X-ray ConferencePresented by F1 Commented by Dr.2011/12/14

CASE 1: 392404CASE 2: 2278384CASE 3:20869877

CASE 1: 392404

General DataAge: 83-year-oldGender: FemaleEthnic: TaiwaneseMarital status: MarriedOccupation: ?Admission date: 2010/03/06

Chief ComplaintDysuria for one week.

Present IllnessThis 88-year-old male has history of hypertension for years and cerebrovascular accident in 2007 under aspirin for prophylactic use.

This time, he suffered from progressive drowsy consciousness since 2 weeks before this admission. There was no fever, chills, productive cough, dyspnea, chest pain, headache, myalgia, muscle weakness, drooling, tarry stool, bloody stool, alcohol consumption nor trauma history.

Tracing back the history, he had suffered from intermittent hematuria, urinary frequency, urgency, nocturia, body weight loss, poor appetite and general malaise since 2011/03.

He had been diagnosed as a victim of benign prostate hyperplasia and received regular follow up at our urologic OPD since 2011/05. Becauses of hematuria, aspirin was hold since 2011/06.

However, the frequency of hematuria increased and the urine output decreased gradually. The patient had experienced acute urinary retention and visited our ER for help 3 days before this admission. Foley catheter was inserted and then he was discharged on the same day.

However, oliguria and consciousness disturbance progressed, so he was sent to our ER for help again on 2011/07/15.

Past HistoryOvarian tumor status post operation 30 years agoIntestinal obstruction status post operation 30 years agoAppendectomy 30 years agoDenied hypertension or diabetes mellitus

Personal HistoryNo known allergy to food or drugsDenies smoking, excess alcohol drinking or betel nuts chewing.

Family HistoryOne of her son has liver cancerOne of her daughter has breast cancerDenied family history with diabetes mellitus or hypertension

Medication historyNeurologic OPD - Aspirin (100mg) 1# qd - Zolpidem (10mg) # prn - Quetiapine (25mg) 2# hs - Clonazepam (0.5mg) 1# hs

Urologic OPD - Dutasteride (0.5mg) 1# qd - Terazocin(2mg) 1# hs

Admission history1999/04 urinary tract infection and pneumonia

Physical ExaminationT:36.8/ P:88/min R:16/min BP:98/63/mmHgGENERAL APPEARANCE: chronic-ill lookingConsciousness: E4V5M6HEENT: pink conjunctiva, anicteric scleraChest: smooth respiration, bilateral clear breathing sounds.Heart: regular heart beats, no murmurs.Abdomen: soft and flat, normoactive bowel soundsBack: No knocking pain over both CV angleExtremity: freely movable, no pitting edema.

Laboratory Findings

Hemogramunit2010/03/06WBC/uL7500RBCmillion/uL4.47Hemoglobing/dL9.0Hematocrit%29.9MCVfL66.9MCHpg/cell20.1MCHCg/dL30.1RDW%16.2Platelets/uL354kSegment%73.5Lymphocyte%20.2Monocyte%3.6Eosinophil%2.4Basophil%0.3

ABG7/15PH7.536PaCO223.5PaO2179.9HCO319.5TCO220.2SBE-3.1ABE-1.1Sa%99.4

Laboratory Findings

BiochemistryUnit2010/03/067/157/16BUNmg/dL10076.260.4Crmg/dL3.0110.588.52NaMeq/L132123127KMeq/L4.86.44.8CaMeq/L7.57.8PMeq/L5.53.9Osmolalitymosm/KgH2O283ASTU/L1955ALTU/L193730LipaseU/L5778Bil(T)mg/dL0.30.9CRPmg/L73.57Albuming/dL2.64

Lab

Urinalysis2010/03/062011/07/16ColorYellowRedTurbidityTurbidCloudySp. Gravity1.0121.020pH6.08.0Leukocyte3++NitriteNegative+Protein1+3+GlucoseNegativeNegativeKetoneNegativeTraceUrobilinogen0.11.0BilirubinNegativeNegativeBacteria++Blood3+3+RBC>500>500WBC>500350Epi.10

7/15 CXR

7/15 Left decubitus view

7/15 Brain CTRecent rt precentral gyral infarct

2011/07/16 Kidney EchoLeft Kidney Length: 10.2 cm

Right Kidney Length: 9.8 cm

2011/7/16 Non-contrast CT

2011/7/16 Abdominal CTFindingsBilateral hydronephrosis with mural thickening and intraluminal hematomas in the urinary bladder

Impressionr/o urinary bladder tumors with obstructive uropathyand hemorrhagic cystitis

2011/07/17 CXR

2011/07/25 Contrast CT

FindingsA bulky heterogeneous mass in the urinary bladder and prostate gland.

Enlarged pelvic LAPs suggest LN metastases.

Diffuse lung nodules in bilateral lungs

Osteolytic and sclerotic lesions in the spine, DDx: osteoporosis change, bone metastases.

Impression R/O tumor as described. DDx: urinary bladder cancer, prostate cancer, both urinary bladder and prostate cancer.

Urine cytology7/16 Negative for malignancy7/25 Negative for malignancy

DiagnosisA bulky heterogeneous mass in the urinary bladder and prostate with diffuse lung nodules and osteolytic lesions in the spine, favor bladder cancer with lung and bone metastasesHematuria, favor bladder tumor related Acute renal failure due to obstructive uropathy, complicated with hyperkalemia and metabolic acidosisNormocystic anemia, favor maligancy related, rule out renal failure relatedRecent right precentral gyral infarctBilateral aspiration pneumonia

DiscussionBladder cancer v.s Prostate cancer

Bladder cancer v.s Prostate cancer

Bladder cancerProstate cancerIncidence386000 cases/yr900000 cases/yrMean age65 y/o70 y/oRisk factoraging, high fat diet, family history, race (blacks)smoking, pollution or chemical exposures, race (whites), aging, radiation therapy, chronic bladder inflammation, family history

Clinical presentationBladder cancerProstate cancerMost commonHematuria(initial sign in 80-90%), flank pain, suprapubic pain, perineal pain, abdominal pain.Obstructive voiding symptomsCommonIrritative voiding symptomsback or hip dull painLess commonObstructive voiding symptomsHematuria (microscopic) hamatospermiaAdvanced cancersexual dysfunction , bone pain, Poor prognosis factorsFatigue, weight loss, anorexia, failure to thriveFatigue, weight loss, anorexia, failure to thrive* Obstructive voiding symptomsurinary straining, intermittent stream* Irritative voiding symptomsdaytime and/or nocturnal frequency, urgency, dysuria, or urge incontinence

Bladder cancerProstate cancerDistant metastasisLung, bone, liverboneDiagnostic instrumentUrinary cytologyultrasonographyIVPcystoscopyCTMRIbone scanPETDREPSATRUS guided biopsybone scanbone MRIPETcirculating prostate cancer cellTreatmentSurperficial (75%) Endoscopic resectionLocal invasive (20%) Surgery, CCRTMetastastic (5%)C/TLocalized Surgery, R/T, H/TAdvanced Androgen deprivation(surgical or medical)H/TC/T Prognosis5-year survival rateSurperficical 85%Local invasive60~75%Metastastic 14~22%5-year survival rateLocalized 100%Advanced 31%

CASE 2: 889344

General DataAge: 27-year-oldGender: maleEthnic: TaiwaneseMarital status: SingleOccupation: Student

Chief ComplaintIntermittent fever for 3 days

Present Illness This 27-year-old male patient has history of frequent hemoperitoneum since 4 years ago and end stage renal disease under continuous ambulatory peritoneal dialysis for 19 years.

He was admitted to this hospital because of intermittent fever up to 39 degree for 3 days.

He denied chills, productive cough, dyspnea, chest pain, urinary frequency, micturation burning sensation, arthralgia or insect bite history.

According to the statement of the patient's mother, he had experienced intermittent nausea, vomiting with dark-green vomitus and watery diarrhea since 2 years ago.

The frequency of nausea and vomiting increased since 2 weeks before this admission. Fever and epigastralgia developed since 2011/06/06. So, the patient was sent to hospital initially where tachycardia and cloudy dialysate were also noted.

Due to above, the patient was transffered to our ER for further management on 2011/06/08.

Past HistoryGastroesophageal reflux disease has been diagnosed in 2009Liver tumors has been found at age of 18Secondary hyperparathyroidism, status post total parathyroidectomy on 2010/10/19

Personal HistoryAllergy: unknown inhalation medication and contrast medium for CT

Alcohol (Denied)

Smoking (Denied)

Betelnut (Denied)

Medication historyNephrologic OPD - Calcium carbonate(500mg) 2# TID - Esomeprazole (40mg) 1# QD - Ferrous gluconate B (300mg) + Vit B1 (10mg) + Vit C (30mg) 1# BID - Folic acid (5mg) 1# QW - MPEG-Epoetin beta 1 amp QM (100mg/0.3ml) - Vitamin B complex 1# QD - Calcitrol (0.25mcg) 2# QD

Admission history (I)2001/03 Acute tonsilitis

2005/04 Acute gastroenteritis

2006/07 Poor function of CAPD catheter2006/10 Acute gastroenteritis

2007/09 Bloody dialysate, favor liver adnemoa bleeding

Admission history (II)2008/01 Bloody dialysate, favor liver adnemoa bleeding

2009/07 Bloody dialysate, favor liver adnemoa bleeding

2010/06 Ileus, suspect post-operation adhesion related

2010/10 Hyperparathyroidism

Surgical historyCAPD catheter implantation in 1993Inguinal hernia status post heniorrhaphy on 2004/07/06

Hickman insertion via right jugular vein on 2006/07/01

CAPD catheter outflow obstruction status post exploratory laparotomy with clean the pertoneal calcifications on 2006/07/10

Secondary hyperparathyroidism status post total parathyroidectomy on 2010/10/19

Physical ExaminationVital signs BT 37.3 PR: 148/min, RR: 18/min, BP: 105/85 mmHgBH:151cm BW:38kgGeneral appearance: acute-ill lookingConsciousness: E4V5M6HEENT: pale conjunctiva, anicteric sclera dry oral mucosaChest: bilateral clear breathing sounds.Heart: Regular heart beat, no audible murmur

Physical ExaminationAbdomen: soft and flat. No rebounding pain **Bowel sound: hyperactive **Tenderness over epigastric area **Tympanic percussion over whole abdomenBACK: No knocking pain over bilateral CV angleEXTREMITIES: Freely movable No pitting edema SKIN: No petechiae nor ecchymosis No skin rash **decreased skin turgor

Laboratory Findings

Hemogramunit6/8WBC/uL13500RBCmillion/uL2.40Hemoglobing/dL8.7Hematocrit%15.8MCVfL75.1MCHpg/cell24.9MCHCg/dL32.3RDW%20.9Platelets/uL174kSegment%64Band%18Lymphocyte%7Monocyte%11Eosinophil%0.1Basophil%0.2

Laboratory Findings

BiochemistryUnit6/8BUNmg/dL53.5Crmg/dL13.80NaMeq/L130KMeq/L2.7ClMeq/L92CaMeq/L8.1PMeq/L4.3ALTU/L 5Bil(T)0.7CRP106.87Albumin2.49Alk-P78LipaseU/L18

ABG6/8PH7.434PaCO236.9PaO242.2HCO324.1Sa%79.7

Laboratory FindingsKleb. Pneumoniae

Ascites2011/6/082011/06/132011/07/21ColorCloudyCloudyTurbidTurbidityYellowColorlessYellowSp. Gravity1.0081.0101.001ProteinPositiveNegativePositiveWBC6095412517875RBC1275 5 875Neutrophil 100 98 92Lymphocyte 0 2 8Macrophage Few Few FewGNB 2+ -

06/08 CXR

06/08 KUB

06/13 Abdominal echoTwo hyperechoic liver tumors 2.72 & 2.5 cm at S4Parenchymal liver disease, score 6Bil. pleural effusion and ascites

Normal liver sizeHeterogeneous parenchyma, even liver surface and obscure vasculature

Admission course06/08~06/08 ER S/S: Fever, nausea/vomiting, epigastralgia, cloudy dialysate => Vancomycin (IP) + Fortum (IP) 8D (06/08)06/08~06/14 8D ward 06/13 S/S: Recurrent fever, shock vomited with massive coffee ground, dyspnea, cloudy dialysate Fluid supply, Give PPI, IntubationRemove CAPD catherter GS ICU (06/14)Vancomycin (IV) + Fortum (IV)Shift CAPD to H/D since 06/15

06/14~06/23 GS ICUS/S: Fever, productive cough, coffee groundKeep Vancomycin (IV) + Fortum (IV) for aspiration pneumonia06/18 PESesophageal ulcer and superficial gastritis06/21 CT peritoneal calcifications, ascites, liver tumor over S406/23 Extubation 8D ward (06/23)06/23~06/24 8D ward 06/24 S/SRecurrent fever, chills, tachypnea, tachycardia, chest discomfort, dyspneaImpending hypoxia respiratory failureIntubation + Dopamine GS ICU (06/24)

06/24~07/08 GS ICU IV form antibioticsFortum + Teicoplanin + Meropenam + Fluconazole 06/27 S/Shematemesis PRBC transffusion, PPI, DDAVP 06/27 Nasophrayngoscope No nasal nor oral bleeding 07/01 Panendoscope Esophageal ulcers, gastric polyp=> 07/05 Extubation 8D ward (07/08)07/08~ 8D ward=> S/Sintermittent fever, fair digestion function, no nausea nor vomiting, cloudy dialysate IV form antibioticsTeicoplanin + Meropenam + Fluconazole

06/21 CT

06/21 CT.

DiagnosisRefractory CAPD peritonitis status post PD tube removal on 6/14 , disease progression with moderate amount of cloudy ascites under pigtail tube drainage since 6/21End stage renal disease under H/D QW135 via right neck Hickmann UGI bleeding, favor esophageal ulcer relatedRight side aspiration penumoniaLiver nodules, suspect hemangioma Diffuse peritoneal calcification, favor CAPD peritonitis related, rule out prior hemoperitoneum related

DiscussionWhat is the etiology of the peritoneal calcification?

Peritoneal calcificationCauses and Distinguishing Features on CTAmerican Journal of Roentgenology:182, Feb 2004

IntroductionThe etiology of peritoneal calcification 1. Peritoneal malignancies 2. Sclerosing peritonitis due to peritoneal dialysis 3. Peritoneal tuberculosis 4. Prior meconium peritonitis 5. Hyperparathyroidism 6. Pneumocystis carinii infection 7. Postsurgical heterotopic ossificationAmerican Journal of Roentgenology.:182, February 2004

Materials and MethodsRetrospective review of reports from 74765 abdominopelvic CT examinations perfromied during a 7-year period.Examining medical and histopathologic recordsCalcification morphology was classified as nodal, nodular or sheetlike on the consensus interpretation by 2 independent radiologists.Chi-square analysis

Result

84-year-old woman with serous ovarian adenocarcinoma.Agarwal A et al. AJR 2004;182:441-4452004 by American Roentgen Ray SocietyNodular calcification

84-year-old woman with serous ovarian adenocarcinoma.Agarwal A et al. AJR 2004;182:441-4452004 by American Roentgen Ray SocietyNodal calcification

30-year-old woman who was undergoing continuous ambulatory peritoneal dialysis.Agarwal A et al. AJR 2004;182:441-4452004 by American Roentgen Ray SocietySheetlike calcification

30-year-old woman who was undergoing continuous ambulatory peritoneal dialysis.Agarwal A et al. AJR 2004;182:441-4452004 by American Roentgen Ray SocietySheetlike calcification

46-year-old woman with ovarian papillary serous adenocarcinoma.Agarwal A et al. AJR 2004;182:441-4452004 by American Roentgen Ray SocietyNodular calcification

ConclusionThe common causes of peritoneal calcification - Benign causes 1. Peritoneal dialysis related (N=4) 2. Prior peritonitis (N=3) 3. Cryptogenic origin (N=1) - Malignant cause 1. Ovarian carcinoma (N=9)

Sheet-like calcification was more common in benign cause; nodal calcification and calcified lymph nodes were seen only in malignant cause.American Journal of Roentgenology.:182, February 2004

THE END

*******************Old lacunar infarcts and microangiopathic leukoencephalopathy

*Irregular contour. * The cortical echogenicity is increased with markedly reduced cortical thickness of right kidney. One echo-free lesion (0.9cm) with posterior wall enhancement over the middle portion of right kidney.No renal mass nor stoneImpression: 1. Severe right hydronephrosis with hydroureter 2. Moderate left hydronephrosis with hydroureter 3. Right renal cyst

*Uro for cystoscope**7/20X-manbilateral PCNright PCNurine ouputBUN/CR110/8.1396/7.46, bedside echo: right hydronephrosis improve*For malginancy survey*Uro high risk for surgeryOnco supportive careH/Danti-cancer tx => hospice Condition donwhill, U/O decrease, BUN/Cr => hyperkalemia => 8/4 critical AAD****Gross hematuria40% bladder cancerMicroscopic hematuria25% prostate cancer*Gross hematuria40% bladder cancerMicroscopic hematuria25% prostate cancer*Gross hematuria40% bladder cancerMicroscopic hematuria25% prostate cancer***** 7 y/o foamy urine, general edema renal insufficiency no biopsy 9 y/o ESRD under H/D years CAPD** Vomiting all day long 5-10min,

***********************2 mechanism1 malignancy LN involevement 2 - Systemic mineral imbalance ( Uremia or hyperparathyroidism ), tissue injury, aging or diz dystrophic calcification*University of California San FranciscoAbdominal CT indication: abdominal pain, nausea/vomiting, known or suspected tumor**84-year-old woman with serous ovarian adenocarcinoma. IV and oral contrastenhanced abdominal CT scan shows large nodular calcifications (arrowheads) in left side of abdomen.84-year-old woman with serous ovarian adenocarcinoma. Pelvic CT scan shows calcified left inguinal lymph node (arrow). Pelvic cavity is largely replaced by large solid and cystic calcified mass.30-year-old woman who was undergoing continuous ambulatory peritoneal dialysis. IV and oral contrastenhanced abdominal CT shows sheetlike calcification around spleen (arrow) and liver (arrowheads) extending into fissure for ligamentum teres. Splenic arterial calcification is present.30-year-old woman who was undergoing continuous ambulatory peritoneal dialysis. Pelvic CT scan shows peritoneal dialysis catheter (white arrow) as well as sheetlike calcification surrounding bowel and mesentery (arrowheads), associated with diffuse bowel wall thickening and soft-tissue components (black arrow).46-year-old woman with ovarian papillary serous adenocarcinoma. IV and oral contrastenhanced CT scan shows several nodular calcifications (arrows) in lesser sac and fissure for ligamentum teres.9 ovarian cancer 3 C/T, 1 R/Tlocation, size, extent and association with soft tissue masses ere not helpful in distinguishingNo Squamous cell lung cancer, RCC, melanoma => paraneoplastic hyperparathyoridism and hypercalcemia No calcified peritoneal carcinomatosis, colon cancer and gastric cancer **