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42 year old male with headache and history of cerebral palsy. What is the diagnosis? • Xray of the Week Figure 1. Head CT. What are the significant findings? Figure 2. Head CT. Red arrows indicate focal encephalomalacia of the left parietal lobe with replacement by a cystic mass that communicates with the left lateral ventricle. Green arrows indicate white matter lining the porencephalic cyst. Note that there is no mass effect. Discussion: Porencephaly is a rare congenital neurological disorder of the central nervous system that is characterized by encephalomalacia that communicates with the ventricular system [1]. Derived from Greek meaning 'holes in the brain', the term porencephaly was coined by Richard L. Heschl in 1859 [2]. The lesions can have varying etiologies including destructive (encephaloclastic), abnormal development (malformities), direct damage, inflammation, or hemorrhage [3]. Depending on the patient and severity, this disorder may cause only minor neurological problems, without any disruption of intelligence, while others may be severely disabled or face death before the second decade of their lives [4]. Recent studies have suggested a genetic etiology to the development of porencephaly [3-6]. Mutated COL4A1 leads to weakened blood vessels within the brain which increases the chance of intracranial hemorrhage and eventually porencephaly during neurodevelopment of infantile stage [3,5]. In utero exposure to cocaine and other street drugs have also been shown to increase the risk of porencephaly [7]. Seizures and spasticity are often the most common initial signs. Other common symptoms include language impairment, intellectual disability, and motor deficits. In severe cases, the cyst can exert mass-effect on the surrounding skull resulting in expansion and cranial deformities. Other possible symptoms include delayed growth and development, hypotonia, macrocephaly, and microcephaly [8,9]. Porencephaly is readily diagnosed via imaging. Antenatal ultrasound may show one or more intracranial cysts that communicate with the ventricular system and/or subarachnoid space. There may also be asymmetrical ventricles with displacement of the midline ventricular echo. On CT and MR imaging, porencephalic cysts appear as an intracranial cyst that has a well-defined border and central attenuation the same as CSF (Fig. 2). Typically, there is no mass effect on the adjacent parenchyma, however enlarging cysts can result in local mass effect. There is no enhancement with contrast and no solid component. The cyst will appear well defined and often corresponds to a vascular territory. The cyst is lined by white matter and communicates with the ventricles and/or the subarachnoid space with possible gliosis depending on the age at which the cyst developed. The earlier the insult occurred in development, the more likely a glial reaction will be present. It is important to distinguish that the cyst is not lined by grey matter. This allows for delineation from arachnoid cysts and schizencephaly, which are typically either lined with heterotopic grey matter or not lined at all [9]. On MRI, the cystic components will appear as low signal intensity on T1 weighted images, high signal intensity on T2 weighted images, low signal intensity on FLAIR images, and will have no restricted diffusion on DWI [10-12]. Since there is no cure for porencephaly, treatment is targeted towards symptomatic relief. This may include physical therapy, rehabilitation, medication for seizures, shunt, or rarely neurosurgical removal of the cyst. Adequate seizure control has been shown in porencephaly patients with appropriate drug therapy such as valproate, carbamazepine, and clobazam [3,5]. ​​​​ References: Gul A, Gungorduk K, Yildirim G, Gedikbasi A, Ceylan Y. Prenatal diagnosis of porencephaly secondary to maternal carbon monoxide poisoning. Arch Gynecol Obstet. 2009;279(5):697-700. doi:10.1007/s00404-008-0776-3 Hirowatari C, Kodama R, Sasaki Y, et al. Porencephaly in a cynomolgus monkey (macaca fascicularis). J Toxicol Pathol. 2012;25(1):45-49. doi:10.1293/tox.25.45. Debus O., Kosch A., Strater R., Rossi R., Nowak-Gottl U. (2004). "The Factor V G1691A Mutation is a Risk for Porencephaly: A Case-control Study". Annals of Neurology. 56 (2): 287–290. doi:10.1002/ana.20184. PMID 15293282. Meuwissen ME, Halley DJ, Smit LS, et al. The expanding phenotype of COL4A1 and COL4A2 mutations: clinical data on 13 newly identified families and a review of the literature. Genet Med. 2015;17(11):843-853. doi:10.1038/gim.2014.210 Thomas L. Genetic mutation predisposes to porencephaly. Lancet Neurol. 2005;4(7):400. doi:10.1016/s1474-4422(05)70114-9 Dominguez R, Aguirre Vila-Coro A, Slopis JM, Bohan TP. Brain and ocular abnormalities in infants with in utero exposure to cocaine and other street drugs. Am J Dis Child. 1991;145(6):688-695. doi:10.1001/archpedi.1991.02160060106030 Cephalic disorders fact sheet. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Cephalic-Disorders-Fact-Sheet Huang SB, Doherty D. “Congenital Malformations of the Central Nervous System.” Avery’s Diseases of the Newborn, Elsevier, 2018, pp. 857-878.e5. doi:10.1016/B978-0-323-40139-5.00059-0. Mikic, Aleksandra Novakov, et al. “Ultrasound and Magnetic Resonance in Prenatal Diagnosis of Congenital Anomalies.” Reproductive and Developmental Toxicology, Elsevier, 2011, pp. 971–82. doi:10.1016/B978-0-12-382032-7.10074-8. Contro, Elena, et al. “Intracranial Hemorrhage, Cysts, Tumors, and Destructive Lesions.” Obstetric Imaging: Fetal Diagnosis and Care, Elsevier, 2018, pp. 204 212.e1. doi:10.1016/B978-0-323-44548-1.00040-1. Russell, Sarah A., et al. “Cranial Abnormalities.” Textbook of Fetal Abnormalities, Elsevier, 2007, pp. 95–141. doi:10.1016/B978-0-443-07416-5.50011-3. “Encephalomalacia, Porencephaly.” Diagnostic Imaging: Obstetrics, Elsevier, 2016, pp. 158–61. doi:10.1016/B978-0-323-39256-3.50045-5. Jay Vora is a medical student at Edward Via College of Osteopathic Medicine (VCOM) – Virginia and plans to pursue a residency in diagnostic radiology. He graduated from UMBC in 2015 with a major in Biochemistry and Molecular Biology. He worked as a research assistant at Brimrose Engineering Corporation of America for 5 years where he completed projects in nanodot detection using imaging and helped develop cancer detection methods in cells using polarized near-infrared autofluorescence and near-infrared reflectance imaging with laser diodes and continuous-wave imaging. He graduated from Eastern Virginia Medical School with a masters in Biomedical science where he was completed research in the study of the barriers that the homeless population faces when seeking healthcare as well as genetic analysis of brain tissue from patients diagnosed with Alzheimer’s. He discovered his passion for radiology during the first radiology lecture at VCOM. Seeing the radiographic images made medical education come to life for him. While shadowing and on rotations, Jay saw how integral the field of radiology is to every other specialty in medicine and its key role in patient care. In his free time, Jay enjoys playing golf and basketball, playing guitar, and technology. Follow Jay Vora on Twitter @JS_Vora Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital 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 and Natalie 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 M. Rice, MD

28-year-old pregnant female with abnormal ultrasound. Next step? • Xray of the Week Figure 1. Pelvic ultrasound of a 28-year-old female. Figure 2. Pelvic ultrasound of a 28-year-old female demonstrating an intrauterine pregnancy with an IUD. A. Sagittal view reveals rotated and inferiorly displaced IUD in the lower uterine segment and cervix (orange arrow) and an intact intrauterine gestational sac (yellow arrows). B. Sagittal image confirms an inferiorly displaced IUD (orange arrow) and an intrauterine pregnancy with gestational sac and embryonic pole (yellow arrows). Discussion: Ultrasonography is the first-line imaging method for evaluating common gynecologic complaints such as abnormal vaginal bleeding, amenorrhea, pelvic pain, or mispositioning of an intrauterine device (IUD), due to its low-cost and lack of radiation exposure [1]. The IUD is the most widespread form of reversible contraception in reproductive-age women. On a standard 2D transvaginal ultrasound (TVUS), it appears as a linear echogenic structure with posterior shadowing [1,2]. The arms of a copper IUD are fully echogenic with posterior shadowing (Fig. 1,2) compared to a hormone-releasing IUD, which is echogenic only at the proximal and distal ends [2]. Nearly 11% of the patients with IUDs experience some type of malpositioning which includes expulsion, displacement, embedment, and perforation. When an IUD is partially or completely out of the external cervical os, it is termed expulsion. Embedment is when an IUD penetrates the myometrium but not the serosa, while perforation is when it penetrates both [1,3]. The copper IUD is rotated and inferiorly displaced >3mm in the lower uterine segment and is no longer touching the fundus of the uterus, a likely cause of the pictured intrauterine pregnancy with gestational sac and fetal pole (Figs. 1,2). The risk of intrauterine pregnancy is higher in a copper IUD than in a hormone-releasing IUD due to copper’s decreased efficacy when displaced. According to a case-control study, approximately 64% of patients with displaced copper IUDs became pregnant compared to only 11% of non-pregnant patients in the control group [1,4,5]. If an IUD cannot be visualized on an ultrasound, an abdominal radiograph can be used to evaluate its position due to its radiopacity. A CT/MRI can be used when suspecting uterine or bowel perforation, pelvic abscesses, or other complications of IUD expulsion or migration. Copper and hormone-releasing IUDs are safe up to 3-T MRI, but more investigation is needed for stainless steel IUDs [1,6]. Pregnancies with an IUD are at a heightened risk for preterm delivery, spontaneous abortion, placental abruption, chorioamnionitis, and vaginal bleeding. Removing the IUD earlier in the pregnancy, especially first trimester when its filaments are visible, decreases the risk of miscarriage [7,8]. ​​​​ References: Nowitzki KM, Hoimes ML, Chen B, Zheng LZ, Kim YH. Ultrasonography of intrauterine devices. Ultrasonography. 2015;34(3):183-194. doi:10.14366/usg.15010 Boortz HE, Margolis DJ, Ragavendra N, Patel MK, Kadell BM. Migration of intrauterine devices: radiologic findings and implications for patient care. Radiographics. 2012;32(2):335-352.doi:10.1148/rg.322115068 Braaten KP, Benson CB, Maurer R, Goldberg AB. Malpositioned intrauterine contraceptive devices: risk factors, outcomes, and future pregnancies. Obstet Gynecol. 2011;118(5):1014-1020. doi:10.1097/AOG.0b013e3182316308 Anteby E, Revel A, Ben-Chetrit A, Rosen B, Tadmor O, Yagel S. Intrauterine device failure: relation to its location within the uterine cavity. Obstet Gynecol. 1993;81(1):112-114. PMID: 8416443. Pakarinen P, Luukkainen T. Five years' experience with a small intracervical/intrauterine levonorgestrel-releasing device. Contraception. 2005;72(5):342-5. doi:10.1016/j.contraception.2005.05.013 Berger-Kulemann V, Einspieler H, Hachemian N, Prayer D, Trattnig S, Weber M, Ba-Ssalamah A. Magnetic field interactions of copper-containing intrauterine devices in 3.0-Tesla magnetic resonance imaging: in vivo study. Korean J Radiol. 2013;14(3):416-22. doi:10.3348/kjr.2013.14.3.416 Kim SK, Romero R, Kusanovic JP, Erez O, Vaisbuch E, Mazaki-Tovi S, Gotsch F, Mittal P, Chaiworapongsa T, Pacora P, Oggé G, Gomez R, Yoon BH, Yeo L, Lamont RF, Hassan SS. The prognosis of pregnancy conceived despite the presence of an intrauterine device (IUD). J Perinat Med. 2010;38(1):45-53. doi:10.1515/jpm.2009.133 Schiesser M, Lapaire O, Tercanli S, Holzgreve W. Lost intrauterine devices during pregnancy: maternal and fetal outcome after ultrasound-guided extraction. An analysis of 82 cases. Ultrasound Obstet Gynecol. 2004;23(5):486-489. doi:10.1002/uog.1036 Mounica Chidurala is a medical student at Marian University College of Osteopathic Medicine in Indianapolis, IN. Prior to medical school, she graduated from Oklahoma State University with a Bachelor of Science degree in Chemical Engineering, minor in Chemistry, and an Honors College Degree. She also obtained her Master of Science degree in Chemical Engineering from the University of Oklahoma where she defended her master’s thesis in biofuels and heterogeneous catalysis. She is excited to pursue a career in Diagnostic Radiology with interests in Interventional Radiology or Nuclear Medicine. She is passionate about research and innovation in medicine and hopes to teach/mentor students in the future. Follow Mounica Chidurala on Twitter @mchidurala227 and Linkedin All posts by Mounica Chidurala Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital 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 and Natalie 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 and Linkedin All posts by Kevin M. Rice, MD

Name the Device • Xray of the Week CXR for CHF. Name the cardiac device and what the 2 images have in common. Fig. 1. Chest X-ray with arrows pointing to the Impella® Heart Pump. Archimedes’ screw. Fig. 2. Arrows pointing to an Impella® Heart Pump. Blue arrow- outflow area, red arrow- inflow area, green arrow- distal pigtail. Fig. 3 Video explaining percutaneous placement technique for the Impella® Heart Pump. Fig 4. Automated Impella® Controller. Discussion: The Impella 2.5® heart pump is a catheter-mounted pump that works on the principle of Archimedes’ screw (Figs.1-5). It is used to temporarily assist the pumping function of the heart during high-risk percutaneous coronary interventions (PCI) to ensure blood flow is maintained to critical organs in patients with severe coronary artery disease. The device may also be used to temporally treat ongoing cardiogenic shock that occurs immediately following acute myocardial infarction or open heart surgery or in the setting of cardiomyopathy. The Impella 2.5 pump is inserted percutaneously through the femoral artery, into the ascending aorta, across the aortic valve and into the left ventricle (Fig.3). The Impella (Fig.2) then pulls blood from the left ventricle through an inlet area near the tip and expels blood from the catheter into the ascending aorta at a maximum rate of 2.5 L/min. The external Automated Impella® Controller (Fig.4) controls the Impella catheter performance, monitors for alarms, and displays real-time hemodynamic and catheter position information. On radiographs, the distal tip of the catheter has a pigtail configuration and is positioned in the left ventricle. The blood inlet and outlet areas are metallic radiopaque and are visualized in the left ventricle and ascending aorta respectively (Fig.2). Fig 5. Archimedes’ screw. The water screw, popularly known as the Archimedes' screw and also known as the screw pump, Archimedean screw, or Egyptian screw, is a machine used for transferring water from a low-lying body of water into irrigation ditches. Water is pumped by turning a screw-shaped surface inside a pipe. Wikipedia References: 1. Abiomed website: https://www.impella.com/how-the-impella-heart-pump-works 2. Wikipedia- Archimedes' screw. https://en.wikipedia.org/wiki/Archimedes'_screw 3. Ginat D, Massey HT, Bhatt S et-al. Imaging of mechanical cardiac assist devices. J Clin Imaging Sci. 2011;1 (1): 21. doi:10.4103/2156-7514.80373 4. Godoy MC, Leitman BS, de Groot PM et-al. Chest radiography in the ICU: Part 2, Evaluation of cardiovascular lines and other devices. AJR Am J Roentgenol. 2012;198 (3): 572-81. 5. Radiopaedia- Impella left ventricular assist device. https://radiopaedia.org/cases/impella-left-ventricular-assist-device?lang=us Related posts: CardioMEMS Device Bicuspid Aortic Valve and Aortic Stenosis Implanted Cardiac Loop Recorder Cardiac Tamponade Following Coronary Artery Rotational Atherectomy Papillary Fibroelastoma of Aortic Valve Micra Intracardiac Pacemaker Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. He has held many leadership positions including Radiology Department Chair and Chief of Staff. 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 and Natalie 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

64 year old male presenting with painless gross hematuria, flank pain, unintentional weight loss, and lower back pain. What is the diagnosis? • Xray of the Week Figure 1. Abdominal CT. What are the significant findings. Figure 2. A,B: Non contrast axial CT images showing a large transitional cell carcinoma obstructing the left renal pelvis (green arrows). There is an incidental renal calculus in left kidney (red arrow). C: Non contrast coronal CT image showing large transitional cell carcinoma obstructing the left renal pelvis (green arrows). D,E: Axial and sagittal CT (Bone window) showing sclerotic metastasis of sacral base (blue arrows) Discussion: Transitional cell carcinoma (also called Urothelial cell carcinoma) is the second most common type of kidney cancer, behind renal cell carcinomas, but only accounts for 5-10% of all primary renal malignant tumors [1]. It is 50x less common than transitional cell carcinoma of the bladder. They are more common in males and typically diagnosed between 60-70 years of age with a mean age at diagnosis of 73 years [2]. Patients with transitional cell carcinoma typically present with hematuria (70-80%) and flank pain secondary to ureter/uretopelvic junction obstruction from tumor mass (20-40%). Other symptoms include bladder irritation and constitutional symptoms such as fatigue, nausea, or diarrhea [3]. The epithelial surface of the renal collecting tubules, calyces, and pelvis share the same embryonic origin as the ureter, bladder, and urethra termed “urothelium”. Transitional/Urothelial carcinoma tend to be multifocal and is believed to arise via field cancerization from potential carcinogens excreted into the urine or active via hydrolyzing enzyme in the urine. Risk factors for developing transitional cell carcinoma include: tobacco use, prolonged exposure to carcinogens (i.e. azo dye, heavy metals, phenacetin, and aromatic amines), chronic/recurrent UTI, schistosomiasis, and prolonged indwelling bladder catheters [3,4,5,6]. Initial choice for diagnosis for patient with suspected transitional/urothelial carcinoma is abdominal CT or retrograde pyelogram. Transitional/urothelial carcinoma typically appear as a soft tissue density with mild enhancement (far less enhancement than renal parenchyma or renal cell carcinomas) [7,8]. They are usually centered on the renal pelvis, rather than the renal parenchyma, and range in size from small filling defects to large masses which can obliterate the renal sinus fat causing appearance of a “faceless” kidney [9]. However, normal renal shape is maintained even in large infiltrating transitional cell carcinomas, whereas large renal cell carcinomas will cause distortion of the renal outline [8,10]. Larger urothelial tumors may have areas of necrosis [8]. In cases of the tumor being small and located at the ureteropelvic junction with resultant hydronephrosis, a small soft tissue mass should be sought. The most common site of metastasis outside the pelvis is the spine, as seen in this patient [10]. Surgical resection is the only curative treatment for localized transitional cell carcinoma. There is limited data/research indicating efficacy of chemotherapy in patients with advanced upper urinary tract urothelial cancers. Advanced clinical trials have shown response with cisplatin-based chemotherapeutical regimens such as MVAC (Methotrexate, Vinblastine, Doxorubicin, and Cisplatin) or GC (Gemcitabine and Cisplatin) [13,14,15,16]. However, these regimens are often complicated or contraindicated in patients with chronic kidney disease which is a very common comorbid condition in patients with transitional cell carcinoma [17]. For these patients, single-agent chemotherapy or checkpoint inhibitor immunotherapy options are currently being researched. Cisplatin-based chemotherapy is not effective for all patients and those for whom this regimen fails, they are often treated with platinum-based therapies, checkpoint inhibitor immunotherapy with PD-1 (programmed cell death 1) or PD-L1 (programmed death ligand 1) antibodies [18,19,20]. ​​​​ References: Andreassen, B. K.; Aagnes, B.; Gislefoss, R.; Andreassen, M.; Wahlqvist, R. (2016). "Incidence and Survival of urothelial carcinoma of the urinary bladder in Norway 1981-2014". BMC Cancer. 16 (1). doi:10.1186/s12885-016-2832-x Raman JD, Messer J, Sielatycki JA, Hollenbeak CS. Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973-2005. BJU Int. 2011 Apr;107(7):1059-64. doi:10.1111/j.1464-410X.2010.09675.x. Epub 2010 Sep 3. PMID: 20825397. Rouprêt M, Babjuk M, Compérat E, Zigeuner R, Sylvester RJ, Burger M, Cowan NC, Gontero P, Van Rhijn BWG, Mostafid AH, Palou J, Shariat SF. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2017 Update. Eur Urol. 2018 Jan;73(1):111-122. doi:10.1016/j.eururo.2017.07.036. Epub 2017 Sep 1. PMID: 28867446. Yang MH, Chen KK, Yen CC, Wang WS, Chang YH, Huang WJ, Fan FS, Chiou TJ, Liu JH, Chen PM. Unusually high incidence of upper urinary tract urothelial carcinoma in Taiwan. Urology. 2002 May;59(5):681-7. doi:10.1016/s0090-4295(02)01529-7. PMID: 11992840. Lee YL, Shih MC, Wu WJ, Chou YH, Huang CH. Clinical and urographic presentation of transitional cell carcinoma of the ureter in a blackfoot disease endemic area in southern Taiwan. Kaohsiung J Med Sci. 2002 Sep;18(9):443-9. PMID: 12515402. Colin P, Koenig P, Ouzzane A, Berthon N, Villers A, Biserte J, Rouprêt M. Environmental factors involved in carcinogenesis of urothelial cell carcinomas of the upper urinary tract. BJU Int. 2009 Nov;104(10):1436-40. doi:10.1111/j.1464-410X.2009.08838.x. Epub 2009 Aug 18. PMID: 19689473. Leder RA, Dunnick NR. Transitional cell carcinoma of the pelvicalices and ureter. AJR Am J Roentgenol. 1990 Oct;155(4):713-22. doi:10.2214/ajr.155.4.2119098. PMID: 2119098. Browne RF, Meehan CP, Colville J et-al. Transitional cell carcinoma of the upper urinary tract: spectrum of imaging findings. Radiographics. 25 (6): 1609-27. doi:10.1148/rg.256045517 Dyer RB, Chen MY, Zagoria RJ. Classic signs in uroradiology. Radiographics. 2004;24 Suppl 1 (suppl 1): S247-80. doi:10.1148/rg.24si045509 Vikram R, Sandler CM, Ng CS. Imaging and staging of transitional cell carcinoma: part 2, upper urinary tract. AJR Am J Roentgenol. 2009;192 (6): 1488-93. doi:10.2214/AJR.09.2577 Punyavoravut V, Nelson SD. Diffuse bony metastasis from transitional cell carcinoma of urinary bladder: a case report and review of literature. J Med Assoc Thai. 1999 Aug;82(8):839-43. PMID:10511795. Owari T, Miyake M, Nakai Y, Morizawa Y, Itami Y, Hori S, Anai S, Tanaka N, Fujimoto K. Clinical Features and Risk Factors of Skeletal-Related Events in Genitourinary Cancer Patients with Bone Metastasis: A Retrospective Analysis of Prostate Cancer, Renal Cell Carcinoma, and Urothelial Carcinoma. Oncology. 2018;95(3):170-178. doi:10.1159/000489218 von der Maase H, Hansen SW, Roberts JT, Dogliotti L, Oliver T, Moore MJ, Bodrogi I, Albers P, Knuth A, Lippert CM, Kerbrat P, Sanchez Rovira P, Wersall P, Cleall SP, Roychowdhury DF, Tomlin I, Visseren-Grul CM, Conte PF. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol. 2000 Sep;18(17):3068-77. doi:10.1200/JCO.2000.18.17.3068. PMID: 11001674. von der Maase H, Sengelov L, Roberts JT, Ricci S, Dogliotti L, Oliver T, Moore MJ, Zimmermann A, Arning M. Long-term survival results of a randomized trial comparing gemcitabine plus cisplatin, with methotrexate, vinblastine, doxorubicin, plus cisplatin in patients with bladder cancer. J Clin Oncol. 2005 Jul 20;23(21):4602-8. doi:10.1200/JCO.2005.07.757. PMID: 16034041. Loehrer PJ Sr, Einhorn LH, Elson PJ, Crawford ED, Kuebler P, Tannock I, Raghavan D, Stuart-Harris R, Sarosdy MF, Lowe BA, et al. A randomized comparison of cisplatin alone or in combination with methotrexate, vinblastine, and doxorubicin in patients with metastatic urothelial carcinoma: a cooperative group study. J Clin Oncol. 1992 Jul;10(7):1066-73. doi:10.1200/JCO.1992.10.7.1066. Erratum in: J Clin Oncol 1993 Feb;11(2):384. PMID: 1607913. Saxman SB, Propert KJ, Einhorn LH, Crawford ED, Tannock I, Raghavan D, Loehrer PJ Sr, Trump D. Long-term follow-up of a phase III intergroup study of cisplatin alone or in combination with methotrexate, vinblastine, and doxorubicin in patients with metastatic urothelial carcinoma: a cooperative group study. J Clin Oncol. 1997 Jul;15(7):2564-9. doi:10.1200/JCO.1997.15.7.2564. PMID: 9215826. Galsky MD, Hahn NM, Rosenberg J, Sonpavde G, Hutson T, Oh WK, Dreicer R, Vogelzang N, Sternberg C, Bajorin DF, Bellmunt J. A consensus definition of patients with metastatic urothelial carcinoma who are unfit for cisplatin-based chemotherapy. Lancet Oncol. 2011 Mar;12(3):211-4. doi:10.1016/S1470-2045(10)70275-8. PMID: 21376284. Burgess EF, Livasy C, Hartman A, Robinson MM, Symanowski J, Naso C, Doherty S, Guerrieri R, Riggs S, Grigg CM, Clark PE, Raghavan D. Discordance of high PD-L1 expression in primary and metastatic urothelial carcinoma lesions. Urol Oncol. 2019 May;37(5):299.e19-299.e25. doi:10.1016/j.urolonc.2019.01.002. Epub 2019 Jan 17. PMID: 30660491. Balar AV, Galsky MD, Rosenberg JE, Powles T, Petrylak DP, Bellmunt J, Loriot Y, Necchi A, Hoffman-Censits J, Perez-Gracia JL, Dawson NA, van der Heijden MS, Dreicer R, Srinivas S, Retz MM, Joseph RW, Drakaki A, Vaishampayan UN, Sridhar SS, Quinn DI, Durán I, Shaffer DR, Eigl BJ, Grivas PD, Yu EY, Li S, Kadel EE 3rd, Boyd Z, Bourgon R, Hegde PS, Mariathasan S, Thåström A, Abidoye OO, Fine GD, Bajorin DF; IMvigor210 Study Group. Atezolizumab as first-line treatment in cisplatin-ineligible patients with locally advanced and metastatic urothelial carcinoma: a single-arm, multicentre, phase 2 trial. Lancet. 2017 Jan 7;389(10064):67-76. doi:10.1016/S0140-6736(16)32455-2. Epub 2016 Dec 8. Erratum in: Lancet. 2017 Aug 26;390(10097):848. PMID: 27939400; PMCID: PMC5568632. Balar AV, Castellano D, O'Donnell PH, Grivas P, Vuky J, Powles T, Plimack ER, Hahn NM, de Wit R, Pang L, Savage MJ, Perini RF, Keefe SM, Bajorin D, Bellmunt J. First-line pembrolizumab in cisplatin-ineligible patients with locally advanced and unresectable or metastatic urothelial cancer (KEYNOTE-052): a multicentre, single-arm, phase 2 study. Lancet Oncol. 2017 Nov;18(11):1483-1492. doi:10.1016/S1470-2045(17)30616-2. Epub 2017 Sep 26. PMID: 28967485. Jay Vora is a medical student at Edward Via College of Osteopathic Medicine (VCOM) – Virginia and plans to pursue a residency in diagnostic radiology. He graduated from UMBC in 2015 with a major in Biochemistry and Molecular Biology. He worked as a research assistant at Brimrose Engineering Corporation of America for 5 years where he completed projects in nanodot detection using imaging and helped develop cancer detection methods in cells using polarized near-infrared autofluorescence and near-infrared reflectance imaging with laser diodes and continuous-wave imaging. He graduated from Eastern Virginia Medical School with a masters in Biomedical science where he was completed research in the study of the barriers that the homeless population faces when seeking healthcare as well as genetic analysis of brain tissue from patients diagnosed with Alzheimer’s. He discovered his passion for radiology during the first radiology lecture at VCOM. Seeing the radiographic images made medical education come to life for him. While shadowing and on rotations, Jay saw how integral the field of radiology is to every other specialty in medicine and its key role in patient care. In his free time, Jay enjoys playing golf and basketball, playing guitar, and technology. Follow Jay Vora on Twitter @JS_Vora Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital 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 and Natalie 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 M. Rice, MD

Name the cardiac device. • Xray of the Week Figure 1. Figure 1. AP Chest X-ray demonstrating placement of 3 MitraClips over the tricuspid valve. Figure 2. A: AP chest X-ray demonstrating placement of 3 MitraClips over the tricuspid valve (yellow arrow) B: Coronal chest CT showing 3 MitraClips over the tricuspid valve in the right atrioventricular septum (red arrow). Mild right atrial dilation is noted. C: Axial chest CT showing 3 MitraClips over the tricuspid valve in the right atrioventricular septum (orange arrow). A normal mitral valve is seen (green arrow). The right atrium is mildly dilated. Discussion: An echocardiogram is the gold standard for evaluating and determining the severity of tricuspid regurgitation (TR)[2]. Severity ranges from mild, moderate, to severe using both qualitative (valve morphology) or quantitative measures (flow calculations and distention of chambers) [2]. The leading cause of TR is due to left heart failure. Rarer causes include rheumatic disease, congenital, myxomatous degeneration, endocarditis, or pulmonary hypertension [3]. Treatment can vary from clinical monitoring, pharmacological therapy, or surgery, depending on the severity and clinical symptoms [4]. Current surgical techniques include tricuspid annuloplasty and tricuspid valve repair. However, minimally invasive methods are starting to gain popularity as the mainstay of treatment. These minimally invasive procedures include heterotopic caval transcatheter valve implantation, transcatheter tricuspid valve annuloplasty, and tricuspid clip placement (MitraClip) [4,5]. Tricuspid clip placement is a unique and innovative procedure; the idea stems from a repair method for regurgitant mitral valves. Pre-procedure planning includes an echocardiogram with a 3D rendering of the tricuspid valve (TV) to increase clip placement accuracy [5]. The procedure first begins with gaining femoral/jugular vein access and inserting a stiff guidewire into the right atrium, confirmed with fluoroscopy [5,6]. A 24 French catheter is advanced over the guidewire. The clip is then inserted through the catheter and positioned perpendicular to the tricuspid valve using 3D rendering of the TV via echocardiogram [6]. An intra-operative echocardiogram is done to measure the change in regurgitation associated with clip placement to optimize reduction. Clips are then placed around the TV leading to an “edge-to-edge” repair [5]. Patients who underwent the procedure showed improvement in the severity of TR and associated symptoms [5,6]. Figures 1 and 2 show tricuspid clip placement. ​​​​ References: Nina VJ, Silva NA, Gaspar SF, et al. Atypical size and location of a right atrial myxoma: a case report. J Med Case Rep. 2012;6:26. Published 2012 Jan 23. doi:10.1186/1752-1947-6-26 Arsalan M, Walther T, Smith RL 2nd, Grayburn PA. Tricuspid regurgitation diagnosis and treatment. Eur Heart J. 2017;38(9):634-638. doi:10.1093/eurheartj/ehv487 Rogers JH, Bolling SF. The tricuspid valve: current perspective and evolving management of tricuspid regurgitation. Circulation. 2009;119(20):2718-2725. doi:10.1161/CIRCULATIONAHA.108.842773 Rodés-Cabau J, Taramasso M, O'Gara PT. Diagnosis and treatment of tricuspid valve disease: current and future perspectives. Lancet. 2016;388(10058):2431-2442. doi:10.1016/S0140-6736(16)00740-6 Hammerstingl C, Schueler R, Malasa M, Werner N, Nickenig G. Transcatheter treatment of severe tricuspid regurgitation with the MitraClip system. Eur Heart J. 2016;37(10):849-853 doi:10.1093/eurheartj/ehv710 Schofer J, Tiburtius C, Hammerstingl C, et al. Transfemoral Tricuspid Valve Repair Using a Percutaneous Mitral Valve Repair System. J Am Coll Cardiol. 2016;67(7):889-890. doi:10.1016/j.jacc.2015.11.047 Deven Champaneri is a medical student at Edward Via College Osteopathic Medicine (VCOM) – Carolinas and plans to pursue residency in diagnostic radiology. While he was rotating through various specialties, he realized his passion for DR and valued its role in all aspects of medicine. He graduated from the University of South Carolina in 2017 with a degree in Business Marketing. During his undergraduate studies, he was involved with multiple volunteer organizations, such as Camp Kemo a summer camp for children with cancer and Palmetto Richland Children’s Hospital. Currently, he mentors at-risk high-school students and tutors students for Step 1/COMLEX 1. In his spare time he enjoys, golfing, backpacking, cooking, and spending time with family. Follow Deven Champaneri on Twitter @devenchampaneri All posts by Deven Champaneri Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital 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 and Natalie 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 M. Rice, MD

​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

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

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

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

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

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