Volume 27



Number 2



February



2016

REFERENCES 1. Osler W. The Gulstonian lectures on malignant endocarditis. Br Med J 1885; 1:467–470. 2. Kawasaki R, Miyamoto N, Oki H, et al. Flow-preserved coil embolization using a side-holed indwelling catheter for common hepatic artery pseudoaneurysm: report of three cases. Surg Today 2015; 45:772–776. 3. Lim SJ, Park KB, Hyun DH, et al. Stent graft placement for postsurgical hemorrhage from the hepatic artery: clinical outcome and CT findings. J Vasc Interv Radiol 2014; 25:1539–1548. 4. Abdelaziz O, Sallam K, Mostafa M, Elansary A, Amin A. Hybrid microsurgical reconstruction and percutaneous endovascular stent placement for management of dissected graft hepatic artery during living donor liver transplantation. J Vasc Interv Radiol 2015; 26:916–918.

Neuroendocrine Malignancy Diagnosed via CT-Guided Percutaneous Biopsy of an Isolated Abnormal Cardiophrenic Lymph Node: Case Report From: Emilio Lopez, MD Ronald Arellano, MD, FSIR Division of Interventional Radiology Massachusetts General Hospital 55 Fruit St. Boston, MA 02114

Editor: We report a rare presentation of metastatic disease of an unknown primary tumor that was isolated to a cardiophrenic lymph node in which detection may have been delayed without percutaneous tissue sampling. This case demonstrates successful computed tomography (CT)– guided percutaneous biopsy of an abnormal cardiophrenic lymph node to establish the diagnosis of metastatic high-grade neuroendocrine tumor. The institutional review board approved this Health Insurance Portability and Accountability Act–compliant case report with a waiver of informed consent. A 53year-old man with no significant history presented with new-onset debilitating opsoclonus and truncal ataxia. Initial neurologic evaluation raised concerns for cerebellitis, but a magnetic resonance imaging scan of the brain was negative. The differential diagnosis also included paraneoplastic syndrome, so positron emission tomography (PET)/CT was performed, which revealed a 1.4  1.2-cm [18F]fluorodeoxyglucose (FDG)-avid right cardiophrenic lymph node (Fig 1). Subsequent paraneoplastic panel, chest/abdomen/pelvis CT, and upper endoscopy were noncontributory. Because the FDG-avid lymph node was the only positive finding on the PET/CT scan, the interventional radiology unit was consulted for percutaneous biopsy. With CT guidance, a 17-gauge coaxial needle was advanced via a parasternal approach to the lymph node, and fine needle aspirates were obtained with a 22-gauge needle (Fig 2). Acute None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.09.015

289

angulation of the introducer needle during positioning precluded passage of the core biopsy needle; therefore, no core tissue samples were obtained. Postbiopsy images demonstrated expected postbiopsy changes without pneumothorax or mediastinal hematoma. Cytopathology results were diagnostic for metastatic high-grade neuroendocrine carcinoma (Fig 3). The patient was initially treated with steroids and intravenous immunoglobulin regimens without improvement in symptomatology. Based on the pathology results, the patient was subsequently treated with simultaneous cisplatin/etoposide and external-beam radiation to the lymph node. At 1 month after initial presentation, the patient had completed his first cycle of chemotherapy and four fractions of radiation therapy, with resolution of opsoclonus and improved ataxia. Cardiophrenic lymph nodes are commonly grouped into anterior and mid-lateral lymph node stations based on their relation to mediastinal structures. Cardiophrenic lymph nodes have a complex drainage network with possible metastatic involvement from thoracic and abdominopelvic neoplasms (1). Cross-sectional imaging, specifically CT, MR imaging, and PET/CT, are the primary modalities to evaluate thoracic lymph nodes. Imaging criteria used to distinguish pathologic lymph nodes are based primarily on size, commonly reported as 4 10 mm along the short axis; however, studies have reported cutoffs as low as 5 mm (2). Image-guided percutaneous needle biopsy of mediastinal masses is most commonly performed in large tumors that occupy the mediastinal spaces, with reported diagnostic yields of 75%–95% (3,4). The preferred imaging modality in most cases is CT, but successful image guidance with ultrasound and fluoroscopy has also been described. Regardless of the imaging modality

Figure 1. Axial PET image of a 58-year-old man with opsoclonus/ataxia syndrome demonstrates focal increased FDG uptake corresponding to the prominent anterior right cardiophrenic lymph node (red arrow).

290



Letters to the Editor

van den Ham et al



JVIR

Figure 2. (a) Axial unenhanced CT image in a 58-year-old man with opsoclonus/ataxia syndrome demonstrates a previously noted prominent anterior right cardiophrenic lymph node (red arrow). (b) Unenhanced CT scan at the time of biopsy demonstrates the parasternal approach with positioning of a 17-gauge coaxial needle adjacent to the target, with a 22-gauge Chiba needle through the coaxial needle terminating within the target right cardiophrenic lymph node (red arrow).

distant metastasis. The present case highlights the value of image-guided biopsy in establishing the diagnosis of this unique case of metastatic high-grade neuroendocrine tumor isolated to a solitary cardiophrenic lymph node and demonstrates the feasibility of performing imageguided needle biopsy in the cardiophrenic space when tissue analysis is warranted.

REFERENCES

Figure 3. Right cardiophrenic lymph node fine needle aspiration specimen shows clusters of malignant cells (red arrow) with small to medium-sized nuclei, with nuclear molding, a moderate amount of cytoplasm, and distinct nucleoli. Mitotic figures are readily visualized (4 12/10 hpf). On immunohistochemistry analysis, the cells stain positively for synaptophysin (not shown). The morphology and immunoprofile are consistent with a high-grade neuroendocrine carcinoma

used, an extrapleural route is generally favored over a transpleural or transpulmonary approach to avoid complications, most commonly pneumothoraces. Reported complications with mediastinal lymph node biopsies are usually self-limiting, with intervention required in 1%–2% of cases (3,4). In high-risk cases in which a transparenchymal approach is unavoidable, hydrodissection or artificial pneumothorax may be warranted (3). Published studies regarding percutaneous mediastinal biopsies overwhelmingly address mediastinal masses or lymph node biopsies almost exclusively performed in the setting of a known malignancy to confirm recurrence or

1. Ragusa M, et al. Isolated cardiophrenic angle node metastasis from ovarian primary. Report of two cases. J Cardiothorac Surg 2011; 6:1. 2. Feragalli B, et al. Extrapleural and cardiophrenic lymph nodes: prevalence, clinical significance and diagnostic value. Radiol Med 2014; 119:20–26. 3. Bressler EL, Kirkham JA. Mediastinal masses: alternative approaches to CT-guided needle biopsy. Radiology 1994; 191:391–396. 4. Gupta S, et al. Imaging-guided percutaneous biopsy of mediastinal lesions: different approaches and anatomic considerations. Radiographics 2005; 25:763–786; discussion 786–8.

Treatment of an Infrarenal Aneurysm with an Eccentric Calcified Lesion in the Infrarenal Neck Using the Nellix Endoprosthesis From: Leo H. van den Ham, MD Luuk Smeets, MD, PhD Michel M.P.J. Reijnen, MD, PhD Department of Surgery Rijnstate Hospital Wagnerlaan 55 6815 AD Arnhem, The Netherlands

M.M.P.J.R. is a consultant for Endologix (Irvine, California). Neither of the other authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.10.010

Neuroendocrine Malignancy Diagnosed via CT-Guided Percutaneous Biopsy of an Isolated Abnormal Cardiophrenic Lymph Node: Case Report.

Neuroendocrine Malignancy Diagnosed via CT-Guided Percutaneous Biopsy of an Isolated Abnormal Cardiophrenic Lymph Node: Case Report. - PDF Download Free
2MB Sizes 0 Downloads 5 Views