What study is this?..and what is the proper indication of it?...soon I'll post the conclusion of this case..
martes, 31 de enero de 2012
CASE 5 (part 2): 65 y/o female pt with seizures and sudden loss of consciousness
For ambiguity of findings...¿?...(apparently)..here is this complementary exam..
What study is this?..and what is the proper indication of it?...soon I'll post the conclusion of this case..
What study is this?..and what is the proper indication of it?...soon I'll post the conclusion of this case..
jueves, 26 de enero de 2012
CASE 5: 65 y/o female pt with seizures and sudden loss of consciousness
Well here is a complete CT scan of a pt with seizures. No history of medications, or any disease. Patient underwent CT scan directly from the ER with a GCS of 9, so therefore slices are a bit oblique.
Again click to enlarge..
Findings please..
Again click to enlarge..
Findings please..
jueves, 19 de enero de 2012
DX: Fourth metacarpal bone hypoplasia
Ok, I think this was by far the most easy to recognize. Hope it's your situation if not, here is the magnified spot:
So, there is a shortened 4th metacarpal bone that has no relation with recent trauma history. To manifest this finding you can draw a line along the 3d and 5th metacarpal heads this is called my "modified" positive metacarpal sign:
If the 4th metacarpal head intersects with the line, is a negative metacarpal sign. In our case is obviously a positive metacarpal sign as the longitudinal axis of the bone shows isolated restricted development. I called it "modified" because the real measurement is done by drawing a line from the 5th and 4th metacarpal head and is a positive sign when encounters the 3rd metacarpal head. Not too much of a modification but anyways...the real deal is the questions that crossed my mind when I saw this.
My first impression is that could be normal. Maybe a normal but rare variant? And I could be right because literaure says is a normal variant in up to 9.8% of individuals. This tells me that there is a good possibility (almost 90%) that this is a manifestation of a systemic or congenital disease. So therefore we have to search an entity and give differentials to help the patient that maybe unaware of his condition.
Let´s see if this is a congenital malformation. My patient was a mid thirties male patient with no clinical manifestations (apparently) as stated in the history. This almost discharges Turner syndrome as a possibility (as one previous comment kindly suggested), because Turner affects exclusively in women (x-related cromosopathy). It has a wide variety of fenotipic stigmata including isolated 4th metacarpal bone hypoplasia. Another syndrome that has the same manifestations and affects males and females the same is Noonan syndrome. This entity has a normal kariotype unlike Turner's. So should I keep Noonan as a possibility?..maybe but is very rare and the clinical manifestations are striking to avoid. Other congenital abnormality found to develop this type of hypoplasia is Cleido-cranial dysostosis. This is a general skeletal condition so named from the collarbone (cleido-) and cranium deformities which people with it often have. The collarbone or clavicle abnormalities include hypoplasia or aplasia and is manifested as a capability of joining both shoulders in the midline. Cranial deformities include microcephaly with bulging of the forehead, wormian bones, etc. Associated anomalies include supernumerary teeth and deformity of phalanges such as 4th metacarpal hypoplasia. Non congenital causes are more frequently observed and they have to be on the top of my diagnostic possibilities. The most associated is pseudohypoparathyroidism wich is a condition of end organ resistance to the parathormone PTH. Serum levels of PTH are high with low calcium serum level. Other conditions include post-traumatic compicated bode healing and post-infective causes such as Osteomyelitis. Less frequent are sickle cell disease with secondary bone infarction and Gorlin's disease.
My differentials are as listed below:
1. Pseudohypoparathyroidism; recomendation -> correlate with PTH serum levels
2. Normal idiopatic variant.
3. Cleido-cranial dysostosis -> correlate with a screening of clavicle, head, and feet x-ray projections.
As always comments are very welcome!
http://radiopaedia.org/articles/short-4th-5th-metacarpal
Reeder and Felson's gamuts in radiology. Maurice M. Reeder; with MRI gamuts by William G. Bradley, Jr., and ultrasound gamuts by Christopher R. Merritt and input from a distinguished 20-member subspecialty editorial board. New York : Springer, c2003
An evaluation of the metacarpal sign (short fourth metacarpal). Pediatrics. 1970;46 (3): 468-71
Rev Cubana Med 1999;38(2):117-22. Hospital Clinicoquirúrgico "Celia Sánchez Manduley". Manzanillo-Granma. Servicio de Medicina Interna. Disostosis cleido-craneal. Estudio clínico, radiográfico y genético de una familiaDr. César Mustelier Fernández, Dra. Marlenes Chang Lago, Dr. Arturo Luis Almunia Leyva y Dra. Mireille Molero Segrera
So, there is a shortened 4th metacarpal bone that has no relation with recent trauma history. To manifest this finding you can draw a line along the 3d and 5th metacarpal heads this is called my "modified" positive metacarpal sign:
If the 4th metacarpal head intersects with the line, is a negative metacarpal sign. In our case is obviously a positive metacarpal sign as the longitudinal axis of the bone shows isolated restricted development. I called it "modified" because the real measurement is done by drawing a line from the 5th and 4th metacarpal head and is a positive sign when encounters the 3rd metacarpal head. Not too much of a modification but anyways...the real deal is the questions that crossed my mind when I saw this.
My first impression is that could be normal. Maybe a normal but rare variant? And I could be right because literaure says is a normal variant in up to 9.8% of individuals. This tells me that there is a good possibility (almost 90%) that this is a manifestation of a systemic or congenital disease. So therefore we have to search an entity and give differentials to help the patient that maybe unaware of his condition.
Let´s see if this is a congenital malformation. My patient was a mid thirties male patient with no clinical manifestations (apparently) as stated in the history. This almost discharges Turner syndrome as a possibility (as one previous comment kindly suggested), because Turner affects exclusively in women (x-related cromosopathy). It has a wide variety of fenotipic stigmata including isolated 4th metacarpal bone hypoplasia. Another syndrome that has the same manifestations and affects males and females the same is Noonan syndrome. This entity has a normal kariotype unlike Turner's. So should I keep Noonan as a possibility?..maybe but is very rare and the clinical manifestations are striking to avoid. Other congenital abnormality found to develop this type of hypoplasia is Cleido-cranial dysostosis. This is a general skeletal condition so named from the collarbone (cleido-) and cranium deformities which people with it often have. The collarbone or clavicle abnormalities include hypoplasia or aplasia and is manifested as a capability of joining both shoulders in the midline. Cranial deformities include microcephaly with bulging of the forehead, wormian bones, etc. Associated anomalies include supernumerary teeth and deformity of phalanges such as 4th metacarpal hypoplasia. Non congenital causes are more frequently observed and they have to be on the top of my diagnostic possibilities. The most associated is pseudohypoparathyroidism wich is a condition of end organ resistance to the parathormone PTH. Serum levels of PTH are high with low calcium serum level. Other conditions include post-traumatic compicated bode healing and post-infective causes such as Osteomyelitis. Less frequent are sickle cell disease with secondary bone infarction and Gorlin's disease.
My differentials are as listed below:
1. Pseudohypoparathyroidism; recomendation -> correlate with PTH serum levels
2. Normal idiopatic variant.
3. Cleido-cranial dysostosis -> correlate with a screening of clavicle, head, and feet x-ray projections.
As always comments are very welcome!
http://radiopaedia.org/articles/short-4th-5th-metacarpal
Reeder and Felson's gamuts in radiology. Maurice M. Reeder; with MRI gamuts by William G. Bradley, Jr., and ultrasound gamuts by Christopher R. Merritt and input from a distinguished 20-member subspecialty editorial board. New York : Springer, c2003
An evaluation of the metacarpal sign (short fourth metacarpal). Pediatrics. 1970;46 (3): 468-71
Rev Cubana Med 1999;38(2):117-22. Hospital Clinicoquirúrgico "Celia Sánchez Manduley". Manzanillo-Granma. Servicio de Medicina Interna. Disostosis cleido-craneal. Estudio clínico, radiográfico y genético de una familiaDr. César Mustelier Fernández, Dra. Marlenes Chang Lago, Dr. Arturo Luis Almunia Leyva y Dra. Mireille Molero Segrera
martes, 17 de enero de 2012
CASE 4: Patient with recent hand trauma
Here is a really small but hopefully useful post....Patient had trauma when working with tools in his home. No relevant data on admission.
Here is the single image, click to enlarge:
Findings and suggestions...
Here is the single image, click to enlarge:
Findings and suggestions...
sábado, 14 de enero de 2012
Commentary on Article
Here is a brief review on a recent article posted in the RSNA journal "Radiology" on December 2011. It was made by these authors:
Anwar R. Padhani, MB, BS, FRCP, FRCR,
Dow-Mu Koh, MD, MRCP, FRCRand
David J. Collins, BA, MInstP
And it was made in The Royal Mardsen Hospital, Sutton Surey, England. Here are some pictures of the Hospital:
So, the purpose of the article was to show how the whole body sequence Diffusion Weighted Image (DWI) used in Magenetic Resonance Imaging (MRI) can be used as a important tool for oncologic patients in every step of the stages either diagnostic, response to treatment or in resolution period.
The DWI sequence is not a novelty itself and it's use in MRI is widely known. It was developed in the 80´s and the main use of this sequence has been detecting brain isquemia or also called acute stroke. The physics of DWI is that allows the mapping of the diffusion process of molecules, mainly water in biological tissues in vivo called the Brownian motion of particles so when there is a restriction of the motion of particles (suchs as stroke) it is represented as a bright signal. In the past decade there has been several advances in the use of DWI in several other entities and in other parts of the body. Special interest has been shown in tumoral processes because hypercelularity and packed tissues as in a tumor has briht signal in DWI. Several other benefits are that there are NO use of ionizing radiation, NO use of any intravenous or oral contrast, relatively short time adquisition of images, NO use of radioactive material, more availability of MRI than PET or SPECT. Right now worldwide there are several investigations published and more yet to come how this sequence is used in several parts of the body but none (to my knowledge) that uses a complete whole body scan in DWI.
The technical aspects of this article are a bit complex and it is not my intention to describe those but is important to say that they use mainly 1.5 Tesla with a body coil. 3 Tesla magnets are not ase useful because they lack of fat supression in wide body areas and are more susceptible to artifacts.
One of the great tools we have in monitoring tumoral disease is positron emmision thomography (PET) so here I share to you the comparision of DWI and PET screening in a 23 y/o patient with Hodgkin Lymphoma pre and post quemotherapy treatment.
The images in A. are DWI coronal images that show a wide tumor in mediastinum with several lymph nodes in supraclavicular and axilar region and some of spleen involment too, but post treatment they were almost gone. In B. we see the PET scanning of the same patient pre and post quemotherapy with almost the same conclusion. Arrow shows the spleen involment also seen in DWI. The black spots in thorax and in pelvis are the radionuclide IV contrast that in the heart there is a increased uptake wich is normal and in pelvis represents the urinary bladder filled with the IV contrast. See kidneys are still eliminating it.
There is also in the article a recomendation to be familiar with the normal intensity of signal in all organs because some of them have physiologic more water concentration. Also there has to be an ADC map wich is comparative and usefull in depicting celularity but it's still a complex technique that requieres some expertise training.
It's a promising tool that we have to check into..
Here is the link to the abstract:
http://radiology.rsna.org/content/261/3/700.abstract
Anwar R. Padhani, MB, BS, FRCP, FRCR,
Dow-Mu Koh, MD, MRCP, FRCRand
David J. Collins, BA, MInstP
And it was made in The Royal Mardsen Hospital, Sutton Surey, England. Here are some pictures of the Hospital:
So, the purpose of the article was to show how the whole body sequence Diffusion Weighted Image (DWI) used in Magenetic Resonance Imaging (MRI) can be used as a important tool for oncologic patients in every step of the stages either diagnostic, response to treatment or in resolution period.
The DWI sequence is not a novelty itself and it's use in MRI is widely known. It was developed in the 80´s and the main use of this sequence has been detecting brain isquemia or also called acute stroke. The physics of DWI is that allows the mapping of the diffusion process of molecules, mainly water in biological tissues in vivo called the Brownian motion of particles so when there is a restriction of the motion of particles (suchs as stroke) it is represented as a bright signal. In the past decade there has been several advances in the use of DWI in several other entities and in other parts of the body. Special interest has been shown in tumoral processes because hypercelularity and packed tissues as in a tumor has briht signal in DWI. Several other benefits are that there are NO use of ionizing radiation, NO use of any intravenous or oral contrast, relatively short time adquisition of images, NO use of radioactive material, more availability of MRI than PET or SPECT. Right now worldwide there are several investigations published and more yet to come how this sequence is used in several parts of the body but none (to my knowledge) that uses a complete whole body scan in DWI.
The technical aspects of this article are a bit complex and it is not my intention to describe those but is important to say that they use mainly 1.5 Tesla with a body coil. 3 Tesla magnets are not ase useful because they lack of fat supression in wide body areas and are more susceptible to artifacts.
One of the great tools we have in monitoring tumoral disease is positron emmision thomography (PET) so here I share to you the comparision of DWI and PET screening in a 23 y/o patient with Hodgkin Lymphoma pre and post quemotherapy treatment.
The images in A. are DWI coronal images that show a wide tumor in mediastinum with several lymph nodes in supraclavicular and axilar region and some of spleen involment too, but post treatment they were almost gone. In B. we see the PET scanning of the same patient pre and post quemotherapy with almost the same conclusion. Arrow shows the spleen involment also seen in DWI. The black spots in thorax and in pelvis are the radionuclide IV contrast that in the heart there is a increased uptake wich is normal and in pelvis represents the urinary bladder filled with the IV contrast. See kidneys are still eliminating it.
There is also in the article a recomendation to be familiar with the normal intensity of signal in all organs because some of them have physiologic more water concentration. Also there has to be an ADC map wich is comparative and usefull in depicting celularity but it's still a complex technique that requieres some expertise training.
It's a promising tool that we have to check into..
Here is the link to the abstract:
http://radiology.rsna.org/content/261/3/700.abstract
martes, 10 de enero de 2012
DX: Adrenal Acute Hematoma (presumptive)
Patient was admitted to emergency with history of abdominal blunt trauma in a motorvehicle incident. He had pain in right upper cuadrant and had urine test with of eritrocituria so it was suspected to have an hepatic or renal hematoma because of location (anatomy). I did a FAST ultrasound and here are US an CT findings:
In here (Image a.)we visualize some amount of free fluid in the posterior renal fossa wich is very important to recognize in a post-trauma patient because it could be hematoperitoneum and we as radiologists need to find the cause of it such as visceral or vascular trauma.
Then (Image b.) this round hiperecogenic image is seen in the right adrenal gland that has the appearance and ecogenicity of an adenoma so therefore, we suggested a CT scan.
In these images we visualize the lesion and with IV contrast we see that has barely enhancement...almost none enhancement one might say...if you look closer you can see that first of all, it has no fat density in order to think of an adenoma and that there is some stranding of IV contrast into abdomen.But here comes the tricky part, what if this was an incidental finding and in fact, we are looking an adenoma that was there long before the trauma happened??...is this finding clinically significant??
First of all, we should rely on history background and some clinical data. This is a pediatric trauma patient who has moderate abdominal pain with suspected visceral trauma so hematoma of any organ should be on top of my differentials and then exclude another posibilities. Rest of physical exam is normal. With this in mind and preliminary CT and US findings, 2 questions crossed my mind:
Literature says that adrenal hematoma is very uncommon and therefore is poorly characterized. A 1992 review published in AJR says that eventhough is more common in pediatric population than in adults, adrenal hemorraghe has a 3% of incidence, is unilateral in 85% of cases and with strong predominance of right gland. In other article published in Journal of Urology states that adrenal hematoma ussually comes as a part in a multyorgan trauma but if unilateral, can be self-limited and requires no surgical or intensive care unit treatment. Dr. Fishman on his web resource CTisus describes adrenal imaging as well as epidemiology and states that eventhough is important to diagnose adrenal hematoma, the real deal is when bilateral and there it becomes a lifethreatning condition with high mortality rates. This takes me to my second question:
Now, this is a challenging question to answer because of the very low incidence and variable spectrum. Dr. Fishman also makes a beautiful description on how is the imaging presentation of adrenal hematoma especially on CT. First, the most common presentation we see is an enlarged adrenal gland with a cyst in appearence but has IV enhancement. He adverts, often we see also barely enhanced adrenal hematomas ussually in the acute setting. Here are some examples of poor enhancement:
If our next differential is adenoma, how are the imaging characteristics?
Again, what we find very helpful in this case is the epidemiology factor. How often we see adenomas in infants?. What other clinical characteristics we need to look up to to suspect that in fact is an adenoma?. The imaging characteristics as we know are almost the same as an adrenal non enhanced hematoma. The main resource we have is to characterize the lesion according to the % of washout of IV contrast as proposed by Dr Caoili. To my concern I don't know if this is used also in pediatric patients. But before we propose this, we have to keep in mind that adrenal hyperplasia is more common than adenomas in children and when suspected has malignant potential and are functional wich means that develops hormonal disturbance with clinical manifestations. So in this case, adenoma is less likely.
Patient had conservatory approach and with 2 days of monitoring, he was sent home with no complications.
Again, fell free to comment...thank you!
Sivit, C.J., Ingram, D.J., Taylor, G.A., Bulas, D.I., Kushner, D.C., Eichelberger, M.R. - Posttraumatic adrenal hemorrhage in children: CT findings in 34 patients. AJR Am. J. Roentgenol, 1992, 158:1299.
Gabak-Shehab L, Alagiri M. Traumatic adrenal injuries J Urol. 2005 Apr;173(4):1330-1.
Caoili EM, Korobkin M, Francis IR, Cohan RH, Platt JF, Dunnick NR, Raghupathi KI.Adrenal masses: characterization with combined unenhanced and delayed enhanced CT.Radiology. 2002 Mar;222(3):629-33.
a.
In here (Image a.)we visualize some amount of free fluid in the posterior renal fossa wich is very important to recognize in a post-trauma patient because it could be hematoperitoneum and we as radiologists need to find the cause of it such as visceral or vascular trauma.
b.
Then (Image b.) this round hiperecogenic image is seen in the right adrenal gland that has the appearance and ecogenicity of an adenoma so therefore, we suggested a CT scan.
c.
In these images we visualize the lesion and with IV contrast we see that has barely enhancement...almost none enhancement one might say...if you look closer you can see that first of all, it has no fat density in order to think of an adenoma and that there is some stranding of IV contrast into abdomen.But here comes the tricky part, what if this was an incidental finding and in fact, we are looking an adenoma that was there long before the trauma happened??...is this finding clinically significant??
First of all, we should rely on history background and some clinical data. This is a pediatric trauma patient who has moderate abdominal pain with suspected visceral trauma so hematoma of any organ should be on top of my differentials and then exclude another posibilities. Rest of physical exam is normal. With this in mind and preliminary CT and US findings, 2 questions crossed my mind:
- Is adrenal hematoma is an urgency?..
Literature says that adrenal hematoma is very uncommon and therefore is poorly characterized. A 1992 review published in AJR says that eventhough is more common in pediatric population than in adults, adrenal hemorraghe has a 3% of incidence, is unilateral in 85% of cases and with strong predominance of right gland. In other article published in Journal of Urology states that adrenal hematoma ussually comes as a part in a multyorgan trauma but if unilateral, can be self-limited and requires no surgical or intensive care unit treatment. Dr. Fishman on his web resource CTisus describes adrenal imaging as well as epidemiology and states that eventhough is important to diagnose adrenal hematoma, the real deal is when bilateral and there it becomes a lifethreatning condition with high mortality rates. This takes me to my second question:
- How is the radiological presentation of adrenal hematoma?..
Now, this is a challenging question to answer because of the very low incidence and variable spectrum. Dr. Fishman also makes a beautiful description on how is the imaging presentation of adrenal hematoma especially on CT. First, the most common presentation we see is an enlarged adrenal gland with a cyst in appearence but has IV enhancement. He adverts, often we see also barely enhanced adrenal hematomas ussually in the acute setting. Here are some examples of poor enhancement:
March 2004 Radiology, 230,669-675.
If our next differential is adenoma, how are the imaging characteristics?
Again, what we find very helpful in this case is the epidemiology factor. How often we see adenomas in infants?. What other clinical characteristics we need to look up to to suspect that in fact is an adenoma?. The imaging characteristics as we know are almost the same as an adrenal non enhanced hematoma. The main resource we have is to characterize the lesion according to the % of washout of IV contrast as proposed by Dr Caoili. To my concern I don't know if this is used also in pediatric patients. But before we propose this, we have to keep in mind that adrenal hyperplasia is more common than adenomas in children and when suspected has malignant potential and are functional wich means that develops hormonal disturbance with clinical manifestations. So in this case, adenoma is less likely.
Patient had conservatory approach and with 2 days of monitoring, he was sent home with no complications.
Again, fell free to comment...thank you!
Sivit, C.J., Ingram, D.J., Taylor, G.A., Bulas, D.I., Kushner, D.C., Eichelberger, M.R. - Posttraumatic adrenal hemorrhage in children: CT findings in 34 patients. AJR Am. J. Roentgenol, 1992, 158:1299.
Gabak-Shehab L, Alagiri M. Traumatic adrenal injuries J Urol. 2005 Apr;173(4):1330-1.
Caoili EM, Korobkin M, Francis IR, Cohan RH, Platt JF, Dunnick NR, Raghupathi KI.Adrenal masses: characterization with combined unenhanced and delayed enhanced CT.Radiology. 2002 Mar;222(3):629-33.
lunes, 9 de enero de 2012
CASE 3: 4 y/o male abdominal pain...history withheld
Click on the images to enlarge them....pain is in right upper cuadrant
I'll wait for comments to reveal diagnosis..
With this, I suggested a CT scan...differentials???
...let us see the CT
I'll wait for comments to reveal diagnosis..
sábado, 7 de enero de 2012
DX: 1. Ivory vertebrae due to osteoblastic breast cancer metastasis. 2. Pleural effusion (malignant ethiology?)
Well, this case got several comments on my Facebook account but yesterday the webpage had inconvenients on PC's worlwide; a "preventive" solution to a virus spread..anyways, here is the conclusion:
Here is a spot image on the finding:
According to history, patient was on Stage II breast cancer and was given surgical and quemotherapy treatment. We had no information on when was the last qxtx cycle. The indication of the screening was to search metastasis. Patient was clinicaly well but had worsening dispnea since the past week. Radiological findings are suggestive of right pleural effusion and osteoblastic metastasic disease on D11 that is visualized as sclerotic radiopaque vertebral body compared to the rest of vertebrae (ivory sign). This is imperative, the reason? it changes the TNM criteria and elevates the cancer staging from II to IV. This means failure to treatment and now has a sistemic disease with low prognosis.
The ivory vertebra sign has numerous causes. While clinical settings will vary, and a list of causes is available, most causes of the ivory vertebra sign are rare. In adults, three conditions should generally be considered: metastatic cancer, Paget disease, and lymphoma. In this case, metastatic disease is more likely.
It´s a worldwide protocol on oncological patients to do several screening tests in every stage of their disease. One of those is Chest X-Ray (CXR) wich is our first-step diagnostic tool to determine complications of the disease itself or consecuences of treatment. Most hospitals and private practice consultants skip the CXR and go directly to CT mailny because of high false negatives rates?. There is some controversy on this subject.
The ACR (American College of Radiology) appropriateness criteria has this recomendation in order to search lung metastasic disease:
Interventions and Practices Considered
So, there is no need to extract CXR in screening of metastasic disease but one has to be very carefull in looking for extrapulmonary signs of mets.
All comments are welcome!
http://radiology.rsna.org/content/235/2/614.full
http://emedicine.medscape.com/article/1157987-overview
http://www.guideline.gov/content.aspx?id=32638
http://en.wikipedia.org/wiki/Breast_cancer_classification
Here is a spot image on the finding:
According to history, patient was on Stage II breast cancer and was given surgical and quemotherapy treatment. We had no information on when was the last qxtx cycle. The indication of the screening was to search metastasis. Patient was clinicaly well but had worsening dispnea since the past week. Radiological findings are suggestive of right pleural effusion and osteoblastic metastasic disease on D11 that is visualized as sclerotic radiopaque vertebral body compared to the rest of vertebrae (ivory sign). This is imperative, the reason? it changes the TNM criteria and elevates the cancer staging from II to IV. This means failure to treatment and now has a sistemic disease with low prognosis.
| Breast cancer stage (AJCC 5th edition) | 5-year overall survival of over 50,000 patients from 1989[26] |
|---|---|
| Stage 0 | 92% |
| Stage I | 87% |
| Stage II | 75% |
| Stage III | 46% |
| Stage IV | 13% |
The ivory vertebra sign has numerous causes. While clinical settings will vary, and a list of causes is available, most causes of the ivory vertebra sign are rare. In adults, three conditions should generally be considered: metastatic cancer, Paget disease, and lymphoma. In this case, metastatic disease is more likely.
It´s a worldwide protocol on oncological patients to do several screening tests in every stage of their disease. One of those is Chest X-Ray (CXR) wich is our first-step diagnostic tool to determine complications of the disease itself or consecuences of treatment. Most hospitals and private practice consultants skip the CXR and go directly to CT mailny because of high false negatives rates?. There is some controversy on this subject.
The ACR (American College of Radiology) appropriateness criteria has this recomendation in order to search lung metastasic disease:
Interventions and Practices Considered
- X-ray, chest
- Computed tomography (CT), chest, without contrast
- Fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET), whole body
- Magnetic resonance imaging (MRI), chest, with or without contrast
So, there is no need to extract CXR in screening of metastasic disease but one has to be very carefull in looking for extrapulmonary signs of mets.
All comments are welcome!
http://radiology.rsna.org/content/235/2/614.full
http://emedicine.medscape.com/article/1157987-overview
http://www.guideline.gov/content.aspx?id=32638
http://en.wikipedia.org/wiki/Breast_cancer_classification
viernes, 6 de enero de 2012
CASE 2: Importance of CXR
Female patient ongoing screening thorax. Rest of history withheld.
Click on the images to enlarge them.
Sorry the poor quality..
martes, 3 de enero de 2012
DX: 1. Abdominal aorta aneurysm with mural thrombus. 2. Acute calculous cholecystitis
The clinical history makes an important contribution to our diagnostic impressions often even without haven't seen the image itself. An elderly women with diffuse abdominal pain is ambigous and the first approach is almost always an ultrasound. The clinical indication could be biliary colic? pancreatitis?
The ultrasound gave us 2 cytic images in appereance that could often be mistaken as cysts or even maybe dilated bowel loops with liquid intraluminal content? (wild guess). We are trying to seek cause of abdominal pain and there are 2 cystic images. Doppler ultrasound confirms that one is the aorta wich is dilated, and the other is the Gallbladder that seems hydropic with engorged walls and intraluminal gallstones.
The reason for angiotomography was? confirm diagnosis? seek complications?. Is the ultrasound enough for treatment options and prognosis?..bottom line, wich one of the findings is the ACTUAL CAUSE OF PAIN?
Angiotomography confirmed both diagnosis and revealed the extension of mural thrombus and that is not blocking ositum of arterial ramification pathways. Also there is no leaking or any sign of disection or rupture. These latter are the most important clues to exclude other causes of life-threating abdominal pain and is a must to recommend AngioCT when encountering abdominal aneurysm.
We know that an aneurysm is ussually defined as an outer aortic diameter over 3 cms (normal 2cms). If the diameter exceeds 5.5 cms is consider to be large and has a 25% probability of rupture. If it's not surgicaly treated it has a 17% of survival in 5 years. This, in terms of prognosis.
If an aneurysm is found incidentally without clinical compliants and is less than 5.5cms, she is qualified for ultrasound screening. This is a grade B recommendation promoted by the US Preventive Services Task Force. The mainstay of this conservative treatment is smokin cessation.
All comments are welcome!
Lederle FA, Wilson SE, Johnson GR, et al. (May 2002). "Immediate repair compared with surveillance of small abdominal aortic aneurysms". N Engl J Med 346 (19): 1437–44
The ultrasound gave us 2 cytic images in appereance that could often be mistaken as cysts or even maybe dilated bowel loops with liquid intraluminal content? (wild guess). We are trying to seek cause of abdominal pain and there are 2 cystic images. Doppler ultrasound confirms that one is the aorta wich is dilated, and the other is the Gallbladder that seems hydropic with engorged walls and intraluminal gallstones.
The reason for angiotomography was? confirm diagnosis? seek complications?. Is the ultrasound enough for treatment options and prognosis?..bottom line, wich one of the findings is the ACTUAL CAUSE OF PAIN?
Angiotomography confirmed both diagnosis and revealed the extension of mural thrombus and that is not blocking ositum of arterial ramification pathways. Also there is no leaking or any sign of disection or rupture. These latter are the most important clues to exclude other causes of life-threating abdominal pain and is a must to recommend AngioCT when encountering abdominal aneurysm.
We know that an aneurysm is ussually defined as an outer aortic diameter over 3 cms (normal 2cms). If the diameter exceeds 5.5 cms is consider to be large and has a 25% probability of rupture. If it's not surgicaly treated it has a 17% of survival in 5 years. This, in terms of prognosis.
If an aneurysm is found incidentally without clinical compliants and is less than 5.5cms, she is qualified for ultrasound screening. This is a grade B recommendation promoted by the US Preventive Services Task Force. The mainstay of this conservative treatment is smokin cessation.
All comments are welcome!
Lederle FA, Wilson SE, Johnson GR, et al. (May 2002). "Immediate repair compared with surveillance of small abdominal aortic aneurysms". N Engl J Med 346 (19): 1437–44
lunes, 2 de enero de 2012
Well this is one of my new year's resolution taking place..it´s the creation of my blog! so it can be used as a non-official virtual plataform of the Radiology status as a speciality here in Guatemala and also to publish some of the relevant topics in Radiology and medicine around the world to my concern in order to keep in touch with continuing medical education. Feel free to add posts, comments or share interesting cases, I'm sure we can all benefit frome each other.
Blessings,
Javier Salguero
Bueno, esta es la realización de una de mis resoluciones de año nuevo..la creación de mi blog!, hecho con el propósito de servir como una plataforma virtual no oficial del estado actual de la especialidad de Radiología en Guatemala y también para publicar algunos contenidos relevantes que conozca de la Radiología alrededor del mundo con el fin de mantenernos en contacto con la educación médica continua. Siéntanse en libertad de publicar contenido, comentar, o compartir casos interesantes, estoy seguro que servirá para beneficio mutuo.
Bendiciones,
Javier Salguero
Blessings,
Javier Salguero
Bueno, esta es la realización de una de mis resoluciones de año nuevo..la creación de mi blog!, hecho con el propósito de servir como una plataforma virtual no oficial del estado actual de la especialidad de Radiología en Guatemala y también para publicar algunos contenidos relevantes que conozca de la Radiología alrededor del mundo con el fin de mantenernos en contacto con la educación médica continua. Siéntanse en libertad de publicar contenido, comentar, o compartir casos interesantes, estoy seguro que servirá para beneficio mutuo.
Bendiciones,
Javier Salguero
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