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​Pre drain images showing RLQ abscess and appendicolith. Video of the drainage procedure. This was done with the patient prone, but I flipped it to compare with the pre-drain images. I had to get the drain between the colon and psoas, while angling caudad into the large abscess in the pelvis. Note the appendicolith on the final images. Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome: "CT-guided percutaneous drainage is both effective and safe in the treatment of patients with acute appendicitis complicated by perforation and abscess. The clinical and technical success rates are high." http://www.ncbi.nlm.nih.gov/pubmed/20093605 Management of Complicated Appendicitis in the Pediatric Population: When Surgery Doesn't Cut It: "The management of complicated appendicitis in children has evolved significantly over the last century. What initially was a surgeon's dilemma is becoming the interventional radiologist's task because image-guided percutaneous drainage of abscesses from a ruptured appendix obviates the need for urgent surgery and allows for selective interval appendectomy at the surgeon's discretion (versus conservative nonoperative management in selected cases). This paradigm shift places the onus on the interventional radiologist to recognize when the procedure is emergently indicated and to be cognizant of the special needs of a pediatric patient." http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577589/ The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis: "Antibiotics for suspected acute appendicitis are safe and effective and may avoid unnecessary appendectomy, reducing operation rate, surgical risks, and overall costs. After 2 years of follow-up, recurrences of nonoperatively treated right lower quadrant abdominal pain are less than 14% and may be safely and effectively treated with further antibiotics." http://www.ncbi.nlm.nih.gov/pubmed/24646528 Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Van Nuys, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin Rice, MD

October is National Breast Cancer Awareness Month. This year, more than 40,000 women will die from breast cancer. Early detection could save as many as 1/3 of them. Mammography plays an important role in saving lives because it can find a breast cancer tumor as early as two years before it can be felt. Far too many women die because they did not find their breast cancer soon enough. In fact, only about 2/3 of women aged 40 and up have had a mammogram in the last 2 years. One out of every eight American women will develop breast cancer in her life time. If breast cancer is diagnosed and treated early, the five year survival rate is more than 90%. Here are the most common reasons why women do not have regular screening mammograms (and why you should have one!) 1. The compression used for mammography is painful. While it is true compression used in mammography may cause some discomfort, it is rarely painful. Compression is necessary for mammography for several reasons. It thins the breast and spreads out the tissue, making it easier for the radiologist to find abnormalities. As well, compression decreases the radiation dose to the breast. It can help to schedule a mammogram at a time when the breasts are less sensitive, such as one week after a period. 2. The radiation to the breast is harmful. The radiation from a typical mammogram is small. The benefits of mammography far outweigh any theoretical risk due to radiation. In fact, the increased risk of death because of the radiation from one mammogram is equal to 60 miles of car travel, smoking three quarters of one cigarette, or being a man age 60 for 20 minutes. 3. No one in my family has ever had breast cancer; therefore, I do not need a mammogram. The fact is most women (75%) who develop breast cancer have absolutely no family history of breast cancer. Therefore, all women are at risk and should have yearly screening mammography by age 40. 4. I don’t have any lumps in my breasts. Therefore, I do not need a mammogram. The benefit of regular screening mammography is that small breast cancers can be found before they are able to be felt by the patient or her physician. If a breast cancer is found earlier, the chances for cure are much greater. 5. I have no time to get a mammogram. The average mammogram would only require a woman to be in the office for about 30 minutes. This is a small amount of time to spend once every year for a procedure that could save your life. 6. I can’t afford a mammogram. The median charge for a screening mammogram is around $100.00. This includes the technical component (images obtained by the technologist) and the professional component (radiologist consultation, review of previous images and full report with recommendations). This is a small investment for a procedure which could save your life. The National Breast and Cervical Cancer Early Detection Program. ​(NBCCEDP) provides breast and cervical cancer early detection testing to low-income, underserved, under-insured, and uninsured women in the US. Uninsured women who are diagnosed with cancer through the NBCCEDP can usually get treatment through their state’s Medicaid program. 7. I am afraid the mammogram might find something. This is a psychological barrier many women experience. However, it should be kept in mind that if an abnormality is found on a mammogram it is much more likely to be at a curable stage than if it is found later when the woman or doctor is able to feel it. 8. I am not sure which facility will provide high quality mammography. All facilities performing mammography must have accreditation from the FDA (Food and Drug Administration). Therefore, women can be assured that all facilities which currently perform mammography are of high quality. Accredited facilities can be found online by entering your zip code. 9. I am under 50; therefore, I do not need a mammogram. In fact, the current recommendations of the American College of Radiolgy (ACR), Society of Breast Imaging (SBI) and American College of Obstetricians and Gynecologists (ACOG) state that women should have screening mammography every year beginning at age 40. Sixteen percent of all breast cancers occur in women ages 40 to 49 and 25% of the years of life lost to breast cancer occur in this age group. Routine screening mammography in women age 40 to 49 can reduce the death rate from breast cancer by up to 40%. 10. I am afraid if cancer is found I will need to have my breast removed (mastectomy). In reality, women who have regular mammography are less likely to have a mastectomy than women who do not. Cancer can be found at an earlier stage, thus obviating the need for mastectomy. Most cancers which are found early can be treated with a lumpectomy and radiotherapy. This usually results in minimal or no cosmetic deformity to the breast. Kevin M. Rice, MD serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Van Nuys, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All posts by Kevin Rice, MD Follow Dr. Rice on Twitter at @KevinRiceMD

What are the important findings here? • Xray of the Week Duplication of the inferior vena cava (IVC) is a rare congenital anomaly, seen in up to 1.5% of the population. The left IVC is visualized as a continuation of the left common iliac vein, then flows into the left renal vein. It is asymptomatic and no treatment is required. However, this variant must be kept in mind when inserting an IVC filter. In order to prevent emboli from both lower extremities, the filter should be placed above the renal veins [1] as in this case. Alternatively, two IVC filters [2] can be inserted, with one in each of the two inferior vena cavas. ​ ​Fig. 1 Coronal CT image demonstrating the two inferior vena cavas.​ ​​Fig. 2 Axial CT image demonstrating the two inferior vena cavas.​ ​Fig. 3 Inferior vena cavagram via the left common femoral vein. Note the left IVC draining into the left renal vein. The right IVC is not opacified. Retrograde filling of the lumbar veins is prominent. ​Fig. 4 IVC filter is placed in the suprarenal IVC. 1. MalgorI RD, SobreiraII ML, BoaventuraII PN, et al. Filter placement in duplicated inferior vena cava: case report and review of the literature. J Vasc Bras. 2008;7(2):167-170. http://www.scielo.br/pdf/jvb/v7n2/en_v7n2a13.pdf 2. Sartori MT1, Zampieri P, Andres AL, Prandoni P, Motta R, Miotto D. Double vena cava filter insertion in congenital duplicated inferior vena cava: a case report and literature review. Haematologica. 2006 Jun;91(6 Suppl):ECR30. http://www.haematologica.org/content/91/6_Suppl/ECR30.long Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital and is a radiologist with Renaissance Imaging in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All posts by Kevin Rice, MD Follow Dr. Rice on Twitter @KevinRiceMD

Short of Breath • Xray of the Week 2016 • Week #1 Differential diagnosis of dilated pulmonary artery (Fleischner sign): Pulmonary arterial hypertension (PAH) Pulmonary embolism Post stenotic dilatation: pulmonary valve stenosis, pulmonary artery coarctation Increased pulmonary blood flow: atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA) Total anomalous pulmonary venous return (TAPVR) pregnancy High output cardiac failure: thyrotoxicosis, anaemia​ Marfan syndrome Idiopathic dilatation of the pulmonary trunk References: Peña E, Dennie C, Veinot J et-al. Pulmonary hypertension: how the radiologist can help. Radiographics. 2012;32 (1): 9-32. Henry Knipe, Frank Gaillard, et al. Radiopaedia: http://radiopaedia.org/articles/pulmonary-hypertension-1 Left image: Axial CT showing markedly enlarged pulmonary arteries. Right image: Enlarged PA seen inferior to aortic arch. Coronal CT showing large right main pulmonary artery. Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Van Nuys, California. Dr. Rice has made several television and radio appearances and given numerous newspaper interviews as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice decided to launch Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All posts by Kevin Rice, MD

Pain and Deformity Following Wrist Trauma This patient fell off his bicycle, landing on his hyperextended ulnar-deviated wrist. There is anterior dislocation of the lunate, and the lunate is rotated 270 degrees such that the concavity of the lunate is directed dorsally rather than distally. The lunate is also displaced inferiorly, resulting in a fracture of the anterior articular surface of the distal radius with a small fracture fragment noted anteriorly. The lunate is the most frequently dislocated carpal bone. The most common type of dislocation is volar, rotated 90 degrees. In this case the lunate has flipped over and rotated an additional 180 degrees, for a total rotation of 270 degrees. This is a rare form of lunate dislocation, comprising less than 5% of cases. Dislocation of 270 degrees should be treated as a surgical emergency due to the risk of acute carpal tunnel syndrome, which manifests as decreased sensation in the median nerve distribution and excruciating pain. Operative stabilization is required to maintain the reduction. Figure 2. The most common type of lunate dislocation with the lunate volar, rotated 90 degrees. The distal radius is abnormally articulating with the capitate, rather than the lunate. A. PA radiograph of lunate dislocation with triangular, “piece of pie” lunate appearance (green arrows), disruption of carpal arcs, increased radiolunate space, and overlap of lunate with other carpals. B. Lateral radiograph showing the “spilled teacup” appearance of lunate dislocation (yellow arrows), with the concavity of the lunate facing anteriorly. The lunate has volar displacement and angulation, and has lost articulation with the radius and capitate. References: http://www.orthobullets.com/hand/6045/lunate-dislocation-perilunate-dissociation http://www.learningradiology.com/archives2007/COW%20255-Lunate%20dislocation/lunatedisloccorrect.html https://www.thieme-connect.de/products/ebooks/pdf/10.1055/b-0034-77622.pdf http://www.grayscalecourses.com/news-cases/case-to-ponder-33-answer-trans-scaphoid-lunate-dislocation Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin Rice, MD

King Herod Died of this Rare Disease • Xray of the Week It is theorized that King Herod, builder of the Second Temple in Jerusalem, died of Fournier gangrene according to Jan Hirschmann, MD in Mystery of Herod's death 'solved'. Roman biographer Flavius Josephus wrote: "He had a fever, though not a raging fever, an intolerable itching of the whole skin, continuous pains in the intestines, tumors of the feet as in dropsy, inflammation of the abdomen, and gangrene of the privy parts." This 58 year old male diabetic smoker was seen in the Emergency Department with a markedly elevated blood glucose level of 1054 mg/dl (58.6 mmol/l) and crepitus in the perineal region. CT scan was performed demonstrating gas in the scrotum and perineum tracking into the anterior abdominal wall [Figs. 1-2]. Two weeks after presentation, the patient developed a pelvic abscess [Fig. 3]. Figure1. Left image: Axial CT showing gas in the scrotum and perineum. Right image: Coronal CT showing gas in the scrotum tracking into the anterior abdominal wall. Figure 2. Axial CT showing gas in the pelvic soft tissues. Figure 3. Axial CT obtained 2 weeks after initial presentation showing abscess formation in the left pelvic sidewall. Figure 4. Axial CT obtained after percutaneous CT guided drainage of the abscess in the left pelvic sidewall. Radiology played a major role in not only diagnosing the disease but also treatment with percutaneous abscess drainage [Fig. 4]. Cultures grew Morganella morgani, Streptococcus agalactiae, Corynebacterium, and his central line later grew Pseudomonas aeruginosa. He required multiple debridements of the inguinal, perineal, and perirectal regions and a colostomy. After 30 days in the hospital, and 10 debridements the patient was discharged to a skilled nursing facility. Discussion: Fournier gangrene is an uncommon but life-threatening infection with rapidly progressing necrotizing fasciitis involving the perineal, perianal, or genital regions seen mainly in elderly males. Gangrene is polymicrobial caused by both aerobic and anaerobic bacteria. Most cases are seen in diabetic or immune compromised patients. CT findings include fascial thickening, abscess formation, fat stranding surrounding the affected areas, and subcutaneous emphysema. This is a true surgical emergency and treatment is radical debridement of the necrotic tissue, and broad spectrum intravenous antibiotics. Hyperbaric oxygen therapy (HBOT) has also been shown to be useful. Mortality is between 15-50% depending on the severity at presentation. References: 1. Levenson RB, Singh AK, and Novelline, RA. Fournier Gangrene: Role of Imaging. RadioGraphics 2008; 28:519 –528 2. Rajan DK, Scharer KA. Radiology of Fournier's gangrene. AJR Am J Roentgenol. 1998;170 (1): 163-168. 3. Uppot RN, Levy HM, Patel PH. Case 54: Fournier gangrene. Radiology. 2003;226 (1): 115-117. doi:10.1148/radiol.2261010714 Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin Rice, MD

Chest Wall Mass & Altered • Xray of the Week This HIV positive 63 year old female patient had an enlarging left anterior chest wall mass which was subsequently biopsied. She presented 2 weeks later with altered mental status, and an MRI brain was performed. Left image: Left parasternal anterior chest wall mass. Right image and image below: Axial T2 FLAIR PROPELLER showing mass in the left lateral aspect of the posterior fossa which is isointense to slightly T2 hyperintense to brain. There is vasogenic edema involving the left cerebellar hemisphere, with mass effect. The mass is causing deviation of the fourth ventricle to the right, as well as partial fourth ventricle effacement. Left image: Axial exponential apparent diffusion coefficient (ADC) map demonstrating low signal at the site of the mass indicating restricted diffusion. Right image: Axial diffusion weighted image (DWI) demonstrating high signal at the site of the mass indicating restricted diffusion, likely reflecting increased cellularity. Differential considerations include lymphoma, metastatic disease, as well as atypical meningeal tumors such as hemangiopericytoma. The patient had a CT guided biopsy of the chest wall mass which proved to be granulocytic sarcoma. Photomicrographs of the biopsy done in this case. Courtesy of Dennis Kasimian, MD - Chair of Pathology at Valley Presbyterian Hospital Left: H&E- Diffuse infiltration of soft tissue by dis-cohesive, immature mononuclear cells with irregular, hyperchromatic nuclei and a moderate amount of faintly granular cytoplasm, consistent with granulocytic sarcoma. Right: Myeloperoxidase immunohistochemical stain: Positive cytoplasmic staining with myeloperoxidase stain confirms myeloid origin. Granulocytic Sarcoma is also known as myeloid sarcoma, chloroma, extramedullary myeloblastoma, and extramedullary myeloid tumor. It is a rare solid tumor composed of primitive precursors of the granulocytic series of white blood cells that include myeloblasts, promyelocytes, and myelocytes The tumor is an extramedullary manifestation of acute myeloid leukemia (AML). History: •1811: First described by the British physician A. Burns. •1853: King initially called it chloroma, because typical forms have a green color caused by high levels of myeloperoxidase in the immature cells. •1966: Rappaport renamed it granulocytic sarcoma, because not all of the cells are green. Granulocytic Sarcoma Associated with: •Acute myelogenous leukemia •Chronic myelogenous leukemia •Myelofibrosis with myeloid metaplasia •Hypereosinophilic syndrome •Polycythemia vera Epidemiology: •Occurs in 2.5-9.1% of patients with acute myelogenous leukemia. •Occurs in <2% of patients with chronic myelogenous leukemia. •Same rate of occurrence in both sexes. •60% of patients are younger than 15 years old. Location: •May involve any part of the body. •Often occur in multiples and preferentially involve orbits and subcutaneous tissue. •Paranasal sinuses, lymph nodes, bone, spine, brain, pleural and peritoneal cavities, breast, thyroid, salivary glands, small bowel, lungs, various pelvic organs. Granulocytic Sarcoma in HIV: In the highly active antiretroviral therapy (HAART) era, the overall survival of patients with AIDS is improving dramatically and, as a result, perhaps the occurrence of malignancies not typically associated with HIV infection, especially those malignancies such as AML in which the incidence increases with age, may become more prevalent as the HIV-infected population ages. Prognosis: •Patients with granulocytic sarcomas who have chronic leukemia or myeloproliferative disorders have a negative prognosis, because these tumors often occur during acute transformation. •Very sensitive to focal irradiation or chemotherapy; they generally resolve completely in less than 3 months. •Poor prognosis in AIDS patients with median survival of 7.5 months if treated and 1 month if not treated. References: 1. Krause JR, and Aburiziq I. Granulocytic sarcoma and HIV. Proc (Bayl Univ Med Cent) 2011;24(4):306–308 2. Navarro WH, Kaplan LD. AIDS-related lymphoproliferative disease. Blood. 2006;107(1):1–13. 3. Rizzo M, Magro G, Castaldo P, Tucci L. Granulocytic sarcoma (chloroma) in HIV patient: a report. Forensic Sci Int. 2004;146(Suppl):S57–S58. 4. Aboulafia DM, Meneses M, Ginsberg S, Siegel MS, Howard WW, Dezube BJ. Acute myeloid leukemia in patients infected with HIV-1. AIDS. 2002;16(6):6–865. Related posts: Pneumocystis pneumonia in AIDS Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All Posts by Kevin Rice, MD

Sinus Pain after Dental Work • Xray of the Week The accidental displacement of a root into the maxillary sinus is a recognized complication of exodontia. Such roots should normally be removed early rather than late in order to minimize the likelihood of maxillary sinus complications. In some cases, the sinus cavity can be irrigated with saline (antral lavage) and the tooth fragment may be brought back to the site of the opening through which it entered the sinus, and may be retrievable. At other times, a window must be made into the sinus in the Canine fossa--a procedure referred to as "Caldwell-Luc". A root left within the maxillary sinus may, on occasion, pass spontaneously into the nose. Left image: Coronal CT of sinuses showing the empty right maxillary second molar tooth socket. (Tooth #2) and a portion of the tooth root in the right maxillary sinus. Right image: Axial CT of sinuses showing a portion of the tooth root (tooth #2) in the right maxillary sinus. There is also bilateral maxillary sinus mucosal thickening. Coronal CT of sinuses showing the empty right maxillary second molar tooth socket. (Tooth #2) Coronal CT of sinuses showing the empty right maxillary second molar tooth socket. (Tooth #2) and a portion of the tooth root in the right maxillary sinus. References: 1. Root in the maxillary sinus J.K. Barclay, M.D.S. (F.R.A.C.D.S.) University of Otago Otago, New Zealand. Oral Surgery, Oral Medicine, Oral Pathology. Volume 64, Issue 2, August 1987, Pages 162–164 http://www.sciencedirect.com/science/article/pii/0030422087900831 Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All posts by Kevin Rice, MD

Refused to Remove Vest • Xray of the Week This patient refused to remove his vest prior to getting a chest X-ray. The concerned tech called the radiologist. Fortunately, the radiologist knew that the radiopaque objects were due to the LifeVest wearable defibrillator made by Zoll which is a treatment option for sudden cardiac arrest. Unlike an implantable cardioverter defibrillator (ICD), the LifeVest is worn outside the body rather than implanted in the chest. This device continuously monitors the patient's heart with dry, non-adhesive sensing electrodes to detect life-threatening arrhythmias. If a life-threatening rhythm is detected, the device alerts the patient prior to delivering a treatment shock, and thus allows a conscious patient to delay the treatment shock. If the patient becomes unconscious, the device releases a Blue™ gel over the therapy electrodes and delivers an electrical shock to restore normal rhythm. Chest Xray of a patient wearing the Zoll LifeVest. We have seen this device used increasingly while patients are waiting for their ICD placement. Dr. Kamran Toluie, a cardiologist in Beverly Hills, California describes how the LifeVest can be used as a temporary potentially life-saving measure in patients with cardiomyopathy who may respond to conservative medical management before an ICD is needed. Illustration of the Zoll LifeVest and how it looks on a patient. (from http://lifevest.zoll.com) Video of the Zoll LifeVest and how it works. References: 1. Adler A, Halkin A, Viskin S. Wearable cardioverter-defibrillators. Circulation. 2013;127 (7): 854-60. 2. Chung MK, Szymkiewicz SJ, Shao M, et al. Aggregate national experience with the wearable cardioverter-defibrillator: event rates, compliance, and survival. J Am Coll Cardiol. 2010;56:194–203. 3. Zoll LifeVest Online Information for Medical Professionals. http://lifevest.zoll.com/medical-professionals Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin Rice, MD

Thirteen Year Old Female with Vague Abdominal Pain • Xray of the Week This 13 year old girl presented with vague abdominal pain and nausea. The patient went to surgery 2 days after the CT and MRI shown here. What did the surgeon find? Figure 1 A: CT showing a large pancreatic mass with peripheral enhancement. B: Coronal T1 weighted image demonstrates the pancreatic mass with central necrosis and peripheral enhancement. Figure 2 A: Axial FSE T2 weighted image showing a large pancreatic mass with central necrosis and hemorrhage. B: Axial LAVA post contrast T1 weighted image demonstrates the pancreatic mass with central necrosis and peripheral enhancement. Discussion: Solid pseudopapillary tumor of the pancreas (SPT) is a rare neoplasm of the pancreas seen predominantly in young Asian and African-American females between ages 10 and 20. Although most tumors are benign, about 15% may be malignant. As in this case, CT and MRI usually demonstrate a peripheral enhancing large mass. MRI shows heterogeneity on all sequences due to necrosis and hemorrhage. Differential diagnosis includes serous cystadenoma, mucinous cystic neoplasm, islet cell tumors, and pancreatoblastoma. Complete surgical resection is usually curative. References: 1. Coleman KM, Doherty MC, Bigler SA. Solid-pseudopapillary tumor of the pancreas. Radiographics. 23 (6): 1644-8 2. Choi JY, Kim MJ, Kim JH et-al. Solid pseudopapillary tumor of the pancreas: typical and atypical manifestations. AJR Am J Roentgenol. 2006;187 (2): W178-86. Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Due to his online teaching initiative, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator in 2016. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin Rice, MD

Thirty nine year old Female with Rapidly Enlarging Right Breast Mass • Xray of the Week This 39 year old female presented with a rapidly enlarging right breast mass. Mammogram and ultrasound were performed. The patient had an ultrasound guided biopsy of the mass, and subsequent excision. What did the surgeon find? Left: Right breast ultrasound showing a large mass measuring 13.8 x 6.4 cm with peripheral heterogeneity. Right: Bilateral MLO mammogram images. Normal left breast and large mass throughout most of the right breast. Ultrasound-guided biopsy of the large right breast mass. Phyllodes tumor is a rare mass of the breast, comprising less than 1% of breast cancers. Usually found as a rapidly enlarging mass in women between ages 35 and 60, the tumor is almost always benign. Some case are classified as borderline, and less than 10% of these tumors are frankly malignant with distant metastases. However, at least 25% of the time there is local recurrence following excision and a wide resection margin is required. Very large masses often require mastectomy. In the rare cases of metastatic disease, treatment is similar to sarcoma, rather than breast cancer regimens. References: 1. Fibrous Lesions of the Breast: Imaging-Pathologic Correlation RadioGraphics 2005; 25:1547–1559 http://pubs.rsna.org/doi/full/10.1148/rg.256045183 2. Tan H, Zhang S, Liu H et-al. Imaging findings in phyllodes tumors of the breast. European J Radiology. 2011; 81 (1):e62–e69 doi:10.1016/j.ejrad.2011.01.085 3. Buchberger W, Strasser K, Heim K et-al. Phylloides tumor: findings on mammography, sonography, and aspiration cytology in 10 cases. AJR Am J Roentgenol. 1991;157 (4): 715-9. 4. Lifshitz OH, Whitman GJ, Sahin AA et-al. Radiologic-pathologic conferences of the University of Texas M.D. Anderson Cancer Center. Phyllodes tumor of the breast. AJR Am J Roentgenol. 2003;180 (2): 332. 5. Wurdinger S, Herzog AB, Fischer DR et-al. Differentiation of phyllodes breast tumors from fibroadenomas on MRI. AJR Am J Roentgenol. 2005;185 (5): 1317-21. 6. Chao TC, Lo YF, Chen SC et-al. Sonographic features of phyllodes tumors of the breast. Ultrasound Obstet Gynecol. 2002;20 (1): 64-71. 7. Yabuuchi H, Soeda H, Matsuo Y et-al. Phyllodes tumor of the breast: correlation between MR findings and histologic grade. Radiology. 2006;241 (3): 702-9. doi:10.1148/radiol.2413051470 Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M. Rice, MD

52 year old Male on Dialysis with Chronic Swelling of the Right Arm • Xray of the Week 2016 • Week #11 This 52 year old male with a dialysis fistula in the right arm presented with chronic swelling of the right arm. The dialysis nurse also reported decreasing efficiency of the dialysis. The patient had a venogram shown here. What has occurred and what is the treatment? Contrast venogram via the dialysis fistula demonstrating a completely occluded right subclavian vein and no contrast entering the superior vena cava (SVC). The guidewire has been maneuvered such that it is across the occluded segment, traverses the right atrium, and the tip is in the inferior vena cava (IVC). A 12 mm balloon is inflated across the occluded segment in the brachiocephalic vein. Post venoplasty. Right subclavian vein and superior vena cava are now wide open. The patient's arm swelling resolved within a few hours of the venoplasty. A dialysis fistula is a surgically created connection between an artery and vein, usually in the upper extremity. The fistula takes about 6 weeks following surgery to mature before it can be used for dialysis. Due to the abnormal high pressure within the outflow vein, it is susceptible to stenosis or occlusion. These narrowings or blockages may be treated with balloon venoplasty as in this case. Other treatments include stents and thrombolysis, depending on the individual situation. Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Van Nuys, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All posts by Kevin Rice, MD Follow Dr. Rice on Twitter @KevinRiceMD