Predictive factors of diagnostic accuracy of CT-guided transthoracic fine-needle aspiration for solid noncalcified, subsolid and mixed pulmonary nodules

Purpose

The aim of this study was to analyse factors predicting the diagnostic accuracy of computed tomography (CT)-guided transthoracic fine-needle aspiration (TTFNA) for solid noncalcified, subsolid and mixed pulmonary nodules, with particular attention to those responsible for false negative results with a view to suggesting a method for their correction.

Materials and methods

From January 2007 to March 2010, we retrospectively reviewed the CT images of 198 patients of both sexes (124 males and 74 females; mean age, 70 years; range age, 44–90) used for the guidance of TTFNA of pulmonary nodules. Aspects considered were: lesion size and density, distance from the pleura, and lesion site. Multiplanar reformatted images (MPR) were retrospectively obtained in the sagittal and axial oblique planes relative to needle orientation.

Results

The overall diagnostic accuracy of TTFNA CTguided biopsy was 86% for nodules between 0.7 and 3 cm, 83.3% for those between 0.7 and 1.5 cm, and 92% for those between 2 and 3 cm. Accuracy was 95.1% for solid pulmonary nodules, 84.6% for mixed nodules, and 66.6% for subsolid nodules. The diagnostic accuracy of CT-guided TTFNA in relation to the distance between the nodule and the pleural plane was 95.6% for lesions adhering to the pleura and 83.5% for central ones. The diagnostic accuracy was 84.2% for the pulmonary upper lobe nodules, 85.3% for the lower lobe and 90.9% for those in the lingula and middle lobe. In 75% of false negative and inadequate/insufficient cases the needle was found to lie outside the lesion, after reconstruction of the needle path by MPR.

Conclusions

The positive predictive factors of CT-guided TTFNA are related to the nodule size, density and distance from the pleural plane. The most common negative predictive factor of CT-guided TTFNA is the wrong position of the needle tip, as observed in the sagittal and axial oblique sections of the MPR reconstructions. The diagnostic accuracy of CT-guided TTFNA can therefore be improved by using the MPR technique to plan the needle path during the FNA procedure.     

Divergent Effects of Glucocorticoids on Cortical and Trabecular Compartment BMD in Childhood Nephrotic Syndrome

Glucocorticoid (GC) effects on skeletal development have not been established. The objective of this pQCT study was to assess volumetric BMD (vBMD) and cortical dimensions in childhood steroid‐sensitive nephrotic syndrome (SSNS), a disorder with minimal independent deleterious skeletal effects. Tibia pQCT was used to assess trabecular and cortical vBMD, cortical dimensions, and muscle area in 55 SSNS (age, 5–19 yr) and >650 control participants. Race‐, sex‐, and age‐, or tibia length‐specific Z‐scores were generated for pQCT outcomes. Bone biomarkers included bone‐specific alkaline phosphatase and urinary deoxypyridinoline. SSNS participants had lower height Z‐scores (p < 0.0001) compared with controls. In SSNS, Z‐scores for cortical area were greater (+0.37; 95% CI = 0.09, 0.66; p = 0.01), for cortical vBMD were greater (+1.17; 95% CI = 0.89, 1.45; p < 0.0001), and for trabecular vBMD were lower (?0.60; 95% CI, = ?0.89, ?0.31; p < 0.0001) compared with controls. Muscle area (+0.34; 95% CI = 0.08, 0.61; p = 0.01) and fat area (+0.56; 95% CI = 0.27, 0.84; p < 0.001) Z‐scores were greater in SSNS, and adjustment for muscle area eliminated the greater cortical area in SSNS. Bone formation and resorption biomarkers were significantly and inversely associated with cortical vBMD in SSNS and controls and were significantly lower in the 34 SSNS participants taking GCs at the time of the study compared with controls. In conclusion, GCs in SSNS were associated with significantly greater cortical vBMD and cortical area and lower trabecular vBMD, with evidence of low bone turnover. Lower bone biomarkers were associated with greater cortical vBMD. Studies are needed to determine the fracture implications of these varied effects.     

Massive Immune Hemolysis Caused by Anti-D After Dual Kidney Transplantation

Massive immune hemolysis due to passenger lymphocyte-derived anti-D has not been reported in renal transplantation. A 50-year-old (B-positive) male received a dual deceased-donor kidney transplant (B-negative) for diabetic renal failure. Two weeks post-transplant, the patient developed severe hemolytic anemia. The donor anti-D titer was 1:8. The recipient anti-D titer (zero pre-transplant) increased from 1:4 to 1:16 over 4 days. Rapid hemolysis caused severe anemia, minimum Hb = 4.2 g/dL, while selectively lysing the patient's autologous red cells during this time. The hemolytic anemia did not impair the allografts and subsided without monoclonal B-cell pharmacotherapy or apheresis. The anti-D titer decreased to barely detectable levels at four months and had cleared when checked 2 years post-transplant. Transfusion support subsided after two months. If complications of anemia can be avoided, the deleterious effects of hemolysis may be well tolerated by renal allografts using antigen negative transfusion alone.     

Salivary Gland Tumor: A Review of 599 Cases in a Brazilian Population

Salivary gland tumors consist of a group of heterogeneous lesions with complex clinicopathological characteristics and distinct biological behaviors. Worldwide series show a contrast in the relative incidence of salivary gland tumors, with some discrepancies in clinicopathological data. The main aim of this study was to describe demographic characteristics of 599 cases in a population from Central Brazil over a 10-year period and compare these with other epidemiological studies. Benign tumors represented 78.3% of the cases. Women were the most affected (61%) and the male:female ratio was 1:1.6. Parotid gland tumors were the most frequent (68.5% of cases) and patient age ranged from 1 to 88 years-old (median of 45 years old). The most frequent tumors were pleomorphic adenomas (68.4%) and benign tumors were significantly more frequent in the parotid (75.9%), while malignant tumors were more frequent in the minor salivary glands (40%) (P < 0.05). In conclusion, women and the parotid gland were the most affected and pleomorphic adenoma was the most frequent lesion, followed by adenoid cystic carcinoma and Warthin’s tumor.     

Strontium ranelate: New data on fracture prevention and mechanisms of action

Osteoporosis treatments need to combine an unequivocally demonstrated reduction of fractures, at various skeletal sites, long-term safety, and a user-friendly profile that optimizes therapeutic adherence. Strontium ranelate is the first compound to simultaneously decrease bone resorption and stimulate bone formation. Its anti-fracture efficacy at various skeletal sites has been established for as long as 5 years through studies of the highest methodological standards. Increases in bone mineral density observed after 1 year of treatment are predictive of the long-term fracture efficacy, suggesting for the first time in osteoporosis that bone densitometry can be used as a monitoring tool. Due to a positive risk/benefit ratio, strontium ranelate is now considered as a first-line treatment in the management of osteoporosis.     

Liver is the site of splanchnic cortisol production in obese nondiabetic humans

OBJECTIVE—To determine the contribution of liver and viscera to splanchnic cortisol production in humans.RESEARCH DESIGN AND METHODS—D4 cortisol was infused intravenously; arterial, portal venous, and hepatic venous blood was sampled; and liver and visceral fat were biopsied in subjects undergoing bariatric surgery.RESULTS—Ratios of arterial and portal vein D4 cortisol/cortisol_total (0.06 ± 0.01 vs. 0.06 ± 0.01) and D4 cortisol/D3 cortisol (1.80 ± 0.14 vs. 1.84 ± 0.14) did not differ, indicating that no visceral cortisol production or conversion of D4 cortisol to D3 cortisol via 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD-1) occurred. Conversely, ratios of both D4 cortisol to cortisol_total (0.05 ± 0.01; P < 0.05) and D4 cortisol to D3 cortisol (1.33 ± 0.11; P < 0.001) were lower in the hepatic vein than in the portal vein, indicating production of both cortisol and D3 cortisol by the liver. The viscera did not produce either cortisol (−8.1 ± 2.6 μg/min) or D3 cortisol (−0.2 ± 0.1 μg/min). In contrast, the liver produced both cortisol (22.7 ± 3.90 μg/min) and D3 cortisol (1.9 ± 0.4 μg/min) and accounted for all splanchnic cortisol and D3 cortisol production. Additionally, 11β-HSD-1 mRNA was approximately ninefold higher (P < 0.01) in liver than in visceral fat. Although 11β-HSD-2 gene expression was very low in visceral fat, the viscera released cortisone (P < 0.001) and D3 cortisone (P < 0.01) into the portal vein.CONCLUSIONS—The liver accounts for all splanchnic cortisol production in obese nondiabetic humans. In contrast, the viscera releases cortisone into the portal vein, thereby providing substrate for intrahepatic cortisol production.Although it has been long known that glucocorticoids are potent regulators of glucose, fat, and protein metabolism, glucocorticoids have not been thought to cause insulin resistance in either obese or diabetic individuals because plasma concentrations do not differ from those present in lean nondiabetic subjects. However, extra-adrenal conversion of cortisone to cortisol via 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD-1) can result in high local concentrations of cortisol. This observation focused attention on the possibility that tissue-specific synthesis of glucocorticoids may contribute to the pathogenesis of insulin resistance and other components of the so called “metabolic syndrome” (1). The enzyme 11β-HSD-2 (which converts cortisol to cortisone) is present primarily in the kidney, whereas 11β-HSD-1 (which converts cortisone to cortisol) is present in both liver and adipose tissue with in vitro activity being greater in omental than subcutaneous fat deposits (2–5). Inhibition (6) or knockout (7–9) of 11β-HSD-1 in mice improves hepatic insulin action and protects against obesity and hyperglycemia. Conversely, selective overexpression of 11β-HSD-1 in adipose tissue in mice results in development of visceral obesity, hyperglycemia, hyperlipidemia, and hypertension (7–11).Using a novel tracer infusion method, Andrew et al. (12) demonstrated that infusion of [9,11,12,12-²H₄] cortisol (D4 cortisol) in fasting, nondiabetic humans resulted in the formation of measurable amounts of plasma [9,12,12-²H₃] cortisol (D3 cortisol). Because conversion of D4 cortisol to D3 cortisone by 11β-HSD-2 results in the loss of the 11 α-deuterium and the generation of D3 cortisone that in turn forms D3 cortisol when D3 cortisone is converted back to cortisol, this observation provides strong experimental evidence that the conversion of cortisone to cortisol occurs in humans (12). More recently, we used the same method in combination with the hepatic venous and leg catheterization techniques to determine the site(s) of conversion of cortisone to cortisol. Those studies (13) led to the discovery that rates of splanchnic cortisol production in healthy nondiabetic individuals equaled or even exceeded those produced by extrasplanchnic tissues (e.g., the adrenals). However, because concomitant uptake of cortisol also occurred within the splanchnic bed, only a small net amount of cortisol was released into the systemic circulation.Because portal venous blood was not sampled in those studies, we could not determine the individual contributions of the viscera and the liver to splanchnic cortisol production. We therefore addressed this question in a chronically catheterized conscious dog model that permitted simultaneous selective sampling of blood from an artery, the portal vein, and the hepatic vein during intravenous infusion of D4 cortisol (14). Surprisingly, we showed that the liver accounted for all of the splanchnic cortisol production in the dog without discernable release by the viscera. However, the dogs were lean, and it is unknown if the pattern of splanchnic cortisol production in dogs reflects that in humans. Therefore, it remained possible that visceral fat releases cortisol into the portal vein in obese humans, thereby exposing the liver to high local glucocorticoid concentrations.The present experiments addressed this question by selectively obtaining simultaneous samples of arterial, portal venous, and hepatic venous blood during a D4 cortisol infusion in severely obese subjects undergoing bariatric surgery. In addition, mRNA for the glucocorticoid receptor (NR3C1), 11β-HSD-1, and 11β-HSD-2 was measured in liver and visceral fat obtained during surgery. We report that the liver accounts for all of the splanchnic cortisol production in obese nondiabetic humans. In contrast, there was no detectible release of cortisol into the portal vein by the viscera. On the other hand, although the mRNA for 11β-HSD-2 in visceral fat was very low, the viscera released cortisone into the portal vein, thereby providing the liver with substrate for intrahepatic cortisol production.     

Teratoid Wilms' tumor: report of a unilateral case

Teratoid Wilms' tumor is a rare histologic variant of the classical Wilms' tumor, containing predominantly heterolougus tissues (adipose, glial, muscle, cartilage, or bone). This report presents the case of a teratoid Wilms' tumor in a 4-year-old girl. The mass, which originated from the right kidney, was very large and encased the inferior vena cava and renal vessels. The child did not respond to chemo- or radiotherapy and underwent operation. Despite the enormous dimensions of the tumor and the involvement of the inferior vena cava, a radical excision was obtained, and now the child is well 32 months after surgery. The behavior of this kind of tumor usually is not aggressive, and the outcome is good. Surgery should be the treatment of choice, because the efficacy of chemotherapy and radiotherapy is probably reduced by the high amount of differentiated and mature tissue which characterizes this neoplasm. J Pediatr Surg 38:259-261.     

Application of stem cells in bone repair

Bone has the ability to repair minor injuries through remodeling. However, when the host source of osteoprogenitors is compromised at the defect site, one effective treatment may be cell-based therapy, as it replenishes the area of bone loss with cells possessing osteogenic potential. This review is a concise comparison of different types of stem cells that have the potential to be used in tissue-engineered scaffolds for bone repair. The clinical use of mesenchymal stem or stromal cells isolated from the bone marrow for treating various diseases has been well documented. However, the scarcity of these cells prompts the search for alternative sources of multipotential cells such as amniotic fluid stem cells and umbilical cord perivascular cells. Embryonic stem cells are another controversial source of cells with osteogenic potential. These cells have the ability to differentiate into all cell types of the adult body. Issues such as the use of human embryos and the risk of contamination from animal-derived culture components continue to prevent the therapeutic use of ESCs. As a result, abundant research has been carried out to design defined culture conditions for culturing ESCs, and alternative strategies such as the generation of induced pluripotent stem cells are being developed to eliminate the need for using embryos for cell derivation. In addition to the cell source, the ability to control stem cell differentiation into functional bone and the choice of biomaterial are also paramount objectives that are being examined in research and clinical trials.     

Anatomy and pathomechanics of ring and small finger carpometacarpal joint injuries

PURPOSE: The purpose of this study was to detail the pathomechanics and pathoanatomy of fracture dislocations of the ring finger and small finger carpometacarpal (CMC) joint by duplicating the pathomechanics of the fist blow. METHODS: A custom-made jig was used to position 20 fresh-frozen cadaver upper extremities in forearm neutral rotation, 90 degrees of elbow flexion, 20 degrees of wrist extension, and 20 degrees and 30 degrees of flexion at the ring and small finger CMC joint, respectively. First 7.7 kg of weight were dropped from a height of 0.76 m to 1.1 m to axially load the ring and small metacarpal (MC) heads through a custom-made apparatus. Fluoroscopic examination before and after loading, and detailed dissection after loading, were used to identify any osseous and/or ligamentous injuries. RESULTS: The most common fractures were a dorsal capitate fracture and a middle MC dorsal base fracture. The most common combinations of fractures were the dorsal capitate and dorsal hamate fractures. Multiple fractures often were identified in a number of locations including dorsally: the capitate, hamate, and index through small metacarpal bases, and volarly: the hook of the hamate and the middle through the small MC bases. CONCLUSIONS: The patterns of injuries encountered at the ring and small CMC joints can be explained by the direction and force of the applied load, position of the CMC joint at the time of loading, and the constraints imposed by specific CMC ligaments. A detailed analysis of the fracture patterns and associated ligament anatomy suggests that the typical ring and small carpometacarpal fracture dislocations are a more complex combination of fractures than identified by plain radiographs alone. The complexity of these injuries is greater than previously recognized and is most likely the result of a combination of axial load and shear stresses resulting in carpal fractures and ligament avulsions as well as fracture dislocations. This study suggests that computed tomography may be the preferred diagnostic imaging method for complete assessment of these injuries.     

Intraoperative Evaluation of Sentinel Lymph Nodes for Metastatic Melanoma by Imprint Cytology

Background Sentinel lymph node biopsy (SLN) has revolutionized nodal staging. Accurate intraoperative evaluation of SLN permits a single procedure, with lymphadenectomy being performed during the initial operative procedure when the SLN is positive. There is a paucity of literature on intraoperative imprint cytology (IIC) evaluation of the SLN in melanoma. The purpose of this article is to present an update to our experience with IIC for SLN in melanoma. Methods Melanoma patients had SLNs examined by IIC. SLNs were bisected, and imprints were made from each half. Imprints were stained with hematoxylin and eosin and with Diff-Quik. Paraffin-embedded sections were examined with multiple hematoxylin and eosin–stained sections from the SLNs in conjunction with immunohistochemical staining for S-100, Melan-A, and HMB-45 proteins. Results Metastases were identified in 40 (17%) of 229 patients. Of these, 13 patients were detected by IIC (sensitivity, 33%). The negative predictive value was 88%. No false-positive results were identified (specificity, 100%). The positive predictive value was 100%. The accuracy of IIC was 78%. The sensitivity for detecting macrometastases (>2 mm) was better than that for detecting micrometastases (≤2 mm): 62% vs. 16% (P < .01). Patients with positive SLNs by IIC had lymphadenectomy under the same anesthetic. A total of 533 nonsentinel lymph nodes were identified in 42 patients. Only two patients (8%) had positive nonsentinel lymph nodes after a negative IIC. Conclusions IIC is a viable alternative to frozen sectioning when intraoperative evaluation is desired. IIC is significantly more sensitive for macrometastases. IIC evaluation of SLNs in melanoma makes a single operative procedure possible for a significant proportion of patients with regional nodal metastases. Presented at the Society of Surgical Oncology, San Diego, California, March 24, 2006.