We read with great interest the recent ar− ticle by Jonas et al. [1] which described the endoscopic ultrasound− (EUS−)guided drainage of a cystic metastasis in the mediastinum, and also the article by Mohl et al. [2] reporting their experience of endoscopic transhiatal drainage of a mediastinal pancreatic pseudocyst. Both articles reported interesting cases of EUS− guided or EUS−assisted drainage of med− iastinal lesions. We recently managed a similar case, a patient with a large pancre− atic pseudocyst that extended through the diaphragmatic hiatus inside the me− diastinum, which was complicated by a left pleural effusion.A 30−year−old man, with a known history of heavy alcohol consumption, was ad− mitted in the Emergency Department complaining of intense epigastric pain, nausea, and vomiting. He was suspected to have acute pancreatitis. Computed to− mography revealed a large (15 cm) pan− creatic body pseudocyst that extended upward through the diaphragmatic hiatus into the posterior mediastinum, close to the descending aorta ( Figure 1). A large left pleural effusion with a high amylase content was also present, which persisted despite two drainage procedures and 1 month of conservative treatment.Because of the close proximity to the aor− ta and the absence of a clear bulge inside the stomach or esophagus, EUS−guided drainage of the mediastinal pancreatic pseudocyst was performed through the terminal esophagus using a large−channel linear ultrasound endoscope (Olympus GF−UC160T AL5; Olympus, Hamburg, Ger− many) and a one−step drainage system consisting of a diathermic catheter−guide− wire assembly and a mounted 5−cm, 10−Fr stent (Giovannini Needle Wire; Wilson− Cook, Limerick, Ireland). The procedure was technically successful, with good vi− sualization of the stent placement inside the mediastinal pancreatic pseudocyst ( Figure 2) and intermittent drainage of fluid inside the esophagus. After 24 hours, upper gastrointestinal endoscopy and computed tomography with coronal re− construction of the images showed that the stent had rolled over, with the upper esophageal end now inside the stomach, in a good downward−facing position that allowed drainage of the mediastinal col− lection directly into the stomach (Fig− ure 3).The clinical course was favorable and after 1 month there was complete disappear− ance of both the mediastinal pancreatic pseudocyst and the left pleural collection. On computed tomographic scans, the stent was visualized with the upper end in the mediastinum in close contact with the descending aorta, without any fluid collections (Figure 4). The stent was gent− ly pulled inside the stomach and subse− quently removed without any complica− tions. The patient was then followed up for 3 months without any evidence of re− currence.EUS−guided drainage of symptomatic pancreatic pseudocysts is currently con− Figure 4 Control contrast−enhanced axial computed tomographic image after 30 days, showing the stent with its upper end in the mediastinum in close contact with the des− cending aorta, and no flu...

Context:The recent introduction of elastography has increased the specificity of USG and enabled early diagnosis of breast cancer. Quantitative elastography, especially with strain ratio (SR) index, improves diagnostic accuracy and decreased number of biopsies.Aims:The purpose of this study was to assess the role of USG elastography in the differential diagnosis of breast lesions.Settings and Design:This prospective study was conducted in the University of Medicine and Pharmacy Research Centre of Craiova.Materials and Methods:Fifty-eight patients diagnosed with breast lesions between January 2009 and January 2010 were included in this prospective study. All the patients were examined in the supine position, and the B-mode USG image was displayed alongside the elastography strain image. For obtaining the elastography images we used a EUS Hitachi EUB 8500 ultrasound system with a 6.5-MHz linear probe. The elastography strain images were scored according to the Tsukuba elasticity score.Statistical Analysis:We performed receiver operator characteristic (ROC) analysis for assessment of the role of USG elastography in the diagnosis of breast lesions.Results:We obtained a sensitivity of 86.7% and a specificity of 92.9% for elasticity score and a sensitivity of 93.3% and a specificity of 92.9% for SR (when a cutoff point of 3.67 was used). There was very good correlation between SR and elasticity score (Spearman coefficient of 0.911).Conclusions:Elastography is a fast, simple method that can complement conventional USG examination. This method has the lowest cost/efficiency ratio and it is also the most noninvasive and accessible imaging method, with an accuracy comparable to MRI.

No abstract

The importance of this case is derived from the atypical clinical appearance and course, with uncertain aetiology after complex imaging, biological and surgical explorations.