10 (50%) 232 (53%)

Stage 2 6 (30%) 102 (23%)

Stage 3 1 (5%) 25 (6%)

HistologyDCIS 3 (15%) 82 (18%)

0.01

DCIS with microinvasion 0 (0%) 1 (1%)

IDC 9 (45%) 266 (60%)

ILC 6 (30%) 61 (14%)

Mixed ductal and lobular 2 (10%) 7 (2%)

Other (mucinous, colloid, papillary) 0 (0%) 24 (5%)* Mammographically Evident Tumors† Mammographically Occult Tumors

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(p=0.91). In four patients, the MOBC represented ipsilateral recurrence after prior breast conserving surgery. For the pur-poses of this analysis, they were staged as new primaries: one presented with DCIS, two patients with T1 lesions, and one patient with a T1b, N1 lesion (staged as IIA). Out of the total MOBC cohort, three patients were diagnosed with pure DCIS which presented after abnormal screening MRI. The most common histology identified in both groups was invasive ductal carcinoma. However, invasive lobular carcinoma oc-curred with greater frequency (30%) in the mammographical-ly-occult group than in the mammographically-evident group of patients (14%) (Table 1). This finding reached statistical sig-nificance, confirming a difference in the pattern of histology between the two groups (p=0.01).

We were interested in the breast density characteristics of both the MOBC and MEBC groups. To provide consistency in in-terpretation, this analysis included breast density findings as interpreted by dedicated breast radiologists at NYULMC. Of the 441 patients with MEBC, information regarding breast den-sity was available for only 281 patients. In the MOBC group, density information was available for all patients. We divided the mammographic density categories into two groups: “less dense” (predominantly fatty [class 1] and scattered fibroglan-dular elements [class 2]) and “more dense” (heterogeneously dense [class 3] and extremely dense [class 4]) (Table 3). The MOBC cohort included a higher proportion of women with dense tissue as compared with the MEBC group. The MEBC group had a higher proportion of women with “less dense” tissue than the MOBC group. This trend was statistically sig-nificant (p=0.02).

DiscussionIn the general population, the majority of women with breast cancer have invasive ductal histology. When comparing the histologic findings between our study cohort of women over 70 years with mammographically-occult and mammographi-cally–evident tumors, there was a higher incidence of invasive lobular carcinoma in patients whose tumors were occult on mammography. In their study of women with mammographi-cally occult breast cancers, Ma et al. also associated MOBC with higher incidences of lobular carcinoma [OR= 7.0, 95%CI, 2.2 to 22.1; P<0.001] (2). There is also information in the medi-

All mammograms were performed with digital technique and were acquired using MAMMOMAT® Novation DR software (version V8.3, Siemens Healthcare). Based on rou-tine institutional practice, the images were further analyzed by iCAD computer-aided detection software (iCAD, version VA20E, iCAD, Inc.). Mammographic density was defined by the standardized BI-RADS schema established by the Ameri-can College of Radiology: predominantly fatty (1), scattered fibroglandular elements (2), heterogeneously dense (3), and extremely dense (4). Specialty breast imaging radiologists de-termined the BI-RADs classification as noted on the radio-logical reports (13).

Statistical analyses were performed using Pearson’s Chi-Square Test and descriptive analyses. All analyses were executed using SPSS software (version 12.0, SPSS) and SAS software (version 9, SAS Institute).

ResultsA total of 461 women older than 70 years were diagnosed with breast cancer at NYULMC between 2002 and 2009. The medi-an age in this group was 77 years (range 71-89 years). The ma-jority of this cohort, 323 (70%) had been regularly screened with annual mammography prior to their diagnosis.

Within the study population, 20 women (4.3%) were identi-fied with MOBC. Only four of these women (20%) had an antecedent history of hormone replacement therapy (HRT). Seven women (35%) had a family history of breast cancer in a first-degree relative (Table 1). Nine (45%) women had a prior personal history of breast cancer. Of these nine women, four cases of MOBC were ipsilateral recurrences after prior breast cancer treatment. In five patients, the MOBC was a contra-lateral second primary cancer. The majority of patients with MOBC, 15 (75%), had a palpable mass that was not discern-able on mammography. One patient’s MOBC was detected via screening ultrasonography, and four women (20%) had malignancies detected by screening MRI (Table 2). These five patients had additional imaging recommended as part of their screening regimens predicated on the basis of their breast can-cer risk assessment.

In both cohorts (patients with MOBC and those with MEBC), the majority of women had early stage disease (Table 1)

Table 2. Clinical Characteristics of MOBC (n=20)

VARIABLE N (%)METHOD OF PRESENTATION

Palpable Mass 15 (75%)Screening Ultrasound 1 (5%)Screening MRI 4 (20%)PREVIOUS HISTORY OF BREAST CANCERIpsilateral recurrence 4 (20%)Contralateral new primary 5 (25%)

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Currently, breast MRI has been recommended as a supplement to mammography in women who are at high risk for breast cancer (21). Breast MRI has been shown to have a sensitivity of 88%-95% for the detection of breast cancer. Bluemke et al. demonstrated that the highest sensitivity of MRI was found in fatty breast tissue (90.7%) as opposed to dense breast tissue (86.5%) (22). This slight difference in MRI sensitivity among breast densities was not significant, making MRI a good op-tion for high risk women in all categories of breast density. In a study of a cohort of predominantly younger high risk women, Kriege et al. demonstrated that MRI was significantly more sensitive than mammography, and increased the partici-pant’s chance for early detection of breast cancer (23). How-ever, the increased sensitivity of MRI comes at the expense of a decrease in specificity (30-80%) (22, 24). The decrease in specificity of MRI leads to false positive exams, which result in an increased number of biopsies and follow up MRIs (25). The decision to recommend MRI screening should therefore rest on careful breast cancer risk assessment to ensure an ap-propriate risk benefit ratio for the patient.

Given the multiple screening modalities that are available, there is emerging interest in the concept of personalized ap-proaches to breast cancer screening. The age at first mammog-raphy may be predicated on family history, particularly if close relatives had early onset breast cancer. Schousboe et al. com-mented, “We believe that considering breast density, previous biopsy, and family history of breast cancer when deciding on a mammography screening strategy is appropriate, on the ba-sis of our analyses” (26). As discussed above, the addition of ultrasound and MRI has established benefit in populations of women with dense breasts and increased risk for breast cancer. As age does not necessarily correlate with breast density, they must be considered independently in this analysis. In the clin-ical setting, screening recommendations for patients should be individualized based on age, breast density and objective assessment of breast cancer risk.

Our data suggest that women over 70 years of age with dense breast tissue on screening mammography have an increased incidence of mammographically-occult breast cancer. The ad-dition of other modalities may be helpful in detecting early, mammographically occult disease in this population. The ac-tual benefit of adding additional screening methods in older patients with dense breasts may also depend on their under-lying risk for breast cancer. An individualized approach to breast cancer screening should incorporate an assessment of

cal literature suggesting that dense breast tissue may predis-pose women to specific types of breast cancer. Arora et al. found that women with dense breasts had a higher propor-tion of luminal A cancers (12). Interestingly, most infiltrating lobular carcinomas are found within the luminal A subtype, and classic infiltrating lobular carcinomas’ gene expression most closely matches the luminal A phenotype (14). Histori-cally, invasive lobular carcinoma was associated with mammo-graphically occult presentation, based on the lack of typical desmoplastic reaction at the margins, allowing the tumor to infiltrate the surrounding parenchyma with less of a mam-mographic fingerprint (15). Thus, invasive lobular carcinoma may be overrepresented in patients with MOBC on the basis of an association with breast density and the infiltrative char-acteristics of the tumors.

Increased mammographic density appears to confer an in-creased risk for breast cancer, while decreasing the sensitiv-ity of standard screening exams. In general, mammographic density decreases over time, particularly after menopause. However, age is not a perfect surrogate for breast density, and 36% of women over 70 were found to have dense breasts in a prior study of the relationship of breast density with age (9). Screening protocols are designed in order to afford women the opportunity for early detection of disease. Higher risk women with dense breasts, even if they are older, may not be adequately screened using mammography alone.

Ultrasonography and breast MRI have been utilized in dif-ferent screening regimens for women who are at increased risk for breast cancer based on features of family, genetic, and personal history. In a study of women at increased risk for breast cancer and heterogeneously or extremely dense breasts on mammography, Berg et al. found an increased diagnostic yield of 11.8 cancers per 1000 women for combined screening with mammography and ultrasound as opposed to 7.6 cancers per 1000 women for mammography alone (16). Other studies have shown that screening ultrasound increases the detection of small, non-palpable, and earlier stage breast cancers, thus making it a valuable screening tool (17-19). However, screening ultrasound is associated with a significant false positive rate and may lead to an increased number of biopsies for women in an intermediate density group (19-20). For an individual patient, the benefits and disadvantages of screening ultra-sound should be considered in light of the underlying breast cancer risk.

Table 3. Breast Density within the Total Population

VARIABLE MO (n=20) ME (n=281) p-valueBREAST DENSITY CATEGORYPredominantly fatty (BIRADS 1) orScattered fibroglandular elements (BIRADS 2)

8 (40%) 185 (66%)0.02

Heterogeneously dense (BIRADS 3) or Extremely dense (BIRADS 4) 12 (60%) 96 (34%)

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original artiCle Schnabel et al. Occult Breast Canceraddition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA 2013; 307(13):1394-1404.

20. Nothacker M, Duda V, Hahn M, et al: Early detection of breast cancer: benefits and risks of supplemental breast ultrasound in asymptomatic women with mammographically dense breat tissue. A systematic re-view. BMC Cancer 2009; 9:335.

21. Saslow D, Boetes C, Burke W, et al: American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin , 2007; 57:75-89.

22. Bluemke DA, Gatsonis CA, Chen MH, et al: Magnetic resonance im-aging of the breast prior to biopsy. JAMA 2004; 292(22):2735-2742.

23. Kriege M, Brekelmans CT, Boetes C, et al: Efficacy of MRI and mam-mography for breast-cancer screening in women with a familial or ge-netic predisposition. N Engl JMed 2004; 351(5):427-437.

24. Warner E, Messersmith H, Causer P, et al: Systematic review: using magnetic resonance imaging to screen women at high risk for breast cancer. Ann Intern Med 2008; 148(9):671- 679.

25. Morris EA, Liberman L, Ballon DJ, et al: MRI of occult breast carcino-ma in a high-risk population. AJR Am J Roentgenol 2003; 181(3):619-626.

26. Schousboe JT, Kerlikowske K, Loh A, et al: Personalizing mammogra-phy by breast density and other risk factors for breast cancer: analy-sis of health benefits and cost-effectiveness. Ann Intern Med 2011; 155(1):10-20.

patient age, breast density, and risk for the disease in order to maximize the benefit of screening women of all ages.

DisclosuresThe authors have no disclosures or conflicts of interest related to this manuscript.

References1. Mandelson MT, Oestreicher N, Porter PL, et al: Breast density as a

predictor of mammographic detection: comparison of interval- and screen-detected cancers. J Natl Cancer Inst 2000; 92(13):1081-1087.

2. Ma L, Fishell E, Wright B, et al: Case-control study of factors asso-ciated with failure to detect breast cancer by mammography. J Natl Cancer Inst 1992; 84(10):781-785.

3. Holland R, Hendriks JH, Mravunac M: Mammographically oc-cult breast cancer: a pathologic and radiologic study. Cancer 1983; 52(10):1810-1819.

4. Feig SA, Sharber GS, Patchefsky A, et al: Analysis of clinically occult and mammographically occult breast tumors. AJR Am J Roentgenol 1977; 128(3):403-408.

5. Byrne C, Shairer C, Wolfe J, et al: Mammographic features and breast cancer risk: effects with time, age, and menopause status. J Natl Can-cer Inst 1995; 87(21):1622-1629.

6. Boyd NF, Guo H, Martin LJ, et al: Mammographic density and the risk and detection of breast cancer. N Engl J Med 2007; 356(3):227-236.

7. Vachon CM, van Gils CH, Sellers TA, et al: Mammographic density, breast cancer risk and risk prediction. Breast Cancer Res 2007; 9(6):217.

8. Harvey JA, Bovbjerg VE: Quanitative assessment of mammographic breast density: relationship with breast cancer risk. Radiology 2004; 230(1):29-41.

9. Checka C, Chun J, Schnabel F, et al: The relationship of mammo-graphic density and age: implications for breast cancer screening. AJR Am J Roentgenol 2013; 198:W1-W4.

10. Henson DE, Tarone RE: Involution and the etiology of breast cancer. Cancer 1994; 74:424-429, (suppl 1).

11. Vacek PM, Geller BM: A prospective study of breast cancer risk using routine mammographic breast density measurements. Cancer Epide-miol Biomarkers Prev 2004; 13(5):715-722.

12. Arora N, King TA, Jacks LM, et al: Impact of breast density on the presenting features of malignancy. Ann Surg Oncol 2010; 17:211-218, (suppl 3).

13. American College of Radiology: Breast imaging reporting and data system (BI-RADS). Reston, VA, American College of Radiology, 2003.

14. Weigelt B, Horlings HM, Kreike B, et al: Refinement of breast can-cer classification by molecular characterization of histological special types. J Pathol 2008; 216(2):141-150.

15. Silverstein MJ, Lewinsky BS, Waisman JR, et al: Infiltrating lobular carcinoma. Is it different from infiltrating ductal carcinoma? Cancer 1994; 73(6):1673-1677.

16. Berg WA, Blume JD, Cormack JB: Combined screening with ultra-sound and mammography vs mammography alone in women at el-evated risk of breast cancer. JAMA 2008; 299(18):2151-2163.

17. Kolb TM, Lichy J, Newhouse JH: Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology 2002; 225(1):165-175.

18. Kolb TM, Lichy J, Newhouse JH: Occult cancer in women with dense breasts: detection with screening US- diagnostic yield and tumor char-acteristics. Radiology 1998; 207(1):191-199.

19. Berg WA, Zhang Z, Lehrer D, et al: Detection of breast cancer with

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Acute Mesenteric Ischemia and Fluorescence Wood’s LampMarlin Wayne Causey MD, Avery Walker MD, James Sebesta MD, and Niten Singh

MD

1. Madigan Healthcare System; Tacoma, WA

Citation Causey MW. Acute Mesenteric Ischemia and Fluorescence Wood’s Lamp. J Surg Radiol. 2013 Jul 1;4(3).

CorrespondenCe Marlin Wayne Causey, MD E-mail mwcausey@msn.com

reCeived March 23, 2013. aCCepted May 1, 2013. epub July 1, 2013.

Abstractoverview Acute Mesenteric Ischemia is important to recognize early as to minimize patient morbidity and mortality. There have been no published reports or videos demonstrating the finding of acute mesenteric ischemia and the use of a fluorescein Wood’s lamp test. In this report, we describe a case of acute mesenteric ischemia requiring SMA thrombectomy and the appropriate utilization of a fluorescein Wood’s lamp test. In this report we demonstrate the area of demarcation of viable and ischemic bowel and the appropriate use of a Wood’s lamp test in determining viable bowel. To our knowledge, this is the first case report demonstrating the findings of this test.

Keywords mesenteric ischemia, woods lamp, fluorescein

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Causey. Mesenteric Ischemia original artiCle

IntroductionAcute mesenteric ischemia is a major source of morbidity and mortality. Prompt treatment is necessary and assessment of vi-able bowel is critical to optimal treatment. General and vascu-lar surgeons must be proficient in analyzing viable bowel and the implications of appropriate assessment. In our case, we describe and demonstrate a case of acute mesenteric ischemia and the findings with fluorescence wood’s lamp test in assess-ing the viability of bowel.1 To our knowledge, this is the first case demonstrating the distinction between viable and isch-emic bowel using a fluorescence Wood’s lamp test. Adequate understanding of the findings in ischemic bowel and viable bowel is critical for both general and vascular surgeons and is demonstrated in this case report.

Case ReportWe describe the case of an 80 year old gentleman who had been on the medical service and developed an acute episode of abdominal pain associated with hemodynamic instabil-ity (chronic atrial fibrillation with acute rapid ventricular response). The medical service obtained a computed tomo-

graphic scan that demonstrated a filling defect within the mid superior mesenteric artery and pneumotosis intestinalis (Figure 1). In order to assess for bowel viability, a fluorescein Wood’s lamp test was performed with the administration of 1mg of fluorescein with distinct demarcation of viable and ischemic bowel. Based upon the finding of the test, a supe-rior mesenteric thrombectomy was performed; however, the ischemic bowel was so profound that the second look opera-tion demonstrated complete ischemia of the small bowel in the SMA distribution.

This case report of this acute mesenteric ischemia demon-strates the first published video demonstration of the Wood’s lamp test in assessing acute mesenteric ischemia. There are multiple methods in determining the viability of bowel, but perhaps the most definitive is the intraoperative fluorescein Woods lamp test. This test is best performed after laparotomy in which ischemic bowel is encountered and there is question of bowel viability. Following the administration of 1mg of flu-orescein, the operating room lights are turned off and a black light (Wood’s Lamp) is used which incorporates a magnifying glass to assess the viability of the small bowel and colon . As demonstrated in the video, the adequacy of the small bowel perfusion is determined with fluorescence of the small bowel following fluorescein administration and black light testing. Other adjunctive measures are possible, as were used in this case, to include Doppler signals along the antimesenteric bor-der and needle puncture to assess gross bleeding, indicating bowel perfusion. All of these measures are necessary to ana-lyze and assess the viability of questionable bowel in order to ensure appropriate attempts at bowel reperfusion. Proper understanding of this technique and the assessment of bowel viability are critical in treating acute mesenteric ischemia.

DiscussionAcute arterial mesenteric ischemia is associated with a 70 to 90% mortality rate. Surgeons must be facile in determining the adequacy of bowel in order to appropriately identify those patients that are in need of acute revascularization. As dem-onstrated in our case, bowel viability is best determined after Doppler signal acquisition and fluorescein Wood’s lamp test.2,3 In our case report, we demonstrate a video demonstration of acute demarcation between ischemia and viable bowel. This

Figure 1. Computed tomography demonstrating findings consistent with acute mesenteric ischemia; A: yellow arrow head - pneumotosis intestinalis, B: white arrowhead - Cut off of the mid superior mesenteric artery.

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original artiCle Causey. Mesenteric Ischemiaassessment prompted an intraoperative consult for revascular-ization that included an SMA thrombectomy with successful intraoperative reperfusion.

General and vascular surgeons need to be aware and knowl-edgeable of appropriate assessment of bowel viability in order to make appropriate clinical management decisions. In cases of ischemic bowel, prompt assessment and diagnosis will lead to appropriate decision making and clinical management. In our case report, we demonstrate the ability for fluorescence to be taken up in areas of healthy and metabolically active bowel as opposed to areas of non-viability in ischemic bowel.4 An understanding of the strengths and limitations of this type of study are also critical. The fluorescein test is critical in iden-tifying areas of ischemic bowel, but do not demonstrate with 100% specificity those areas of bowel that would be ischemic following reperfusion.5 This is supported by several preclinical and clinical studies.6-8 The overarching theme of these studies is that any single method (clinical judgment, fluorescein, or Doppler analysis) of intraoperative bowel viability has severe limitations when used initially whether alone or in combina-tion. These initial intraoperative techniques are best suited for determining the vascular distribution of the ischemic event, but a second look laparotomy at 12-24 hours in cases of ques-tionable bowel is critical and the recommended gold standard in equivocal cases, and certainly warranted after revascular-ization.9,10 This analysis of bowel viability is critical in surgical training and education; however, this assessment is rare and only encountered in rare, typically call situations. We demon-strate in this case report, the assessment and intraoperative decision making in determining bowel viability in cases of acute mesenteric ischemia.

ConclusionIn conclusion, this is the first case report demonstrating the appropriate use of the fluorescein Wood’s lamp test in the as-sessment of bowel viability. This is a critical component of surgical training that is rarely reported and intraoperative decision making is often done by surgeons who have encoun-tered this situation in very few situations. By analyzing the findings of fatal acute mesenteric ischemia, surgeons will be able to appropriately consult and assess ischemic bowel. In our case report, we present the first video example of acute mesenteric ischemia and the assessment using a fluorescein Wood’s lamp test. In addition, this case emphasizes the find-ings seen on CT scan of ischemic bowel and the necessity of prompt surgical diagnosis.

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journal of surgery. Oct 1980;67(10):699-702.

2. Wright CB, Hobson RW, 2nd. Prediction of intestinal viability using Doppler ultrasound technics. Am J Surg. Jun 1975;129(6):642-645.

3. O’Donnell JA, Hobson RW, 2nd. Operative confirmation of Dop-pler ultrasound in evaluation of intestinal ischemia. Surgery. Jan 1980;87(1):109-112.

4. Mann A, Fazio VW, Lucas FV. A comparative study of the use of fluo-rescein and the Doppler device in the determination of intestinal vi-ability. Surgery, gynecology & obstetrics. Jan 1982;154(1):53-55.

5. Carter MS, Fantini GA, Sammartano RJ, Mitsudo S, Silverman DG, Boley SJ. Qualitative and quantitative fluorescein fluorescence in de-termining intestinal viability. Am J Surg. Jan 1984;147(1):117-123.

6. Holmes NJ, Cazi G, Reddell MT, et al. Intraoperative assessment of bowel viability. Journal of investigative surgery : the official journal of the Academy of Surgical Research. Mar-Apr 1993;6(2):211-221.

7. Ballard JL, Stone WM, Hallett JW, Pairolero PC, Cherry KJ. A critical analysis of adjuvant techniques used to assess bowel viability in acute mesenteric ischemia. Am Surg. May 1993;59(5):309-311.

8. Whitehill TA, Pearce WH, Rosales C, Yano T, Van Way CW, Rutherford RB. Detection thresholds of nonocclusive intestinal hypoperfusion by Doppler ultrasound, photoplethysmography, and fluorescein. J Vasc Surg. Jul 1988;8(1):28-32.

9. Yanar H, Taviloglu K, Ertekin C, et al. Planned second-look laparos-copy in the management of acute mesenteric ischemia. World journal of gastroenterology : WJG. Jun 28 2007;13(24):3350-3353.

10. Betzler M. [Surgical technical guidelines in intestinal ischemia]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. Jan 1998;69(1):1-7.

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Citation Hsu et al. Reading The Fine Print On PET/CT Interpretation: An Unusual Presentation of Metastatic Oral Cavity Squamous Cell Carcinoma. J Surg Radiol. 2013 Jul 1;4(3).

CorrespondenCe Nicole Hsu, MD E-mail nih9023@nyp.org

reCeived April 4, 2013. aCCepted May 1, 2013. epub July 1, 2013.

Reading The Fine Print On PET/CT Interpreta-tion: An Unusual Presentation of Metastatic Oral Cavity Squamous Cell CarcinomaNicole M. Hsu, MD,1 David I. Kutler MD,1 William I. Kuhel MD,1 Andrew M. Schreiner,

MD,2 Marc A. Cohen, MD1

1. Department of Otolaryngology - Head and Neck Surgery. New York Presbyterian Hospital – Weill Cornell Medical College. New York, NY.2. Department of Pathology and Laboratory Medicine. New York Presbyterian Hospital – Weill Cornell Medical Col-lege. New York, NY.

Abstractoverview Distant soft tissue metastases are rarely seen in patients with head and neck squamous cell carcinoma. When such metastatic foci are found, they are typically painful, discretely palpable masses found in skeletal tissue. However, we describe a rare case of distant soft tissue me-tastasis of a patient with oral cavity SCC presenting as an asymptomatic subcutaneous nodule of the lower extremity detected on PET/CT.

Keywords distant metastasis, subcutaneous nodule, soft tissue, lower extremity

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IntroductionThe incidence of non-lymphatic distant metastasis has been reported in up to 11% of cases of head and neck squamous cell carcinoma (HNSCC).1 The lungs are the most common site of distant metastases, followed by bone, liver, skin, and mediastinum.1 Distant soft tissue metastasis from HNSCC is exceedingly rare with only isolated cases or limited case series reported in the literature. Furthermore, parameters for assess-ing distant metastasis using positron-emission tomography/computed tomography (PET/CT) scans are unclear and have not been adequately studied. We report an unusual case of a 60-year-old patient with floor of mouth squamous cell car-cinoma (SCC) who had an asymptomatic metastatic focus involving the subcutaneous tissue of the left lower extremity detected on PET/CT imaging.

Case ReportA 60-year-old man with a history of left floor of mouth SCC was initially diagnosed and underwent treatment with defini-tive chemoradiation therapy at an outside institution. He had persistent oral pain, worsening odynophagia, and weight loss, and presented to our institution with residual versus recurrent disease at the primary site less than one year after completing treatment.

On physical examination, the patient had a fungating, ulcer-ated mass extending from left alveolar ridge to the floor of mouth bilaterally, anterior tongue fullness (left side greater than the right), and palpable left level II cervical lymphade-nopathy. An incisional biopsy of the left floor of mouth con-firmed that the patient had invasive SCC of the oral cavity. He underwent a CT scan of the neck with contrast showing an ill-defined peripherally enhancing lesion at the base of the tongue, cortical erosion of the anterior mandible, and a 2.1 cm peripherally enhancing multilocular lesion just anterior to the left sternocleidomastoid muscle consistent with a conglomer-ate of level 2A jugulodigastric lymph nodes. A CT scan of the chest revealed a 1.8 x 1.2 cm nodular density in the left upper lobe and left apical pleural thickening. A PET/CT scan was performed which showed [18F]-fluoro-deoxyglucose (FDG) avidity at the primary site, a hypermetabolic 2 cm left level II lymph node, and hypermetabolic activity at the left upper lobe pulmonary nodule and left apical pleural thickening (Figure 1).

On preparation for potential salvage surgery, a CT-guided biopsy of the left lung nodule was scheduled. However, on extensive review of the PET images, an incidental 8mm FDG avid subcutaneous soft tissue nodule of the left lower poste-rior thigh was identified (Figure 2). The patient had not been aware of this nodule, but on palpation, a small mobile subcu-taneous nodule was appreciable. There was no musculoskel-etal pain, surrounding tenderness, or overlying skin changes of the left posterior thigh noted on examination. An ultra-sound-guided fine needle biopsy of the left thigh nodule was performed. Cytologic examination of the aspirate showed

malignant cells diagnostic for SCC (Figure 3). Comparison of this cytologic specimen with the patient’s previous oral cavity biopsy revealed that the morphology of the thigh SCC was consistent with the primary oral cavity SCC (Figure 4).

DiscussionDistant soft tissue metastasis from HNSCC is extremely rare, with less than 1% of metastases from hematogenous origin spreading to the soft tissue.2 While the mechanism by which adipose tissue resists metastasis is unknown, there have been

Figure 1. Skull base to thigh PET scan reveals multiple foci of FDG avidity. There are foci within in the oral cavity, left level II neck, and left lung (upper lobe). Additionally, a small area of FDG avidity is noted in the left thigh.

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presented with palpable cervical lymph nodes, histologic evi-dence of nodal metastasis, extracapsular spread, and multi-nodal involvement are at higher risk of developing distant metastases despite surgical management of their disease.6

Patients with distant soft tissue metastases typically present with a painful, discretely palpable mass or deformity at the metastatic site.7,8 However, they may rarely be asymptomatic at presentation, such as our patient, making diagnosis ex-tremely difficult. 3 When there is a discrete mass, it is impor-tant to differentiate between a primary soft tissue sarcoma and a HNSCC that has metastasized to soft tissue because the management and prognosis are markedly different.2 The pres-ence of soft tissue metastases is associated with an extremely poor prognosis because they generally occur in the setting of systemic spread. As the soft tissue metastasis is unlikely to be the survival-limiting factor, the focus of management should primarily be palliative and aim to limit morbidity.

several specific factors are thought to explain the rarity of skeletal muscle metastases, including: (a) lactic acid produc-tion within muscle creating an unfavorable environment that inhibits growth of tumor cells, (b) high tissue pressure sec-ondary to increase of blood flow during exercise and muscle movement creating a difficult condition for tumor implanta-tion and growth of metastatic cells, and (c) protease inhibitors within the extracellular matrix of muscle resisting invasion by metastatic cells.2-4 Irrespective of these factors, the morbidity and mortality of distant metastatic disease have become in-creasingly recognized, as the overall survival rates of HNSCC have not significantly improved despite better locoregional control secondary to advancements in therapeutic interven-tions.

The occurrence of distant metastases is correlated with ad-vanced stage HNSCC. Kuperman, et al. published a study based on the Surveillance Epidemiology and End Results (SEER) database examining patient factors associated with distant metastasis at the time of presentation.5 They showed that large tumor size, site of primary (glottis, hypopharynx, oropharynx, or oral cavity), advanced nodal status, advanced age, and race were significant risk factors of distant metasta-sis. Additionally, Alvi and Johnson have shown patients who

Figure 2. The fused PET/CT images showing the FDG avid left thigh lesion. The axial image (A.) highlights the hyper-metabolic lesion in the left thigh. However, one can see how subtle this finding can be on the coronal (B.) and sagittal (C.) images.

Figure 3. A cell block section from the left thigh soft tissue FNA showing keratinizing squamous cell carcinoma (H&E, x200).

Figure 4. The floor of mouth biopsy showing infiltrating nests of squamous cell carcinoma, moderately differenti-ated, with keratinization (H&E, x200).

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6. Alvi A, Johnson JT. Development of distant metastasis after treat-ment of advanced-stage head and neck cancer. Head Neck. 1997 Sep;19(6):500-5.

7. Pichi B, Marchesi P, Manciocco V, Ruscito P, Pellini R, Cristalli G, Terenzi V, Spriano G. Carcinoma of the buccal mucosa metastasizing to the talus. J Craniofac Surg. 2009 Jul;20(4):1142-5.

8. Molina-Garrido MJ, Guillén-Ponce C. Muscle metastasis of carcino-ma. Clin Transl Oncol. 2011 Feb;13(2):98-101.

9. Wong RJ, Lin DT, Schöder H, Patel SG, Gonen M, Wolden S, Pfister DG, Shah JP, Larson SM, Kraus DH. Diagnostic and prognostic value of [(18)F]fluorodeoxyglucose positron emission tomography for re-current head and neck squamous cell carcinoma. J Clin Oncol. 2002 Oct 15;20(20):4199-208.

10. Gourin CG, Watts T, Williams HT, Patel VS, Bilodeau PA, Coleman TA. Identification of distant metastases with PET-CT in patients with suspected recurrent head and neck cancer. Laryngoscope. 2009 Apr;119(4):703-6.

11. Subramaniam RM, Truong M, Peller P, Sakai O, Mercier G. Fluorode-oxyglucose-positron-emission tomography imaging of head and neck squamous cell cancer. AJNR Am J Neuroradiol. 2010 Apr;31(4):598-604. Epub 2009 Nov 12.

PET/CT imaging is utilized in the pre-treatment evaluation of HNSCC as well as surveillance imaging to evaluate for recur-rence and development of distant metastasis.9,10 Our patient was completely unaware of his lower thigh nodule until it was detected on the PET/CT scan, which extended from the skull base down through the entire thigh, during his evaluation for potential salvage surgery. The initial report by the radiologist did not comment on the FDG avid nodule in his thigh. It was on the review of the imaging prior to a CT-guide biopsy of the FDG avid pulmonary lesion that this lower extremity nod-ule was identified. Interestingly, if the PET/CT scan extended from skull base to the mid-thigh, as some studies have report-ed is standard, the distant metastatic disease may not have been detected.10,11 This scenario suggests that in cases with ad-vanced disease in which a PET/CT is obtained, it could be potentially useful to have the scan assess inferior to the upper thigh. Furthermore, it is also imperative to note the impor-tance of examining hypermetabolic foci identified on PET/CT scans. Although small areas of hypermetabolic activity may be non-specific and secondary to various other etiologies, such as inflammation or infection, it is essential to investigate areas of FDG avidity to evaluate for possible metastatic disease in HNSCC, which can have a substantial impact on the treat-ment plan for patients with HNSCC.

In conclusion, we describe a rare case of distant soft tissue metastasis of a patient with oral cavity SCC presenting as an asymptomatic subcutaneous nodule of the lower extremity detected on PET/CT. Identifying this subcentimeter meta-static focus in the posterior thigh soft tissue, which went un-noticed during the initial review of the imaging, significantly altered the management of this patient’s care. This scenario illustrates the importance of thoroughly investigating areas of FDG avidity on surveillance PET/CT scan when evaluating for potential metastatic disease in HNSCC.

DisclosuresThe authors have no disclosures or conflicts of interest related to this manuscript.

References1. Calhoun KH, Fulmer P, Weiss R, Hokanson JA. Distant metastases

from head and neck squamous cell carcinomas. Laryngoscope. 1994 Oct;104(10):1199-205.

2. Yoshimura Y, Isobe K, Koike T, Arai H, Aoki K, Kato H. Metastatic Car-cinoma to Subcutaneous Tissue and Skeletal Muscle: Clinicopatho-logical Features in 11 Cases. Jpn J Clin Oncol 2011;41(3)358–364

3. Yurut-Caloglu V, Caloglu M, Oz-Puyan F, Unlu E, Karagol H, Ibis K, Uzal C. An unusual metastatic site of tongue carcinoma: Shoulder muscles. Auris Nasus Larynx 35 (2008) 443–446

4. Sudo A, Ogihara Y, Shiokawa Y, Fujinami S, Sekiguchi S. Intramuscular metastasis of carcinoma. Clin Orthop Relat Res 1993;213–7.

5. Kuperman DI, Auethavekiat V, Adkins DR, Nussenbaum B, Collins S, Boonchalermvichian C, Trinkaus K, Chen L, Morgensztern D. Squa-mous cell cancer of the head and neck with distant metastasis at pre-sentation. Head Neck. 2011 May;33(5):714-8. doi: 10.1002/hed.21529. Epub 2010 Sep 24.

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Case ReportA 14 year boy presented to our hospital with generalized pain in abdomen, vomiting, loss of appetite, low grade fever and weight loss over a period of 2 months. Hae-moglobin was 8gm% and ESR was elevated to 70mm/hr. Matoux test was positive (15mm induration) supporting the diagnosis of tuberculosis. Contrast enhanced CT scan of abdomen was performed for further evaluation. Cen-trally necrotic mesenteric and paraaortic lymph nodes are seen with diffuse thickening of terminal ileum, ileo-caecal junction, caecum, ascending colon and hepatic flexure (Figure1).

A well-defined, thick walled tract is seen arising from the junction between second and third part of duodenum. The tract extends caudally and laterally towards the right iliac fossa to become continuous with terminal ileum suggestive of spontaneous duodenoileal fistula (Figure 2). No surrounding loculated collection or extra luminal air specks are seen ruling out any perforation. Mesenteric

lymph node biopsy revealed caseating granulomas con-firming the diagnosis of tuberculosis.

Fistula is an abnormal communication between two epithelial lined surfaces. Duodenoileal fistula represents abnormal communication between retroperitoneal and intraperitoneal part of small bowel. Duodenoileal fistula has been reported in cases of Crohn’s disease, malignancy and Behcet’s disease.1-4 A single case of tubercular duode-noileal fistula has been reported.5 To the best of authors’ knowledge, cross sectional imaging features of spontane-ous duodenoileal fistula secondary to tuberculosis has not been reported in the literature. Besides demonstrat-ing the tract,

CT scan provides status of distal small and large bowel which is extremely important in the management of duo-denoileal fistula as closure of fistula with diseased distal bowel will lead to recurrence of fistula.

Conflict of InterestThe authors declare that they have no conflict of interest.

References1. Donnerstag F, Kirchner J, Laufer U, Kickuth R, Doberauer C,

Liermann D. Duodeno-ileal fistula development due to retro-peritoneal lymph node metastases of sigmoid carcinoma. Z Gas-troenterol. 2000 Jun;38(6):505-8.

2. Ghidirim G, Ignatenco S, Mişin I, Gagauz I, Tiple I, Cuţitari I,

Citation Naphade et al. Computed Tomography of spon-taneous Tubercular Duodenoileal Fistula. J Surg Ra-diol. 2013 Jul 1;4(3).

CorrespondenCe Prashant Naphade, M.D., D.N.B. E-mail prashant.nafade@gmail.com

reCeived June 1, 2013. aCCepted May 1, 2013. epub July 1, 2013.

Computed Tomography of Spontaneous Tubercular Duodenoileal FistulaPrashant Naphade1, M.D., D.N.B., Abhishek R. Keraliya1, D.M.R.D., D.N.B.

1. Department of Radiology, E.S.I. hospital, Mumbai-400093

Abstractoverview A 14 year boy presented to our hospital with generalized pain in abdomen, vomiting, loss of appetite, low grade fever and weight loss over a period of 2 months. Haemoglobin was 8gm% and ESR was elevated to 70mm/hr. Matoux test was positive (15mm induration) supporting the diag-nosis of tuberculosis. Contrast enhanced CT scan of abdomen was performed for further evaluation.

Keywords Duodenoileal fistula, Tuberculosis, Computed Tomography

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Zastavniţchi G. Recurrent Crohn's disease in the ileocolonic anasto-mosis complicated with duodenal fistula. Chirurgia (Bucur). 2007 Sep-Oct;102(5):607-10.

3. HwangBo Y, Kim HJ, Ahn HS, Lee MR, Jang JY, Kim NH et al. A Case of Spontaneous Duodenoileal Fistula in Behcet's Disease. Korean J Gastrointest Endosc. 2006 Jan;32(1):57-61.

4. Wilk PJ, Fazio V, Turnbull RB Jr. The dilemma of Crohn's disease: il-eoduodenal fistula complicating Crohn's disease. Dis Colon Rectum. 1977 Jul-Aug;20(5):387-92.

5. Mezey E, Nichols AW, Holt PR. Tuberculous ileoduodenal fistula. Gas-troenterology. 1967 Jan;52(1):83-7.

Figure 1. Contrast enhanced CT axial (A) and coronal (B) multiplanar reconstruction reveal thickening of hepatic flexure (white arrow), adjacent thick walled enhancing tract (black arrow) and multiple enlarged necrotic mesenteric and paraaortic lymph nodes.

Figure 2. Contrast enhanced CT coronal (A) and sagittal (B) curved planar reconstruc-tions reveal thick walled peripherally enhancing fistulous tract (thin white arrow) ex-tending from junction of second(thick white arrow) and third part(thick black arrow) of duodenum to the distal ileum.

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IntroductionAcute abdominal pain is one of the most common pre-senting complaints in emergency department visits 1. An overwhelming number of cases present with pain local-ized to the right lower quadrant, indicative of acute ap-pendicitis, a diagnosis is often made clinically and for which surgery is required 2. The use of CT scan has risen dramatically in the evaluation and management of pa-tients presenting to the emergency department with acute abdominal pain. A recent study estimated that 69% of

patients in 2006 underwent CT scan to assist in the diag-nosis of acute appendicitis, compared with 6.3% in 1996 3. In the context of a normal appearing appendix on CT scan, common conditions that mimic appendicitis must be considered, including diverticular disease of the ce-cum or right colon, mesenteric adenitis, bowel ischemia, Crohn’s disease, epiploic appendagitis, intussusception, Meckel’s diverticulitis, pyelonephritis, and urinary tract obstruction. In female patients, common gynecologic in-cluding pelvic inflammatory disease, ectopic pregnancy, endometriosis, and ruptured ovarian cyst must be in-cluded.

Meckel’s diverticulum, with an estimated prevalence of 2-3%, is the most common congenital abnormality of the gastrointestinal tract 4. It is caused by failure of complete obliteration of the omphalomesenteric duct (also known as the Vitelline duct) during the 7th week of gestational development of the gastrointestinal tract. A Meckel’s di-verticulum is a true diverticulum, containing all three lay-ers of the small intestine, and is most commonly located

Citation Mullen et al. Preoperative CT Scan Diagnosis of Acute Meckel’s Diverticulitis: Case Report and Litera-ture Review. 2013 Jul 1;4(3).

CorrespondenCe Matthew G. Mullen E-mail mmullen314@gmail.com.reCeived June 3, 2013. aCCepted July 1, 2013. epub July 1,

2013.

Preoperative CT Scan Diagnosis of Acute Meckel’s Diverticulitis: Case Report and Literature ReviewMatthew G. Mullen, BS1; Joseph P. Bannon, MD1, 2;Scott Dalane, BS1; John Farrell, MD1, 3

1. The Commonwealth Medical College, Scranton PA2. Delta Medix, PC, Scranton PA3. Radiology Consults Inc., Scranton PA

Abstractoverview Meckel’s diverticulitis presentation often mimics other intra abdominal pathologies. In most cases, diagnosis occurs during exploratory surgery. Preoperative CT diagnosis of an inflamed Meckel’s diverticulum is rarely reported. Diagnostic criteria include visualization, location continu-ous with the distal ileum, size, mural thickness, content of the diverticulum, and identification of a normal appendix. Most patients with Meckel’s diverticulitis could be diagnosed with CT scan of the abdomen and pelvis, and accurate preoperative diagnosis greatly facilitates surgical intervention.

Keywords Meckel’s diverticulum, Meckel’s diverticulitis, CT scan diagnosis

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2 feet (60.96 cm) proximal to the ileocecal valve with average dimensions of 2.99-cm long and 1.92-cm wide 5,6.

Meckel’s diverticula generally remain asymptomatic. Studies have shown a lifetime complication rate of 4-16%. An esti-mated 62% of cases of Meckel’s diverticulum contain ectopic gastric mucosa, which may ulcerate and classically presents with painless rectal bleeding in a young child 7,8. Other com-plications, more common in the adult population, include intussusception, bowel obstruction (most commonly due to omphalomesenteric band), inflammation, and perforation. A Meckel’s diverticulum has been known as “a great mimic that must be considered in all cases of intra-abdominal disease in which the cause is not readily apparent” 9. Meckel’s diver-ticulitis, as described in this case, is more commonly seen in older patients. Pathogenesis of the complication is analogous to that of acute appendicitis, resulting from obstruction by a lymphatic hypertrophy or presence of an enterolith at the base of the diverticulum. For this reason, long narrow-based diver-ticula are at greatest risk of obstruction and inflammation 10.

Case ReportA 33-year-old male presented to the emergency department with complaints of lower abdominal pain of several days du-ration. The pain had localized to the right lower quadrant of his abdomen during the morning prior to his presentation. The pain was associated with nausea and anorexia. He de-nied recent vomiting, diarrhea, constipation, melena, hema-tochezia, or other associated symptoms. He did not have any prior abdominal surgery. He was not taking any medications regularly.

On examination, the patient was not in acute distress. He was afebrile with stable vitals signs. Physical examination dem-onstrated a slightly distended, soft abdomen with tenderness and localized guarding in the right lower quadrant.

A non contrast-enhanced, axial CT scan of the abdomen and pelvis taken in the emergency department demonstrated a thick walled, air and debris containing ovoid structure medial to the cecum. The structure appeared to be continuous with the distal ileum and measured 6.6 cm in its greatest dimen-sion. Infiltration of fat was observed immediately adjacent to the structure and two course calcifications were seen with-in the structure. No perforation or adjacent drainable fluid collection was seen. Multiple, mildly prominent mesenteric lymph nodes were visible in the right lower quadrant, likely representative of a reactive process. The appendix and cecum were both clearly visible and normal in appearance. CT scan findings were consistent with an inflamed Meckel’s diverticu-lum.

Based on the patient’s clinical presentation and radiographic findings, preoperative diagnosis of acute inflammation of a Meckel’s diverticulum (Meckel’s diverticulitis) was made. The patient was taken to the operating room and explored lapa-roscopically. A large, inflamed diverticulum protruding from the distal ileum was visualized. The diverticulum appeared

Figure 1. Non contrast-enhanced axial CT scan of the ab-domen shows an ovoid, thick-walled mass (M) containing gas and debris in the right lower quadrant. There are inflammatory changes in the adjacent fat. The structured measured 6.6 cm in its greatest dimension. Mass is me-dial to the cecum (C) and is continuous with the terminal ileum (TI). The images also demonstrate that the appendix (A) is normal in caliber and demonstrates no inflammatory changes.

Figure 2. Coronal reconstruction of axial CT scan of the abdomen without contrast demonstrates ovoid mass (M) in the right lower quadrant medial, but not continuous with the cecum and ascending colon. The structure is filled with gas and debris, and has a thickened wall compared with large and small bowel. The images depict that the finding is continuous with the terminal ileum (TI).

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original artiCle Mullen et al. CT Diagnosis of Meckel’s DiverticulitisThis is likely due to a variable appearance on imaging stud-ies, difficulty in distinguishing a Meckel’s diverticulum from a loop of small bowel, and ambiguous clinical presentation. A study performed by Bennett et al. retrospectively reviewed contrast enhanced helical CT scans of 11 patients with pathol-ogy proven Meckel’s diverticulitis to evaluate the ability to ob-serve known cases of Meckel’s diverticulitis on preoperative CT scan. In nine out of 11 patients, the diverticulum could be definitively identified. The diagnostic criteria for identifying an inflamed Meckel’s diverticulum on CT scan include visual-ization, location continuous with the distal ileum, size, mural thickness, and content of diverticulum (commonly air, fluid and debris). Mesenteric lymphadenopathy, inflammation, perforation and obstruction are other findings associated with inflamed diverticula. A normal appendix should also be iden-tified, due to similarities in clinical presentation 18. It is im-portant to note that non-visualization of the appendix at CT scan also can virtually exclude the diagnosis of appendicitis 2.

Symptoms resulting from a Meckel’s diverticulum require prompt surgical correction, which is generally performed lap-aroscopically. Bleeding complications of Meckel’s diverticula occurs due to mucosal ulceration caused by ectopic gastric tissue. Ulcerations may occur from within the diverticulum or from the adjacent segment of ileum; therefore, wedge resection of the adjacent segment of ileum with anastamosis is the rec-ommended treatment in a patient who presents with bleeding. Surgical excision of asymptomatic Meckel’s diverticula found incidentally at laparotomy or laparoscopy remains an issue of controversy, and is not recommended when the diverticulum is short, with a wide base, and in patients over 50 years of age 10,19. Meckel’s diverticulitis generally does not involve the adja-cent segment of ileum; therefore, simple excision using endo-staplers at laparoscopy is often sufficient, provided the base is normal. Appendectomy should be performed in all patients with Meckel’s diverticulitis 6.

ConclusionMeckel’s diverticulum complications should be included in the differential diagnosis of patients presenting with acute ab-dominal pain localized to the right in the context of a normal appearing appendix on CT scan. With increased use of high quality imaging studies in emergency department for the eval-uation of patients with acute abdominal pain, the accuracy of preoperative diagnosis of intra-abdominal pathology, includ-ing symptomatic Meckel’s diverticula will inevitably increase 17. If the diagnosis of Meckel’s diverticulitis can be established preoperatively, the operative approach may be altered. For ex-ample, in the case of an open operation, a midline incision may be preferable to a McBurney’s incision. Laparoscopy of-fers multiple advantages to the surgeon and to the patient, and when available, a laparoscopic approach for the resection of an inflamed Meckel’s diverticulum is advised. Most patients with Meckel’s diverticulitis could be diagnosed on CT scan imaging of the abdomen and pelvis, and accurate preoperative diagno-ses greatly facilitate surgical intervention.

to have a walled-off perforation encased in greater omentum. Laparoscopic findings were consistent with the preoperative diagnosis of acute Meckel’s diverticulitis. The visibly inflamed diverticulum was resected and an incidental appendectomy performed. Pathologic examination confirmed the preopera-tive and intraoperative diagnosis of Meckel’s diverticulitis.

The patient was seen for follow-up two weeks later without pain or discomfort. His activities and appetite had returned to normal and postoperative course was uneventful.

DiscussionThe preoperative diagnosis of Meckel’s diverticulitis, especial-ly those presenting in adults with non-bleeding complications, has proven to be a great challenge to clinicians. As said by Charles Mayo, “Meckel’s diverticulum is frequently suspected, often looked for and seldom found”. A “Meckel scan” is the gold standard imaging study to diagnose a Meckel’s diverticu-lum, performed by injection of 99m technetium and subse-quent scintigraphy to identify areas of ectopic gastric mucosa. Although this study has a high sensitivity and specificity for making a diagnosis, most Meckel’s diverticula are discovered incidentally at laparotomy. Other imaging studies have been used to make a diagnosis of Meckel’s diverticulum, includ-ing barium studies, selective arteriography, ultrasonography, capsule endoscopy, and CT scan, but overlapping clinical and imaging features of other acute abdominal conditions make preoperative diagnosis a challenge 11.

Multidetector CT scan, because of its high accuracy in the di-agnosis of appendicitis, is considered the imaging method of choice in patients presenting with right lower quadrant pain 2. Despite this, few reports exist in the radiologic, surgical, or emergency medicine literature that has described the pre-operative diagnosis of Meckel’s diverticulitis by CT scan 12-17.

Figure 3. Photograph of large, inflamed Meckel’s diver-ticulum (M) taken laparoscopically at the time of surgery, located in the right lower quadrant and arising from adja-cent distal ileum (TI)

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DisclosuresThe authors have no disclosures or conflicts of interest related to this manuscript.

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2. Purysko AS, Remer EM, Filho HM, Bittencourt LK, Lima RV, Racy DJ. Beyond appendicitis: common and uncommon gastrointestinal causes of right lower quadrant abdominal pain at multidetector CT. Radio-graphics. Jul-Aug 2011;31(4):927-947.

3. Tsze DS, Asnis LM, Merchant RC, Amanullah S, Linakis JG. Increas-ing Computed Tomography Use for Patients With Appendicitis and Discrepancies in Pain Management Between Adults and Children: An Analysis of the NHAMCS. Ann Emerg Med. Jul 28 2011.

4. Moore TC. Omphalomesenteric duct malformations. Semin Pediatr Surg. May 1996;5(2):116-123.

5. Uppal K, Shane Tubbs R, Matusz P, Shaffer K, Loukas M. Meckel’s di-verticulum: a review. Clin Anat. May 2011;24(4):416-422.

6. Palanivelu C, Rangarajan M, Senthilkumar R, Madankumar MV, Kavalakat AJ. Laparoscopic management of symptomatic Meck-el’s diverticula: a simple tangential stapler excision. JSLS. Jan-Mar 2008;12(1):66-70.

7. Elsayes KM, Menias CO, Harvin HJ, Francis IR. Imaging manifestations of Meckel’s diverticulum. AJR Am J Roentgenol. Jul 2007;189(1):81-88.

8. Schmid SW, Schafer M, Krahenbuhl L, Buchler MW. The role of lapa-roscopy in symptomatic Meckel’s diverticulum. Surg Endosc. Oct 1999;13(10):1047-1049.

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Citation Desai et al. Infectious Mononucleosis-Like Syn-drome Presented in Toxoplasmosis Infection. J Surg Radiol. 2013 Jul 1;4(3).

CorrespondenCe Anahita Dua, MD Contact: anahita.dua@uth.tmc.edu

reCeived July 1, 2013. aCCepted July 1, 2013. epub July 1, 2013.

Infectious Mononucleosis-Like Syndrome Presented in Toxoplasmosis InfectionPathik J Desai MD1, Anahita Dua MD2,3, Jason McMaster MD3, Bhavin Patel BS3, Arshish Dua BA3, SreyRam Kuy MD, MHS3, Sapan Desai MD, PhD, MBA4, Joanna Krzowska-Firych MD1

1. Department of Medicine - The Medical University of Lublin, Poland2. Center for Translational Injury Research (CeTIR), Department of Surgery - The University of Texas Health Science Center at Houston, TX3. Department of Surgery, Medical College of Wisconsin, Milwaukee, WI4. Duke University Medical Center, Durham, NC

AbstractintroduCtion Thorough physical exam and a systematic approach to patients who present with non-specific symptoms of IM-Like syndrome are imperative to appropriate therapy. We discuss a case of a 25-year-old Caucasian male who presented with a fever of 38C (100.4F), pharyngeal red-ness, and lymphadenopathy and was admitted to the medicine service with a diagnosis of EBV. This case report details the diagnosis, management and treatment of a patient with IM-LIKE disease and discusses the current literature around the topic.

Keywords infectious mononucleosis, toxoplasmosis, EBV, Ebstein-Barr virus

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IntroductionToxoplasmosis is caused by infection with an obligate intra-cellular protozoan Toxoplasma gondi;although it infects one-third of the world's population, majority of cases are found to be latent and asymptomatic. In this case we evaluated how a presentation of toxoplasmosis was similar to symptoms consistent with Infectious mononucleosis-like syndrome. It is important to consider all causative pathogens in patients presenting with mononucleosis-like syndrome by using sys-tematic diagnostic processes that would avoid unnecessary investigations and treatment.

Case PresentationA 25-year-old Caucasian male presented with a fever of 38C (100.4F), pharyngeal redness, and lymphadenopathy. His pri-mary care physician started a standard regimen of Amoxicil-lin and discharged the patient. Two weeks later the patient was referred to the Infectious Disease Department at the Medical University of Lublin due to the presence of flu-like symptoms, characterized by malaise, myalgia, headache, fatigue, pharyn-gitis and lymphadenopathy and with a rash described with a distribution as “measles-like”, starting from the patient's trunk and spreading to the extremities. The physical examination consists with symptoms of mononucleosis-like syndrome. Laboratory evaluations showed the patient to have lymphocy-tosis, monocytosis, neutropenia and the presence of abnormal liver enzymes without jaundice (Table 1). This presentation was consistent with Infectious mononucleosis caused by Ep-stein-Barr virus which was the primary differential diagnosis.

Serology was taken to confirm this diagnosis (Table 2). How-ever serology revealed that VCAIgM was negative for EBV. Further studies showed antibodies for CMV IgM&IgG to be negative; tests for Hepatitis A, B, & C negative; antibodies for Toxoplasma gondii IgM as positive. The diagnosis for Toxo-plasmosis was confirmed and the patient was treated with Py-rimethamine and Suldadiazine. He made a full recovery

DiscussionOur case highlights the importance of a thorough physical exam and a systematic approach to patients who present with non-specific symptoms such as muscle aches, fatigue, and lymphadenopathy termed "Mononucleosis-like syndrome." IM-like syndromes are independently associated with fever lasting longer than seven days, lymphadenopathy, elevated liver enzymes, and lymphocytosis greater than or equal to 40% of white blood cells. The causative pathogens in patients presenting with IM-like syndrome include CMV, HIV, HAV, HBV, HCV, HEV, HHV6, parvovirus B19, Rubella virus, sec-ondary syphilis, cat-scratch disease, Chlamydia psittaci, and Toxoplasma gondii and these must be systematically ruled out in a patient who is EBV negative. The pathophysiology that leads to this non-specific symptom development is similar for all of these infections; IL-12 is released early in infection and potentiates the production of IFN-A by NK cells and T cells. Pro-inflammatory cytokines and macrophages respond directly to parasite antigens by producing IL-12 and TNF-A perpetuating this inflammatory cycle until the inciting patho-gen is controlled.1-4 Toxoplasmosis is caused by infection with an obligate intracellular protozoan; which infects more than one-third of the world's population, passing from animal res-ervoirs to humans.

Infections fall into three basic patterns: congenital, a weakened immunological state along with presenting itself in a healthy adult.1-5 Patients with otherwise healthy immune systems can present with symptoms similar to those with Infectious mono-nucleosis-like syndrome are characterized by malaise, myal-gia, headache, fatigue, sore throat and lymphadenopathy. The clinical course of mononucleosis-like syndrome is relatively common and has a benign presentation. The non-allergic Amoxicillin rash may also have been an indicator of infec-tious mononucleosis (EBV) or mononucleosis like syndrome attributed to Cytomegalovirus, Human Immunodeficiency vi-rus, Hepatitis A, B, C or E virus and Toxoplasma gondii. It has been suggested by dermatologists that the observed rash could be due to a drug-induced hypersensitivity syndrome or a simi-

Table 1. Laboratory data

Total WBC Values (%) Normal (%) Lymphocytes 60.8 17.4 - 44.3 Monocytes 13.9 3.1 - 8.7 Neutrophils 20.7 48.7 - 70.1 Serum Values (K/uL) Normal(K/uL) Lymphocytes 5.59 0.8 – 4.3 Monocytes 1.28 0.2 - 0.8 Neutrophils 1.90 2.8 - 6.8 Liver Enzymes Values (U/L) Normal(U/L) ALT 376.8 9 - 60 AST 196.9 10 - 40

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original artiCle Desai et al. Infectious Mononucleosis

lar reaction seen with drugs such as minocycline, allupurinol and carbamazepines. In an immune-competent host, acute in-fection usually is asymptomatic according to a study that was conducted in 2006 by the Institute of Tropical Medicine in Belgium; over a five year period 72/1,842 patients (4%) were diagnosed with an IM-like syndrome, including 36 CMV, 16 T gondii, 15 EBV, and 5 HIV primary infections.1 Patients that presented with Infectious Mononucleosis featured lymphocy-tosis greater or equal to 40% of the white blood cells and reac-tive/atypical lymphocyte morphology was observed in 30% of the patients. The pathogens that were responsible for giving mononucleosis like syndromes appeared to be indistinguish-able from each other. IM-like syndromes were independently associated with fever lasting longer than seven days, lymph-adenopathy, elevated liver enzymes, and lymphocytosis greater than or equal to 40% of white blood cells. Diagnosis of toxo-plasmosis most commonly relies on the recognition of host risk factors and clinical symptoms, in conjunction with sup-portive information from radiographic and serologic studies. Conclusion: We discuss the presentation and management of a patient with non-specific symptoms of IM-Like syndrome. Thorough physical exam and a systematic approach are im-perative to appropriate therapy and successful outcome.

References1. Bottieau E, Clerinx J, Van den Enden E, Van Esbroeck M, Colebunders

R, Van Gompel A, Van den Ende J. Infectious mononucleosis-like syn-dromes in febrile travelers returning from the tropics. J Travel Med. 2006 Jul-Aug;13(4):191-7.

2. Bottieau E, Florence E, Clerinx J, Vlieghe E, Vekemans M, Moerman F, Lynen L, Colebunders R, Van Gompel A, Van den Ende J. Fever after a stay in the tropics: clinical spectrum and outcome in HIV-infect-ed travelers and migrants. J Acquir Immune DeficSyndr. 2008 Aug 15;48(5):547-52. doi: 10.1097/QAI.0b013e31817bebc5.

3. Bravender T. Epstein-Barr virus, cytomegalovirus, and infectious mononucleosis. Adolesc Med State Art Rev. 2010 Aug;21(2):251-64, ix.

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5. Hossain A. Infectious mononucleosis and mononucleosis-like ill-nesses in children and adults in Saudi Arabia. J Trop Pediatr. 1989 Jun;35(3):121-5.

Table 2: Serology

Epstein-Barr VCAIgM Negative Cytomegalovirus IgM antibody Negative Cytomegalovirus IgG antibody Negative Hepatitis A, B, C Negative HIV Negative Toxoplasma IgM antibody 5.15 IU/mL Toxoplasma IgG antibody 279 IU/mL

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