Case 248: Cystic Duodenal Dystrophy with Groove Pancreatitis.

History A 59-year-old man presented to the gastroenterology outpatient department with acute abdominal pain centered in the epigastrium. He had experienced similar episodes of abdominal pain in the past that had been treated with surgery. He reported multiple failed attempts at upper gastrointestinal endoscopy. Laboratory tests were performed at the time of admission and revealed a serum glutamic-oxaloacetic transaminase level of 9 U/L [0.15 µkat/L] (normal range, 5-40 U/L [0.08-0.67 µkat/L]), a serum glutamic-pyruvic transaminase level of 34 U/L [0.57 µkat/L] (normal range, 5-45 U/L [0.08-0.75 µkat/L]), a serum γ-glutamyltransferase level of 210 U/L (3.50 µkat/L) (normal range, 10-50 U/L [0.17-0.83 µkat/L]), a serum alkaline phosphatase level of 157 U/L (2.62 µkat/L) (normal range, 30-120 U/L [0.50-2.0 µkat/L]), a serum amylase level of 210 U/L (3.50 µkat/L) (normal range, 30-100 U/L [0.50-1.66 µkat/L]), a serum lipase level of 391 U/L (6.52 µkat/L) (normal range, 13-60 U/L [0.21-1.0 µkat/L]), an α-fetoprotein level of 3.81 ng/ mL (normal range, 0-9 ng/mL), a total protein level of 4.6 g/dL (normal range, 6.0-8.5 g/dL), and an albumin level of 2.6 g/dL (normal range, 3.5-5.2 g/dL). The rest of the laboratory data were unremarkable. The patient underwent erect abdominal radiography, contrast material-enhanced multidetector row computed tomography (CT) of the abdomen with 100 mL of iohexol (300 mg iodine per milliliter, Omnipaque; GE Healthcare, Shanghai, China) followed by combined positron emission tomography (PET) and CT (hereafter, PET/CT) with 6.9 mCi of fluorodeoxyglucose (FDG) and magnetic resonance (MR) imaging of the upper abdomen.

Isolated splenic tuberculosis detected only on FDG-PET.

Tuberculosis (TB) is a well-known problem in developing countries but has shown resurgence in non-endemic populations in recent years. This may be due to increased migration, and is more commonly seen in populations with lowered immunity due to various causes. Isolated splenic TB is extremely rare, especially in immunocompetent patients. In this case report we have described an immunocompetent female, presenting to the physician with fever, without any chest symptoms or weight loss. All microbiological investigations for pyrexia of unknown origin were done, which did not reveal the cause. Imaging modalities including chest radiographs and ultrasound did not reveal any significant abnormalities. Finally, fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed FDG-avid multiple focal nodular lesions (not seen on contrast and non-contrast CT). MRI including diffusion-weighted imaging did not reveal the splenic nodules. PET-directed CT-guided biopsy of the splenic lesions was performed, with histopathology findings suggestive of TB. Atypical clinical and imaging presentations are not uncommon in TB. History of exposure to TB may not be present. Nevertheless, TB should be kept in mind as a differential diagnosis in patients with fever, and extensive search of the source is important. Splenic TB reported in literature to date has been detected by morphological imaging modalities such as ultrasound or contrast CT. Ours is possibly the first case reported in the English literature where FDG-PET has detected the lesions that other imaging modalities failed to show, thus illustrating the role of molecular imaging in the evaluation of pyrexia of unknown origin to localize the site of affection.

Unusual presentation of an usual condition-cystic ganglionosis.

Cystic ganglionosis is an unusual benign condition, which presents as multiple ganglion cysts involving multiple joints. The case we report here is probably the first case of an adult reported in the literature. The only other case of multiple ganglion cysts reported in the literature is that of an 11-year-old child with ganglion cysts in multiple joints. A 57-year-old female presented with an approximately 4-year history of pain and swelling below the left knee and in the right hand. An MRI of the left knee showed multiloculated cystic-intensity lesions around the knee joint with intra-/extra-articular and intraosseous components. Similar lesions were noted around the right knee joint, right wrist and ring finger. With all the above findings and in view of multiple joint involvement, the possibility of cystic ganglionosis or multiple giant ganglion cysts was considered and confirmed by biopsy of one of the knee lesions. It is because of this rarity and the unusual presentation involving multiple joints that we have reported this case. The importance of the diagnosis is that unnecessary surgical intervention and hospitalization can be avoided, provided the patient's symptoms are not severe.

Robotic-arm stereotactic radiosurgery as a definitive treatment for gelastic epilepsy associated with hypothalamic hamartoma.

Gelastic seizures, characterised by paroxysms of pathological laughter, are most often associated with an underlying hypothalamic hamartoma. This report describes the definitive treatment using stereotactic-radiosurgery for a teenaged child whose gelastic epilepsy was found refractory to various antiepileptic drugs. Since surgery was not consented to, the child was referred to us for stereotactic radiosurgery (SRS), which was delivered with robotic-arm -SRS to a dose of 30 Gy in five fractions in five consecutive days. A decrease in the frequency of seizures was noticeable as early as within a week, and at 12 months after the procedure, there has been a total cessation of seizures.

Re-irradiation with hypo-fractionated stereotactic robotic radiotherapy for salvage in adult patients with brainstem glioma.

PURPOSE: Brainstem glioma (BSG) is often treated with definitive irradiation. However, subsequent progression and death occur as a rule rather than the exception, after varying periods of control. The outlook of patients with post-irradiation progression is dismal, and most of these patients are treated with supportive care alone. Despite the obvious risks with an area as critical as the brainstem, it is a possibility to encounter situations wherein the patients (themselves or their associates) ask for re-irradiation, with the hope of a few extra months of life. The risk of radiation-induced brainstem toxicity may be justifiable under the strict assumption that the patients stand a chance of benefiting from re-irradiation but still may not live long enough to manifest brainstem toxicity. METHODS: Five adult BSG patients were treated with re-irradiation using robotic-arm stereotactic radiation therapy (SRT) between September 2009 and July 2012, primarily at the request of the concerned patient parties. Re-irradiation doses ranged from 16 to 25 Gray (Gy) delivered by robotic arm stereotactic irradiation in 2-5 fractions. RESULTS: Four out of five patients enjoyed a prolongation of survival in the order of months (three, five, six, and 14 months), which was very significant given that all patients had severe neurological compromise and poor performance status prior to re-irradiation. One patient has survived 36 months after re-irradiation and thus has lived long enough to manifest late radiation-induced brainstem toxicity. CONCLUSION: Despite the obvious risks of brainstem toxicity associated with the use of re-irradiation for BSG, the use of fractionated stereotactic re-irradiation seems to offers prospects of additional periods of local control and augments duration of life.

Pictorial essay: Salivary gland imaging.

Salivary glands are the first organs of digestion secreting their digestive juices into the oral cavity. Parotid, submandibular, and sublingual glands are the major paired salivary glands in the decreasing order of their size. In addition, multiple small minor salivary glands are noted randomly distributed in the upper aerodigestive tract, including paranasal sinuses and parapharyngeal spaces. The imaging is directed to the major salivary glands. Commonly used imaging methods include plain radiography and conventional sialography. Recently, high-resolution ultrasonography (HRUS) is being increasingly used for targeted salivary gland imaging. However, the advent of cross-sectional imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) have revolutionized the imaging of salivary glands. This article illustrates the role of imaging in evaluating the variegated disease pattern of the major salivary glands.

Technical note: Image guided internal fiducial placement for stereotactic radiosurgery (CyberKnife).

Internal gold fiducials are necessary for tracking the translational and rotational movements of target lesions during stereotactic radiosurgery. The fiducials are generally placed under image guidance in and around the lesions by interventional radiologists. Specific challenges are encountered during the procedure. This article discusses the basic principles and techniques as well as the specific complications.

PET/CT-guided percutaneous biopsy of isolated intramuscular metastases from postcricoid cancer.

(18)F-FDG PET/CT has made it possible to identify many unsuspected lesions such as isolated intramuscular metastases because of its ability to detect abnormal metabolic activity in an early stage even without clinical symptoms or morphologic changes. We need to modify our routine techniques for performing biopsies of such lesions because they may not be visualized on morphologic imaging. We describe a technique in which fused PET/CT is used to guide the percutaneous biopsy needle for sampling isolated intramuscular metastatic lesions in a patient whose intramuscular metastases were identified only on PET/CT, not on CT or ultrasound, and were clinically occult.