J Surg Rad Volume 4 - April 2013

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53Contents

74 Original ArticleUltrasound-Guided Biopsies

sabina amin et al.

78 Original ArticleRetroperitoneal Paraganglioma

benjamin bates and james ouellette

82 Original ArticleBrachial Plexus Injury

Rashmi Gupta et al.

86 Original ArticleElongated Styloid Process

ioannis Vasileiadis et al.

58 Original ArticleAdolescent Breast Mass

Katie n. jones et al.

64 Original ArticleBariatric Surgery Complications

lauRa doyon et al.

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54 editoRs | apRil 2013

Journal of Surgical Radiology

Executive EditorSapan Desai

Surgisphere Corporation

Science EditorThomas KoenigsbergerSurgisphere Corporation

Staff EditorCarol Fisher

Surgisphere Corporation

Editor-in-ChiefCynthia Shortell

Duke University Medical Center, Durham, North Carolina

Managing EditorMark Shapiro Duke University Medical Center, Durham, North Carolina

Journal EditorsHasan Alam Massachusetts General Hospital, Boston, MassachusettsAli Azizzadeh University of Texas at Houston, Houston, TexasStanley Ashley Brigham and Women’s Hospital, Boston, MassachusettsAnthony Atala Wake Forest Baptist Health, Winston-Salem, North CarolinaDavid Bentrem Northwestern University, Chicago, IllinoisGavin Britz Duke University Medical Center, Durham, North CarolinaAlasdair Conn Massachusetts General Hospital, Boston, MassachusettsJames Cusack Jr. Massachusetts General Hospital, Boston, MassachusettsDaniel Dent University of Texas Health Sciences Center, San Antonio, TexasCelia Divino Mount Sinai School of Medicine, New York, New YorkAnahita Dua University of Texas at Houston, Houston, TexasN. Joseph Espat Roger Williams Medical Center, Providence, Rhode IslandSteven Evans Georgetown University Medical Center, Washington, DCThomas Fahey III Weill Cornell Medical College, New York City, New YorkAllan Friedman Duke University Medical Center, Durham, North CarolinaRichard Gray Mayo Clinic, Phoenix, ArizonaRalph Greco Stanford University, Stanford, CaliforniaRajan Gupta Duke University Medical Center, Durham, North CarolinaTimothy Hall Stamford Hospital, Stamford, ConnecticutW. Scott Helton Hospital of Saint Raphael, New Haven, ConnecticutG. Chad Hughes Duke University Medical Center, Durham, North CarolinaRonald C. Jones Baylor University Medical Center, Dallas, TexasCharles Kim Duke University Medical Center, Durham, North CarolinaDavid King Massachusetts General Hospital, Boston, MassachusettsChristopher J. Kwolek Massachusetts General Hospital, Boston, MassachusettsMichael leitman Beth Israel Medical Center, New York City, New YorkMatthew Menard Brigham and Women’s Hospital, Boston, MassachusettsMichael Miller Duke University Medical Center, Durham, North CarolinaStephen Milner Johns Hopkins University, Baltimore, MarylandEugene Moretti Duke University Medical Center, Durham, North CarolinaTheodore Pappas Duke University Medical Center, Durham, North CarolinaJeff Pruitt UT Southwestern Medical Center, Dallas, TexasScott Pruitt Duke University Medical Center, Durham, North CarolinaHazim Safi University of Texas at Houston, Houston, TexasRanjan Sudan Duke University Medical Center, Durham, North CarolinaGilbert Upchurch, Jr University of Virginia, Charlottesville, Virginia

Advisor to the JournalDanny O. Jacobs Duke University Medical Center, Durham, North Carolina

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56 j suRG Rad | apRil 2013

Journal of Surgical Radiology

Published by the Surgisphere Corporation

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Citation Jones et al. Management of Adolescent Breast Masses. J Surg Radiol. 2013 Apr 1;4(2).

CorrespondenCe Katie N. Jones MD E-mail [email protected].

reCeived June 22, 2012. aCCepted January 1, 2013. epub April 1, 2013.

Management of Adolescent Breast Masses Katie N. Jones, MD,1 Sandhya Pruthi, MD,2 Judy C. Boughey, MD,3 Patricia S. Simmons, MD4,5

1. Department of Radiology, 2. Division of General Internal Medicine, 3. Department of Surgery, 4. Division of Pediat-ric and Adolescent Gynecology, and 5. Division of Gynecology, Mayo Clinic, Rochester, Minnesota.

Abstractoverview Palpable abnormalities in the female breast are common and can be anxiety provok-ing. Although breast malignancy is rare in the adolescent population, a palpable mass can still instill worry in both the patient and her family about the possibility of or potential association with breast cancer. Fortunately, most adolescent breast masses are benign or associated with normal breast de-velopment. There are limited data in the literature regarding the management of palpable lesions in the adolescent breast. We present 3 cases of adolescent girls with palpable breast lesions and discuss the role of breast imaging, image-guided intervention, and surgical and medical management.

Keywords adolescent; breast diseases/diagnosis; breast neoplasms/diagnosis; female; ultra-sound

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Jones et al. Adolescent Breast Masses original artiCle

IntroductionPalpable abnormalities in the breast are disconcerting to both the adolescent patient and her family, especially given the in-creasing awareness and incidence of breast malignancy in the adult population. Despite worry and anxiety when a lesion is detected, malignancy of the breast in the adolescent popula-tion is rare; most abnormalities in the adolescent breast relate to benign masses or normal development.1 There is a paucity of literature on the evaluation and management of common palpable lesions in the adolescent breast. We present 3 cases of palpable breast lesions in adolescent girls, review their clinical evaluation and management, and provide practical teaching points.

Case SeriesCase 1 A 15-year-old girl sought care from her primary care provider for evaluation of a palpable breast mass. Her symptoms began 1 week earlier, with generalized discomfort in her left breast. Six days later, she palpated a “plum-size” mass in the inferior aspect of the left breast. She did not recall any recent trauma and reported no fever or chills. Menarche was at age 13 years, and menses were regular. She reported no prior pregnancy and

did not use oral contraceptives. There was no family history of breast cancer. She was seen by her primary care provider the day after palpation of the mass. On evaluation by focused breast ultrasonography (Figure 1), the mass was assessed a Breast Imaging Reporting and Data System (BI-RADS) score of 4, suspicious for malignancy, and a breast biopsy was rec-ommended.

The patient was referred by her primary care provider to the breast clinic at our institution for a second opinion the follow-ing week. At this visit she reported that the mass had decreased in size, and she estimated the pain from it to be 2 on scale of 1 to 10. On physical examination, she was Tanner stage IV with no skin erythema or nipple retraction. In the left breast, there was a well-demarcated 2-cm mass, which was smooth, firm, and mobile. Examination of the right breast was unremark-able and there was no axillary adenopathy. On repeat focused breast ultrasonography, the mass was unchanged in size and was interpreted as likely representing a complicated cyst.

The findings were discussed with the patient and her mother. They were very anxious about the mass and opted to undergo cyst aspiration with possible biopsy. Using ultrasound guid-ance, the cyst was completely aspirated, yielding clear, green-ish fluid, which was discarded. At the time of clinical follow-up a week later, the patient reported resolution of the palpable concern.

Case 2A 14-year-old girl palpated a mass in her right breast that she described as the size of a “ping-pong ball.” One month later, she informed her mother about the mass, and an appoint-

Figure 1. Palpable Breast Mass in a 15-Year-Old Girl. A, Ultrasonography demonstrates a lobulated, circumscribed mass with increased through-transmission and internal echoes. B, No vascularity is seen within the mass with Dop-pler interrogation. Findings are suggestive of a complicat-ed cyst. C, Ultrasound image after aspiration demonstrates resolution of the cyst.


original artiCle Jones et al. Adolescent Breast Masseseither side.

Given the interval rapid growth of the mass, surgical consul-tation was obtained. The patient and her mother elected to proceed with surgical excision. Excisional biopsy of the mass demonstrated a fibroadenoma with pseudoangiomatous stro-mal hyperplasia. The patient did well postoperatively. She was pleased with the cosmetic outcome and did not pursue plastic surgery consultation.

Case 3A 17-year-old girl detected a “dime-sized” mass in her right breast and sought care at our breast clinic 3 months later. The patient indicated that the mass had increased in size over the past 3 months. She reported no pain, skin changes, or nipple discharge. Family history was remarkable for her mother hav-ing breast cancer at age 37 years; to the patient’s knowledge, her mother had not pursued genetic testing. The patient was using an intravaginal ring for contraception. On physical ex-amination, the patient was Tanner stage IV. The left breast was slightly larger than the right. In the right breast, there was a well-demarcated, firm, smooth, 2-cm mass at 2 o’clock, 2 cm from the nipple. The left breast was normal, and there was no axillary adenopathy.

On ultrasonography, the sonographic characteristics were believed to most likely represent a fibroadenoma (Figure 3). The options of short-term follow-up or percutaneous biopsy were offered to the patient. She elected to undergo percuta-neous biopsy. Ultrasound-guided biopsy was performed with a 14-gauge spring-loaded device; pathologic analysis dem-onstrated a fibroadenoma with multinucleated stromal gi-ant cells. Follow-up clinical examination and ultrasound 6 months after biopsy showed no clinically significant change in the mass.

ment was made for evaluation by her primary care provider. The primary care provider advised follow-up in 4 weeks to assess for resolution of a “probable cyst.” The patient returned for follow-up as recommended and noted that the lesion had increased in size and was now “larger than a lemon” and as-sociated with more discomfort. Findings on ultrasonography were consistent with a differential diagnosis of fibroadenoma or phyllodes tumor (Figure 2).

Three months after she initially noticed the mass, the patient was referred to the breast clinic at our institution for an evalu-ation. On physical examination, the patient was Tanner stage III. The right breast was larger than the left, and there was a 3x4-cm, well-demarcated, palpable mass with associated ten-derness in the lower outer right breast. The left breast was normal, and there was no palpable axillary adenopathy on

Figure 2. Rapidly Growing, Palpable Breast Mass in a 14-Year-Old Girl. A, Ultrasonography shows an oval, circum-scribed, hypoechoic mass parallel to the chest wall measur-ing 4x2x3 cm. B, Internal vascularity is seen with Doppler in-terrogation. C, Intraoperative photograph showing excision of the fibroadenoma.

Figure 3. Palpable Breast Mass in a 17-Year-Old Girl. With ultrasonography, an 8x4-mm, oval, circumscribed, hypoechoic mass parallel to the chest wall is seen at the site of palpable concern.

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result.6 Usually, preoperative percutaneous core biopsy is rec-ommended to establish histologic diagnosis. This enables the surgeon to plan for surgical resection, including resection with adequate margins around the lesion in the case of phyllodes tumor, and for pathologic processing of the specimen for mar-gin evaluation. Indications for surgical intervention for a mass in the adolescent breast include a rapidly growing mass, as in Case 2; a mass larger than 5 cm; a mass with distortion of the breast architecture or overlying skin changes; a persistent mass without regression; stromal hypercellularity or cystic change on ultrasonography; worrisome findings on clinical examination (nipple or skin retraction); presence of a high-risk genetic mutation or history of chest irradiation; and a histologically complex fibroadenoma.6

When surgical intervention is planned for the adolescent breast, areas of concern include the cosmetic outcome as well as potential damage to the developing breast bud and nipple-areolar complex. Plastic surgery with a tissue expander is an option if there is a significant cosmetic defect, but this is not recommended immediately because the compressed breast parenchyma expands with time in most patients.7

Conservative management is generally the best option for management of small fibroadenomas in the adolescent, as was seen in Case 3. In a prospective review of 447 adolescent patients with breast masses, only 1 mass (0.3%) was found to be malignant.8 In retrospect, the mass did not fit criteria for a benign mass using the Stavros criteria.9

Vacuum-assisted, ultrasound-guided biopsy has been suggest-ed as a minimally invasive technique to excise small, palpable fibroadenomas. The procedure, which involves a large-bore, hand-held, vacuum-assisted device, is performed in the outpa-tient setting under local anesthesia. Success rates vary, but the percentage of sonographically apparent residual or recurrent lesions has been reported to range from 15% to 33%.10-12 The technique is promising for patients with multiple masses or in

DiscussionFibrocystic change in the adolescent breast is relatively com-mon, present in 8.5% of adolescents in 1 series.2 Complicated cysts, as seen in Case 1, are a part of the spectrum of cystic change in the breast and can pose a diagnostic challenge as a result of internal echoes within the mass resulting from proteinaceous debris from cell turnover, pus, or hemorrhage. They can be difficult to distinguish sonographically from sol-id masses because of the internal echoes but otherwise fit the sonographic criteria of a simple cyst. Often the cysts are as-ymptomatic but can present clinically in an adolescent patient if they are rapidly enlarging or become infected or inflamed. The differential diagnosis includes hematoma, abscess, or ga-lactocele in a lactating patient; clinical history will help dis-tinguish these entities.

Management of complicated cysts is usually conservative. In the American College of Radiology Imaging Network 6666 trial, which evaluated screening ultrasonography in the adult population, complicated cysts were categorized as a BI-RADS 2, benign, finding when in the presence of multiple simple cysts.3 A BI-RADS score of 3, probably benign, with short-term follow-up, was recommended for solitary lesions. Using these criteria, the investigators found that only 0.42% of le-sions were malignant in the adult population. Extrapolation of those data to the pediatric population, with an incidence of breast malignancy of 0.08 per 100,000 children 19 years and younger,4 shows the risk of malignancy from a complicated cyst to be minimal.

Short-term clinical or sonographic follow-up is usually ap-propriate in these cases. Diagnostic and therapeutic aspira-tion can be reserved for cases of painful cysts or those that arouse concern for infection. However, resolution of the cyst with ultrasound-guided aspiration often provides psychologi-cal benefit to the patient. If the patient or guardian remains anxious, as in Case 1, a simple outpatient aspiration may be reasonable to alleviate worry.

If typical cyst fluid (clear, cloudy, yellowish, or greenish) is as-pirated under ultrasound guidance and the cyst completely resolves, the fluid may be discarded. Cytologic evaluation of typical cyst fluid may result in false-positive results and un-necessary further treatment.5 If the aspirate is bloody, the fluid should be sent for cytologic evaluation and the site marked with a clip under sonographic guidance. If the cyst does not resolve completely or proves to be solid, core needle biopsy with clip placement should be performed.

Surgical management is recommended for large or rapidly growing masses in the juvenile breast. Physical examination and imaging cannot reliably distinguish fibroadenomas from phyllodes tumors, and large, rapidly growing masses can cause deformity of the adolescent breast. In Case 2, core needle bi-opsy was not performed; the role of core biopsy in this setting is controversial. Some authors view core needle biopsy as an unnecessary step in the management of these masses, because the mass will be surgically excised regardless of the biopsy

Figure 4. Algorithm for Management of a Palpable Breast Mass in an Adolescent.


original artiCle Jones et al. Adolescent Breast MassesOct;184(4):332-6.

12. Grady I, Gorsuch H, Wilburn-Bailey S. Long-term outcome of benign fibroadenomas treated by ultrasound-guided percutaneous excision. Breast J. 2008 May-Jun;14(3):275-8. Epub 2008 Apr 6.

13. Kaufman CS, Littrup PJ, Freeman-Gibb LA, Smith JS, Francescatti D, Simmons R, et al. Office-based cryoablation of breast fibroadenomas with long-term follow-up. Breast J. 2005 Sep-Oct;11(5):344-50.

14. Littrup PJ, Freeman-Gibb L, Andea A, White M, Amerikia KC, Bouw-man D, et al. Cryotherapy for breast fibroadenomas. Radiology. 2005 Jan;234(1):63-72. Epub 2004 Nov 18.

15. Caleffi M, Filho DD, Borghetti K, Graudenz M, Littrup PJ, Freeman-Gibb LA, et al. Cryoablation of benign breast tumors: evolution of technique and technology. Breast. 2004 Oct;13(5):397-407.

patients with small masses (<2 cm) who refuse conservative surveillance. In some reports, cryoablation has been used suc-cessfully in the outpatient setting for management of palpable breast masses, with good patient satisfaction and only minor complications.13-15

ConclusionManagement of palpable adolescent breast masses is most often conservative, given the very low incidence of breast ma-lignancy in this population. An algorithm for management of palpable adolescent breast lesions is included in Figure 4. Cystic lesions and small masses with a benign appearance sonographically can be managed with watchful waiting; per-cutaneous intervention can be considered if there is rapid growth, pain, or concern for infection. For rapidly enlarging solid masses in the adolescent breast, surgical management is preferred. Timely referral is critical in the case of rapidly enlarging masses to decrease the risk of potential damage to underlying breast parenchyma and poor cosmetic outcomes. In all cases, informed discussion with the patient and her par-ent or guardian is important to alleviate anxiety and facilitate appropriate management.

References1. Chung EM, Cube R, Hall GJ, Gonzalez C, Stocker JT, Glassman LM.

From the archives of the AFIP: breast masses in children and adoles-cents: radiologic-pathologic correlation. Radiographics. 2009 May-Jun;29(3):907-31.

2. Gogas J, Sechas M, Skalkeas G. Surgical management of diseases of the adolescent female breast: a clinicopathologic study. Am J Surg. 1979 May;137(5):634-7.

3. Berg WA, Sechtin AG, Marques H, Zhang Z. Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 2010 Sep;48(5):931-87.

4. Gutierrez JC, Housri N, Koniaris LG, Fischer AC, Sola JE. Malignant breast cancer in children: a review of 75 patients. J Surg Res. 2008 Jun 15;147(2):182-8. Epub 2008 Apr 14.

5. Smith DN, Kaelin CM, Korbin CD, Ko W, Meyer JE, Carter GR. Impal-pable breast cysts: utility of cytologic examination of fluid obtained with radiologically guided aspiration. Radiology. 1997 Jul;204(1):149-51.

6. Jayasinghe Y, Simmons PS. Fibroadenomas in adolescence. Curr Opin Obstet Gynecol. 2009 Oct;21(5):402-6.

7. Gobbi D, Dall’Igna P, Alaggio R, Nitti D, Cecchetto G. Giant fibroad-enoma of the breast in adolescents: report of 2 cases. J Pediatr Surg. 2009 Feb;44(2):e39-41.

8. Smith GE, Burrows P. Ultrasound diagnosis of fibroadenoma: is bi-opsy always necessary? Clin Radiol. 2008 May;63(5):511-5. Epub 2008 Jan 14.

9. Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use of sonography to distinguish between be-nign and malignant lesions. Radiology. 1995 Jul;196(1):123-34.

10. Kim MJ, Park BW, Kim SI, Youk JH, Kwak JY, Moon HJ, et al. Long-term follow-up results for ultrasound-guided vacuum-assisted re-moval of benign palpable breast mass. Am J Surg. 2010 Jan;199(1):1-7. Epub 2009 May 1.

11. Fine RE, Boyd BA, Whitworth PW, Kim JA, Harness JK, Burak WE. Percutaneous removal of benign breast masses using a vacuum-as-sisted hand-held device with ultrasound guidance. Am J Surg. 2002

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Radiographic Diagnosis of Postoperative Complications of Bariatric SurgeryLaura Doyon, MD, Edward H. Chin, MD, Celia M. Divino, MD, Scott Q. Nguyen, MD

Division of Surgery, Mount Sinai Hospital, New York, NY.

Citation Doyon L, et al. Radiographic Diagnosis of Post-operative Complications of Bariatric Surgery. J Surg Radiol. 2013 Apr 1;4(2).

CorrespondenCe Scott Q. Nyugen, MD E-mail [email protected]

reCeived September 22, 2012. aCCepted January 1, 2013. epub January 1, 2013.

AbstractobjeCtive Bariatric surgery is indicated for treatment of morbidly obese patients. Medical prac-titioners should be familiar with the common complications associated with post-surgical anatomy. Methods A Medline database search was conducted to review morbid obesity, bariatric sur-gery, postoperative complications, and treatments. results Roux-en-Y gastric bypass (RNYGB), laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (SG), and biliopancreatic diversion-duodenal switch (BPD-DS) are the four most commonly performed bariatric procedures. Although the safety and efficacy are well documented, there are a variety of important complications. These include band slippage and erosion for LAGB; staple line leak and stenosis for SG; and SBO, anastomotic leak, and anastomotic stenosis for RNYGB and BPD-DS.ConClusion Knowledge of bariatric procedures, postoperative anatomy, and a high index of sus-picion for serious post-surgical complications will allow practitioners to expeditiously diagnose and treat these problems.

Keywords bariatric, morbid obesity, complications, imaging, leak, LAGB, band, RNYGB

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Doyon et al. Bariatric Surgery original artiCle

IntroductionIn 2009-2010, there were more than 78 million obese adults over the age of 20, comprising 35.7% of the U.S. population.1 Data from the most recent evaluation of the National Inpa-tient Sample revealed that 124, 838 bariatric procedures were performed in 2008.2 Nonsurgical treatments for obesity have been minimally effective in treating this epidemic. Bariatric surgery has been found to have marked and lasting loss of excess body weight (EBW), upwards of 60-70% in some cases. Although these procedures have clear benefit and are relatively safe, there is a reported incidence of complications that should be familiar to medical practitioners who encounter these pa-tients.

As the number of patients undergoing bariatric procedures have increased, it is important for the medical community to be aware of the possible complications. Traditional history and physical exam can be challenging in obese patients, due to body habitus and nonspecific way in which many compli-cations present. Typically, there are few measurable objective signs such as tachycardia. Thus, radiologic diagnosis of com-plications is especially important for early recognition of these problems, since delays risk substantial morbidity and mortal-ity. This article will review a background on morbid obesity, the types of bariatric surgeries, and relevant complications with associated radiologic diagnoses.

MethodsA computerized literature search was performed using the Medline database from January 1979 to November 2012 with keywords related to bariatric surgery and its complications (“bariatric”, “postoperative”, and “complications”). Letters, communications, and non-English language papers were ex-cluded. References from all articles retrieved were subsequent-ly studied for any additional articles. Original data referred to by review articles was cited as written by the original au-thors. For each publication, the full manuscript was obtained. P values less than 0.05 were used to determine significance of measured results.

ResultsMorbid ObesityThe prevalence of morbid obesity has increased dramatically over the past 20 years. In 2009-2010, there were more than 78 million obese adults over the age of 20, comprising 35.7% of the U.S. population.1 Overweight is defined as a BMI 25.0 to 29.9, and obesity is defined as a BMI of greater than 30. Obe-sity is broken into classes: grade 1 (BMI 30 - <35), grade 2 (BMI 35 - <40), grade 3 (BMI>40). (Table 1) Morbid obesity is defined as BMI ≥ 40 or ≥35 with severe obesity-related co-morbidity.3

Obesity is associated with a diverse set of comorbidities. These include insulin resistance, diabetes, dyslipidemia, coronary artery disease, hypertension, obstructive sleep apnea.

Lifestyle modification and medical management of obesity have been marginally successful, thus leaving bariatric sur-gery as the only effective treatment for obesity. 94% and 76% of patients after gastric bypass were able to maintain at least a 20% weight loss at 2 and 6 years respectively, as compared to only 1 and 0% of non-surgical control patients.4 Addition-ally, the treatment of comorbidities is effective with surgery. In patients with uncontrolled diabetes, those who under-went either gastric bypass or gastric sleeve as well as medical therapy had better glycemic control than those patients with medical therapy alone.5 In another study, diabetes remission rate 6 years after gastric bypass was found to be 62% versus 1% and 8% in two groups of nonsurgical controls.4 The all-cause mortality rate in patients having undergone bariatric surgery versus non-surgical control group was 0.68% versus 6.17% with risk reduction of 89% in Christou’s study of >6000 obese patients.6

The NIH has concluded that bariatric surgery offers morbidly obese patients the best chance of long term weight loss. The 1991 consensus conference concluded that surgery should be offered to morbidly obese patients (BMI >40 or BMI>35 with obesity-related comorbidities), if traditional medical, nutritional, and behavioral therapies have failed.3 A multidis-ciplinary team of surgeons, medical specialists, nutritionists, psychiatrists, and physical or exercise therapists are typically involved in the preoperative evaluation and postoperative care of these patients.

The in-hospital mortality rate for patients undergoing bariatric

Table 1. Classes of Obesity

Category BMI

Normal weight 18.5-24.9

Overweight 25-29.9

Obesity Grade 1 30-34.9

Obesity Grade 2 35-39.9

Obesity Grade 3 40+

Table 2. Types of Bariatric Surgery

RestrictiveMalabsorptive and Restric-tive

Laparoscopic adjustable gastric band

Roux-en-Y gastric bypass

Sleeve GastrectomyBiliopancreatic diversion – duodenal switch


original artiCle Doyon et al. Bariatric Surgery

surgery has decreased from 0.8% in 1998 to 0.1% in 20082, with high-volume hospitals performing over 100 cases per year having lower mortality rates than low volume centers (0.3% versus 1.2%, p<0.01).7 In addition to decrease in mortality, overall complications are decreased at institutions with greater volumes of cases.89

Types of Bariatric ProceduresThere are a variety of different bariatric procedures that have previously been and are currently performed. The procedures can be classified into two major categories: restrictive, or mal-absorptive. The restrictive types simply limit the amount of food that can be ingested, thus decreasing calories taken in, producing weight loss. These types of procedures typically produce a loss of about 30-50% of EBW.10 Two studies in-vestigating 4-year postoperative data on patients who have undergone laparoscopic adjustable gastric bands showed an excess weight loss of 44 ± 24% and 68 ± 21% respectively.11,

12 Malabsorptive procedures direct the flow of ingested food away from a portion of the intestines so that the amount of nutrients absorbed is limited. These patients lose an estimated of 50-70% of EBW. Due to significant reductions in 30-day complications, bariatric procedures are now mostly per-formed laparoscopically in the US.13 Laparoscopic procedures have no difference in all-cause mortality or anastomotic leak as compared to open procedures, although they do have a de-crease in incidence of wound infection and incisional hernia.14 From 2003 to 2008, the proportion of bariatric procedures performed laparoscopically increased from 20.1% to 90.2%.2

The most common type of restrictive procedure is the Laparo-scopic Adjustable Gastric Band (LAGB). An inflatable silicone ring is secured around the upper fundus of the stomach to cre-ate a small gastric pouch. (Figure 1) This reduces the volume that can be ingested at any one time to about 20cc. The tight-ness of the band is adjusted by injection of sterile water into the band via a subcutaneous port; a tighter band produces more restriction on how much can be consumed. Another re-strictive procedure is the laparoscopic sleeve gastrectomy (SG). SG was originally described as a portion of the biliopancreatic diversion,15 but now is commonly performed as a stand-alone procedure that produces comparable EWL without the risks of anastomotic leak and internal hernia that come with gastric bypass. With the gastric sleeve, a linear stapler is used to excise

Figure 1. laparoscopic adjustable gastric band.

Figure 2. Sleeve gastrectomy.

Table 3. Postoperative Bariatric Complications

Restrictive Malabsorptive/Restrictive

LAGBBand erosion

Band Slippage RNYGB

BPD-DS

Small bowel obstruction Anastomotic leak

Anastomotic stricture

SG

Stricture/Steno-sis

Staple line leak

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all but a thin tube of stomach (usually measured around a 40Fr bougie), sparing the antrum and pylorus. (Figure 2) An-other type of restrictive procedure that is essentially no longer performed is the vertical banded gastroplasty (VBG).

The most common combined restrictive and malabsorp-tive procedure is the laparoscopic roux-en-y gastric bypass (RNYGB). This has been the gold standard of bariatric sur-gery since the 1991 NIH Consensus Conference.3 RNYGB in-volves creation of a small gastric pouch of about 20cc capac-ity, similar to the LAGB. The distal stomach, duodenum, and proximal jejunum are bypassed by creating an anastomosis of the divided jejunum to the gastric pouch (roux limb). The proximal jejunum emptying the duodenum (including pan-creas and biliary drainage) is anastomosed to 100-150cm from the original jejunal division to create a common channel for food digestion and absorption. (Figure 3)

The procedure still performed with most malabsorptive ef-fects is the biliopancreatic diversion-duodenal switch (BPD-DS). This begins with a sleeve gastrectomy, then division of the first portion of the duodenum. A long roux-en-y anastomosis of about 250cm to the distal jejunum is then fashioned to the first portion of duodenum in similar manner to the RNYGB. (Figure 4)

The proportions of bariatric procedures performed over the past 10 years have been changing. In 2003, the RNYGB com-

prised 99% of all bariatric procedures performed, which de-clined to 69% in 2008. Conversely, LAGB increased to 29% in 2008 from 1% in 2004.2 Moreover, the surgeon-reported Bariatric Outcomes Longitudinal Database (BOLD) from the American Society for Metabolic and Bariatric Surgery desig-nated Bariatric Surgery Centers of Excellence collected data between June 2007 and May 2009 of 57, 918 patients revealed that 54.68% underwent some type of gastric bypass, 39.62% underwent some form of gastric banding, 2.29% underwent sleeve gastrectomy, and 0.89% underwent biliopancreatic di-version.9 Over the past 5 years, sleeve gastrectomy has become increasingly popular as a stand-alone procedure, whereas LAGB has diminished markedly.

Radiologic concerns in obese patientsThere are a number of challenges that make accurate imaging of obese patients more difficult than normal weight individu-als. Special equipment may be necessary to help move patients, and skilled nurses may be needed to obtain IV access.16 Ra-diography is limited by increased body wall thickness which causes X-ray scatter and photon attenuation. Overcoming this requires an increased exposure time, which increases as-

Figure 3. Roux-en-Y gastric bypass. A and A mark site of jejunal division.

Figure 4. Biliopancreatic diversion – duodenal switch A and A mark duodenal division. B and B mark jejunal divi-sion.



manifestation. (Table 3)

lAGB complications

Band SlippageThe most common complication of LAGB is due to migration of the band; this is referred to as band slippage, or conversely, prolapse of the stomach. The reported incidence ranges from less than 1% up to 20% in the superobese19, 20, and is more frequent when the surgeon uses a posterior or perigastric ap-proach to place the band, rather than the pars flaccida tech-nique.19 Aside from technical problems, prolapse of the stom-ach is thought to occur after forceful vomiting by pulsion of the stomach up through the ring. Some have classified slip-page into anterior and posterior types.21 These are both differ-ent from circumferential dilation of the pouch due to overeat-ing, which presents with symptoms of reflux and early satiety but not the obstructive symptoms that mark the seriousness of band slippage.22

The symptoms are epigastric pain, nausea, vomiting, and dys-phagia to both liquids and solids.21 Plain frontal upper abdomi-nal radiograph should demonstrate the orientation of the band. Proper orientation is when the upper edge of the band lies obliquely at a 45% angle to the spine with the left side higher. After band slip, the left edge of the band is displaced downward towards the feet.23 Upper GI series will demonstrate the incor-rect angle of the band, enlarged gastric pouch, and minimal if any passage of contrast into the distal stomach when obstruc-tion is present. (Figure 5)

The treatment for slipped band is IV resuscitation and imme-diate deflation of the band by accessing the port with a non-coring (Huber) needle. If symptoms persist or the patient de-compensates, operative intervention is necessary. Either open or laparoscopic approach can be taken to unclip or remove the band. Some argue that there may be a role for repositioning the band and imbricating the edge of the stomach around it to reduce the risk of migration.24

sociated motion artifact.17 Fluoroscopy and CT scan are both limited by the equipment. Typical fluoroscopy tables have a weight limit of 350lbs, are only 45cm wide, and allow only 45cm distance between the table and image tower. CT tables have a weight limit of 450lbs, and gantry size of 70cm in diam-eter. CT images can be compromised by increased noise from insufficient photon transmission through wider tissue diam-eter, horizontal truncation artifact, and difficulty with proper patient positioning.18

Postoperative bariatric complicationsComplications after bariatric surgery can be classified based on type of procedure performed, and by immediate or late

Figure 5. lAGB band slip. Arrow marks the band, which is seen displaced downward toward the left. An enlarged gastric pouch is seen partially opacified by contrast.

Figure 6. SG staple line leak. Solid arrow marks the white staple line. Clear arrow marks the adjacent contained leak, or abscess, with air-fluid level and surrounding in-flammatory changes.

Figure 7. SG stenosis. Arrow marks GE junction. little con-trast entering the sleeve distally.

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gastric perforation. Weight gain is essentially inevitable after band removal, so after an adequate period of healing, a salvage bariatric procedure such as RNYGB may be performed.27

Sleeve Gastrectomy Complications

Staple-line leakThe most common complication of SG is a leakage of stom-ach contents from the vertical staple line. This has an overall incidence of 2.4%, with rates up to 2.9% in the superobese (BMI >50).10 Technical factors have been implicated as caus-ative etiology, such as the type of staples and whether the staple line was oversewn or buttressed, however the literature is mixed on whether any of these factors make a difference.10,

28 Presentation occurs on average > 10 days postoperatively, and therefore typically once the patient has been discharged home.10 Symptoms can range depending on the severity of the leak. A contained leak or abscess may present with fever and epigastric pain, whereas a more diffuse leak may present with outright abdominal peritonitis and sepsis.

Upper GI series may demonstrate leakage of contrast from the staple line. More often, CT scan is preferred, especially in patients with signs of sepsis. CT can show extravasation of contrast form the gastric pouch, with or without an adjacent collection that may contain either air bubbles or an air-fluid level. (Figure 6) It has been noted that usually the upper 1/3 of the staple line, closest to the esophagogastric junction, is most susceptible to staple line leak.10

Treatment involves draining the collection, ideally percuta-neously if the patient is stable enough, or laparoscopically if there is a more diffuse peritonitis. A period of parenteral nutri-tion may be necessary with more severe leaks.

Band ErosionThe next most common type of problem with LAGB is band erosion. Similar to band slippage, this too has a widely ranging reported incidence, although recent systematic review found an average incidence of 1.46%.25 Several suggested etiologies have been proposed. These include an over-tightened band causing ischemia; gastro-gastric suturing over the band, again causing pressure-induced ischemia; cautery, or missed gastric injury during dissection; perigastric rather than pars-flaccida dissection method; and patient variables, such as smoking, alcohol consumption, and NSAID use.25 Symptoms typically include abdominal pain and cessation of weight loss. Addi-tionally, a persistent port-site infection may occur, due to mi-gration of bacteria from the gastric perforation along the tub-ing to the port.26

Upper GI series may demonstrate extravasation of contrast from the stomach at the level of the band. Diagnosis is usually made with upper endoscopy.

Treatment involves removal of the band and repair of the

Figure 8. Internal hernias. A RNYGB with retrocolic GJ anastomosis. A = mesocolic hernia. B = Petersen’s hernia. C = mesenteric hernia

Figure 9. Internal hernia with closed loop obstruction 1. Arrow marks site of “whirling of the mesentery”, with adja-cent contrast-filled loops of dilated small bowel.



space created by the surgery. Of all types of SBO, internal her-nias are of gravest concern because they produce closed-loop obstructions, and thus are at high risk for intestinal strangu-lation and necrosis. There are three special types of internal hernias caused by RYNGB. These are the mesenteric (56%), Peterson’s (27%), and mesocolic (17%).31 The Peterson’s her-nia occurs posterior to the limb of jejunum brought up to the gastric pouch. The mesenteric hernia occurs posterior to the mesenteric defect between the jejuno-jejunal anastomosis. The mesocolic hernia occurs in the opening of transverse me-socolon through which a retrocolic limb of jejunum is passed. (Figure 8) The retrocolic anastomotic technique has been cor-related with a 4.8 v. 1.8% incidence of SBO as compared to the antecolic approach.29

Intussusception is another important cause of SBO, which most often occurs at the J-J anastomosis. Like internal her-nias, it tends to occur after significant weight loss, perhaps due to increased slack on the mesentery. Unlike most types of intussusception which are antegrade, the intussusception as-sociated with RNYGB is a retrograde telescoping of the com-mon channel into the jejunal anastomosis.32

Symptoms of SBO include nausea, vomiting, colicky perium-bilical pain, distention, and obstipation. Fever, tachycardia, leukocytosis, or abdominal tenderness are especially concern-ing signs that suggest strangulation or necrosis of the bowel wall.

Radiologic diagnosis includes a set of supine and upright ab-dominal X-rays which will show dilated loops of bowel and air-fluid levels. CT scan will show similarly dilated loops, and potentially the location of the transition point, where dilated loops abruptly change in caliber to collapsed loops. Other findings can include dilation of the excluded stomach and biliopancreatic limb. Signs concerning for internal hernia are

StrictureStricture is a relatively rare, although well-documented com-plication, occurring about 0.5% of the time.10 This focal tight-ening of the sleeve may be related to technical factors, such as oversewing the staple line, or too-small a bougie used to size the sleeve. Another technical pitfall is the so-called “spiral-ing” of the staple line, where the twisted staple line can distort the gastric pouch and cause partial obstruction. Symptoms include dysphagia, vomiting, and dehydration. Diagnosis can be performed with upper GI series which may demonstrate delayed transit of contrast across the sleeve or a focal area of narrowing. (Figure 7)

Treatment involves encouraging a liquid diet until endoscopic balloon dilation permits increased diet tolerance.

Roux-en-Y Gastric Bypass and Biliopancreatic Diversion-Duodenal Switch Complications

Small Bowel Obstruction (SBO)A single-institution’s experience with 2325 RNYGB revealed an overall incidence of SBO of 4.4%.29 There are multiple pos-sible causes of SBO after either RNYGB or BPD-DS. These can be related to internal hernia, compression of the Roux (ali-mentary) limb by adjacent structures, intraabdominal adhe-sions, trocar-site incisional hernias, stricture at the gastroje-junal (GJ) anastomosis, kinking of the alimentary limb, and intussusception. A systematic review demonstrated that lapa-roscopic, rather than open approach, confers a greater risk of SBO (3.15 v 2.1%).30

Internal hernia is due to the bowel herniating into a potential

Figure 10. Internal hernia with closed loop obstruction 2. Note the cluster of dilated loops in the left hemi-abdomen which are not filled with contrast. These loops are asso-ciated with a small amount of peritoneal fluid and wall thickening.

Figure 11. Intussusception. White arrow marks retrograde intussusceptum. Black arrow marks intussusceptiens, dilat-ed and filled with contrast.

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Presentation of anastomotic leak generally occurs in the early postoperative period, classically with unexplained tachycar-dia. Later, more severe presentation might include abdominal pain, nausea, vomiting, fever, and sepsis with hemodynamic instability.

Radiologic diagnosis may include upper GI series demon-strating contrast extravasation, although this is best suited for leak at the GJ anastomosis. Alternatively, CT scan with IV and PO contrast can identify extravasation of contrast, and free air. A contained fluid collection adjacent to an anastomosis, especially with an air-fluid level would also be concerning for leak. (Figure 12)

A contained leak may be able amenable to percutaneous or laparoscopic drainage. If the leak is very large, revision of the anastomosis may be required. Parenteral feeding may be nec-essary, especially if the leak is at the JJ anastomosis. It is en-couraged to place a gastrostomy tube into the gastric remnant and provide enteral nutrition if the leak is at the GJ anasto-mosis.

Anastomotic StenosisThe considerable variability in methods to create the GJ and JJ anastomoses in terms of positioning (retrocolic, antecolic and retrogastric and antegastric), and method (hand sewn, linear stapler, circular stapler) attests to the fact that there is

the “whirl sign” or swirling of mesenteric vessels and fat, and focal cluster of dilated small bowel loops suggestive of closed loop obstruction. (Figures 9, 10) Signs concerning for compro-mise of the small bowel include bowel wall thickening, free fluid, and pneumatosis intestinalis (air in the wall of the small bowel).33 CT may reveal a target sign for patients with intus-susceptions.34 (Figure 11)

Treatment of internal hernia and trocar site hernia with SBO, is urgent reduction of the hernia and repair of the defect; this may be done either open or laparoscopically. A delay in op-erative treatment of internal hernia risks catastrophic loss of a large amount of small bowel. SBO due to intussusception must also be treated operatively, either by laparoscopic reduc-tion with or without enteropexy, or by resecting and recreating the JJ anastomosis.32 Adhesive SBO without concerning his-tory, physical, or radiologic findings may be treated initially with conservative management including bowel rest and re-suscitation under inpatient monitoring by a bariatric surgeon. An important caveat is that obstruction of the biliopancreatic limb and excluded stomach cannot be drained by an NGT so these cases must be treated operatively.

Anastomotic leakAs mentioned above, the anastamoses in the RNYGB are gas-trojejunal (GJ) and jejuno-jejunal (JJ). The BPD-DS has a du-odeno-jejunal (DJ) anastomosis rather than the GJ anastomo-sis. Any of these anastomoses may have leak postoperatively, which is a potentially lethal complication. The incidence of anastomotic leak is 3.2% with a nearly 50% mortality rate.35 A single institution review of 3073 patients undergoing open and laparoscopic RNYGB identified the following risk factors for leak: older age, male sex, and higher BMI.35 The most com-mon site of anastomotic leak is the GJ anastomosis.36

Figure 12. RNYGB with GJ anastomotic leak. Staple line of the GJ anastomosis is marked by the arrow. The large collection to the left is filled with complex material, air, and PO contrast.

Figure 13. RNYGB GJ stenosis. The light arrow marks the GE junction, with proximal esophagus filled with contrast, and smaller amount of contrast in the distal gastric pouch (heavy arrow). Note there is no passage of contrast into the jejunum.


original artiCle Doyon et al. Bariatric Surgeryin the treatment of morbid obesity. Br. J. Surg. 86, 113-118 (1999).

13. Hutter, M. M. et al. Laparoscopic versus open gastric bypass for mor-bid obesity: a multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Ann. Surg. 243, 657-62; discussion 662-6 (2006).

14. Reoch, J. et al. Safety of laparoscopic vs open bariatric surgery: a sys-tematic review and meta-analysis. Arch. Surg. 146, 1314-1322 (2011).

15. Ren, C. J., Patterson, E. & Gagner, M. Early results of laparoscopic bil-iopancreatic diversion with duodenal switch: a case series of 40 con-secutive patients. Obes. Surg. 10, 514-23; discussion 524 (2000).

16. Carucci, L. R. Imaging obese patients: problems and solutions. Ab-dom. Imaging (2012).

17. Uppot, R. N., Sahani, D. V., Hahn, P. F., Gervais, D. & Mueller, P. R. Impact of obesity on medical imaging and image-guided intervention. AJR Am. J. Roentgenol. 188, 433-440 (2007).

18. Modica, M. J., Kanal, K. M. & Gunn, M. L. The obese emergency pa-tient: imaging challenges and solutions. Radiographics 31, 811-823 (2011).

19. Mognol, P., Chosidow, D. & Marmuse, J. P. Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: a comparative study of 290 patients. Obes. Surg. 15, 76-81 (2005).

20. Ponce, J., Lindsey, B., Pritchett, S., Bleech, M. & Marlowe, K. New ad-justable gastric bands available in the United States: a comparative study. Surg. Obes. Relat. Dis. 7, 74-79 (2011).

21. Egan, R. J. et al. The reporting of gastric band slip and related com-plications; a review of the literature. Obes. Surg. 21, 1280-1288 (2011).

22. Hamdan, K., Somers, S. & Chand, M. Management of late postopera-tive complications of bariatric surgery. Br. J. Surg. 98, 1345-1355 (2011).

23. Pieroni, S., Sommer, E. A., Hito, R., Burch, M. & Tkacz, J. N. The “O” sign, a simple and helpful tool in the diagnosis of laparoscopic adjust-able gastric band slippage. AJR Am. J. Roentgenol. 195, 137-141 (2010).

24. Weber, M. et al. Laparoscopic Roux-en-Y gastric bypass, but not re-banding, should be proposed as rescue procedure for patients with failed laparoscopic gastric banding. Ann. Surg. 238, 827-33; discussion 833-4 (2003).

25. Egberts, K., Brown, W. A. & O’Brien, P. E. Systematic review of erosion after laparoscopic adjustable gastric banding. Obes. Surg. 21, 1272-1279 (2011).

26. Abu-Abeid, S., Bar Zohar, D., Sagie, B. & Klausner, J. Treatment of intra-gastric band migration following laparoscopic banding: safety and feasibility of simultaneous laparoscopic band removal and replace-ment. Obes. Surg. 15, 849-852 (2005).

27. Calmes, J. M., Giusti, V. & Suter, M. Reoperative laparoscopic Roux-en-Y gastric bypass: an experience with 49 cases. Obes. Surg. 15, 316-322 (2005).

28. Choi, Y. Y., Bae, J., Hur, K. Y., Choi, D. & Kim, Y. J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: does it have advantages? A meta-analysis. Obes. Surg. 22, 1206-1213 (2012).

29. Husain, S., Ahmed, A. R., Johnson, J., Boss, T. & O’Malley, W. Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass: etiol-ogy, diagnosis, and management. Arch. Surg. 142, 988-993 (2007).

30. Podnos, Y. D., Jimenez, J. C., Wilson, S. E., Stevens, C. M. & Nguyen, N. T. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch. Surg. 138, 957-961 (2003).

31. Paroz, A., Calmes, J. M., Giusti, V. & Suter, M. Internal hernia after lapa-roscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery. Obes. Surg. 16, 1482-1487 (2006).

32. Varban, O. et al. Resection or reduction? The dilemma of managing retrograde intussusception after Roux-en-Y gastric bypass. Surg. Obes. Relat. Dis. (2012).

33. Kawkabani Marchini, A. et al. The four different types of internal her-nia occurring after laparascopic Roux-en-Y gastric bypass performed for morbid obesity: are there any multidetector computed tomography (MDCT) features permitting their distinction? Obes. Surg. 21, 506-516 (2011).

no best method for preventing leak or stenosis. The most com-mon site for stricture is the GJ anastomosis. Large series have reported the rate of anastomotic stricture to be between 1.1-7.1%.37-39 The etiology of strictures is believed to be related to ischemia, as well as inflammatory processes such as leak or marginal ulcer. Most patients present several weeks or months postoperatively with vomiting, dysphagia, and little or no ab-dominal pain.40

Upper GI series can demonstrate a stenosis (Figure 13), al-though most often the stenosis is directly visualized with upper endoscopy since the treatment is endoscopic balloon dilation.41

ConclusionBariatric surgery is a dynamic field that has been adapting over the last 20 years to treat the obesity epidemic. Although bariatric surgery is safe and is currently the gold standard for treatment of morbid obesity, it carries a well-documented set of complications which can have a high morbidity and mor-tality. Knowledge of the various procedures and post-surgical anatomy, along with a high index of suspicion can help early diagnosis and improved treatment of these conditions.

References 1. Ogden, C. L., Carroll, M. D., Kit, B. K. & Flegal, K. M. Prevalence of

obesity in the United States, 2009-2010. NCHS Data Brief (82), 1-8 (2012).

2. Nguyen, N. T. et al. Trends in use of bariatric surgery, 2003-2008. J. Am. Coll. Surg. 213, 261-266 (2011).

3. NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann. Intern. Med. 115, 956-961 (1991).

4. Adams, T. D. et al. Health benefits of gastric bypass surgery after 6 years. JAMA 308, 1122-1131 (2012).

5. Schauer, P. R. et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N. Engl. J. Med. 366, 1567-1576 (2012).

6. Christou, N. V. et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann. Surg. 240, 416-23; discussion 423-4 (2004).

7. Nguyen, N. T. et al. The relationship between hospital volume and out-come in bariatric surgery at academic medical centers. Ann. Surg. 240, 586-93; discussion 593-4 (2004).

8. Kohn, G. P., Galanko, J. A., Overby, D. W. & Farrell, T. M. High case vol-umes and surgical fellowships are associated with improved outcomes for bariatric surgery patients: a justification of current credentialing initiatives for practice and training. J. Am. Coll. Surg. 210, 909-918 (2010).

9. DeMaria, E. J., Pate, V., Warthen, M. & Winegar, D. A. Baseline data from American Society for Metabolic and Bariatric Surgery-designat-ed Bariatric Surgery Centers of Excellence using the Bariatric Out-comes Longitudinal Database. Surg. Obes. Relat. Dis. 6, 347-355 (2010).

10. Aurora, A. R., Khaitan, L. & Saber, A. A. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg. Endosc. 26, 1509-1515 (2012).

11. DeMaria, E. J. et al. High failure rate after laparoscopic adjustable sili-cone gastric banding for treatment of morbid obesity. Ann. Surg. 233, 809-818 (2001).

12. O’Brien, P. E., Brown, W. A., Smith, A., McMurrick, P. J. & Stephens, M. Prospective study of a laparoscopically placed, adjustable gastric band

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34. Byrne, A. T. et al. The imaging of intussusception. Clin. Radiol. 60, 39-46 (2005).

35. Fernandez, A. Z.,Jr et al. Experience with over 3,000 open and laparo-scopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg. Endosc. 18, 193-197 (2004).

36. Ballesta, C., Berindoague, R., Cabrera, M., Palau, M. & Gonzales, M. Management of anastomotic leaks after laparoscopic Roux-en-Y gas-tric bypass. Obes. Surg. 18, 623-630 (2008).

37. Carrodeguas, L., Szomstein, S., Zundel, N., Lo Menzo, E. & Rosenthal, R. Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery: analysis of 1291 patients. Surg. Obes. Relat. Dis. 2, 92-97 (2006).

38. Goitein, D., Papasavas, P. K., Gagne, D., Ahmad, S. & Caushaj, P. F. Gas-trojejunal strictures following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg. Endosc. 19, 628-632 (2005).

39. Lujan, J. A. et al. Experience with the circular stapler for the gastroje-junostomy in laparoscopic gastric bypass (350 cases). Obes. Surg. 15, 1096-1102 (2005).

40. Dolce, C. J. et al. Gastrojejunal strictures after Roux-en-Y gastric by-pass with a 21-MM circular stapler. JSLS 13, 306-311 (2009).

41. Nguyen, N. T., Stevens, C. M. & Wolfe, B. M. Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass. J. Gastrointest. Surg. 7, 997-1003; discussion 1003 (2003).


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Citation Amin et al. Analysis of 640 Sequential Percu-taneous Ultrasound-Guided Biopsies Using Clean Technique at a Reduced Cost. J Surg Radiol. 2013 Apr 1;4(2).

CorrespondenCe Erin Moody, MD, MBA E-mail [email protected].

reCeived February 16, 2013. aCCepted April 1, 2013. epub April 1, 2013.

Analysis of 640 Sequential Percutaneous Ultra-sound-Guided Biopsies Using Clean Technique at a Reduced Cost

Sabina Amin, MD, Yi Chuang, MD, Michael Ulissey, MD, and Erin Moody, MD, MBA

1. Department of Radiology, Texas Health, Dallas, TX

AbstractintroduCtion It is universally accepted that when tissue diagnosis of a breast mass is needed, percutaneous ultrasound guided biopsy is the standard method employed. The clean tech-nique we utilize demonstrates equivalent safety to a biopsy done with a dedicated sterile region uti-lizing a sterile drape, ultrasound (US) probe, and US gel, and does so at a secondarily reduced cost.

Methods After obtaining IRB approval, the medical records from 640 sequential bi-opsy events done at our institution 2/21/2008 to 12/16/2010 were retrospectively reviewed to ascer-tain our complication rate with respect to post-biopsy infections. These biopsies were done using the clean technique.

results There were zero of 640 post procedure infections. The pathology reports in 10/640 showed evidence of inflammation from pre-existing abscess or chronic inflammation/masti-tis. Specifically, there were 2 cases of chronic abscess, 3 cases of acute abscess, 4 cases of nonspecific chronic inflammation/mastitis, and 1 case of necrotic inflammation. However, no new infections developed related to this procedure. Our patient population was >99% female (637/640 were male). The age range was from 12 to 89 years with an average age of 46.

ConClusion Breast cancer is prevalent and affects 1 out of 8 women. However, death rates have been decreasing since 1990 due to earlier detection through screening, treatment advances, and increased awareness1,2. To this end, percutaneous ultrasound guided breast biopsies are becom-ing increasingly more common. In an effort to decrease costs and increase efficiency, we utilize a clean technique with a non-sterile field for ultrasound guided breast biopsies, with equivalent safety com-pared to traditional ultrasound guided breast biopsies. This is an important technical point given the rising cost of health care and the overall need to safely decrease costs without sacrificing quality.

Keywords breast biopsy, ultrasound, clean technique, reduced cost

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Amin et al. Percutaneous Ultrasound-Guided Biopsies original artiCle

IntroductionBreast cancer is prevalent and affects 1 out of 8 women. How-ever, death rates have been decreasing since 1990 due to ear-lier detection through screening, treatment advances, and increased awareness1,2. This focus on increased screening has secondarily led to an increased number of breast biopsies per-formed overall on suspicious lesions. It is widely accepted that, in the correct clinical setting, percutaneous breast biopsies are preferable to open surgical breast biopsies as there is proven equivalent accuracy with decreased morbidity, cost, and lag-time to tissue diagnosis. Percutaneous biopsies may be per-formed using ultrasound (US), mammographic, or magnetic resonance imaging guidance, and the chosen technique is dic-tated by the lesion characteristics3,4,5,6,7,8.

The technique for performing ultrasound guided breast bi-opsies is fairly standardized with a few operator and institu-tion dependent variations. The general technique begins with appropriate patient and lesion identification, including tar-geting lesions that warrant biopsy and that are accessible by US-guided biopsy, and ensuring patients do not regularly take anticoagulants or aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for any reason. Use of anticoagulants and an-ti-platelet agents for 5 days prior to the procedure is a relative contraindication as one of the more common adverse events following breast biopsy is bleeding and, less commonly, he-matoma formation. Prior to the procedure, informed consent is obtained and documented. The procedure involves, in brief, appropriate patient positioning, pre-procedural identification of the lesion using real-time, high-frequency, hand-held ultra-sound, skin sterilization, local anesthesia, biopsy acquisition with continuous visualization of the needle path, and place-ment of a post-biopsy marker5,6,7,8. Our review of the latest American College of Radiology (ACR) guidelines and litera-ture indicates that steps should be taken to sanitize both the skin and equipment to reduce the risk of infection5,6,7,8. In the radiology literature, use of aseptic technique and creation of a sterile area is advocated. This includes maintaining a semi-sterile tray, cleansing the skin of the biopsy target site with betadine, placing a sterile drape, and utilizing a sterile ultra-sound probe cover and sterile gel to perform the biopsy, with-out the use of operator mask or sterile gown and gloves 6,7.

The technique that we employ is less conservative and en-sures that everything that goes through the skin is sterile, but without the use of the sterile drape, US probe cover, or gel. In brief, the biopsy area is cleansed with betadine but no sterile drape is applied. The biopsy is then acquired using sterile ma-terials, but the US probe is kept out of the biopsy acquisition area, negating the need for a sterile probe cover or US gel. Our procedure is fully described under the methods section. The

benefit of this technique is two-fold: it allows us to perform an increased number of efficient biopsies in less time, which is crucial to patient care in our busy breast center, and it cuts the materials expense of the procedure. This compounded effect means we can cut the cost of the procedure exponentially, with equivalent safety to a biopsy done with complete sterile drap-ing, as defined as the absence of post-procedural infection.

MethodsAfter obtaining IRB approval, a retrospective review of the electronic medical records of 640 sequential biopsy events from 2/21/2008 to 12/16/2010 was performed to evaluate for the development of post-procedure infection. These biopsy events were all performed according to the aforementioned clean procedure.

Specifically, following appropriate patient selection and con-sent acquisition, the patient is optimally positioned with the ipsilateral arm raised as for a breast exam and with the pa-tient angled on one side for maximal lesion visualization and access. This involves careful appropriate patient positioning and pre-procedural identification of the lesion using real-time, hand-held ultrasound (Phillips IU 22, 12.5 MHz), outside of the area of planned biopsy acquisition. This step is crucial as the US probe will remain non-sterile and therefore must remain outside of the sterile biopsy zone. This is followed by skin sterilization at the biopsy site with betadine to cre-ate a sterile biopsy zone, without placement of a sterile drape. Then, a sterile needle is utilized for local anesthetic adminis-tration (2% lidocaine without epinephrine, approximately 3-5 cc) and a sterile scalpel is used for the skin nick. Biopsy acqui-sition is then performed using a Bard Tru-Cut spring loaded biopsy needle (14 gauge for most breast lesions and 18 gauge for axillary lymph nodes, as per standard procedure6) under continuous sonographic visualization of the needle path. Typically, three biopsy specimen are obtained. A post-biopsy marker is then placed under sonographic guidance, and post-biopsy mammograms for clip localization are performed. All materials that pass through the patient’s skin are sterilized pri-or to the procedure and our procedure is in accordance with recommended ACR guidelines5.

ResultsThe retrospective review of 640 sequential ultrasound guided breast biopsy events revealed zero of 640 post procedure in-fections. The pathology reports in 10/640 showed evidence of inflammation from pre-existing abscess or chronic inflam-mation/mastitis. Specifically, there were 2 cases of chronic ab-

Figure 1. CT evaluation of an 80 year-old man with right sided abdominal pain due to primary vermiform appendiceal torsion. A-D, Coronally reformatted contrast-enhanced CT images showing the appendix (arrows) with a midshaft transi-tion point (A) and a whirling appearance of the mesoappendiceal fat and vessels (area between the asterices) as well as the appendix itself (B,C), suggesting torsion. Note the distal appendix is mildly thickened and dense (D, 9 mm). The ap-pendicular artery (arrowhead) appears to enter and follow the whirling pattern of the appendix and mesoappendix (A-C).


original artiCle Amin et al. Percutaneous Ultrasound-Guided Biopsiesscess, 3 cases of acute abscess, 4 cases of nonspecific chronic inflammation/mastitis, and 1 case of necrotic inflammation. However, no new infections developed related to this proce-dure. Our patient population was >99% female (637/640 were male). The age range was from 12 to 89 years with an average age of 46.

DiscussionBreast cancer is the second most common type of cancer diagnosed in women, with 209,060 reported new cases and 40,230 deaths in men and women in the United States in 20102. However, death rates have been decreasing since 1990 due to more vigilant screening, treatment advances, and in-creased awareness2. To this end, percutaneous breast biopsies, particularly US guided biopsies when appropriate, are becom-ing increasingly more common. In an effort to decrease costs and increase efficiency, we utilize a clean technique with a non-sterile field for US guided breast biopsies, with equivalent safety compared to traditional US guided breast biopsies with defined sterile regions. The benefit of this technique is that it allows us to perform an increased number of efficient biop-sies in less time while decreasing the materials expense of the procedure. This is an important consideration given the rising cost of health care and the overall need to safely decrease costs without sacrificing quality.

AcknowledgementsWe would like to thank Pam Curry, our institution’s medical illustrator, for her amazing work illustrating and animating the biopsy technique.

References1. Breast cancer statistics. Breastcancer.org. http://www.breastcancer.org/

symptoms/understand_bc/statistics.jsp. 1/11/2011

2. National Cancer Institute. www.cancer.gov. 2011.

3. Acheson MB, et al. Histologic correlation of image-Guided Core Bi-opsy With excisional Biopsy of non-Palpable Breast Lesions. Arch Surg 1997;132(8):815-821.

4. Helbich TH, et al. Stereotactic and ultrasound-guided breast biopsy. European Radiology 2004; 14: 383-393.

5. American college of Radiology Practice Guideline for the performance of Ultrasound-guided Percutaneous Breast Interventional Procedures. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Guided_Breast.pdf. 2009.

6. Harvey J, Moran R. US-guided Core Needle Biopsy of the Breast: Tech-nique and Pitfalls. RadioGraphics 1998; 18: 867-877.

7. Ikeda DM. Breast Imaging: the Requisites, 2nd edition. St Louis, MS: Elsevier, Inc, 2011. 194-288.

8. Singletary SE, Robb GL, Hortobagyi GN. Advanced therapy of breast disease, 2nd edition. Hamilton, Ontario: B. C. Decker 2004. 227.

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IntroductionParagangliomas are rare tumors found in approximately two to eight individuals per million and only a small sub-set of those is in the retroperitoneum.1 Of these rare tu-mors a portion can become metastatic and the majority of all paragangliomas will lead to death without interven-tion. However, with the proper knowledge that has come from other’s experiences a diagnosis can be reached easily and interventions performed that will greatly increase the chance of survival. In this report we will present a recent case of a retroperitoneal paraganglioma found adjacent to the duodenum and review the literature concerning important elements of the disease characteristics, epide-miology, diagnosis, treatment, and follow-up.

Case ReportA 23 year old woman complaining of nausea and lower abdominal pain radiating to the right lower back was

referred to our hospital. The patient was 5’6” in height and weighed 171 lbs. She had essentially a positive review of symptoms and a history of severe drug abuse which complicated interpretation of any true pain or symptoms. Review of systems indicated sudden changes in heart rate, headaches, fatigue, shortness of breath, dizziness, nervousness, depression, and extensive gastrointestinal symptoms. Initial lab testing showed normal electrolytes.

Abdominal CT scan showed a 5.5 cm retroperitoneal mass in close approximation to the second and third por-tions of the duodenum. Based on the location of the le-sion, it was not amenable to CT guided biopsy. There was no pre-operative indication of significant hypertension. Decision was made to proceed with laparoscopic biopsy. During laparoscopy the mass was adherent to the liver and retroperitoneal tissues along the duodenum and in-ferior vena cava. The mass was freed and remained along the lateral wall of the duodenum, but could not be sepa-rated. Three core biopsies were then performed. At this time, anesthesia reported premature ventricular contrac-tions as well as hypertension resulting in a halting of the tumor manipulation. After some improvement with time, a second manipulation was attempted with the same re-sult. At this point, procedure was abandoned. Pathology reported the immunohistochemistry profile positive for chromogranin, synaptophysin, and focally for S100 most compatible with paraganglioma. 24 hour urine studies were completed showing total metanephrines of 15,378 micrograms/24hr. (normal 94-604). Fractionated meta-nephrine was 5845 mcg/24h, normetanephrine 9533

Citation Lim et al. Gastrinoma Localization in a Patient with Variations in the Celiomesenteric Axis. J Surg Ra-diol. 2013 Apr 1;4(2).

CorrespondenCe Benjamin J. Bates E-mail [email protected].


Retroperitoneal Paraganglioma Adjacent to the Duodenum: A Case Report and literature ReviewBenjamin J. Bates BS,1 James R. Ouellette DO2

1. Wright State University Boonshoft School of Medicine, Dayton, OH2. Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH

Abstractoverview We present a case of a 23 year old female with a retroperitoneal paraganglioma ad-jacent to her duodenum. She presented with nausea, lower abdominal pain, and other non-specific complaints. The tumor was found by CT scan and definitive diagnosis made by laparoscopic biopsy. Resection was completed en bloc with partial duodenectomy and partial vena cava resection. We will discuss the important aspects of diagnostic testing with biochemical and imaging techniques. Treat-ment planning using medical and surgical interventions is reviewed. While rare, cure rates are quite high with surgical resection, which necessitates early and accurate diagnosis and treatment.

Keywords extra-adrenal neoplasm, octreotide, scintigraphy

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mcg/24h, and 5HIAA was 54.3 mg/24h (normal <6). Addi-tionally, thyroglobulin, thyroglobulin antibody, calcitonin, PTH, and calcium levels were found to be normal to rule out multiple endocrine neoplasia type 2. Localizing imaging stud-ies were then performed. The patient underwent octreotide scan including SPECT imaging using indium-111-octreotide at 4 hour and 24 hour. All scans indicated increased uptake only in the area of the known tumor confirming the diagnosis of focal paraganglioma.

The patient was placed on alpha and beta blockers and pre-pared for surgery. At surgery, circumferential dissection of the mass was performed. The tumor was inseparable from the duodenum and lateral wall of the IVC. Partial duodenectomy and partial caval resection were performed. Primary closure of both was completed without difficulty. Some hyperten-sion and tachycardia occurred during the initial portion of

the procedure, but no significant hypertensive or hypotensive episodes were encountered once tumor was removed. The fi-nal pathology confirmed diagnosis of extra-adrenal paragan-glioma.

DiscussionExtra-adrenal paragangliomas are rare chromaffin cell neo-plasms that can be found surrounding paraganglia through-out the body including: the carotid body, jugular foramen, me-diastinum, organ of Zuckerkandl or any other location where paraganglia are present.2 The retroperitoneal paragangliomas are typically found surrounding the para-aortic sympathetic ganglia.1 Due to the neuroendocrine nature of the tumor, the histologic and clinical presentations are almost identical to adrenal tumors or pheochromocytomas with exception that pheochromocytomas are often epinephrine producers while extra-adrenal paragangliomas are almost exclusively norepi-nephrine producers.3 In a few extremely rare cases paragan-gliomas have been reported to secrete corticotropin4 or even insulin.5 Consequently, the almost exclusive catecholamine production resulted in one institutions symptom statistics from 67 retroperitoneal paragangliomas as hypertension (43%), a palpable mass (29%), diaphoresis (19%), palpitations (19%), pain (19%), and panic or anxiety (14%).6 Migraines are often listed as well as a common symptom.1 On the other hand, many other paragangliomas are non-functional secre-tors and present only with the damaging effects of the tumors spatial growth.

The epidemiology of extra-adrenal paragangliomas is only around two to eight per million.1 While extremely rare, 20-42% metastasize in comparison to only 2-10% of pheochro-mocytomas.1 Also, retroperitoneal paragangliomas have been shown in a John’s Hopkins study to be 57% hyperfunctional secretors and in a Mayo Clinic Study to be >80% hyperfunc-tional secretors in contrast to carotid body paragangliomas

Figure 1. En bloc resection of the retroperitoneal paragan-glioma along with partial duodenectomy and partial vena cava resection.

Figure 2. A disorganized sheet of pleomorphic cells con-taining abundant granular cytoplasm with an atypical mi-totic figure located centrally. (H&E, 400x)

Figure 3. A cohesive cluster of cells containing granular cytoplasm located within an endothelial-lined channel. This is consistent with vascular invasion. (H&E, 100x)


original artiCle Bates and Ouellette. Retroperitoneal Paraganglioma Adjacent to Duodenum43.9 months.7 In agreement, a Sloan-Kettering Cancer Center study determined a 75% 5-year survival rate post-resection and only a 19% survival rate for those without tumor resec-tion.6 The same Sloan Kettering study also determined a 50% recurrence rate.6 The majority of these operations have been open surgical procedures due to concerns for malignancy, multicentricity, and closeness to major blood vessels which are all common in these tumors.14 However, recent improvements in laparoscopic instrumentation and preoperative imaging suggests that surgeons with advanced skills and thorough knowledge of the tumor could perform laparoscopic resec-tions because of shortened hospital stays, decreased pain, and an earlier return to normal activity with very little risk to the patient.2,14,15,16 In either case, it is of extreme importance that the patient receives alpha adrenergic blockade preoperatively in order to prevent hypertensive crisis due to hypersecretion caused by manipulation of the tumor.8 Following alpha ad-renergic blockade, beta adrenergic blockade is often used as well to prevent tachycardia, cardiac arrhythmias, or persistent hypertension present after the alpha block.8

In the case of malignancy, experts recommend initial surgical reduction of tumor load through removal of operable tumors and reduction or ablation of others, followed by radionucleo-tide therapy and/or chemotherapy.9 In one study the 5-year survival rate was significantly decreased in association with malignancy, but not with size status, functional status, mar-gin status, or nodal status.6 The initial tumor load reduction ameliorates symptoms caused by tumor size and secretory capacity and increases the tumor responsiveness to the later treatments.9 After surgery, a radiopharmaceutical treatment that has been shown effective in management is 131I-MIBG. In a study of 116 patients under a 131I-MIBG treatment regimen 30% showed objective tumor response, while 57% showed disease stabilization, and only 13% with continued progres-sion.9 The side-effects of this high dose treatment are primar-ily transient leucopenia and thrombocytopenia.9 Evidence has also shown that 131I-MIBG therapy used post surgically can also effectively eradicate residual disease.9 A second form of radiopharmaceutical treatment uses analogs of somatostatin which bind to the somatostatin receptor on the chromaffin cell tumors.9 This treatment is also only effective with tumors that are shown through scintigraphy to actively uptake the pentetreotide or octreotide analogs.9 This treatment has been reported to reduce the size of 20% of tumors and stabilize another 25% with the same side effects as 131I-MIBG therapy.9 Chemotherapy has also been used, but due to a decrease in tumor response and worse side effects it is recommended only after radionucleotide therapy has been ruled out or has failed to stabilize the condition.9

In conjunction with treatment genetic counseling is often needed and genetic testing is indicated for every case.17 Recent studies have shown approximately 25% of paragangliomas and pheochromocytomas are hereditary in nature,18 while others suggest up to 50% are related to hereditary condi-tions.19 Hereditary association has been found with several conditions including: familial paraganglioma, neurofibro-

which are only 4.8% hyperfunctional.7 Paragangliomas are found more commonly in children, where 30% of all pediat-ric pheochromocytomas are paragangliomas, but only 10% of adult pheochromocytomas are paragangliomas8. While rare, these tumors have the potential to be very dangerous and can present in more than one way requiring some knowledge of the nature of the tumor.

The variations in secretory abilities and presentation can lead to difficulties in diagnosis. In hyperfunctional paragan-gliomas, clinical signs indicate follow-up with measurements of plasma free and urinary fractionated metanephrines and normetanephrines, which is the single best initial screening test.9 Increased Plasma Chromogranin A levels can also be used diagnostically since it is secreted with catecholamines from chromaffin cells.9 Non-functional paragangliomas, while there are no biochemical signs, can be diagnosed by bi-opsy. Once the biopsy is obtained immunohistochemical ap-proaches are used to detect neuron-specific enolase and chro-mogranin in the secretory cells and S-100 in the sustentacular cells around the periphery.6 On the other hand, experts recom-mend against needle biopsy of functional paragangliomas due to risk of hypertensive attacks in the patient.2 Further investi-gation into functional paragangliomas often result in visual-ization using 123I-metaiodobenzylguanadine (123I-MIBG) scin-tigraphy where 123I-MIBG is taken into chromaffin cells via the human norepinephrine transporter and visualized using sin-gle-photon emission computerized tomography.9,10 Lastly, PET scans can also be performed using 6-[18F]-fluoroDOPA and result in superior imaging to 123I-MIBG SPECT scans.9 Due to the necessity of tumor functionality these scans have unclear usefulness in non-functional paragangliomas.11 While cur-rently, there are no clinical, histologic, or biochemical methods to definitively determine malignancy even though many in-dicators have been studied showing increased probabilities,9,12 full body studies using 123I-MIBG can be used to diagnosis malignancies.9 Since diagnoses can easily be reached, it is im-portant that physicians are aware of this tumor and keep it in their differential diagnosis until ruled out.

Octreotide is a somatostatin analog that, when coupled to a radioisotope, produces a scintigraphic image of tumors ex-pressing somatostatin type 2 receptors. Paragangliomas, like many neuroendocrine tumors, have been found to have a high density of somatostatin type 2 receptors on the cell surface. Octreotide scanning has been used for localization of para-gangliomas, particularly of the head and neck. However, for detecting paragangliomas, In 111 octreotide acetate scintigra-phy (Sandostatin; Sandoz Pharmaceuticals, East Hanover, NJ) has been advocated as superior to MIBG scintigraphy.13 In a study directly comparing the 2 methods in 8 patients with his-tologically confirmed paragangliomas, the authors reported a sensitivity of 50% for MIBG and 100% for In 111 octreotide scintigraphy using In 111 chloride–labeled octreotide.13

The only treatment of paragangliomas that can result in cure is surgical resection while other treatments are available to help manage inoperable tumors. The Mayo clinic reports a 69% overall post-resection cure rate with a mean follow-up of

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10. Sahdev A., Sohaib A., Monson J., et al. CT and MR Imaging of Unusual Locations of Extra-adrenal Paragangliomas (pheochromocytomas). Eur Radiol 2005;15:85-92.

11. Yamaguchi T., Tada M., Takahashi H., et al. An Incidentally Discovered Small and Asymptomatic Para-Aortic Paraganglioma. Eur Surg Res 2008;40:14-18.

12. Mitsuhiro T., Fujimoto K., Miyake M., et al. Clinicopathological Re-view of 46 Primary Retroperitoneal Tumors. International Journal of Urology 2007;14:785-788.

13. Telischi FF, Bustillo A, Whiteman ML, et al. Octreotide scintigraphy for the detection of paragangliomas. Otolaryngol Head Neck Surg. 2000 Mar;122(3):358-62.

14. Whitson B.A., Tuttle T.M. Laparoscopic Resection of Periaortic Para-gangliomas. Amer Surg 2005;71:450-454.

15. Walz M.K., Alesina P.F., Wenger F.A., et al. Laparoscopic and Retroper-itoneoscopic Treatment of Pheochromocytomas and Retroperitoneal Paragangliomas: Results of 161 Tumors in 126 Patients. World J Surg 2006;30:899-908.

16. Nozaki T., Iida H., Tsuritani S., et al. Laparoscopic Resection of Ret-rocaval Paraganglioma. Journal of Laparoendoscopic and Advanced Surgical Techniques 2010;20(4):363-367.

17. Plouin P.F., Gimenez-Roqueplo A.P. Pheochromocytomas and Secret-ing Paragangliomas. Orphanet Journal of Rare Diseases 2006;1:49.

18. Gimenez-Roquelpo A.P., Burnichon N., Amar L., et al. Recent Ad-vances in the Genetics of Phaeochromocytoma and Functional Para-ganglioma. Clinical and Experimental Pharmacology and Physiology 2008;35:376-379.

19. Young W.F. Paragangliomas: Clinical Overview. Ann. N. Y. Acad. Sci 2006;1073:21-29.

20. Kelliher K., Santiago A., Estrada D. E., et al. Laparoscopic Excision of a Familial Paraganglioma. Journal of Laparoscopic and Advanced Surgi-cal Techniques 2009;19:155-158.

21. Favier J., Briere J.J., Strompf L. Hereditary Paraganglioma/Pheochro-mocytoma and Inherited Succinate Dehydrogenase Deficiency. Horm Res 2005;63:171-179.

matosis type 1, von Hippel-Lindau disease, the Carney triad, and multiple endocrine neoplasia type 2.19 The most closely linked, familial paraganglioma has a mutation in the genes for succinate dehydrogenase indicating a link between mitochon-drial function and oncogenesis.18 Mutations in the SDH gene particularly the B subunit have been correlated to poor prog-nosis and increased likelihood of malignancy.18,20 In one study patients with a SDHB mutation had a 36% 5-year survival rate while patients without that mutation had a 67% 5-year survival rate.18 Several of these other mutation based diseases are diagnosed at birth however additional screening following paraganglioma diagnosis is recommended including analysis of family pedigree, physical exam for neurofibromas, fundo-scopic exam for retinal hemangioblastomas, and head, neck, and abdomen CT or MRI scans for additional tumors.21 Lastly, if a genetic etiology is determined then genetic testing of first degree relatives is also recommended.21

Paragangliomas, while rare, present a unique diagnostic di-lemma, treatment algorithm, and follow-up. With the knowl-edge gained from others experience, a proper diagnosis can be made and successful treatment can be implemented. With the ability to increase the overall 5-year survival rate from 19% to 75% with surgical resection, it is imperative that surgeons as well as other physicians be aware of this tumor and imple-ment diagnostic evaluation until ruled out.

DisclosuresThe authors have no disclosures or conflicts of interest related to this manuscript.

References 1. Wen J., Li H.Z., Ji Z.G., et al. A Decade of Clinical Experience with

Extra-adrenal Paragangliomas of Retroperitoneum: Report of 67 Cas-es and a Literature Review. Urology Annals 2010(Jan-Apr);2(1):12-16.

2. Brewster J.B., Sundaram P. Laparoscopic Resection of an Interaorto-caval Paraganglioma: Diagnosis Following a Needle Biopsy. J.S.L.S. 2007;11:502-505.

3. Tischler A., Kimura N., Mcnicol AM. Pathology of Pheochromocytoma and Extra-adrenal Paraganglioma. Ann. N. Y. Acad. Sci. 2006;1073:557-570.

4. Willenberg HG, Feldkamp J, Lehmann R, et al. A Case of Catechol-amine and Glucocorticoid Excess Syndrome Due to a Corticotropin-Secreting Paraganglioma. Ann. N. Y. Acad. Sci. 2006;1073:52-58.

5. Uysal M., Temiz S., Gul N. et al. Hypoglycemia due to Ectopic Release of Insulin from a Paraganglioma. Horm. Res. 2007;67:292-295.

6. Cunningham S.C., Suh H. S., Winter J. M., et al. Retroperitoneal Para-ganglioma: Single Institution Experience and Review of the Literature. J. of G.I. Surgery 2006;10:1156-1163.

7. Daab L.J., Cook P., Woo K., et al. Management of a Catecholamine-Secreting Paraganglioma Requiring Aortic Reconstruction. Vascular and Endovascular Surgery 2010;44(2):150-154.

8. Singh J., Rana S. S., Sharma R., et al. A Rare Cause of Hypertension in Children: Intrathoracic Pheochromocytoma. Pediatric Surg Int 2008;24:856-867.

9. Chrisoulidou A., Kaltsas G., Ilias I, et al. The Diagnosis and Manage-ment of Malignant Phaeochromocytoma and Paraganglioma. Endo-crine-Related Cancer 2007;14:569-585.


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IntroductionRadiofrequency ablation (RFA) has been known to be a safe and effective treatment for lung cancer. During the procedure, a radiofrequency generator transmits an alter-nating current through an electrode placed in the tumor using image guidance. The mechanism of action is by in-duction of frictional heating caused by the rapid oscilla-tion of ions, resulting in coagulation necrosis of the cells at temperature above 57 degree celsius. The commonly associated complications include pneumothorax, pleural

effusion, and pneumonia. Bronchopleural fistula, postab-lation syndrome of low grade fever and fatigue, air embo-lism has also been described. There have been only single reports of ablation of adjacent nerves, including phrenic nerve involvement in paramediastinal lesions, and bra-chial plexus injury in apical lesions.

Case ReportWe obtained approval from the research ethics board of the institute to review the cases of RFA and report the relevant data regarding the outcome and complications.

The case involved a 53 year old female with a non-small cell cancer in the right apex. The patient had received pri-or chemotherapy and radiotherapy with local recurrence. There was no evidence of mediastinal lymphadenopathy or systemic metastasis. The tumor measured 4 cm and was located in the right apex (fig 1). The procedure was considered to have a high risk of brachial plexus injury and the risks were discussed with the patient prior to the

Citation Dua et al. Appropriate Antibiotic Prescribing For Patients With Community Acquired (CA) Methi-cillin Resistant Staphylococcus Aureus (MRSA). J Surg Radiol. 2013 Apr 1;4(2).

CorrespondenCe Rashmi Gupta MD, FRCR E-mail [email protected].

reCeived August 31, 2012. aCCepted April 1, 2013. epub April 1, 2013.

Brachial Plexus Injury After Radiofrequency Ablation of lung Tumors: An Unusual ComplicationRashmi Gupta MD, FRCR, Jean M Seely MD, FRCPC, Mudit Gupta MD, FRCRDepartment of Radiodiagnosis, The Ottawa Hospital, Ottawa, Ontario, Canada.

Abstractoverview Radiofrequency ablation (RFA) of lung tumor is generally a safe procedure with very low incidence of neurological complications. Injury to brachial plexus is a very uncommon oc-currence. Herein, we present a case of brachial plexus injury associated with RFA of a tumor in the right lung apex. To the best of our knowledge, there has been only a single reported series of 4 patients with this complication.

Keywords brachial plexus, Radiofrequency ablation, Computed tomography, magnetic reso-nance imaging

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procedure and an informed consent was obtained.

The RFA was performed under conscious sedation. A 3.5cm multi-tined expandable electrode (LeVeen; Boston scientific) was introduced into the tumor 1 cm below the apical pleura

(fig 2a and 2b). RF energy was applied for 15 minutes at a maximum of 140 W. After the RF energy application was started, patient started complaining of pain in the right arm. The patient initially felt better with repositioning of the arm and tilting the tip of the probe inferiorly, however due to per-sistence of the discomfort and fear of injury to the brachial plexus, the procedure was stopped. The patient complained of severe neuropathic type of pain after the procedure and her right hand was nonfunctional. She had no active right thumb movement, and she was unable to flex the fingers, and when tried passively, the movement was painful. She had lost sen-sation in her fingertips and along the anterior aspect of her lower arm. The electromyogram performed a week after the RFA showed evidence of a severe right brachial plexopathy which affected the lower trunk. MRI of the right brachial plex-us demonstrated T2 hyperintense signal around the scalene muscles and along the roots and trunks of the brachial plexus (Fig 3).

She underwent a course of physiotherapy and occupational therapy. The patient was reevaluated six months after the pro-cedure and reported a subjective increase in power in the arm and hand, however, she remained completely dependent on her left side for her activities of daily living.

DiscussionRFA has been now widely used as an alternative treatment modality for recurrent lung tumors and for those patients who are not surgical candidates and have other comorbidities contraindicating radiation and chemotherapy. The commonly reported complications include pneumothorax (11% to 63%), pleural effusion, pneumonia, hemoptysis. Bronchopleural fis-tula and postablation syndrome of fatigue and fever have also been described. 2-5 There have been only isolated case reports describing neurological injuries in RFA.

Figure 1. Axial Contrast enhanced CT of chest demon-strates a mass lesion (white arrow) in right lung apex.

Figure 2. A&B. Axial Unenhanced CT of chest during ra-diofrequency ablation procedure, demonstrates multitined expandable probe within the tumor, approximately 1 cm below the pleura.

Figure 3. Oblique coronal MRI short tau inversion recov-ery (STIR) image for right brachia plexus demonstrates T2 hyperintense signal along root and trunks of right brachial plexus (white arrows).


original artiCle Gupta et al. Brachial Plexus Injury After RFA of the lungobserve for any sensory or motor deficit in the distribution of the nerves, since timely termination of the procedure may limit the degree of the neurological deficit.

References1. Hiraki T, Gobara H, Mimura H, et al. Brachial nerve injury caused by

percutaneous radiofrequency ablation of apical lung cancer: a report of four cases J Vasc Interv Radiol.. 2010;21:1129–1133

2. Yasui K, Kanazawa S, Sano Y, et al. Thoracic tumors treated with CT-guided radiofrequency ablation: initial experience. Radiology 2004;231:850–857.

3. Simon CJ, Dupuy DE, DiPetrillo TA, et al. Pulmonary radiofrequen-cy ablation: long-term safety and efficacy in 153 patients. Radiology 2007;243:268–275.

4. Gadaleta C, Mattioli V, Colucci G, et al. Radiofrequency ablation of 40 lung neoplasms: preliminary results. AJR Am J Roentgenol 2004;183:361–368.

5. VanSonnenberg E, Shankar S, Morrison PR, et al. Radiofrequency ab-lation of thoracic lesions: part 2, initial clinical experience—technical and multidisciplinary considerations in 30 patients AJR Am J Roent-genol.. 2005;184:381–390

6. Goldberg SN, Gazelle GS, Dawson SL, et al. Tissue ablation with ra-diofrequency: effect of probe size, gauge, duration, and temperature on lesion volume Acad Radiol. 1995;2:399–404.

7. Goldberg SN, Gazelle GS, Halpern EF, et al. Radiofrequency tissue ablation: importance of local temperature along the electrode tip ex-posure in determining lesion shape and size Acad Radiol.. 1996;3:212–218.

8. Steinke K, Glenn D, King J, et al. Percutaneous pulmonary radiofre-quency ablation: difficulty achieving complete ablations in big lung lesions Br J Radiol.. 2003;76:742–745.

9. Anderson EM, Lees WR, Gillams AR. Early indicators of treatment success after percutaneous radiofrequency of pulmonary tumors Car-diovasc Intervent Radiol.. 2009;32:478–483.

10. Millesi H. Brachial plexus injuries. In:Jupiter JB, ed. Flynn’s hand sur-gery, 4th ed. Baltimore: Williams and Wilkins, 1991;457-463.

11. Thornton RH, Solomon SB, Dupuy DE, et al. Phrenic nerve injury resulting from percutaneous ablation of lung malignancy AJR Am J Roentgenol. 2008;191:565–568.

The principle of RFA is to cause irreversible cell death by means of coagulation necrosis at temperatures greater than 57°C. 6,7 It is also well known that the ablation zone is larger than the diameter of the probe and there are changes in the tissues surrounding the site of ablation. In fact, several studies have documented treatment failure if the ablation zone does not completely surround the tumor with a safety margin of 5 to 10 mm. 8,9 There is a potential risk of ablation of the sur-rounding nerves which are extremely sensitive to heat.

The brachial plexus is constituted by C5 to T1 nerve roots. The lower trunk of the brachial plexus formed by the C8, T1 nerve roots is in close proximity to the apical pleura and is at risk of damage during the RFA of apical tumors. These nerve roots supply the flexors of the forearm and the muscles of the hand. The sensory supply is to the hand and the ulnar side of the forearm 10.

Thornton et al first reported 2 cases of phrenic nerve injury after RFA of tumors situated close to the mediastinum. They reported one case in which the injury to phrenic nerve was avoided by creating an artificial pneumothorax. 11 Recently, Hiraki et al reported 4 patients with brachial plexus injury following RFA for apical tumors.1 In one of their patients, fol-lowing initial application of radiofrequency pulse, the patient experienced numbness in the hand suggestive of brachial plexus injury. An artificial pneumothorax was then created which appeared to relieve the symptoms of the patient initial-ly, however subsequently brachial nerve injury developed and they hypothesized that the injury had developed before the pneumothorax was created. In their series, two patients expe-rienced sensory dysfunction in the hand during the procedure and the other two patients developed numbness and pain later (3 hours after the procedure in one patient and 3 days after the procedure in the other). All the patients had involvement of the lower trunk of brachial plexus, with 3 patients having sensory dysfunction in the T1 nerve area and 1 showing mo-tor dysfunction in the C8 nerve area. Our patient had symp-toms during the ablation and subsequently developed both motor and sensory dysfunction in C8,T1 nerve area. The au-thors graded the injury according to National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0, grade 1, asymptomatic; grade 2, moderate symptoms limiting instrumental activities of daily life; and grade 3, severe symp-toms limiting self-care activities of daily life. The severity of injury in our patient was grade 3 according to this scale. Our patient had also received prior chemotherapy and radiation which may have contributed to the severity of the symptoms. All of the four reported cases demonstrated partial recovery of the brachial nerve injury over time, which was also the case with our patient.

In conclusion, it is extremely important to be aware of the neurological complication that can occur with RFA, since it is a potentially permanent and disabling injury. Informed con-sent should be obtained in all cases where such injury is an-ticipated. Creation of artificial pneumothorax may be helpful to separate the lesion from the nerves and thereby decreasing the chance of injury. During the RFA, care should be taken to

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Citation Vasileiadis et al. Bilateral Elongated Styloid Pro-cess Causing Atypical Head and Neck Pain. J Surg Ra-diol. 2013 Apr 1;4(2).

CorrespondenCe Ioannis Vasileiadis, M.D. Contact: [email protected].


Bilateral Elongated Styloid Process Causing Atypical Head and Neck PainIoannis Vasileiadis MD,1,2 Stylianos Kapetanakis MD,PhD,1 Dimitrios Vasileiadis MD,1 Aristotelis Petousis MD,2 Aliki Fiska MD,PhD,1 Georgios Gavridakis MD3

1. Department of Anatomy, Medical school of Alexandroupolis, Democritus University of Thrace, Greece.2. Department of Otolaryngology/Head and Neck surgery, Venizeleio-Pananeio Hospital, Herakleion, Greece.3. Department of Radiology, Venizeleio-Pananeio Hospital, Herakleion, Greece.

AbstractintroduCtion The styloid process arises from the temporal bone immediately in front of the stylo-mastoid foramen. The normal length of this process is 20 to 30 mm in adults. In about 4% of general population an elongated process occurs, while only about 4% of these patients are symptomatic. Eagle’s syndrome is characterized by the symptomatic elongation of the styloid process or mineral-ization of the styloid ligament complex. The symptoms range from mild discomfort to acute neuro-logic and referred pain.Methods Case study and review of the literatureresults We present a rare case of bilateral elongated styloid process causing atypical head and neck pain and the rare and diagnostic radiographic evidence in both plain film radiographs and CT scan. A 72-year-old man presented with a 6 year history of neck pain. The pain increased when he turned his neck either left or right and by swallowing. In addition, he reported a dull headache occurring several times per week and lasted for a few hours. The symptoms were aggravated with overhead work. The patient underwent ENT examination on which a bony projection was felt to the right and the left tonsillar fossa. A neck CT with 3-D reformation revealed extensive elongation of the left ( 96 mm ) and right ( 88 mm ) styloid process. The patient underwent surgical removal of the elongated portion of the styloid processes.disCussion Eagle’s syndrome may be the source of craniofacial and cervical pain. A CT of the scull base and neck with 3-D reformation is an extremely valuable imaging tool. Treatment options include medical management and surgical therapy.

Keywords Eagle’s syndrome, elongated styloid process, cervical pain, atypical pain

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Vasileiadis et al. Eagle Syndrome original artiCle

IntroductionEagle’s syndrome was first described by Watt W. Eagle in 1937.1 Eagle’s syndrome is characterized by recurrent pain in the oropharynx and face due to an elongated styloid process or calcified stylohyoid ligament. These structures can compress cervical nerve or pharynx causing symptoms including ody-nophagia, dysphagia, neck pain on turning head and foreign body sensation.2,3 Eagle’s syndrome is classified into classic and carotid types. The first involves patients who had classi-cal symptoms of a foreign body lodged in the throat with a palpable mass in the tonsillar region following tonsillectomy. The latter affects patients with or without palatine tonsils who present continuous cervical pain following the carotid artery distribution.2

This is the first case in literature that bilateral elongation of styloid processes over 8 cm was documented. The normal length of the styloid process is about 25 mm and length longer than 30mm is the criterion of elongation. Although approxi-mately 4% of the general population is thought to have an elongated styloid process and a calcified stylohyoid ligament, only 4% of patients of this group is symptomatic.4,5 Diagno-sis of Eagle’s syndrome is made by both physical examination

and imaging study. Physical examination can reveal a palpable elongated styloid process in the tonsillar fossa. The imaging study modalities include panoramic radiograph and CT scan-ning. 3D-CT is a valuable diagnostic tool in the diagnosis of Eagle’s syndrome because of its ability to facilitate accurate image of the anatomy and measurement of the length of the styloid process.

Case ReportA 62-year old man presented to the Otolaryngology Depart-ment with a 5 years history of a dull intermittent pain in the

Figure 1. lateral view plain radiograph of the cervical spine shows two large ossified structure extending from the temporal bone anterolaterally and caudally to the hyoid bone.

Figure 2. lateral multiplanar reforming bone window im-age shows the right elongated styloid process (87.8 mm).

Figure 3. lateral multiplanar reforming bone window im-age shows the left elongated styloid process (96.2 mm).


original artiCle Vasileiadis et al. Eagle Syndromepatient underwent surgical removal of both styloid processes. The patient re-mained symptom free 14 months after surgery.

DiscussionStyloid process is derived from the Greek word “Stylos” that means a pil-lar. The styloid process arises from the temporal bone immediately in front of the stylomastoid foramen. It is an elongated conical projection of the temporal bone which lies anteriorly to the mastoid process between the internal and external carotid arter-ies and laterally the tonsilar fossa. In this space the internal jugular vein, the internal carotid artery, vagus, glos-sopharyngeal, facial and hypoglos-sal nerves are located. The tip of the styloid process is continuous with the stylohyoid ligament, which extends to the lessen cornu of the hyoid bone. Three muscles, the stylohyoid, the sty-loglossal and the stylopharyngeal and two ligaments, the stylohyoid and the stylomandibular originate from the styloid process.

The normal length of this process is 20 to 30 mm in adults. Most authors agree that any measurement over 30 mm is enlarged. The length of styloid process varies between individuals. The normal size of the length in the majority of the people is approxi-

mately 2.5 to 3.0 centimeters.6 Studies suggested that age and gender did not show correlation with the length of styloid process.7,8 Very few literatures cite the length of styloid process more than 40 cm (Table 1). In our case, the precise length was 88 mm for the right process and 96 mm for the left. This is the first case in literature that bilateral elongation of styloid processes over 8 cm was documented. This was the result of completely ossification of the stylohyoid ligament bilaterally. Except of these findings, an uncommon pseudoarticulation of the tip of styloid apparatus and the lesser cornu of the hyoid bone was revealed.

Styloid apparatus is constituted by the styloid process of the temporal bone, the stylohyoid ligament and the minor horn of the hyoid bone. The styloid process, stylohyoid ligament and minor horn of the hyoid bone are derived from Reichert’s cartilage that arises from the second branchial arch. During fetal development Reichert’s cartilage links styloid bone to the hyoid bone. Several theories have been proposed for the cause of the elongation of the styloid process :

oropharynx and a neck pain that was more severe on the left and was exacerbated when he rotated his head either left or right. He also reported dysphagia , cervical pain and reflex ipsilateral otalgia that lasted only few minutes and then disap-peared. Physical examination revealed an exacerbation of the pain by palpation of the left tonsillar fossa. Present but less severe was the pain by palpation on the right fossa. A hard bony projection could be palpated in either fossa. It was also revealed a global decrease in active range of motion of the cer-vical spine with pain on the end-range of extension and lateral flexion. He had no history of tonsillectomy or neck trauma. Diagnosis was suspected based on clinical history. A lateral plain radiograph of the neck revealed two symmetric bony formations extending from the temporal bone to the hyoid bone (Figure 1). The patient underwent a CT scan of head and neck. Images were obtained in the axial, coronal and sagittal planes and three-dimensional (3D) reconstructions were done and demonstrated thick and excessive elongated styloid pro-cess, 88 mm to the right and 96 mm to the left (Figure 2,3,4). It also revealed an pseudoarticulation between the inferior edge of the left styloid process and the hyoid bone (Figure 5). The

Table 1. Review of reported cases of bilateral elongation of styloid process over 40 mm.

AUTHORSLENGTH OF STYLOID PROCESS ,

R = Right L = left

1) Sisman Y et al R = 47 mm , L = 58 mm

2) Savranlar A et al R = 46 mm , L = 37 mm (case 1)



5) Casale M. et al R = 57 mm , L = 48 mm

6) Padeyappanavar K. et al R = 45 mm , L = 50 mm (case 1)



9) Hernandez JL et al R = 46 mm , L = 43 mm

10) Bozkir MG et al R = 65 mm , L = 67 mm (case 1)






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thought to have an elongated styloid process and a calci-fied stylohyoid ligament, only 4% of patients of this group is symptomatic.14 The few patients that are symptomatic are usually over 40 years old. The majority of symptomatic pa-tients have no medical history of tonsillectomy or cervical or pharyngeal trauma.8,9 Bilateral involvement is quite common but does not always involve bilateral symptoms.8,12

As the diagnosis is not very easy, it is reported that the number of cases are underestimated in the population.12 The diagno-sis of Eagle’s syndrome requires awareness and high index of suspicion. Diagnosis is based on clinical history and physical manipulation and its confirmation depends on the imaging exam. The major symptoms are foreign body sensation in the pharynx, cervical pain, dysphagia, odynophagia and ear pain. Palpation of the styloid process in the tonsillar fossa is indica-tive of elongated styloid in that processes of normal length are not normally palpable. The elongated styloid process can be palpated by inserting a finger orally along the occlusal line posterior to the region of the tonsillar fossa. This procedure usually exacerbates the pain. In addition, relief of symptoms with injection of an anesthetic solution into tonsillar fossa is highly indicative of this diagnosis.11,12

A variety of head and neck conditions should be considered in the differential diagnosis of Eagle’s syndrome and cervico-pharyngeal pain. These include trigeminal neuralgia, glos-sopharyngeal neuralgia, sphenopalatine neuralgia, head and neck tumors, migraine-type headaches, Sluder’s syndrome, temporomandibular disorders, temporal arteritis, cervical ver-tebral arthritis, otitis, salivary gland disease, unerupted or im-pacted molar teeth and faulty dental prostheses.12,13

The imaging investigation can be performed through cervi-cal planigraphy ( body-section radiography), side and ante-

1. Congenital elongation of the process due to persistence of a cartilaginous part in the stylohyale.

2. Calcification of the stylohyoid ligament giving the ap-pearance of an elongated styloid process.

3. Growth of osseous tissue at the insertion of the stylohy-oid ligament.9,10

The elongation of the styloid process and/or calcification of the stylohyoid ligament can result in styloid-stylohyoid syn-drome also known as Elongated styloid process Syndrome, Stylohyoid Syndrome, Styloid process neuralgia or Eagle’s Syndrome.

Eagle, an ENT surgeon described in 1937 a group of patients who had symptoms of intermittent and nagging pain in the pharynx that radiated to the ipsilateral ear, dysphagia and for-eign body sensation.1 All the patients of the original group had a history of tonsillectomy. He also described and a second group of patients who complained of constant throbbing pain along the distribution of the internal or external carotid artery. Eagle considered that the scar tissue formation around the sty-loid apex compress or stretch the vascular and nervous struc-tures contained in the retrostyloid compartment, particularly branches of glossopharyngeal nerve and perivascular carotid sympathetic fibers.

The pathophysiological mechanisms of symptoms are not clear. Some of the theories are the following: 1) traumatic frac-ture of the styloid process causing proliferation of granula-tion tissue that put pressure on the surrounding structures, 2) tendonitis of the stylohyoid insertion, 3) compression of adjacent nerves, 4) irritation of the pharyngeal mucosa and 5) impingement of the carotid artery, producing irritation of the sympathetic nerves in the arterial sheath.9,10,11

Although approximately 4% of the general population is

Figure 4. left lateral 3D-CT image: Bilateral elongated sly-loid process with complete calcification of both stylohyoid ligaments (the mandible was exluded). Figure 5. lateral multiplanar reforming bone window im-

age shows the pseudoarticulation between the tip of the left elongated styloid process and the hyoid process.


original artiCle Vasileiadis et al. Eagle SyndromeSurg. 1977;35:355-60.

7. Basekim CC, Mutlu H, Gungor A et al. Evaluation of styloid process by three dimensional computed tomography. Eur Radiol. 2005; 15: 134-139.

8. Ferrario VF, Sigurta D, Daddona A, Dalloca L, Miani A, Tarufo F, Sfor-za C. calcification of the styloid ligament : Incidence and morpho-quantitave evaluations. Oral Surg Oral Med Oral Path. 1990;69;524-29.

9. Balcioglu HA, Kilic C, Akyol M, Ozan H, Kokten G. Length of the sty-loid process and anatomical implications for Eagle’s syndrome. Folia Morphol. 2009; 68(4): 265-70.

10. Camarda AG, Deschamps C, Forest DI. Styloid chain ossification: A discussion of etiology. Oral Surg Oral Med Oral Path, 1989;67: 514-518.

11. Balbuena L, Hayes D, Ramirez SG, Johnson R. Eagle’s syndrome (elon-gated styloid process). South Med J. 1997; 90: 331-334.

12. Casale M, Rinaldi V, Quattrocchi C, Bressi F, Vincenzi B, Tonini G, Salvinelli F. Atypical chronic head nad neck pain: don’t forget Eagle’s syndrome. Eur Rev Med Pharmacol Sci. 2008; 12(2): 131-3.

13. Murtagh RD, Caracciolo JT, Fernadez G. CT findings associated with Eagle syndrome. Am J Neuroradiol. 2001; 22: 1401-1402.

14. Chiang KH, Chang PY, Chou AS, Yen PS, Ling CM, Lee. Eagle’s syn-drome with 3-D reconstructed CT: two cases report. Chin J Radiol. 2004;29: 353-7.

15. Huang CC, Tsai YH, Liao YS, Weng HH, Yang BY. Three-dimensional reconstruction CT in diagnosis of Eagle’s syndrome: a retrospective study. Chin J Radiol. 2006; 31: 221-225.

16. Savranlar A, Uzun L, Ugur MB, Özer T. Three-dimensional CT of Ea-gle’s syndrome. 2005; 11: 206-9.

17. Hossein R, Kambiz M, Mohammad D, Mina N. Complete recovery after an intraoral approach for Eagle syndrome. J Craniofac Surg. 2010;

21: 275-6.

rioposterior skull radiography, lateral-oblique mandible plain film, panoramic radiography and CT of the base of the skull with three dimensional reconstructions.14 Among all imag-ing exams, CT of the base of the skull with three dimensional reconstructions seems to be the most effective one, since it provides all the information about the styloid process, includ-ing its length, direction and anatomical variations. Another advantage of the 3D-CT images is three dimensional length measurements which are impossible in 2D images such as in coronal or axial planes.15,16

Once diagnosis of Eagle’s syndrome is made, surgical or non surgical treatment should be considered. Analgesics, anticon-vulsants, antidepressant and local infiltration with steroids or long-acting local anesthetic agents have been proposed as medical treatment. Patients who fail medical therapy may benefit from surgical removal of the elongated portion of the styloid process.12,15 Styloidectomy is the treatment of choice. It can be performed by a transoral or an extraoral approach.15,17 The treatment’s choice usually depends on the experience of the surgeon. The 3- dimensional CT scan is an extremely valu-able imaging tool in head and neck pathologies because of its ability to accurately image the anatomy and help to the surgeon planning preoperative.

The advantages of the transoral approach are simplicity, safety, shorter time and no external scar while the disadvantages are the risk of injury to major vessels and the possibility of infec-tion of deep neck spaces. The advantages of the extraoral ap-proach are the better visualization and the reduced possibility of deep neck space infections while the disadvantages are the longer hospitalization, the cutaneous scar and the risk of in-jury of the facial nerve.17

Conclusion In patients presented with symptoms in the throat with asso-ciated facial pain or headache, the Eagle syndrome should be considered in the differential diagnosis. A detailed case history and physical examination are mandatory. 3D-CT is a valuable diagnostic tool in the diagnosis of Eagle’s syndrome, measur-ing accurate the length of the styloid process and demonstrate the anatomical relations with the surroundings structures.

References1. Eagle WW. Elongated styloid process. Arch Otolaryngol. 1937; 25: 584-

7.

2. Eagle WW. The symptoms, diagnosis and treatment of the elongated styloid process. Am Surg. 1962;28: 1-5.

3. Lorman JG, Biggs JR. The eagle syndrome. Am J Roentgenol. 1983; 140(5): 881-2.

4. Murphy PSN, Hazarika P, Mathai M, Kumar A, Kamath MP. Elongated styloid process: an overview. Int J Oral Maxillofac Surg. 1990; 29: 230-1.

5. Rechtweg JS, Wax MK. Eagle’s syndrome : a review. Am J Otolaryngol. 1998;19: 316-321.

6. Gossman JR, Tarsitano JJ. The styloid-stylohyoid syndrome. J Oral

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Citation Rajesh and Bhatnagar. Radiological Diagnosis of Midgut Volvulus, Primary as well as Secondary to Mesenteric Cyst, with Clinico-Surgical Correlation. J Surg Radiol. 2013 Apr 1;4(2).

CorrespondenCe Shorav Bhatnagar M.D. E-mail [email protected].

reCeived July 22, 2012. aCCepted April 1, 2013. epub April 1, 2013.

Radiological Diagnosis of Midgut Volvulus, Primary as well as Secondary to Mesenteric Cyst, with Clinico-Surgical CorrelationS. Rajesh1,2 and Shorav Bhatnagar1

1. Departments of diagnostic and interventional Radiology. Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi-1100702. Departments of Radiodiagnosis, G.R. medical College and J.A. Group of Hospitals, Veer Savarkar Marg, Lashkar, Gwalior (Madhya Pradesh) - 474009

AbstractintroduCtion To evaluate the role of whirlpool sign on sonography in the diagnosis of midgut volvulus and to emphasize the importance of considering this diagnosis even in patients presenting beyond the neonatal period with atypical symptoms. Upper gastrointestinal series has been tradi-tionally used for the diagnosis of intestinal malrotation and midgut volvulus. But since the presenta-tion of many of these patients can be atypical and the index of suspicion especially in adult patients is low, sonography is often the initial investigation requested in these cases. The whirlpool sign on sonography caused by the wrapping of the superior mesenteric vein (SMV) and its mesentery around the superior mesenteric artery (SMA) has been shown to be highly specific for midgut volvulus.Methods Sonography was performed on three patients, the youngest a 14 day old neonate and the oldest a 12 year old boy, presenting with varied symptomatology ranging from recurrent episodes of colicky abdominal pain, distension and bilious vomiting to lump in the abdomen, to look for the underlying cause.results The whirlpool sign was present in all the patients. In addition, two patients had reversal of the normal relationship between SMV and SMA with evidence of duodenal obstruction, suggesting malrotation as the cause of volvulus. In the third child the relationship between SMV and SMA was not disturbed but she had a large mesenteric cyst which was suggested as the cause of vol-vulus. Upper gastrointestinal examination, CT and subsequently surgery confirmed the sonographic findings in all the patients.ConClusion The identification of whirlpool sign with small bowel obstruction on sonography is highly suggestive of midgut volvulus even in patients with atypical presentation, allowing early diagnosis and timely operative intervention in this potentially life threatening condition.

Keywords Midgut Volvulus, Whirlpool, Mesenteric cyst, Sonography

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Traditionally the upper gastrointestinal (UGI) series has been used to diagnose this disorder.2 But the atypical clinical pic-ture of many of these patients especially the ones that present beyond the neonatal period has ensured that sonography is often the initial investigation requested by the clinician in such cases. The whirlpool sign on sonography, caused by the wrap-ping of the superior mesenteric vein (SMV) and its tributaries around the superior mesenteric artery (SMA) has been shown to be highly specific for midgut volvulus.3 Thus sonography can play a crucial role in early diagnosis of this disorder. We report three cases of midgut volvulus, two of them presenting atypically and another in a more classical fashion, diagnosed primarily on sonography and subsequently confirmed on

UGI series, CT and surgery.

Case 1A 12 year old boy with complaints of recurrent episodes of colicky abdominal pain, abdominal distension and vomiting for 6 years was referred to us for abdominal sonography. So-nography was performed on Aloka prosound SSD-4000 unit (Aloka Trivitron Medical Technologies Pvt. Ltd., Tokyo, Japan) using 3-5MHz curvilinear and 5-10 MHz linear transducer. On transverse scanning in the epigastric region a dilated fluid filled stomach and duodenum with a tapering end was noted (Figure 1). The SMV was present ventrally and to the left of

Introduction Midgut volvulus is a potentially life threatening surgical emergency characterized by a clockwise twisting of the bowel around the superior mesenteric artery (SMA) axis. Although it is usually diagnosed in newborns and young infants who present with bilious vomiting and abdominal distension, it can also present in adolescents and adults in whom the diag-nosis is difficult because of the non-specific clinical presenta-tion and low index of suspicion.1 Recurrent episodes of col-icky abdominal pain with vomiting over a period of months or years are typical and may eventually lead to imaging.1

Rajesh and Bhatnagar. Midgut Volvulus original artiCle

Figure 1. Transverse sonogram showing dilated duodenum (arrow) having a tapering end and a ring of vascularity representing twisting of SMV around SMA (arrowhead), giving the whirlpool sign.

Figure 2. Transverse sonogram showing SMA (arrow) to the right of SMV (arrowhead) reflecting reversal of normal relationship. lumen of superior mesenteric artery can be recognized by surrounding rim of echogenicity.

Figure 3. Upper GI series showing grossly dilated second part of duodenum (arrow) with duodenojejunal junction to the right of midline and cork-screw shaped configuration of proximal jejunal loops (arrowhead).


original artiCle Rajesh and Bhatnagar. Midgut Volvulus

Case 2A 14 day old neonate with complaints of abdominal distension and bilious vomiting presented to us for abdominal sonogra-phy. Sonography revealed dilated duodenum, and abnormal relationship between the SMV and SMA. Colour doppler examination revealed the whirlpool sign (Figure 4). The con-stellation of sonographic findings suggested midgut volvulus. UGI series and later surgery confirmed the diagnosis.

Case 3A 7 year old girl presented to us with primary complaints of lump in the abdomen and mild upper abdominal pain for nine months. Examination revealed a soft, non-tender, freely mobile mass in the left paraumbilical region. Sonography demonstrated a well defined, thin walled, unilocular cystic le-sion (Figure 5) measuring 8.6 x 5.4 x 8.8 cm along with the whirlpool sign. The relationship between SMA and SMV was not disturbed. A diagnosis of small bowel volvulus due to mesenteric cyst was made which was later confirmed on CT (Figure 6) and surgery (Figures 7 and 8).

Discussion In fetal life, the GI tract begins as a straight, short tube. Sny-der and Chaffin4 classified the primitive midgut into two parts on the basis of its position relative to the SMA. The first part consists of the proximal, prearterial duodenojejunal and ter-minal ileum loops that lie anterior to and above the SMA. The second part includes the distal postarterial loop that lies be-low and behind the SMA and includes the distal ileum, right colon, and proximal two-thirds of the transverse colon. As the intestine elongates, the prearterial and postarterial segments rotate 2700 in a counterclockwise direction around the SMA so

SMA reflecting abnormal orientation (Figure 2). On colour doppler examination, a ring of vascularity surrounding the SMA representing the whirlpool sign was seen (Figure 1). A di-agnosis of intestinal malrotation with midgut volvulus caus-ing duodenal obstruction was suggested and UGI study was carried out. It revealed dilatation of second part of duodenum and abnormal position of duodenojejunal junction as well as the jejunal loops to the right of midline with corkscrew configuration of proximal jejunum (Figure 3). Surgery dem-onstrated a 3600 midgut volvulus with associated Ladd bands. Lysis of the bands and reduction of the midgut volvulus was performed, and the postoperative course was uneventful.

Figure 4. Gray scale and colour doppler ultrasound im-ages demonstrating the whirlpool sign.

Figure 5. Sonogram showing the mesenteric cyst.

Figure 6. Axial contrast enhanced CT scan image showing the whirlpool sign (arrow)

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thrive, or late onset of symptoms.9

Sonography is often the initial investigation requested in such patients as it is less time consuming, widely available, non in-vasive and does not need any prior preparation. It can demon-strate the abnormal orientation of mesenteric vessels in cases with malrotation, with the SMV located either ventrally or to the left of SMA.10 This sign, although not highly specific, can be helpful in the diagnosis of unsuspected malrotation and its associated complications.10 The whirlpool sign on sonogra-phy, proposed by Pracros et al3, directly indicates the anatomic alteration of midgut volvulus characterized by wrapping of the SMV and mesentery around the SMA11. On color Dop-pler sonography, the whirlpool sign consists of a side-by-side arrangement of vessels with opposing flow directions. Other sonographic signs of midgut volvulus, including duodenal obstruction with a tapering configuration, thickened bowel loops to the right of the spine, a hyperdynamic pulsating SMA, a truncated SMA, and free peritoneal fluid, are nonspe-cific and complement the whirlpool sign11. All our cases dem-onstrated the sonographic clockwise whirlpool sign with two cases showing abnormal relationship between the SMV and SMA and evidence of duodenal obstruction while the third one showed a mesenteric cyst as the cause of volvulus. UGI radiographic examination and CT carried out subsequently confirmed the diagnosis but did not reveal any additional in-formation.

Conclusion Malrotation and midgut volvulus should always be con-sidered in the differential diagnosis of acute or chronic ab-dominal pain even in patients presenting beyond the neonatal

that the duodenojejunal junction is located to the left of the spine, while the caecum is located in the right lower quadrant of the abdomen. At the completion of this rotation, there is a broad attachment of the small bowel mesentery extending from the ileocaecal valve in the right lower quadrant to the ligament of Treitz in the left upper quadrant. Midgut malrota-tion refers to a failure in the counter clockwise rotation of the midgut.5

In patients with malrotation, the mesenteric pedicle is nar-rowed and the duodenojejunal junction is typically low ly-ing, to the right of the midline, and anteriorly positioned. The most serious complication of malrotation is volvulus. Midgut volvulus occurs when the malfixed bowel twists in a clockwise fashion on the narrow base of the mesentery. The twisting ob-structs the bowel and also the SMA and superior mesenteric vein, which lie within the short mesenteric pedicle resulting in bowel obstruction, ischemia and in severe cases necrosis.5

Midgut volvulus can also occur secondary to other congenital conditions such as a persistent omphalomesenteric duct and a mesenteric cyst. Acquired conditions like adhesions, ascaria-sis, mesenteric cyst or tumor have also been implicated in the pathogenesis.6

It is usually diagnosed in neonates and infants who present with abdominal distension and bilious vomiting but can also occur later in life.7

Upper GI series has long been used in the diagnosis of midgut volvulus.2 In cases of malrotation it demonstrates duodenoje-junal junction lying to the right of midline and inferior to the duodenal bulb. When associated with midgut volvulus, cork-screw pattern due to spiral configuration of the fourth portion of the duodenum and the proximal jejunum is visualized.2 Al-though the findings are often classic on images obtained in an upper gastrointestinal tract series, malrotation may at times be difficult to diagnose radiographically.8 The clinical presenta-tion of patients with malrotation can also be problematic, with some having atypical or chronic symptoms, such as failure to

Figure 7. Operative image showing the mesenteric cyst with midgut volvulus causing small bowel obstruction.

Figure 8. Operative image after reduction of volvulus.


original artiCle Rajesh and Bhatnagar. Midgut Volvulusperiod. Identification of the sonographic whirlpool sign is highly suggestive of this diagnosis. Since sonography is often the initial investigation requested in such patients, it can play a crucial role in early diagnosis and prompt surgical manage-ment of these cases.

References1. Pickhardt PJ, Bhalla S. Intestinal malrotation in adolescents and

adults: spectrum of clinical and imaging features. Am J Roentgenol 2002;179:1429-35.

2. Applegate KE, Anderson JM, Klatte EC. Intestinal Malrotation in Chil-dren: A Problem-solving Approach to the Upper Gastrointestinal Se-ries. RadioGraphics 2006;26:1485–1500.

3. Pracros JP, Sann L, Genin G, Tran-Minh VA, Morin de Finfe CH, Foray P, et al. Ultrasound diagnosis of midgut volvulus: the “whirlpool” sign. Pediatr Radiol 1992; 22:18–20.

4. Snyder WH Jr, Chaffin L. Embryology and pathology of the intestinal tract: presentation of 40 cases of malrotation. Ann Surg 1954;140:368-79.

5. Ortiz-Neira CL. The Corkscrew Sign: Midgut Volvulus. Radiology 2007; 242:315-6

6. Vijayaraghavan SB, Ravikumar VR, Srimathy G. Whirlpool sign in small-bowel volvulus due to a mesenteric cyst. J Ultrasound Med 2004; 23:1375–77.

7. Ladd WE. Surgical diseases of the alimentary tract in infants. N Engl J Med 1936;215:705-8.

8. 8. Beasley SW, de Campo JF. Pitfalls in the radiological diagnosis of malrotation. Australas Radiol 1987;31:376-83.

9. Brandt ML, Pokorny WJ, McGill CW, Harberg FJ. Late presentations of midgut malrotation in children. Am J Surg 1985;150:767-71.

10. Weinberger E, Winters WD, Liddell RM, Rosenbaum DM, Krauter D. Sonographic diagnosis of intestinal malrotation in infants: impor-tance of the relative positions of the superior mesenteric vein and ar-tery. Am J Roentgenol 1992;159:825-8.

11. Taori K, Sanyal R, Attarde V, Bhagat M, Sheorain VS, Jawale R, et al. Unusual presentations of midgut volvulus with the whirlpool sign. J Ultrasound Med 2006;25:99-103.

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Citation Tran et al. A Rare Case of Ileocecal Intussus-ception with Benign Giant Lipoma as the Lead Point Mass. J Surg Radiol. 2013 Apr 1;4(2).

CorrespondenCe Leslie M. Kobayashi, MD, FACS E-mail [email protected].

reCeived July 22, 2012. aCCepted April 1, 2013. epub April 1, 2013.

A Rare Case of Ileocecal Intussusception with Benign Giant lipoma as the lead Point MassKimberly D. Tran1 BS, Marc A. Rodriguez1 MS, Hannah Copeland MD2, Leslie M. Kobayashi1 MD, Raul Coimbra1 MD, PhD1. Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of California at San Diego, CA2. Department of Cardiovascular and Thoracic Surgery Loma Linda University

AbstractintroduCtion Intussusception is the most common cause of bowel obstruction in children; how-ever it accounts for less than 1% of bowel obstructions in adults. Though rare, malignant tumors predominate as the leading cause of symptomatic adult intussusception; thus, the implications of such a finding can be quite grave. In this case report, we present a rare case of ileocecal intussuscep-tion with a benign giant lipoma as the causative lesion.

Keywords intussusception, lipoma

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IntroductionIntussusception is the most common cause of bowel obstruc-tion in children; however it accounts for less than 1% of bowel obstructions in adults.1 Though rare, malignant tumors pre-dominate as the leading cause of symptomatic adult intussus-ception; thus, the implications of such a finding can be quite grave.2 In this case report, we present a rare case of ileocecal intussusception with a benign giant lipoma as the causative lesion.

Case ReportWe report the case of a thirty-five year old Caucasian female with an ileocecal intussusception caused by a benign lipoma. The patient first presented to the Emergency Department (ED) with several weeks of mid-epigastric pain and a two-day history of blood-streaked, black stools. She reported previous ibuprofen use for lower back pain, and recent completion of Helicobacter pylori therapy. Her family history was negative for gastrointestinal malignancy; however, both the patient’s ma-ternal grandmother and father had died of cancers. Because of the concern for an upper gastrointestinal (GI) bleed, she

underwent endoscopy, which revealed gastric erosions. Her iron studies were consistent with iron-deficiency anemia, the patient was advised to stop all NSAID use and was started on a proton-pump-inhibitor and iron supplements. Her he-moglobin was stable overnight, without need for transfusion, and she was discharged home the next day.

Two days later, the patient’s symptoms progressed, and she represented to the ED with severe abdominal pain, nausea, vomiting, continued rectal bleeding, and orthostatic symp-toms. An electrocardiogram was performed to rule out myo-cardial infarction, and computed tomography (CT) imaging of her abdomen and pelvis revealed an ileocecal intussusception with multiple pericecal lymph nodes and with a lead point suggestive of a mass (Figs. 1, 2). The intussusception contained significant quantities of fat, suggestive of a lipoma; however, other etiologies could not be excluded.

The Acute Care Surgery team was consulted. The patient un-derwent exploratory laparotomy and right hemicolectomy. In the operating room, the team saw the terminal ileum intussus-cepted through the right colon into the proximal transverse colon. A palpable, firm, grey 5.5 x 4.5 x 4.5 cm mass on the cecal mucosal surface appeared to be the lead point. The final pathology report demonstrated a benign submucosal lipoma with superficial ulceration and granulation tissue (Fig. 3).

The patient had an uncomplicated post-operative course, and antibiotics were discontinued on post-operative day (POD) 1. On POD 2, the nasogastric tube was removed, and the pa-tient’s pain was well-controlled via patient-controlled analge-sia (PCA). Over the next few days she continued to improve clinically, tolerating a clear liquid diet, increasing her level of activity out of bed, and requiring progressively less narcotic analgesia. She remained afebrile with no signs or symptoms of infection. On POD 5, the patient experienced return of bowel function, and was tolerating a soft mechanical diet, as such she was discharged home with a proton-pump-inhibitor, iron supplements, and oral pain medications.

Tran et al. Ileocecal lipoma Causing Intussusception original artiCle

Figures 1 Axial and 2. Coronal sections of the CT abdo-men with contrast revealing an ileocolic intussusception. The lead point mass contained a significant quantity of fat, suggestive of a lipoma.

Figure 3. Microscopic view of benign submucosal lipoma with superficial ulceration and granulation tissue (H&E staining).


original artiCle Tran et al. Ileocecal lipoma Causing IntussusceptionIn this case the decision for surgical intervention was direct-ed by the combination of her obstructive and hemorrhagic symptoms, as well as the concern for malignancy in the set-ting of a symptomatic, intussusception-provoking mass. In these cases, en bloc segmental resection remains the primary diagnostic and treatment modality of choice.9 Lesions involv-ing the jejunum or proximal ileum should be treated by wide excision of tissues at risk for contiguous spread,10 and a right hemicolectomy is indicated for tumors of the distal ileum, ce-cum, ascending colon, and hepatic flexure. In some cases, an extended right hemicolectomy may be indicated for lesions of the transverse colon, while lesions of the distal transverse colon are resected with a left hemicolectomy.9

In summary, while detailed imaging has facilitated the diag-nosis of intussusception, this finding remains rare in adults and is most commonly associated with obstructive symptoms and malignant etiology. GI lipomas, while also included on the extensive differential of intussusception, are generally as-ymptomatic and most do not require surgical intervention. In this case report, we identified a rare ileocecal intussuscep-tion with a benign giant lipoma as the lead point, requiring surgical intervention for recurrent bleeding and pain, as well as concern for malignancy in the setting of a symptomatic, intussusception-provoking mass.


References1. Azar T, Berger DL. Adult Intussusception. Ann Surg. 1997

Aug;226(2):134-8.

2. Donhauser JL, Kelly EC. Intussusception in the adult. Am J Surg. 1950 May;79(5):673-7.

3. Kim YH, Blake MA, Harisinghani MG, Archer-Arroyo K, Hahn PF, Pitman MB, Mueller PR. Adult intestinal intussusception: CT appear-ances and identification of a causative lead point. Radiographics. 2006 May-Jun;26(3):733-44.

4. Huang WS, Changchien CS, Lu SN. Adult intussusception: a 12-year experience, with emphasis on etiology and analysis of risk factors. Chang Gung Med J. 2000 May;23(5):284-90.

5. Weilbaecher D, Bolin JA, Hearn D, Ogden W 2nd. Intussusception in adults. Review of 160 cases. Am J Surg. 1971 May;121(5):531-5.

6. Sanders GB, Hagan WH, Kinnaird DW. Adult intussusception and car-cinoma of the Colon. Ann Surg. 1958 Jun;147(6):796-804.

7. Taylor et al. Gastrointestinal Lipomas: A Radiologic and Pathologic Review. AJR. 1990 Dec; 155:1205-1210.

8. Thompson WM. Pictorial essay: Imaging and Findings of Lipomas of the Gastrointestinal Tract. AJR 2005; 184:1163-1171.

9. Rodriguez-Bigas MA. Surgical management of primary colon cancer. In: UpToDate, Tanabe KK, Savarese DMF, Duda RB (Eds), UpToDate, Waltham, MA, 2011.

10. Cusack JC Jr, Overman MJ, Woff RA. Treatment of small bowel neo-plasms. In: UpToDate, Goldberg RM, Savarese DMF (Eds), UpToDate, Waltham, MA, 2011.

DiscussionIntussusception occurs when a segment of bowel telescopes into the neighboring bowel. More commonly seen in children, intussusception in adults is rare, accounting for only 5% of all intussusceptions, and 0.003%-0.02% of all hospital admis-sions.1 In adults, intussusception is associated with a non-specific clinical picture, and patients typically present with a history of vague, intermittent abdominal pain suggestive of partial intestinal obstruction. Atypical presentations more suggestive of an underlying neoplastic process have also been reported and may include; weight loss, melena, constipation, or palpable abdominal mass. The differential causes of adult intussusception can be quite extensive, and a variety of benign and malignant processes including lipomas, adenomatous polyps, Meckel’s diverticulae, adhesions, motility disorders, adenocarcinoma, lymphoma, and metastatic disease must be considered.3 The advent of detailed CT imaging has facilitated the non-invasive diagnosis of intussusception, and the classic finding of a target-like bowel-within-bowel configuration is considered to be pathognomonic (Figs. 1, 2). By itself, adult in-tussusception is readily treated and confers a very good prog-nosis.4 It is therefore the etiology of the intussusception that prevails as the most important factor in a patient’s prognosis. While in rare instances, it is possible that a benign lesion may act as the lead point for intussusception, by and large the ma-jority of adult intussusceptions are due to malignant tumors. Approximately 70% of colonic lead point masses are associ-ated with malignancy.5 In practice, non-invasive techniques to diagnose and correct intussusception are almost never at-tempted in the symptomatic adult, due in part to a high recur-rence rate,6 but most importantly due to the high likelihood of malignancy.

Gastrointestinal lipomas are benign, slow-growing, fat-con-taining tumors that can occur anywhere along the gastroin-testinal tract. The vast majority of GI lipomas, however, are found in the large and small bowel submucosa where they are the second most common benign tumor, following adeno-matous polyps, and leiomyomas. In the large bowel, lipomas most commonly involve the cecum and right colon; in the small bowel, they occur most frequently in the ileum.7

While generally single and asymptomatic, GI lipomas may also present as multiple lesions and cause pain, bleeding, diar-rhea, constipation, and in rare cases, intussusception. Lipo-mas are most often found incidentally, during procedures for other indications, and can be identified on endoscopy by their grossly round, smooth-surfaced, orange-yellow appearance and compressibility, with or without surface ulceration and lobulation. With severe ulceration, lipomas may sometimes be mistaken for more aggressive lesions. Radiologic imaging can also be used as the first step in identifying lipomas due to their characteristic fat attenuation pattern on CT imaging. A well-demarcated, homogeneous mass with Hounsfield units between -80 and -120 is considered nearly pathognomonic for a lipoma.7,8 Excision of lipomas is seldom necessary in the ab-sence of symptoms.

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Citation Schmidt et al. Characterization of Pre-operative MRI for Triple Negative Breast Cancer. J Surg Radiol. 2013 Apr 1;4(2).

CorrespondenCe Hank Schmidt MD PhD FACS E-mail [email protected].

reCeived November 28, 2011. aCCepted April 1, 2013. epub April 1, 2013.

Characterization of Pre-operative MRI for Triple Negative Breast CancerHank Schmidt MD, PhD1, Angela Keleher MD1, Richard Friedland MD2,3

1. Department of Surgery, Dyson Center for Cancer Care at Vassar Brothers Medical Center, Poughkeepsie, NY.2. Department of Radiology, Vassar Brothers Medical Center, Poughkeepsie, NY.3. DRA Imaging, Poughkeepsie, NY.

AbstractintroduCtion The tumor phenotype negative for expression of estrogen, progesterone, and HER2 receptor (triple negative breast cancers; TNBC) has worse outcomes with higher rates of local and systemic recurrence than other forms of breast cancer. Significant controversy remains surrounding use of MRI for pre-operative evaluation of newly diagnosed breast cancer. Methods We retrospectively evaluated the impact of breast MRI on surgical manage-ment of TNBC patients compared to a control cohort. Search of our institutional tumor registry identified triple negative breast cancers and an unmatched non-triple negative control group with preoperative MRI. Multimodality imaging was independently reviewed and new measurements obtained. results Closer correlation with tumor size in the surgical specimen was noted with MRI than mammogram or ultrasound by Pearson’s correlation (r = .907, .643, .590 respectively). Ultrasound underestimated size of disease in both groups. MRI overestimated size of disease more frequently in the control group. Pre-operative MRI changed surgical management in 21% and 26% of control versus TNBC cases respectively. disCussion Pre-operative MRI is a valuable tool in determining extent of disease for newly diagnosed breast cancer. Although its impact on surgery did not vary by tumor receptor phenotype, MRI offers a more precise means of estimating tumor size than other modalities.

Keywords invasive breast cancer, breast magnetic resonance imaging, mammogram, ultrasound

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Schmidt et al. MRI for Triple-Negative Breast Cancer original artiCle

IntroductionExpansion of our understanding of breast cancer as a het-erogeneous disease with multiple subtypes has spurred the development of novel targeted therapies. In order to facilitate further development of targeted personalized cancer treatment, careful study of these subtypes contin-ues. Triple negative breast cancer is distinguished by lack of expression of receptors for estrogen (ER), progesterone (PR), and HER2. The majority of triple negative breast cancers demonstrate gene expression profiles consistent with the basal-epithelial phenotype of normal breast bas-al/myoepithelial cells.1 This diagnosis occurs in 12-17% of breast cancers and portends increased risk of local recur-rence and worse disease-specific survival rates, particu-larly in the metastatic setting .2 Triple negative tumors appear to represent a more biologically aggressive pheno-type, with rapid growth, and greater propensity for dis-tant metastases within the first five years after diagnosis.3,4 Breast MRI currently represents the most sensitive modal-ity for breast tumor imaging, and has demonstrated utility in pre-operative evaluation of newly diagnosed disease.5-7 In an effort to determine the value of breast MRI unique to triple negative cancers, we retrospectively evaluated a cohort of patients diagnosed with triple negative breast tumors who underwent preoperative imaging with mam-mogram, ultrasound, and MRI, and compared them to a control group of non-triple negative breast cancer patients.

Materials and MethodsSearch of an institutional tumor registry from 2006 to 2009 was performed to identify triple negative breast can-cers. Inclusion criteria were triple negative phenotype, available surgical pathology results, and comprehensive pre-operative breast imaging including MRI available for review. The tumor registry contained 107 triple negative breast cancers and 32 of these patients had pre-operative MRI available for review. An unmatched recently and consecutively diagnosed control group (also 32 patients) was identified, all of whom had non-triple negative tumors with pre-operative MRI. All breast imaging was independently re-viewed by a single radiologist with expertise in breast MRI (>300 studies per year) and correlated with pathologic data. The radiologist was blinded to surgical pathology data at the time of MRI study interpretation. Measurements of tumor size for each imaging modality were performed and compared with surgical pathology specimen dimensions. A database was constructed to allow correlation of all variables from surgical pathology specimens with quantitative and qualita-tive assessments of imaging studies for each patient, includ-ing mammogram, ultrasound, and MRI. Presence or absence of concordance was recorded between imaging modalities for each patient. For all patients the impact of MRI on surgical planning was recorded after comparison to clinical presenta-tion, mammogram, and ultrasound. Comparisons between groups were performed using Chi squared analysis or inde-

pendent sample t-test when appropriate. Pearson’s correla-tion was used to relate size determinations for each imaging modality using pathology dimension as reference. Patients treated with neoadjuvant chemotherapy were excluded from analysis of size correlation.

Bilateral diagnostic mammograms were performed with digital technique using General Electric (GE Healthcare,

Table 1. MRI features and pathologic dataTNBC CONTROLMRI FEATURES

Mass on MRI 23 (85) 25 (93)NMLE 4 (15) 2 (7)Rim enhancement 5 (19) 2 (7)Skin enhancement 1 (4) 3(11)Surround enhance-ment

0 (0) 4 (15) *

Unifocal 23 (85) 18 (67)

Multifocal 2 (7) 7 (26)

Multicentric 2 (7) 3 (11)

Suspicious LN 11 (41) 4 (15) *

Suspicious and Pos LN 6 (22) 3 (11)

Contralateral 3 (11) 2 (7)

MRI Correlates with mmg

22 (81) 19 (70)

MRI Correlates with US

22 (81) 21 (78)

PATHOLOGYGrade 1 0 (0) 5 (19)Grade 2 6 (22) 14 (52)Grade 3 21 (78) 8 (30)Lymphovascular inva-sion

13 (48) 12 (44)EIC 6 (22) 14 (52) *Close/Positive Margin 5 (19) 6 (22)T1 13 (48) 17 (63)T2 9 (33) 9 (33)T3 1 (4) 1 (4)N0 13 (48) 12 (44) N1 6 (22) 14 (52)

Abbreviations: Percentage in parentheses, non-mass-like enhancement (NMLE), lymph node (LN), mammogram (mmg), ultrasound (US), extensive intraductal component (EIC), * p< .05, ** p< .01

Table 2. Correlation of Size by Imaging Modality versus Pathology Specimen

Control

r

TNBC

rMRI .784 .907 NSUltrasound .690 .590 NSMammogram .666 .643 NS

r = Pearson’s correlation, NS = not significant difference be-tween phenotypes


original artiCle Schmidt et al. MRI for Triple-Negative Breast Cancer

Waukesha, WI) or Hologic (Hologic Inc, Bedford, MA) mam-mography equipment and image workstations. Diagnostic ul-trasound was performed with the Philips iu22 (Philips Medi-cal, Bothell, WA).

Sagittal MR imaging of both breasts was performed with T2-weighting, T2-fast spin echo weighting, T1-weighted images with and without fat suppression. Dynamic enhanced MR

Table 3. MRI Changed Surgical ApproachControl TNBC

Multicentric Disease 2 1Contralateral Disease 2 2Size Differential 2 3Lymph Node Metastases 0 2

6 (21%) 8 (26%)

Figure 1. Size Discrepancy Between Imaging Modalities. When dimension from surgical pathology specimen is used as gold standard, ultrasound consistently underestimates tu-mor size. MRI more frequently overestimate size in TNBC.

Figure 2. 80 yo with palpable 3 cm R breast TNBC found to have small l breast ER+ invasive ductal carcinoma by MRI. A. Maximum Intensity Projection MRI B. R breast MRI C. l breast MRI D. l breast Ultrasound E. R breast Mammogram *Negative l mammogram not shown.

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contrast administration. These studies were interpreted with the assistance of the Dynacad computer-assisted interpretation program including complete time-intensity curve computation for the entire breast. Dy-namic contrast enhancement time-intensity curves were recorded for each MRI exam with the aid of Dynacad based on a selected single voxel of 3 pixels demonstrating maxi-mal peak enhancement within the tumor.

ResultsSearch of an institutional tumor registry from 2006 to 2009 identified 107 triple nega-tive breast cancers out of a total 917 breast cancer initial diagnoses. Thirty-two patients with triple negative tumors had pre-operative MRI available for review. Breast MRI be-came available at our institution in 2006 and all newly diagnosed breast cancer patients without a contraindication were referred for breast MRI beginning in 2008. One patient was excluded for metastatic disease found during work-up. One control patient was excluded who had surgery elsewhere and un-available surgical pathology data. Another

control patient was excluded for a non-diagnostic MRI exam. Neoadjuvant chemotherapy was administered in 11 cases, 8 triple negative and 3 control, and were therefore excluded from size correlation analysis only. For all other analyses 31 triple negative patients and 29 control patients were compared.

Several imaging characteristics on MRI were compared be-tween the two groups. The majority of subjects in both groups demonstrated evidence of a mass on breast MRI with only 6 patients having non-mass-like enhancement (Table 1). Since most tumors were smaller early stage lesions, their true morphology on MRI is difficult to characterize as most stud-

imaging was performed with 3D multiplanar spoiled GRASS (Gradient Recalled Acquisition in Steady State) imaging and subtracted images generated on a work station. Images were acquired utilizing the GE Horizon LX 1.5 Tesla Magnet. Im-ages were obtained before and after intravenous Multihance

Table 4. MRI Changed Surgical ApproachImaging Surgery

TNBC Multicentric disease evident on MRI SSM

TNBCExtensive multifocal disease evident on MRI un-derestimated by US, nonvisualized on mammo

TM

TNBCContralateral suspicious lesion on MRI induced lumpectomy after CNB with papillary lesion

PM bilateral

TNBCAdjacent lesion noted on MRI induced wider partial mastectomy

PM

TNBCLarger focal disease seen on MRI induced wider partial mastectomy

PM

TNBCContralateral lobular carcinoma diagnosed as a result of MRI finding

PM bilateral

TNBCSuspicious lymph nodes on MRI prompted axil-lary LN biopsy and neoadjuvant chemotherapy

SSM bilateral

TNBCSuspicious lymph nodes on MRI prompted axil-lary LN biopsy and neoadjuvant chemotherapy

PM

ControlContralateral DCIS diagnosed as a result of MRI finding

PM bilateral

Control Multicentric disease evident on MRI MRMControl Extensive focal disease evident on MRI SSM

ControlMRI indicated true size of disease that was sig-nificantly underestimated by mmg/US

SSM

Control Multicentric disease evident on MRI TM

ControlMRI allowed diagnosis of contralateral carci-noma

PM bilateral

Skin sparing (SSM), Total mastectomy ™, Partial mastectomy (PM), Modified Radical Mastectomy (MRM), triple negative breast cancer (TNBC), mammogram (mmg), ultrasound (US), core needle biopsy (CNB)


original artiCle Schmidt et al. MRI for Triple-Negative Breast Cancer

No difference was observed in rate of close or positive surgical margins between the two groups (19% vs 22% for TNBC and Control group respectively).

Concordance analysis between findings on imaging modali-ties was performed for each patient. MRI was felt to corre-late with mammogram in 81% of TNBC and 70% of controls (NS = not significant). MRI was felt to correlate with ultra-sound findings in 81% of TNBC and 78% of controls. MRI visualized disease in all patients. Mammogram was slightly less sensitive in the TNBC group than controls (78% vs 89%, p=NS). Excluding patients treated with neoadjuvant chemo-therapy, tumor size in the surgical specimen was used as a ref-erence to determine accuracy of each imaging modality for the two patient populations (Table 2). MRI demonstrated the greatest degree of size correlation with pathology in both the TNBC and control group (r =.784 and r =.907 respectively) which were not significantly different. When individual tu-mor size discrepancies (threshold greater than or equal to 1 cm) between pathology and imaging were compared, ultra-sound consistently underestimated maximum dimension of disease in both TNBC and control cases (Figure 1). MRI, how-ever, more often overestimated dimension of disease, and this was observed more frequently in the control group (NS).

MRI findings altered surgical planning in 26% of TNBC cases and 21% of control cases (NS)(Table 3,4). MRI findings that impacted surgical decision making were categorized into four groups. These categories included MRI observation of more

ies were performed post biopsy. Post biopsy changes likely contributed to some lesion profile heterogeneity in shape and enhancement patterns. Mean tumor volume was similar for triple negative and non-triple negative disease (15-18 cm3), and greatest single dimension averaged 2.5 to 2.9 cm on MRI, 1.7 to 1.9 cm on ultrasound, and 2.2 to 2.4 cm on mammogram. Rim-enhancing tumors were infrequently seen although with slightly greater frequency in the triple-negative group. All tu-mors in the study demonstrated Type III kinetics for dynamic contrast enhancement curves. Triple negative tumors had slightly higher yet more variable peak enhancement values than controls (Mean peak 225 and 188 respectively). TNBC cases also displayed more rapid washout than control cases. The majority of studies revealed unifocal disease in both groups. There was a non-significant trend toward more mul-tifocal disease in the control group (26% vs 7%). Evaluation of axillary lymph nodes on MRI indicated significantly more nodes felt to be “suspicious” in the TNBC group (41% vs 15%, p<.05). In this subset, however, the true rate of positive axil-lary lymph nodes was not different. MRI sensitivity and spec-ificity for axillary metastases in the TNBC group were 60% and 75 % respectively. Sensitivity and specificity for controls were 25% and 94% respectively.

Pathologic data indicates that both groups were similar in distribution of tumor stage. Triple negative tumors tended to be higher grade than controls, and significantly less likely to have extensive intraductal component (> 10% DCIS). The rate of lymphovascular invasion was similar in both groups.

Figure 3. MRI alters surgical approach in these two examples. A) MRI reveals contralateral breast cancer. B) Mammo-gram and US significantly underestimate disease revealed by MRI.

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ing the control group. Other investigators have also observed a propensity for triple negative tumors to be unifocal.8,15 Sev-eral studies have documented rates of “inappropriate” conver-sion to mastectomy based on MRI findings that overestimate extent of disease.16-18 Careful pursuit of these findings during pre-operative workup with second look ultrasound and core needle biopsy with ultrasound or MRI guidance is imperative. MRI findings also impact surgery by elucidating findings in the contralateral breast. Other studies find that breast MRI leads to diagnosis of contralateral carcinoma in approximately 3-5% of cases.19 This rate was also seen in our study for both groups of patients evaluated (one contralateral carcinoma di-agnosed exclusively by MRI findings in each group). It should also be noted that MRI occasionally necessitates contralateral surgery for findings not suitable for diagnosis by percutane-ous tissue sampling. This is likely directly related to the lim-ited specificity of MRI in evaluation of the breast. One patient with TNBC required a contralateral partial mastectomy for further evaluation of a papillary lesion found on MRI guided core needle biopsy.

Breast MRI that indicates more extensive focal disease and leads to a larger partial mastectomy than may have been indi-cated by mammogram or ultrasound alone represents a sce-nario that is much more difficult to investigate retrospectively. Prospective data incorporating careful analysis of surgical specimens is required to determine the validity of a larger tis-sue resection. In this data set, “size differential” that changed surgical approach occurred with similar frequency for both tumor types. Judgment regarding need for a larger partial mastectomy based on preoperative MRI is directly dependent on the ability of MRI to accurately represent size of disease. Ability of MRI to accurately represent tumor size based on pathologic correlation was better than mammogram or ultra-sound in this study; however, no significant differences were observed in size correlation between pathology and imaging for TNBC versus control patients. Using a relatively large threshold of 2cm difference for a series of 72 invasive ductal carcinomas, Berg and colleagues found overestimation of dis-ease in size or foci in 14% of cases where breast conservation was planned.17 In another series of 62 tumors however, MRI was just as likely to overestimate as to underestimate tumor size (10-18%).20 A larger study including 190 patients found concordance between MRI and pathologic size in 53% of cas-es, with MRI slightly more likely to overestimate than under-estimate disease (33% vs 15%).21 In this study we also found that breast ultrasound more often under estimated size than mammography or MRI. Other retrospective analyses have re-ported similar limitations.22-24 More accurate tumor size rep-resentation on MRI would be expected to benefit patients in terms of better preoperative staging, reduced rates of close/positive margins, and subsequent need for re-excision. In spite of better tumor size determination by MRI, a large multicenter randomized trial comparing patients scheduled for breast conserving surgery with or without preoperative MRI found no difference in re-operation rate.18 Our study did not find a difference in margin status between triple negative patients and controls treated with breast conserving surgery. As de-

extensive focal disease than discerned by physical exam/mam-mogram/ultrasound (size differential), observation of contra-lateral disease, observation of multicentric disease, or observa-tion of suspicious axillary lymph nodes leading to core needle biopsy and diagnosis of axillary metastasis. These different types of conversions occurred with similar frequency within and between groups. It should be noted that during the years from which cases were collected, axillary ultrasound was used sparingly and typically only in the case of palpable ad-enopathy at this institution. For this reason, suspicious lymph nodes observed on MRI stimulated axillary ultrasound with possible lymph node sampling leading to preoperative diag-nosis of axillary lymph node metastases. These cases were classified as MRI changing surgical management (via induc-tion of axillary node dissection or via choosing neoadjuvant chemotherapy over primary surgery).

DiscussionThis study represents a comprehensive examination of breast MRI in the setting of two specific breast cancer subtypes. Triple negative tumors represent a segment of breast cancer with current limited therapeutic options and a more concern-ing pattern of disease progression. The goal in this investiga-tion was to explore an array of imaging features with breast MRI for two distinct receptor phenotypes and to determine how these imaging exams impacted surgical decision making. In this small single institution series, triple negative tumors accounted for 12% of newly diagnosed breast cancers; this proportion is consistent with distribution of receptor pheno-types observed in much larger patient populations .8 There was no significant difference in change of surgical plan by MRI findings based on triple negative or non-triple negative receptor status. In both cohorts, MRI impacted surgery for one in every four to five cases. This result is comparable to other studies demonstrating utility of breast MRI in the pre-operative setting.5,7,9,10 With routine use of axillary ultrasound to evaluate possibility of lymph node metastases, total impact of pre-operative MRI is now likely somewhat smaller. This study also corroborated the poor sensitivity and specificity of MRI for prediction of axillary lymph node involvement ob-served in other reports.11-12 Loss of the fatty hilum in lymph nodes on MRI has been documented as a much better indica-tor than nodal size or morphology.13 TNBC cases more of-ten demonstrated lymph nodes on MRI felt to be suspicious; however, actual rate of lymph node involvement was not dif-ferent between the two groups. Larger studies of basal-like tu-mors indicate significantly lower rates of regional lymph node involvement than in luminal A or luminal B type lesions.14

It is clear that MRI may alter the surgical plan from a breast conserving approach to mastectomy by identification of mul-ticentric disease not evident on mammogram or ultrasound. Likewise, patients with extensive multifocal disease on MRI in relation to total breast volume may be converted to mastecto-my by this finding. In this study a non-significant trend in in-cidence of multifocal or multicentric disease was noted favor-


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scribed previously, triple negative disease seems more often to be unifocal with a lower rate of associated extensive intraduct-al component. This observation may offer an advantage in both interpretation of MRI (i.e. what enhancement represents true disease) as well as surgical excision with clear margins in the setting of breast conservation. One might hypothesize that in triple negative tumors that are less likely to have an extensive intraductal component and more likely to be unifo-cal, MRI may offer a more accurate size determination; this improved accuracy (over non-TNBC) on MRI may translate into decreased re-operation rates for triple negative disease. Although not observed in this limited study, MRI may in fact have a greater impact for this tumor subtype in a much larger cohort analysis.

This study of MRI in triple negative breast cancer has sev-eral obvious limitations. As discussed above, a larger study population may be influential in better defining relationships between MRI findings and extent of disease on histopathol-ogy. Likewise, differentiation of tumor characteristics on im-aging in general according to receptor phenotype requires a larger experience. Our study is also limited by data collec-tion from MRI performed after core needle biopsy. Other investigators have been able to study MRI imaging of solid tumors before any percutaneous intervention, perhaps pro-viding a more accurate picture of contrast enhancement on MRI. In this study population few patients had breast MRI prior to biopsy and cancer diagnosis; consequently, study in-terpretation is always somewhat clouded by potential post-biopsy changes, and directly impacts ability to judge extent of disease on MRI. Another limitation is retrospective assess-ment of whether or not MRI changed surgical approach. The ideal categorical measurement would be made prospectively as surgeons record their surgical plan before and after review of breast MRI. Finally, our method of correlation of true size of disease on MRI versus surgical specimen allows for some error. One of the strengths of breast MRI is ability to collect high resolution contrast images for analysis in three dimen-sions; however, measurement of disease in the surgical speci-men was recorded as the greatest span in two dimensions. A prospective study would provide the opportunity for a more analytical approach to determination of volume of the tumor specimen in three dimensions, and allow better size correla-tion. In spite of these limitations, this comparative study does demonstrate that for triple negative tumors, preoperative MRI has similar rates of detection of additional disease and change in surgical management when compared with studies of all tumor phenotypes.


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24. Allen SA, Cunliffe WJ, Gray J, et al. Pre-operative estimation of pri-mary breast cancer size: a comparison of clinical assessment, mam-mography and ultrasound. Breast 2001;10(4):299-305.