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Alexander A, Hunter K, Rubin M, Bhat AP. Extraosseous Ewing's Sarcoma: Pictorial Review of Imaging Findings, Differential Diagnosis, and Pathologic Correlation. Indian J Radiol Imaging 2021; 31:203-209. [PMID: 34316128 PMCID: PMC8299506 DOI: 10.1055/s-0041-1729770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Extraosseous Ewing's sarcoma (EES), first described in 1969, is a malignant mesenchymal tumor just like its intraosseous counterpart. Although Ewing's sarcomas are common bone tumors in young children, EESs are rarer and more commonly found in older children/adults, often carrying a poorer prognosis. We discuss the multimodality imaging features of EES and the differential diagnosis of an aggressive appearing mass in proximity to skeletal structures, with pathologic correlates. This review highlights the need to recognize the variability of radiologic findings in EES such as the presence of hemorrhage, rich vascularity, and cystic or necrotic regions and its imaging similarity to other neoplasms that are closely related pathologically.
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Affiliation(s)
- Alan Alexander
- Department of Radiolog, Imaging Medical Associates, Inc., Northridge, California, United States
| | - Kyle Hunter
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, United States
| | - Michael Rubin
- Department of Radiology, Akron Children's Hospital, Akron, Ohio, United States
| | - Ambarish P Bhat
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Missouri Columbia, Columbia, Missouri, United States
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2
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Nance ME, Tarim AO, Nguyen V, Malhotra K, Davis RM, Bhat AP. Risk Factors for Major Hemorrhage Following Percutaneous Image-Guided Renal Biopsy: What is the "core" of the Problem? A Retrospective Case-control Study. J Clin Imaging Sci 2020; 10:54. [PMID: 33024609 PMCID: PMC7533095 DOI: 10.25259/jcis_87_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/13/2020] [Indexed: 11/19/2022] Open
Abstract
Objectives: Percutaneous renal biopsy (PRB) plays a critical role in the work-up of renal parenchymal disease. Although it is considered a low-risk procedure, additional interventions may be required in about 7% of the cases following biopsy. The purpose of this study was to identify risk factors for major hemorrhage by microscopic analysis of the cores obtained following PRB, with an intent to enhance the sensitivity and specificity of the risk stratification process, especially in patients undergoing this procedure in an outpatient setting. Material and Methods: A retrospective review identified 17 of 179 patients (9.50%) with major hemorrhage following PRB between July 2014 and June 2019. Using propensity score matching, 26 controls (without major hemorrhage) were matched to 17 cases (with major hemorrhage). The biopsy cores obtained from the cases and controls were analyzed by a single pathologist for medullary, cortical, total (medullary + cortical) lengths, and the number of arcuate arteries (AAs). Medullary:cortical (M:C), cortical:total (C:T), and medullary:total (M:T) length ratios were then calculated. Results: A stratified version of logistic regression was used to test for an association between each of the variables identified on the cores and the probability of a major hemorrhage. The analysis revealed that there was a statistically significant association between the number of AAs per specimen with the risk of major hemorrhage (P = 0.0006). When 0, 1, or >2 AAs were identified, the frequency of major hemorrhage was 13.04%, 66.67%, and 75.00%, respectively. The odds of major hemorrhage were 6 times higher with one AA and (95% CI, 1.28–32.30) and 15 times higher with >2 AAs (95% CI, 1.41–169.57). No significant association was found between medullary length (P = 0.228), medulla:cortex (M:C) (P = 0.089), medulla:total (M:T) (P = 0.108), or cortex:total (C:T) (P = 0.112) length ratios and major hemorrhage. Conclusion: There was a strong and incremental correlation between major renal hemorrhage following PRB and the number of AAs per core specimen. Identification of AAs by the pathologist, while assessing for sample adequacy, in the US suite can help predict major hemorrhage in patients undergoing PRBs.
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Affiliation(s)
- Michael E Nance
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Andrew O Tarim
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Van Nguyen
- Departments of Pathology, University of Missouri, Columbia, Missouri, United States
| | - Kunal Malhotra
- Department of Medicine, Division of Nephrology, University of Missouri, Columbia, Missouri, United States
| | - Ryan M Davis
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, Missouri, United States
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, Missouri, United States
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Nance ME, Biedermann GB, Bhat AP, Davis RM. Chemorefractory liver metastasis from cervical cancer successfully treated with a combination of yttrium-90 and immunotherapy. Radiol Case Rep 2020; 15:1359-1365. [PMID: 32636973 PMCID: PMC7327429 DOI: 10.1016/j.radcr.2020.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/24/2022] Open
Abstract
Liver metastases in cervical cancer is rare and can be difficult-to-treat. The current guidelines established by the Gynecologic Oncology Group recommend platinum-based systemic chemotherapy in combination with an anti-angiogenic agent such as bevacizumab, however, overall survival remains poor following diagnosis and options for patients who fail chemotherapy are limited. Yttrium-90 (Y90) radioembolization (RE) has shown great promise in the treatment of chemo-refractory colorectal liver metastases. We describe a 30-year-old female with a history of stage IB endocervical adenocarcinoma who later developed metastases to the liver, that were unresponsive to multiple chemotherapeutics and chemoembolization, and was successfully treated with Y90 RE with concurrent systemic Pembrolizumab. The Y90 RE treatment resulted in positive clinical and imaging responses with improvement in her quality of life, all of which continue to persist at the time of writing this manuscript about 8-months into her RE treatment.
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Affiliation(s)
- Michael E. Nance
- School of Medicine, University of Missouri, Columbia, MO, USA
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, One Hospital drive, Columbia, MO 65212, USA
| | - Gregory B. Biedermann
- Department of Radiology, Section of Radiation Oncology, University of Missouri, Columbia, Columbia, MO, USA
| | - Ambarish P. Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, One Hospital drive, Columbia, MO 65212, USA
- Corresponding author.
| | - Ryan M. Davis
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, One Hospital drive, Columbia, MO 65212, USA
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Alexander A, Hunter K, Passerini S, Bhat R, Bhat AP. Appendiceal diverticulosis in a patient with family history of Birt-Hogg-Dubé syndrome--a case report. Radiol Case Rep 2020; 15:1317-1322. [PMID: 32612732 PMCID: PMC7322125 DOI: 10.1016/j.radcr.2020.05.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 12/12/2022] Open
Abstract
Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant disorder that predisposes patients to cutaneous tumors, pulmonary cysts with recurrent spontaneous pneumothoraces, and a variety of renal neoplasms including hybrid oncocytic and chromophobe renal cell carcinomas. There has been much debate regarding the genetic link with the occurrence of colorectal cancer and other colonic anomalies. Associations between BHD and intestinal adenomatous polyposis and sigmoid diverticulosis have been described in the literature, but there have been no prior reports of appendiceal diverticulosis in patients with BHD. Here, we present a 40-year-old female patient with a known family history of BHD, who was found to have diverticulosis of the appendix and pulmonary blebs on computed tomography upon routine screening for renal and pulmonary abnormalities, suggesting additional focus be given to the gastrointestinal tract (including the appendix) at the time of CT assessment.
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Affiliation(s)
- Alan Alexander
- Renaissance Imaging Medical Associates, Northridge, CA, USA
| | - Kyle Hunter
- Department of Radiology, Cleveland Clinic, OH, USA
| | | | - Roopa Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri- Columbia, One Hospital Drive, Columbia, MO, 65212, USA
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri- Columbia, One Hospital Drive, Columbia, MO, 65212, USA
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Marjara J, Hilli J, Davis RM, Bhat AP. Metastatic retro-crural lymph nodes from transitional cell carcinoma of bladder successfully treated with single session cryoablation. Radiol Case Rep 2020; 15:1197-1201. [PMID: 32550958 PMCID: PMC7292893 DOI: 10.1016/j.radcr.2020.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 01/09/2023] Open
Abstract
Bladder cancer (BC) is a relatively common tumor, with a male preponderance. High-grade muscle invasive bladder cancer (MIBC) has a very high incidence of pelvic lymph node metastasis at presentation. Involvement of the retro-crural lymph nodes, although has been described in other pelvic tumors, is very uncommon for BC. Cryoablation in the retro-crural region is extremely challenging due to the proximity to the critical structures like inferior venacava and aorta and has not been extensively reported. We describe a 56-year old male patient with MIBC who underwent extensive treatments including radical cystoprostatectomy, chemoradiation and immunotherapy, ultimately with localized disease in the retro-crural region. Single session cryoablation of these lymph nodes was performed with a curative intent yielding a positive response that has persisted for more than 2 years.
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Affiliation(s)
- Jasraj Marjara
- University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO, USA
| | - Jaffar Hilli
- Department of Medicine, Division of Hematology and Oncology, University of Missouri-Columbia, One Hospital Drive, Columbia, MO, USA
| | - Ryan M Davis
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri-Columbia, One Hospital Drive, Columbia, MO, 65212, USA
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri-Columbia, One Hospital Drive, Columbia, MO, 65212, USA
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Atkins NK, Marjara J, Kaifi JT, Kunin JR, Saboo SS, Davis RM, Bhat AP. Role of Computed Tomography-guided Biopsies in the Era of Electromagnetic Navigational Bronchoscopy: A Retrospective Study of Factors Predicting Diagnostic Yield in Electromagnetic Navigational Bronchoscopy and Computed Tomography Biopsies. J Clin Imaging Sci 2020; 10:33. [PMID: 32547836 PMCID: PMC7294316 DOI: 10.25259/jcis_53_2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/20/2020] [Indexed: 12/26/2022] Open
Abstract
Objectives: Over 25% of the high-risk population screened for lung cancer have an abnormal computed tomography (CT) scan. Conventionally, these lesions have been biopsied with CT guidance with a high diagnostic yield. Electromagnetic navigational bronchoscopy (ENB) with transbronchial biopsy has emerged as a technology that improves the diagnostic sensitivity of conventional bronchoscopic biopsy. It has been used to biopsy lung lesions, due to the low risk of pneumothorax. It is, however, a new technology that is expensive and its role in the diagnosis of the solitary pulmonary nodule (SPN) is yet to be determined. The purpose of this study was to evaluate the diagnostic yield of CT-guided biopsy (CTB) following non-diagnostic ENB biopsy and identify characteristics of the lesion that predicts a low diagnostic yield with ENB, to ensure appropriate use of ENB in the evaluation of SPN. Materials and Methods: One hundred and thirty-five lung lesions were biopsied with ENB from January 2017 to August 2019. Biopsies were considered diagnostic if pathology confirmed malignancy or inflammation in the appropriate clinical and imaging setting. We evaluated lesions for several characteristics including size, lobe, and central/peripheral distribution. The diagnostic yield of CTB in patients who failed ENB biopsies was also evaluated. Logistic regression was used to identify factors likely to predict a non-diagnostic ENB biopsy. Result: Overall, ENB biopsies were performed in 135 patients with solitary lung lesions. ENB biopsies were diagnostic in 52% (70/135) of the patients. In 23 patients with solitary lung lesions, CTBs were performed following a non-diagnostic ENB biopsy. The CTBs were diagnostic in 87% of the patients (20/23). ENB biopsies of lesions <21.5 mm were non-diagnostic in 71% of cases (42/59); 14 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% of them were diagnostic (12/14). ENB biopsies of lesions in the lower lobes were non- diagnostic in 59% of cases (35/59); 12 of these patients with non-diagnostic ENB biopsies had CTBs, and 83% were diagnostic (10/12). ENB biopsies of lesions in the outer 2/3 were non-diagnostic in 57% of cases (50/87); 21 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% were diagnostic (18/21). Conclusion: CTBs have a high diagnostic yield even following non-diagnostic ENB biopsies. Lesions <21.5 mm, in the outer 2/3 of the lung, and in the lower lung have the lowest likelihood of a diagnostic yield with ENB biopsies. Although CTBs have a slightly higher pneumothorax rate, these lesions would be more successfully diagnosed with CTB as opposed to ENB biopsy, in the process expediting the diagnosis and saving valuable medical resources.
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Affiliation(s)
- Naomi K Atkins
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Jasraj Marjara
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Jussuf T Kaifi
- Departments of Cardiothoracic Surgery, University of Missouri, Columbia, Missouri, United States
| | - Jeffrey R Kunin
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Sachin S Saboo
- Department of Radiology, University of Texas Health Science Center, San Antonio, Texas, United States
| | - Ryan M Davis
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Ambarish P Bhat
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
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Kabeel K, Marjara J, Bhat R, Gaballah AH, Abdelaziz A, Bhat AP. Spontaneous hemorrhage of an adrenal myelolipoma treated with transarterial embolization: A case report. Radiol Case Rep 2020; 15:961-965. [PMID: 32419895 PMCID: PMC7214766 DOI: 10.1016/j.radcr.2020.04.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/14/2023] Open
Abstract
Adrenal myelolipoma is a benign tumor of the adrenal cortex composed predominantly of fat and hematopoietic tissue. These lesions are usually asymptomatic, and most often incidentally detected on imaging. Uncommonly, they present with retroperitoneal hemorrhage, and these have been traditionally treated with emergent surgery. Although, transarterial embolization has been effectively and safely used in patients presenting with active hemorrhage from acute traumatic and nontraumatic causes, literature specifically pertaining to adrenal artery embolization is scant, perhaps due to smaller size and variability of adrenal arteries. With recent advances in endovascular techniques and imaging, there are emerging case reports and series of adrenal artery embolization in acute and nonacute settings. We report a case of spontaneous hemorrhage within an adrenal myelolipoma in a 43-year-old male patient, successfully treated with transarterial embolization, thereby avoiding major surgery. Our report adds to the growing body of literature pertaining to adrenal artery embolization.
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Affiliation(s)
- Khalid Kabeel
- Department of Radiology, Body Imaging Section, University of Missouri, Columbia, MO 65212, USA
| | - Jasraj Marjara
- University of Missouri-Columbia School of Medicine, Columbia, MO 65212, USA
| | - Roopa Bhat
- Department of Radiology, Body Imaging Section, University of Missouri, Columbia, MO 65212, USA
| | - Ayman H Gaballah
- Department of Radiology, Body Imaging Section, University of Missouri, Columbia, MO 65212, USA
| | - Amr Abdelaziz
- Department of Radiology, Body Imaging Section, University of Missouri, Columbia, MO 65212, USA
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA
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Endovascular Treatment of Chronic Total Occlusions of the Iliac Arteries: Early and Midterm Results. Ann Vasc Surg 2015; 29:1508-15. [DOI: 10.1016/j.avsg.2015.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 05/30/2015] [Accepted: 07/03/2015] [Indexed: 11/23/2022]
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