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included patients with a diagnosis of IBS who underwent endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology, forceps biopsies, and FISH test. Patients' charts were reviewed. The outside laboratory that performed FISH test for our institution was contacted. Details of FISH test at that particular laboratory were obtained and compared to the FISH test reported in the literature. Results: The pancreatobiliary FISH test reported in most studies detects aneuploidy for chromosomes 3, 7, and 17 as well as gain or loss of 4 genomic loci (1q21 (MCL1), 7p12 (EGFR), 8q24 (MYC), and 9p21 (CDKN2A)). The FISH test available at our institution detects aneuploidy for the chromosomes 3, 7, and 17 only. We identified a total of 83 adult patients with a diagnosis of IBS who underwent 107 ERCP procedures at our institution. Most patients were middle aged males with distal IBS (table 1). A total of 15 patients were eventually diagnosed with malignancy. Cholangiocarcinoma was the most common diagnosis followed by pancreatic adenocarcinoma. Among the 15 patients with malignancy, 10 had positive cytology, forceps biopsies, or FISH test. Forceps biopsies were positive in 9 patients, while cytology was positive in 2 patients, and FISH in 2 patients. 4 patients were diagnosed with malignancy after surgical excision and 1 patient after percutaneous biopsy. In patients with negative cytology, two had positive FISH test and one had equivocal FISH result, but all three patients had positive forceps biopsy for malignancy. In patients with negative forceps biopsies, FISH test did not detect any additional patient with malignancy. The performance characteristics of the three tests can be found in table 2. Conclusion: Although FISH test was able to identify malignancy in two patients who had negative cytology, it did not identify any additional cases in patients with negative forceps biopsies. The performance of FISH test at our institution was below what was reported in the literature for evaluation of IBS, especially in patients with negative brush cytology and forceps biopsies. Using the 3-chromosome FISH test instead of the 3 chromosomes plus 4 genomic loci may explain the suboptimal results. Physicians need to be familiar with the details of FISH test available at their institution before including it in the diagnostic evaluation of IBS.

We present a case of an 87-year-old female with new-onset hoarseness of unclear etiology. Imaging demonstrated a penetrating aortic ulcer (PAU) in the proximal descending thoracic aorta with an associated pseudoaneurysm that enlarged to a depth of 32 mm over 2 years. This patient was diagnosed with hoarseness being secondary to left recurrent laryngeal nerve (LRLN) palsy, a variant of Ortner syndrome. Patient was treated with endovascular stent-grafting successfully covering of the PAU and pseudoaneurysm with zone 3 proximal landing zone. The patient had moderate improvement in hoarseness after 1 year of follow-up. Endovascular repair is indicated for symptomatic patients with PAUs complicated by enlarging pseudoaneurysms or rupture. Endovascular treatment is effective with low procedural morbidity and mortality. In this case, the PAU and associated pseudoaneurysm at the level of the ligamentum arteriosum caused compression on the LRLN, resulting in a nerve palsy and hoarseness. This case highlights the importance of vascular imaging for patients presenting with unclear etiology of hoarseness or other signs of LRLN palsy. Therefore, aortic arch abnormalities, a variant of Ortner syndrome, even though rare, should be on the differential diagnosis of new onset hoarseness.