Should Core Needle Lymph Node Biopsy be a Relevant Alternative to Surgical Excisional Biopsy in Diagnostic Work Up of Lymphomas?

OBJECTIVE: Surgical excisional biopsy is accepted as the standard of care approach in the diagnosis of lympho- mas. Financial issues related to the increased cost and the invasive nature of the procedure forced physicians to use some alternative diagnostic methods. Percutaneous core needle biopsy, which gained a reputation for the diagnosis of lymphomas with the advent of improved pathological, immunohistochemical, and molecular analysis, made it possible to have an accurate diagnosis with limited tissue samples. In this retrospective study, we aimed to compare the diagnostic yield of surgical excisional biopsy and core needle biopsy. MATERIALS AND METHODS: This study included 131 patients who were diagnosed with lymphoma with a nodal biopsy which was acquired via surgical excisional biopsy or core needle biopsy between 2014 and 2020 in our center. Around 68 patients underwent surgical excisional biopsy and the remaining 63 underwent core needle biopsy. Samples that allowed to the identification of the exact tumor type and/or subtype were accepted as fully diagnostic. Sufficient amount of tissue that the pathologist could have any suspicious findings considering malignant lymphoma was classified as partial diagnostic group. Inadequate samples were the ones who were not enough to report any final diagnosis. RESULTS: The patients who underwent a core needle biopsy were significantly older than the patients who underwent to surgical excisional biopsy (56.8 vs. 47.6, P = .003). Despite the full diagnostic ability of surgical excisional biopsy outperformed core needle biopsy (95.2 % vs. 83.8 %, P=.035), in 92.6% of the patients whose tissue samples were obtained via core needle biopsy were accepted to have a sufficient diagnosis to initiate the treatment and not required a second biopsy, which was comparable with the ones achieved by surgical excisional biopsy (92.6% vs. 95.2%, P = .720). CONCLUSION: According to the results obtained in our study, we may conclude that core needle biopsy is a viable and comparable alternative to surgical excisional biopsy, offering a less invasive and less-expansive approach.

Flow Diversion Therapy of Remnant and Recurrent Intracranial Aneurysms Treated Surgically.

AIM: To evaluate the safety and efficacy of flow diverter stents (FDSs) for treating remnant or recurrent intracranial aneurysms that were treated surgically. MATERIAL AND METHODS: The patients who were treated with FDSs due to remnant or recurrent intracranial aneurysms after microsurgery were included in the study. The patients' demographics, treatment histories, aneurysm features, complications associated with flow diversion, and neurological and angiographic follow-up findings were evaluated. RESULTS: Twenty patients (eight males) with 20 aneurysms were included in the study. Of 20 aneurysms, 18 (90%) were in the anterior, and two (10%) were in the posterior circulation. The initial treatment methods were clipping in 17 (85%) and wrapping in three (15%) aneurysms. The endovascular procedure was successful in all patients. In three patients (15%), periprocedural and postprocedural complications were encountered. No hemorrhagic complications were detected on cone-beam computed tomography. One patient with a basilary aneurysm died because of brain stem ischemia. The total morbimortality was 5%. The mean length of follow-up was 13.7 ± 7.3 months in 18 patients. The first angiographic follow-up (3-6 months) revealed the complete occlusion in 7 of 11 aneurysms (63.6%). By contrast, 16 aneurysms (94.1%) were occluded at the last angiographic follow-up, one aneurysm (5.9%) was still filling. CONCLUSION: An FDS seems effective, safe, and extremely attractive in treating remnant and recurrent intracranial aneurysms treated surgically.

Evaluation of abdominal computed tomography findings in patients with COVID-19: a multicenter study

PURPOSE: To evaluate the frequency of abdominal computed tomography (CT) findings in patients with coronavirus disease-2019 (COVID-19) and interrogate the relationship between abdominal CT findings and patient demographic features, clinical findings, and laboratory test results as well as the CT atherosclerosis score in the abdominal aorta. METHODS: This study was designed as a multicenter retrospective study. The abdominal CT findings of 1.181 patients with positive abdominal symptoms from 26 tertiary medical centers with a positive polymerase chain-reaction test for severe acute respiratory syndrome coronavirus 2 were reviewed. The frequency of ischemic and non-ischemic CT findings as well as the association between CT findings, clinical features, and abdominal aortic calcific atherosclerosis score (AA-CAS) were recorded. RESULTS: Ischemic and non-ischemic abdominal CT findings were detected in 240 (20.3%) and 328 (27.7%) patients, respectively. In 147 patients (12.4%), intra-abdominal malignancy was present. The most frequent ischemic abdominal CT findings were bowel wall thickening (n = 120; 10.2%) and perivascular infiltration (n = 40; 3.4%). As for non-ischemic findings, colitis (n = 91; 7.7%) and small bowel inflammation (n = 73; 6.2%) constituted the most frequent disease processes. The duration of hospital stay was found to be higher in patients with abdominal CT findings than in patients without any positive findings (13.8 ± 13 vs. 10.4 ± 12.8 days, P < 0.001). The frequency of abdominal CT findings was significantly higher in patients who did not survive the infection than in patients who were discharged after recovery (41.7% vs. 27.4%, P < 0.001). Increased AA-CAS was found to be associated with a higher risk of ischemic conditions in abdominal CT examinations. CONCLUSION: Abdominal symptoms in patients with COVID-19 are usually associated with positive CT findings. The presence of ischemic findings on CT correlates with poor COVID-19 outcomes. A high AA-CAS is associated with abdominal ischemic findings in patients with COVID-19.

Management of Spontaneous Major Rectus Sheath Hematoma in a COVID-19 Patient: A Case Report and Literature Review.

A rectus sheath hematoma, which is mostly encountered due to abdominal traumas or anticoagulant use, can be challenging, and a delayed diagnosis may lead to hypovolemic shock and even death. In this study, we aimed to present the management of a case of rectus sheath hematoma that developed in a patient who was hospitalized and under coronavirus disease 2019 (COVID-19) treatment. A 70-year-old female patient was admitted to the intensive care unit (ICU) due to respiratory failure and developed a sudden onset of tachycardia and hypotension. The patient was then diagnosed with a rectus sheath hematoma and after ensuring hemodynamic stability she was treated with angiographic embolization. Following the treatment, the patient remained hemodynamically stable and a control computed tomography (CT) revealed regression in the hematoma. Rectus sheath hematomas especially accompanied by additional comorbidities or aggressive surgical interventions may result in high mortality rates in the early period. It should also be kept in mind that during the COVID-19 pandemic, which has affected the world in the last two years, rectus sheath hematomas may be the underlying cause of sudden hypotension and abdominal distension, and it should not be forgotten that angiographic embolization performed by experienced interventional radiologists is the mainstay of treatment in cases where hemodynamic stability can't be achieved.

Current Strategies for the Management of Anomalous Origin of Coronary Arteries from the Pulmonary Artery.

INTRODUCTION: The coronary arteries, which have to originate from the aorta, may sometimes rise from the pulmonary artery. This study evaluated clinical and diagnostic findings, treatment methods, and follow up of cases with anomalous coronary arteries arising from the pulmonary artery. PATIENTS AND METHODS: Eight patients with the diagnosis of anomalous left coronary artery from the pulmonary artery (ALCAPA) (N = 6) and anomalous right coronary artery from the pulmonary artery (ARCAPA) (N = 2), between January 2014 and January 2020 from a single center university hospital, were included in the study. Data from patients' demographic characteristics, electrocardiography, echocardiography, angiographic findings, operation, hospitalization, and follow up were evaluated. RESULTS: The study included eight patients (six females and two males) - six patients with ALCAPA and two with ARCAPA. The ages of the patients ranged between 3-135 (average: 53.25) months. The median body weight was calculated as 17.4 kg. Severe mitral valve insufficiency was detected in two patients and two other patients had a moderate degree of mitral insufficiency on echocardiography. Ejection fractions ranged between 16-74%. One patient had perimembranous malalignment large ventricular septal defect with pulmonary stenosis. Operative techniques were Takeuchi procedure (three patients), direct implantation (four patients), and left internal thoracic artery to left main coronary artery bypass (one patient). Mechanical cardiac support was not required in the postoperative period. Mortality did not occur. Mitral insufficiency and ejection fractions improved following correction of the coronary anatomy. CONCLUSION: It is important to diagnose the ALCAPA or ARCAPA, where the coronary artery originates from the pulmonary artery. Patients should be treated before congestive heart failure and fatal complications occur. Surgical correction should be planned regardless of symptom status, even though some of patients reach adulthood with an increased number of collaterals.

Flow diverter stents in the treatment of recanalized intracranial aneurysms.

BACKGROUND: We assessed the safety and efficacy of flow diverter stents (FDSs) in the treatment of recanalized or residual intracranial aneurysms treated endovascularly. MATERIALS & METHODS: Patients whose recanalized or residual aneurysms were treated with FDSs in five tertiary hospitals were reviewed retrospectively. The patients' demographic data, aneurysm characteristics, types of previous treatment, and clinical complications, or serious adverse events associated with FDSs, as well as the results of neurological and angiographic follow-up assessments, were recorded. RESULTS: Eighty-six patients (37 males) with 87 aneurysms were included in this study. Eighty (91.9%) aneurysms were in the anterior and seven (8.1%) in the posterior circulation. The initial treatment methods were the primary coiling or balloon remodeling technique in 69 (79.3%) and stent-assisted coiling in 18 (20.7%) aneurysms. The endovascular procedure was successful in all patients. Complications occurred in four patients, for a total complication rate of 4.6%. A technical complication developed in one patient (1.2%). An in-stent thrombosis treated with tirofiban was seen in two cases. Late in-stent stenosis exceeding 50% was treated with balloon angioplasty in one patient. The mean length of follow-up was 21.0 months. The first angiographic follow-up (3-6 months) revealed the complete occlusion of 74 aneurysms (85.1%). While 76 aneurysms (87.4%) were occluded at the last angiographic follow-up (mean: 26.0 months), 11 aneurysms (12.6%) were still filling. Morbimortality was zero. CONCLUSION: The drawback of endovascular treatment is aneurysmal remnants or recurrences, which is safely and durably amenable to flow diversion.

Flow Diverter Stents in the Treatment of Cerebral Aneurysms Less than 5 mm.

AIM: To evaluate the safety and efficacy of flow diverter (FD) stents in the treatment of intracranial aneurysms less than 5 mm. MATERIAL AND METHODS: We treated 66 aneurysms in 43 patients with aneurysms less than 5 mm. Of the patients, 29 were females and 14 males (mean age: 50.2 years). Headache was the most frequent symptom. In 8 patients, the aneurysms were recanalized and these had been treated with coils or stent-assisted coiling. All aneurysms were in the anterior circulation. In the treatment, one of the SILK, Pipeline, Derivo or FRED FD stents was used for each patient. Neurointerventional stent medication (double antiplatelet) was used. All patients were investigated for new ischemic lesions with diffusion-weighted imaging one day later. The first follow-up angiogram was planned 3-6 months later. RESULTS: The treatment was technically successful in all patients. Minor complications occurred in 3 patients (7%). In one patient, thrombus inside the SILK was seen and was relieved with tirofiban. The second patient bled from the right common femoral artery entrance, which was operated on. In the third patient, the complication was technical. All patients were discharged without any neurological deficit. The mean follow-up period was 26 (6-52) months. Of the aneurysms, 64 (97.0%) were completely closed. CONCLUSION: The FD treatment of cerebral, anterior circulation small aneurysms less than 5 mm is effective and safe.

Should be Remembered in the Differential Diagnosis of Klatskin Tumour: Alveolar Echinococcosis

Alveolar echinococcosis is an infectious disease caused by Echinococcus multilocularis and it is frequently diagnosed as a space-occupying lesion in the liver. The growth pattern may be similar to that of a malignant tumour with extensive liver infiltration, spreading into neighbouring organs and forming metastasis-like masses in distant organs. Thus, it is one of the differential diagnoses of liver cancer. We report a case that presented as a klatskin tumour clinically and radiologically, but was revealed by pathologic and serologic work-up. Since the courses of these two diseases, a malignancy and an infectious disease, are far beyond comparison, echinococcosis should always be considered in differential diagnosis of obstructive jaundice, especially in the endemic regions.

Intense fluoro-2-deoxyglucose uptake in high-grade prostatic adenocarcinoma with negligible prostate-specific membrane antigen expression.

While 68Gallium prostate-specific membrane antigen positron emission tomography/computed tomography (68Ga-PSMA) has demonstrated increasing utility in the evaluation of prostatic carcinoma, it is essential to be aware of false-negative findings. Further subtype analyses of prostate cancer will be helpful in the understanding of the underlying reasons. We herein present a high-grade prostate adenocarcinoma, with metastatic lesions showing high 18F-labeled fluoro-2-deoxyglucose uptake instead of 68Ga-PSMA.

Is the presence of left atrial diverticulum associated with recurrence in patients undergoing catheter ablation for atrial fibrillation?

INTRODUCTION: Catheter ablation (CA) for atrial fibrillation (AF) has been a major cornerstone in the management of AF. Despite promising advances in CA techniques, long-term results reveal a high rate of recurrence after the procedure. Left atrial diverticulum (LAD), a common anatomic variant of the left atrium, was previously shown to be associated with increased risk of thrombus formation, cardiac perforation and arrhythmia. In this study we aimed to investigate the relationship between LAD and recurrence in patients undergoing CA for AF. MATERIAL AND METHODS: A total of 100 consecutive patients with a mean age of 53 ±12.1 years (53% male) underwent radiofrequency (RF) (46, 46%) or cryoballoon (54, 54%) catheter ablation for atrial fibrillation preceded by cardiac computed tomography (CT) imaging. Clinical and procedural characteristics of the patients with and without AF recurrence were compared. RESULTS: Twenty-three (23%) patients had AF recurrence and 77 (77%) patients had no recurrence. The clinical parameters such as hypertension, diabetes mellitus, coronary artery disease and stroke did not differ between the groups. Left atrium diameter was significantly different between the two groups (4.1 ±0.5 vs. 3.9 ±0.5, p = 0.042). Presence of LAD was not different between the two groups (7 (31.8) vs. 21 (28.8); p = 0.794). Multivariate logistic regression analysis revealed RF ablation as the most important independent variable for AF recurrence (ß = 3.115, p< 0.001, OR = 22.526, 95% CI: 4.287-118.351). CONCLUSIONS: The presence of left atrial diverticulum is not associated with recurrence in patients undergoing RF and cryoballoon CA for atrial fibrillation.

Comparison of CT methods for determining graft steatosis in living donor liver transplantation.

PURPOSE: To evaluate and compare the diagnostic performance of non-enhanced computed tomography (NECT) and contrast-enhanced CT (CECT) attenuation indices in the assessment of hepatic steatosis by using biopsy as the reference standard. MATERIALS AND METHODS: This retrospective study was approved by our Institutional Review Board. 55 Potential donors who underwent both NECT and triphasic CECT and core liver biopsy, were included the study. Average attenuation measurements that were obtained from multiple regions in liver, spleen, and psoas muscle on both unenhanced and CECT were used for analysis. Hepatic attenuation measurements were analyzed with and without normalization with the spleen and psoas muscle. Linear regression and receiver operating characteristic (ROC) curve analysis were used to evaluate the statistical association between CT indices and steatosis at histology. RESULTS: Linear regression analysis confirmed the strongest correlation between steatosis and normalized measurements of hepatic attenuation with splenic attenuations on hepatic venous phase of CECT scan (R 0.821; R2 0.674 and R 0.816; R2 0.665, respectively). The use of ROC curve analysis also demonstrated that normalized measurements of hepatic attenuation with splenic attenuations on hepatic venous phase of CECT showed high diagnostic performance regarding the qualitative distinction of steatosis (AUC values greater than 0.9). CONCLUSION: Attenuation measurements of liver normalized with spleen on hepatic venous phase may be useful in evaluating steatosis in donor candidates with moderate to severe steatosis who are unacceptable for liver donation. In this manner unnecessary liver biopsy may be avoided in those donor candidates.

Hydatid disease of the liver with portal vein invasion mimicking portal vein thrombosis.

Hydatid cyst disease is a zoonosis caused by the parasite Echinococcus. It may infest any organ of the body, but it most frequently involves the liver, lungs, and nervous system. Portal vein involvement by hydatid cyst disease is extremely rare with only five cases published in the English literature to our knowledge. We present the ultrasonography (US) and computed tomography (CT) findings of a 77-year-old male with hydatid disease of the liver with portal vein invasion mimicking portal vein thrombosis. Colour Doppler US confirmed the lack of blood flow within the portal vein and stigmata of cavernomatosis. CT clearly demonstrated a communication between the multiloculated lesion and the portal vein and the multiple daughter vesicles obstructing the portal vein. The consideration of this complication will make it possible to distinguish this entity from portal vein thrombosis and, thus, the management of the patients with hydatid cyst disease particulary in endemic regions.

Dosimetric evaluation of right coronary artery in radiotherapy for breast cancer.

Comparison with control groups of untreated patients suggests that right-breast-cancer patients who receive radiotherapy have a higher rate of heart disease. Dose constraint for heart has been established to minimize radiotherapy-induced cardiotoxicity during left breast cancer treatment. Additionally, it is suggested to minimize the dosage on left anterior descending (LAD) artery. Right coronary artery (RCA), is the second largest artery, after left main coronary artery, supplying the heart. A dose evaluation study is not present for RCA; the proximal part of which is included in the irradiation field during breast cancer treatment of right breast. To investigate the presence of a correlation, doses resulting from right and left breast radiotherapy on proximal RCA (pRCA), LAD, and heart are evaluated in this study. Forty breast cancer patients who went under breast-conserving surgery are the subject of this study. Four groups were established; right breast, right breast and internal mammary (IM), left breast and left breast, and IM. pRCA, LAD, and heart volumes were contoured for each group on the planning tomographies. Resultant doses of tangential fields planning on these volumes were compared using dose-volume histograms. Mean and maximum doses of pRCA were statistically compared between groups. The highest mean and maximum point doses (192 to 284 cGy) were found in the right breast + IM group (p < 0.05). The mean and maximum doses only in the right breast and left breast + IM group did not differ statistically. However, the mean and maximum pRCA doses in these 2 groups were higher than only the left breast group (p < 0.05). pRCA receives high doses during radiotherapy of right and left breast especially if IM is included. This may predispose to coronary artery disease.

Aneurysm of Portosystemic Fistula: A Case Report and Review of Literature.

AIM: A case of asymptomatic aneurysm of spontaneous portosystemic venous fistula (SPVF) with the radiologic findings is described. BACKGROUND: Although advances and more widespread use of ultrasound (US) and computed tomog -raphy angiography (CTA) have enabled more detection of SPVF in the liver, it is a rare entity. CASE REPORT: A 49-year-old male was referred to our hospital's nephrology outpatient clinic due to hypertension. Abdominal sonography examination detected a well-defined cystic lesion adjacent to the middle hepatic vein in the liver. The lesion showed venous flow in the color Doppler US examination. Computed tomography angiography examination revealed an aneurysm of the fistula. CONCLUSION: Radiologists should be aware of this vascular anomaly and cyst-like lesions in the liver should be examined with color Doppler ultrasonography for possible vascularization, and be differentiated with CTA if necessary. CLINICAL SIGNIFICANCE: This condition is usually encountered incidentally and patients usually have no symptoms. However, severe complications, such as hepatopulmonary syndrome, liver tumors, encephalopathy, and heart failure can be seen.How to cite this article: Ulus S, Akan GE, Erol C. Aneurysm of Portosystemic Fistula: A Case Report and Review of Literature. Euroasian J Hepato-Gastroenterol 2017;7(2):178-180.

Successful radiofrequency pulmonary vein isolation in a patient with pneumonectomy.

Among electrophysiologic procedures, catheter ablation of atrial fibrillation (AF) is challenging, requiring the isolation of all pulmonary veins (PVs). AF is associated with serious complications including PV stenosis. Presently described was a technically challenging case of PV isolation in a patient with left-sided pneumonectomy due to lung cancer.

Ex Vivo Resection and Renal Autotransplantation for the Treatment of a Large Renal Vein Aneurysm Causing Recurrent Pulmonary Embolism and a Coexisting Vascular Malformation: A Case Report.

A 36-year-old young woman with a medical history of recurrent pulmonary embolism and chronic pelvic pain was admitted to our hospital. Contrast-enhanced imaging techniques revealed a large left renal vein aneurysm with a coexisting vascular mass. The patient was operated on electively, and the left kidney was autotransplanted to the right ileac fossa following the ex vivo resection of the vascular mass and the left renal vein aneurysm. Herein, we report an unusual coexistence of a vascular mass and recurrent pulmonary embolism treated successfully with our surgical treatment strategy.

Meandering right pulmonary vein associated with retrocaval ureter and vertebral fusion anomalies.

We present multimodality imaging of a meandering right pulmonary vein in a 29-year-old female patient. It was associated with right retrocaval ureter causing hydronephrosis and stone formation, vertebral fusion anomalies and corrected cardiac anomalies (patent ductus arteriosus and ventricular septal defect). To the best of our knowledge, only a few meandering right pulmonary vein have been presented in the literature until now and this is the first reported case that is associated with retrocaval ureter and vertebral fusion anomalies.

Portal biliopathy, magnetic resonance imaging and magnetic resonance cholangiopancreatography findings: a case series.

Portal biliopathy (PB) is a rare disorder, characterized by biliary ductal and gallbladder wall abnormalities seen in patients with portal hypertension. It most commonly occurs due to idiopathic extrahepatic portal vein obstruction (EHPVO). The abnormalities consist mainly of bile duct compression, stenoses, fibrotic strictures and dilation of both extrahepatic and intrahepatic bile ducts, as well as gallbladder varices. PB may mimic cholangiocarcinoma, sclerosing cholangitis, or choledocholithiasis. Misdiagnosis can be avoided using appropriate imaging modalities to prevent complications. We present the magnetic resonance imaging (MRI) and magnetic resonance cholangiography (MRCP) features of three patients with PB.