Retroperitoneal Leiomyosarcoma with Elevated CA 19-9.

Leiomyosarcomas are malignant soft tissue tumors that can arise nearly anywhere in the body. These tumors may rarely originate within the retroperitoneum and may be found incidentally or present with nonspecific symptoms due to mass effect on abdominal or pelvic organs. The presentation of a leiomyosarcoma with a massively elevated CA 19-9 level is exceedingly rare with only one other report in the literature. This presentation makes for a diagnostic challenge, especially in the presence of metastatic disease to adjacent organ systems, and often requires a tissue sample obtained with core needle biopsy to make a definitive diagnosis.

Intraperitoneal Extravasation of TPN and Associated Hepatic Hemorrhage as a Complication of a Malpositioned UVC in a Preterm Neonate.

Extravasation of total parenteral nutrition (TPN) from a malpositioned umbilical venous catheter (UVC) is a rare cause of ascites in neonates. The gross appearance of the aspirated peritoneal fluid may mimic congenital chylous ascites, delaying an accurate diagnosis of the causative source. UVC malpositioning is associated with complications of various organs as related to the position of the UVC tip. TPN from laterally positioned UVC tips may penetrate into the liver and provoke hepatic damage with subsequent peritoneal fluid accumulation. Factors including biochemical characteristics of the peritoneal fluid, radiographic findings with specific attention to the location of the UVC tip, and clinical timing of ascites presentation have been associated with TPN extravasation from UVCs. This report presents a case of a preterm neonate with intraperitoneal extravasation of TPN and associated hepatic hemorrhage due to a malpositioned UVC while highlighting the cumulative clinical, radiographic, and laboratory findings that should prompt consideration of this complication as the cause of ascites in neonates.

Effectiveness of Radiofrequency Ablation in the Treatment of Painful Osseous Metastases: A Correlation Meta-Analysis with Machine Learning Cluster Identification.

A systematic review and meta-analysis of pain response after radiofrequency (RF) ablation over time for osseous metastases was conducted in 2019. Analysis used a random-effects model with GOSH plots and meta-regression. Fourteen studies comprising 426 patients, most with recalcitrant pain, were identified. Median pain reduction after RF ablation was 67% over median follow-up of 24 weeks (R2 = -.66, 95% confidence interval -0.76 to -0.55, I2 = 71.24%, fail-safe N = 875) with 44% pain reduction within 1 week. A low-heterogeneity subgroup was identified with median pain reduction after RF ablation of 70% over 12 weeks (R2 = -.75, 95% confidence interval -0.80 to -0.70, I2 = 2.66%, fail-safe N = 910). Addition of cementoplasty after RF ablation did not significantly affect pain scores. Primary tumor type and tumor size did not significantly affect pain scores. A particular, positive association between pain after RF ablation and axial tumors was identified, implying possible increased palliative effects for RF ablation on axial over appendicular lesions. RF ablation is a useful palliative therapy for osseous metastases, particularly in patients with recalcitrant pain.

Integrated Interventional Radiology Residency Program Websites: A Development in Progress.

OBJECTIVE: The purpose of this study is to evaluate the comprehensiveness of interventional radiology (IR) residency program websites. MATERIALS AND METHODS: We determined whether all integrated IR residency programs approved in 2016 by the Society for Interventional Radiology had a dedicated residency program website. On each website, we searched for 38 elements identified as important considerations for medical students applying to diagnostic radiology residency and IR fellowship programs. With the use of t tests and ANOVA, both the prevalence of criteria between regions and program sizes were compared. RESULTS: Of 61 IR residency programs that were identified, 44 (72%) had dedicated websites. On average, the websites included 38% of the 38 elements evaluated. Only two residency program websites (5%) included more than 50% of the criteria assessed. The information most commonly found was a contact e-mail (95% of websites), a mailing address (91%), and a comprehensive listing of faculty (75%). The information that was least commonly included was clinical responsibility progression (7%), a description of didactics (5%), and simulation experience (5%). No significant difference in website comprehensiveness was noted between regions (p = 0.590) or between different quartiles of ranking of IR fellowship on an online social networking service for U.S. clinicians (p = 0.198). CONCLUSION: Nearly one-third of integrated IR residency programs do not have a dedicated website. Those that do exist are inadequately comprehensive, with less than 40% of assessed criteria present. Contact information and information about life outside of work were the most commonly included elements, with a description of clinical training opportunities less frequently included. Addressing these gaps in website content will help IR residency programs better inform prospective students and may increase the number of applicants.

Cryoablation of Osteoid Osteoma in the Pediatric and Adolescent Population.

PURPOSE: To evaluate the technical feasibility and clinical efficacy of osteoid osteoma (OO) cryoablation in a large, pediatric/adolescent cohort. MATERIALS AND METHODS: An electronic medical record and imaging archive review was performed to identify all cryoablations performed for OOs between 2011 and 2015 at a single tertiary care pediatric hospital. The subsequent analysis included 29 patients with suspected OOs treated by cryoablation (age range, 3-18 y; mean age, 11.3 y; 17 boys; 12 girls). Conventional CT guidance was used in 22 procedures; cone-beam CT guidance was used in 7 procedures. Follow-up data were obtained via a standardized telephone questionnaire (23/29 patients; 79.3%) and clinical notes (5/29 patients; 17.2%). One patient was lost to follow-up. RESULTS: Technical success was achieved in 100% of patients (29/29). Immediate clinical success (cessation of pain and nonsteroidal antiinflammatory drug [NSAID] use within 1 mo after the procedure) was achieved in 27/28 patients (96.4%). Short-term clinical success (cessation of pain and NSAID use for > 3 mo after the procedure) was achieved in 24/25 patients (96%). Long-term clinical success (cessation of pain and NSAID use for > 12 mo after the procedure) was achieved in 19/21 patients (90.5%). Median pain scale score before the procedure was 10 (range, 5-10); median pain scale score after the procedure was 0 (range, 0-8; P < .0001). There were 6 minor complications (21%) and no major complications. CONCLUSION: Image-guided cryoablation is a technically feasible, clinically efficacious therapeutic option for children and adolescents with symptomatic OO.

Increased Incidence of Pyogenic Liver Abscess in a Midwest System With Emphasis on Rural Impact.

OBJECTIVE: To assess if hepatic abscess incidence in a Midwest cohort was higher in rural areas compared to metropolitan areas in relation to water infrastructure. MATERIALS AND METHODS: All cases of hepatic abscesses from Jan 1, 2016 through Dec 31, 2019 at Avera McKennan Hospital in Sioux Falls, South Dakota (SD), were retrospectively collected. Chart review was completed for each case for risk factor analysis. Microbiology cultures and patient demographic data were collected including age, gender, hometown, and ethnicity. Risk factors assessed included a history of abdominal surgery, gallbladder disease, sepsis, diverticulitis, cancer, and diabetes. The incidence of hepatic abscesses was calculated using the Poisson rate test and confidence interval equation. Averages of each risk factor were calculated. Finally, hometown was utilized to create a heatmap of disease burden and compared to the density of private wells. RESULTS: Our data yielded 116 confirmed adult hepatic abscesses between 2016 and 2019. The corrected incidence per 100,000 hospitalized patients per year is 95.66. The Poisson exact probability P-value was <0.01. Rural areas had a higher per capita incidence of abscesses and higher density of private wells. CONCLUSIONS: The incidence of hepatic abscesses is higher than national averages in this single-center study of Avera McKennan Hospital. Demographics, especially geographic location, play an important role in abscess rates. Rural location may be affecting the incidence of hepatic abscesses, explaining the much higher than expected incidence in this study. Infrastructure could be a contributing factor as much of the rural area is reliant on untreated groundwater.

Case report of transplant renal artery stenosis secondary to mechanical renal artery kinking: Balloon angioplasty as a supportive diagnostic tool?

INTRODUCTION AND IMPORTANCE: Renal vascular complications are a significant cause of morbidity in living donor renal transplantation. Among renal vascular complications, transplant renal artery stenosis (TRAS) secondary to mechanical kinking is a rare but important cause of early graft dysfunction. Identifying this phenomenon and correcting the underlying cause is critical to graft viability in the post-operative period. This case illustrates the importance of balloon angioplasty in identifying this complication and prompting surgical correction. CASE PRESENTATION: We describe the case of a 67-year-old male who received a right-sided living donor kidney graft for Stage IV Chronic Kidney Disease secondary to biopsy proven Ig-A nephropathy. In the post-operative course, serum creatinine remained elevated and Doppler showed low-normal vascular flow velocities. Renal angiogram indicated transplant renal artery stenosis secondary to the rare phenomenon of mechanical kinking. Findings noted during unsuccessful angioplasty supported the diagnosis and surgical repositioning of the graft provided definitive repair. Post-operative serum creatine trended down and urine output improved within 24 h. Patient was stable at two month follow up. CLINICAL DISCUSSION: Transplant renal artery stenosis secondary to mechanical kinking can cause significant graft dysfunction in the post operative period. Previous case reports and literature review has found balloon angioplasty to be ineffective in correcting this underlying cause of TRAS. In line with previous reports, balloon angioplasty failed to correct the stenosis; however, this provided additional diagnostic information by identifying the kink and prompting surgical repair. CONCLUSION: Transplant renal artery stenosis secondary to mechanical kinking can be difficult to identify by renal angiogram alone. Attempted balloon angioplasty can confirm the diagnosis and prompt definitive surgical repair.

Pubic symphysis osteomyelitis with associated vesico-symphyseal fistula: a difficult diagnosis.

Pubic symphysis osteomyelitis is an infectious complication that rarely arises in men who have undergone treatment for prostate cancer. This process may more rarely arise from a fistulous tract between the pubic symphysis and the urinary tract. In this case report, we discuss the most common clinical presentations and laboratory findings that lead to the diagnosis of this disease process, as well as the role of MRI and other imaging modalities in confirmation of the diagnosis. This case serves as a reminder to clinicians to have earlier consideration of pubic symphysis osteomyelitis in their differential diagnosis to reduce the risk of long-term complications associated with undertreatment.

Stretch too far: rectus sheath haematoma secondary to repetitive trauma and increased intra-abdominal pressure.

A 26-year-old man presented with a 4-week history of right lower quadrant abdominal pain which was managed conservatively at home with ibuprofen. Three days later, he presented to the emergency department with worsening pain and swelling following an episode of coughing and slipping in the bathroom. Following his admission, CT angiography showed an active bleed into a 4.6×6.7×11 cm right rectus sheath haematoma, just inferior to the umbilicus. The patient was then referred to interventional radiology for an angiogram and coil embolisation. A superselective branch angiogram showed contrast extravasation from a medial branch of the right inferior epigastric artery, successfully embolised without incident.

Endoleak and Pseudoaneurysm Formation in the Setting of Stent Graft Infection Following Endovascular Uretero-Arterial Fistula Repair: The Dreaded Complication.

The complication of uretero-arterial fistula after prolong ureteral stenting is well recognized. The treatment is primarily endovascular stenting across the fistulous communication accepting the potential risk of stent graft infection. Herein we present a case of a 71-year-old female who developed an uretero-arterial fistula after prolong ureteral stenting and exchanges following ileal conduit obstruction. Initial treatment with left common iliac stenting controlled the hematuria, but only temporarily. Repeat angiography revealed a type 1b endoleak requiring stent extension. Unfortunately, persistent hematuria necessitating further angiography showed the development of a saccular pseudoaneurysm around the stent graft requiring proximal stent extension. A nuclear medicine indium 111-tagged white blood cell scan with single-photon emission CT (SPECT)/CT confirmed stent graft infection. Conservative therapy with antibiotics failed, causing graft failure that ultimately required bypass surgery.

Recurrent, Idiopathic Spontaneous Hemoperitoneum Requiring Multiple Laparoscopic Evacuations: A Rare Case of Bleeding Adnexal Arteriovenous Malformation.

Arteriovenous malformations (AVMs) are abnormal vascular connections that can form in many anatomic locations. The adnexa are particularly rare sites of AVM formation and the symptomatology is heterogeneous. Herein we present a case of life-threatening adnexal AVM. A 21-year-old female presented with abdominal pain and syncope, her third such presentation within 10 days. Her history was significant for ectopic pregnancy six months prior. Diagnostic laparoscopy revealed intraperitoneal blood without active bleeding. Transabdominal pelvic ultrasound revealed a large amount of complicated pelvic fluid and increased right-adnexal vascularity. Interventional radiology performed an urgent uterine arteriogram revealing a right-adnexal AVM with supply from both the right uterine and right ovarian arteries. The AVM was subsequently embolized, resolving her symptoms. AVMs are exceedingly rare, often unconsidered causes of occult pelvic bleeding. Pelvic, and in particular, adnexal AVMs should be considered in females with idiopathic spontaneous hemoperitoneum.

Gastric Inguinoscrotal Hernia.

A 75-year-old man presented to our facility with a 5-day history of hematemesis. He reported a left inguinoscrotal hernia that had been present since 1990. Physical examination demonstrated an incarcerated inguinoscrotal hernia. Abdominal computed tomography revealed the stomach, small, and large bowel in the hernia. Esophagogastroduodenoscopy revealed food and brownish liquid in the stomach. Neither the antrum nor the pylorus could be identified during the esophagogastroduodenoscopy, consistent with an incarcerated portion of the stomach. Blood was not seen in the examined portion of the gastrointestinal tract. He was emergently treated with surgical intervention.

Jejunal varices: an unconsidered cause of recurrent gastrointestinal haemorrhage.

A 78-year-old woman presented with melaenic stool and severe anaemia 4 years after a pancreaticoduodenectomy for adenocarcinoma of the pancreas. Initial workup revealed haemorrhage from the choledochojejunostomy site. Despite multiple endoscopic clips to the region, bleeding reoccurred multiple times over a period of several months. Due to ongoing haemorrhage, her case was urgently presented at the hospital's multidisciplinary hepatobiliary conference. The contrast-enhanced abdominal CT revealed severe stenosis of the extrahepatic portal vein and large afferent jejunal varices at the choledochojejunostomy, suspected as the cause of her persistent bleed. The recommendation was a percutaneous transhepatic approach for stenting of the portal vein stenosis that resulted in rapid decompression of the jejunal varices and control of her haemorrhage.

Revascularization for Posterior Cerebral Artery Infarction in Decompensated Moyamoya Disease.

Moyamoya disease is a rare pathological disorder characterized by progressive intracranial artery stenosis and collateral vessel formation. Posterior cerebral artery involvement is rare with a predilection towards infarction. Herein we present a case of a young female with moyamoya disease treated with bilateral encephalomyosynangiosis which subsequently progressed to posterior cerebral artery involvement, requiring encephalomyosynangiosis to prevent further infarction.

Opinions, Views, and Expectations Concerning the Radiology Report: A Rural Medicine Report.

This study seeks to examine a potential agreement and/or discordance of specific aspects of the radiology report between referring clinicians and radiologists within a medical group in a predominately rural setting. This study also aims to compare results with similar studies conducted in other geographic regions. This was done using a previously validated survey tool that examines five different aspects of the radiology report: importance, clinical correlation, clinicians' satisfaction, content, structure, and style. Dichotomized results were statistically analyzed using χ 2 or Fischer's exact test and showed significant differences in the areas of importance and content. Non-dichotomized results unique to clinicians and radiologists were assessed qualitatively. Most clinicians found the radiology report to be useful in their clinical decision making and that they received radiology reports in a timely enough fashion to affect their decision making. These results were largely found to be in accordance with similar studies, but significant differences unique to the sampled population were present. Based on these findings, we have included specific recommendations that may enhance the clinical efficiency of radiology reports as used by clinicians and potentially reduce medical errors secondary to clinical information not always fully captured in radiology reports.

Amiodarone-induced Hemoptysis: A Rare Presentation of Amiodarone-induced Pulmonary Toxicity Occurs at a Low Dose.

Amiodarone-induced pulmonary toxicity (APT) is one of the most feared and underappreciated adverse effects of this commonly prescribed antiarrhythmic. APT has a variable presentation, among the rarest of these is amiodarone-induced diffuse alveolar hemorrhage with hemoptysis. Though previous cases confirmed with biopsy averaged a dose of 570 mg PO daily, APT can occur at any dose. Previous literature has suggested the importance of cumulative exposure to amiodarone rather than the patient's actual dose. The presented case describes amiodarone-induced hemoptysis occurring at a dose of 200 mg PO daily for five years. Additionally described is the treatment regimen which managed a patient with metabolic syndrome and elevated A1c while addressing the recommended treatment of extended high-dose steroids for APT with complicated respiratory status. To the best of the authors' knowledge, only two biopsied cases have been described at a dose this low. Furthermore, this case describes a more typical timeline for APT than those two cases.

Massive Cecal Variceal Hemorrhage Treated with Transjugular Intrahepatic Portosystemic Shunt with Right Colic Vein and Ileocolic Vein Embolization.

A 40-year-old male suffering from hallucinations and bizarre behavior was brought to our emergency room (ER) by the police. His drug and alcohol screens were positive for amphetamines and a blood alcohol content of 0.029 mg/dL. His past medical history was significant for alcohol use disorder, end-stage liver disease, ascites, esophageal varices, portal hypertension, and hepatic encephalopathy. He was admitted in an encephalopathic state and developed worsening hematochezia and hemodynamic instability over the course of days. Multiple investigations including contrast enhanced computed tomography (CT), upper and lower endoscopy, and mesenteric angiography did not identify a clear cause of the bleeding. Eventually, his source of bleeding was found to be from cecal varices. A transjugular intrahepatic portosystemic shunt procedure and coil embolization of the right colic and ileocolic veins stabilized the patient and he was discharged home a few days later.

A Unique Case of Esophageal Bleeding: Arterioenteric Fistula Secondary to Intercostal-Bronchial Trunk Pseudoaneurysm Rupture.

Esophageal bleeding has a broad differential. One rare cause of esophageal bleeding is an intercostal artery pseudoaneurysm, which usually presents as hemothorax secondary to trauma or an iatrogenic cause; we identified only 9 reported cases in the English literature. Rarer still is pseudoaneurysm of the intercostal-bronchial trunk, which has not been reported in the literature. We report a 61-year-old man with an intercostal-bronchial trunk pseudoaneurysm who presented with hematemesis and signs of upper gastrointestinal bleeding without previous history of trauma. This case report serves to broaden the differential for esophageal bleeding.

Evolution in the Treatment of Delayed Postpancreatectomy Hemorrhage: Surgery to Interventional Radiology.

OBJECTIVES: We summarized a single center's evolution in the management of postpancreatectomy hemorrhage (PPH) from surgical toward endovascular management. METHODS: Between 2003 and 2013, 337 patients underwent Whipple procedures. Using the International Study Group of Pancreatic Surgery (ISGPS) consensus definition, patients with PPH were identified and retrospectively analyzed for the presentation of hemorrhage, type of intervention, and 90-day mortality outcome measures. RESULTS: Management evolved from operative intervention alone, to combined operative and on-table angiographic intervention, to endovascular intervention alone. The prevalence of PPH was 3.0%. Delayed PPH occurred with a mean of 13.8 days. On angiography, visceral arteries affected were the gastroduodenal artery, hepatic artery, jejunal branches of the superior mesenteric artery, pancreaticoduodenal artery, and inferior phrenic artery. Ninety-day mortality for PPH was 20%. From early to recent experience, the mortality rate was 100% for operative intervention alone, 25% for combined operative and on-table angiographic intervention, and 0% for endovascular intervention alone. CONCLUSIONS: Our 10-year experience supports current algorithms in the management of PPH. Key considerations include the recognition of the sentinel bleed, the presence of a pancreatic fistula, and the initial operative role of a long gastroduodenal artery stump with radiopaque marker for safe and effective embolization should PPH occur.