A rare case of paratesticular leiomyoma in a child

Leiomyomas are benign, slow-growing, smooth muscle tumors, which can occur at many locations in the body. The male genitourinary tract is seldom affected and scrotal leiomyomas are extremely rare. Most of the scrotal leiomyomas are localized in the testis, epididymis, spermatic cord, subcutaneous tissue, tunica albuginea, and scrotal skin and only a few of them are reported in the origin of isolated tissue without paratesticular structures in the paratesticular region. We are presenting a case of solitary paratesticular leiomyoma in a child, which is very rare in terms of lesion location and patient age, and describing the imaging features of this lesion.

Hydatid disease of the liver with portal vein invasion mimicking portal vein thrombosis

Hydatid cyst disease is a zoonosis caused by the parasite Echinococcus. It may infest any organ of the body, but it most frequently involves the liver, lungs, and nervous system. Portal vein involvement by hydatid cyst disease is extremely rare with only five cases published in the English literature to our knowledge. We present the ultrasonography (US) and computed tomography (CT) findings of a 77-year-old male with hydatid disease of the liver with portal vein invasion mimicking portal vein thrombosis. Colour Doppler US confirmed the lack of blood flow within the portal vein and stigmata of cavernomatosis. CT clearly demonstrated a communication between the multiloculated lesion and the portal vein and the multiple daughter vesicles obstructing the portal vein. The consideration of this complication will make it possible to distinguish this entity from portal vein thrombosis and, thus, the management of the patients with hydatid cyst disease particulary in endemic regions.

Abstract P5-02-03: Testing machine learning algorithms' performance for non-invasively identifying breast cancer molecular subtypes using BI-RADS evaluations

Purpose: Inter- and intra-observer variability adversely affects interpretation of highly advantageous MRI data in breast cancer diagnosis, prognosis and therapeutic decisions. Machine learning (ML) might potentially provide support to the physicians for objective decision strategies. In this work, ML methods using BI-RADS features were tested for non-invasively determining molecular subtypes of breast cancer.

Methods: In this IRB approved study, Out of 126 consecutive patients' retrospective data with written consent, 69 patients (mean±std age 48.24±11.62 and range [27-82]) with full histopathological and MRI data were selected. In surgical histopathological data ER+PR+HER2- was classified as luminal HER2(-), ER+PR+HER+ was classified as luminal HER2(+), ER-PR-HER2+ was classified as HER2(enriched) and ER-PR-HER2- was classified as triple negative. The cohort revealed 51 luminal HER2(-), 11 luminal HER2(+), 7 triple negative cases without any HER2(enriched) occurrence. DCE, DW, T2W MRI data were obtained on a 1.5T Magnetom Espree (Siemens, Erlangen, Germany) scanner which were subsequently interpreted in consensus by 2 radiologists of 15 and 10 years of experience.

Age, mass and non-mass properties, non-enhancing BI-RADS findings, ADC values obtained from radiologist drawn ROIS and kinetic curve properties were fed to 22 standard ML algorithms provided in Matlab® (Mathworks, Natick, MA, USA) as predictors for 3 categories. The algorithms were run by cross validating on 50 folds whereby reported classifier accuracy was obtained from each of the observations when in held-out fold.

Results: Out of 22 ML algorithms tested Support Vector Machine's Fine Gaussian variant, Ensemble Boosted Trees and Fine K-Nearest Neighbor resulted in 76.8%,71.0% and 53.6% accuracy with (100%, 18%, 0%), (92%, 9%, 14%) and (67%, 18%, 14%) true positive rates for predicting each histopathological category respectively. Furthermore, PCA based dimension reduction worsened the outcomes indicating high sensitivity to the feature set.

Conclusion: ML algorithms demonstrated potential as a decision support system increasing assessment objectivity with an added non-invasiveness advantage. However, overall algorithm performance indicates further studies with larger cohorts and broader feature are necessary for refinements and improving ML methodology in breast cancer imaging.

Citation Format: Ozcan A, Aksoy Ozcan U, Ekemen S, Ulus S, Oyan B. Testing machine learning algorithms' performance for non-invasively identifying breast cancer molecular subtypes using BI-RADS evaluations [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-02-03.

Abstract P5-02-05: Correlation of proliferation index markers (Ki-76 and PHH3) with breast MRI apparent diffusion coefficient values

Objective: In recent literature, increasing number of studies have analyzed associations between the MRI findings and histopathological features of breast cancer. Ki-67 index is an important prognostic factor in breast cancer which provides information about the mitotic activity and the growth rate of the tumor. The proliferation index markers like Ki-67 and PHH3 (Phosphohistone H3) play an important role in decision making in the treatment regimes. PHH3 is a relatively new entity which is specific only to the proliferation giving it a unique characteristic because it is not observed at the interphase. PHH3 provides a more sensitive and accurate mitotic index with less interobserver variability when compared with conventional H&E staining, thus emphasizing its potentially increased value in practice. In this study, our aim is to correlate both proliferation index markers (Ki-67 and PHH3) with breast MRI features in cases of invasive breast carcinoma.

Material and Methods: In this IRB approved study, out of 126 consecutive patients' retrospective data with written consent, 29 patients (mean±std age 48.86±13.10 and range [28-82]) with full apparent diffusion coefficient (ADC), Ki67 and PHH3 data were selected. In all of these surgical specimens, immunohistochemically administered Ki-67 and PHH3 and immunopositive cells in the digital pathology were counted. MRIs were performed in a 1.5T MR unit (MagnetomEspree with Syngo MR B15 software; Siemens, Erlangen, Germany). Images were evaluated by two radiologists in consensus. Mean ADC values were obtained from radiologist drawn ROIs. The results were analyzed with principle component analysis (PCA) and pairwise covariance analysis.

Results: Mean ADC value was (mean±std) 0.92±0.18 with range [0.67-1.3] (10-3mm2/s), mean Ki67 was 18.62±13.32 with range [5-62] ('%' for Ki-67) and PHH3 27.17±30.81 with a range [1-111] ('10HPF' for PHH3). When PCA was conducted in (ADC, Ki67, PHH3) space, after normalizing each of the variables 45.223% of total variance was explained mainly by the new variable obtained as a linear combination of the normalized values -0.0866*ADC - 0.9879* Ki67 - 0.7910*PHH3, 37.282% by -0.9879*ADC + 0.1545Ki67 -0.0101*PHH3 and 17.494% by 0.1283*ADC + 0.7806*Ki67 - 0.6117*PHH3 respectively. The analysis demonstrates that while Ki67 and PHH3 values explain much of the variance (45.223% + 17.494%) and thereby are highly correlated as expected, ADC on its own determines a significant portion(37.282%) of the data as well. Moreover, pairwise covariance analysis resulted in ADC, Ki67 and PHH variance values of 2.170, 1.528 and 2.197 respectively and, covariances of ADC|Ki67 (-0.1169), ADC|PHH3 (0.2048) and Ki67|PHH (1.31).

Conclusion: Ki-67 and PHH3 both show good correlation in the assessment of proliferative status of breast cancer. However, breast MRI ADC values cannot be reliably used for the prediction of Ki-67 and PHH3 status of the invasive breast tumors. More studies with larger series are needed to assess the potential of breast MRI to serve as a clinical and/or prognostic factor.

Citation Format: Ekemen S, Ozcan A, Aksoy Ozcan U, Ulus S, Oyan Uluc B. Correlation of proliferation index markers (Ki-76 and PHH3) with breast MRI apparent diffusion coefficient values [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-02-05.

Acute carpal tunnel syndrome caused by thrombosed persistent median artery associated with bifurcated median nerve in a pregnant woman

Carpal tunnel syndrome (CTS) is a common form of peripheral nerve entrapment, which is observed due to compression of the median nerve at the level of the carpal tunnel in the wrist. Bifid median nerve and persistent median artery association are rare, and they may be independent risk factors for CTS. These rare entities are usually asymptomatic, but in cases of acute thrombosis or dilatation of the persistent median artery, acute findings can be seen. We report a case of acute CTS due to thrombosis of a persistent median artery and associated bifurcated median nerve during pregnancy.

Differentiation of secondary involvement of the breast by lymphoreticular malignancy from fibroadenoma using ultrasound elastography: A report of two cases

Extramedullary lymphoma infiltration of the breast by lymphoblastic lymphoma is very rare and most cases are of B-cell lineage; T-cell neoplasms represent less than 10% of all breast lymphomas. Here, we report one patient with lymphoblastic lymphoma and one patient with leukemia, who have similar lesions in breasts with different ultrasound elastography findings. Ultrasound-guided tru-cut biopsies were performed and the first lesion was confirmed as lymphoma infiltration and the second as fibroadenoma. In cases of breast mass presence in patients with a history of hematologic malignancies such as lymphoma or leukemia, breast infiltration should be kept in mind. Elastography findings can assist in the differentiation of these lesions and further investigations or biopsies can be avoided.

Aneurysm of Portosystemic Fistula: A Case Report and Review of Literature

Aim:

A case of asymptomatic aneurysm of spontaneous portosystemic venous fistula (SPVF) with the radiologic findings is described.

Background:

Although advances and more widespread use of ultrasound (US) and computed tomog -raphy angiography (CTA) have enabled more detection of SPVF in the liver, it is a rare entity.

Case report:

A 49-year-old male was referred to our hospital’s nephrology outpatient clinic due to hypertension. Abdominal sonography examination detected a well-defined cystic lesion adjacent to the middle hepatic vein in the liver. The lesion showed venous flow in the color Doppler US examination. Computed tomography angiography examination revealed an aneurysm of the fistula.

Conclusion:

Radiologists should be aware of this vascular anomaly and cyst-like lesions in the liver should be examined with color Doppler ultrasonography for possible vascularization, and be differentiated with CTA if necessary.

Clinical significance:

This condition is usually encountered incidentally and patients usually have no symptoms. However, severe complications, such as hepatopulmonary syndrome, liver tumors, encephalopathy, and heart failure can be seen.

How to cite this article: Ulus S, Akan GE, Erol C. Aneurysm of Portosystemic Fistula: A Case Report and Review of Literature. Euroasian J Hepato-Gastroenterol 2017;7(2):178-180.

De Novo Vascular Lesions After Liver Transplant in a Case With Hereditary Hemorrhagic Telangiectasia and Fibropolycystic Liver Disease: Long-Term Follow-Up With Magnetic Resonance Imaging and Magnetic Resonance Angiography

We report a case of a 62-year-old woman who received a liver transplant 19 years previously for end-stage liver disease due to hereditary hemorrhagic telangiectasia and fibropolycystic liver disease. During long-term follow-up 8 years after the liver transplant, de novo vascular lesions were detected with magnetic resonance imaging and magnetic resonance angiography. Hepatic vascular lesions had slowly progressed, despite no symptoms. To our knowledge, there are few reports in the English literature of de novo vascular lesions after liver transplant in patients with hepatic telangiectasias.

Whole-Body MRI Screening in Asymptomatic Subjects; Preliminary Experience and Long-Term Follow-Up Findings

BACKGROUND

The aim of this study is to describe the technique and to evaluate the results of whole-body magnetic resonance imaging in an asymptomatic population.

MATERIAL/METHODS

Between March 2009 and December 2011, 118 consecutive subjects undergoing thorough medical check-up were prospectively included in the study. MRI was performed with a 205-cm moving table, parallel imaging and automatic image composing software.

RESULTS

In 83 subjects (70%), 103 benign lesions were detected. Two malignant (adrenal and renal carcinoma) lesions and one precancerous (pancreatic mucinous carcinoma) lesion were detected. The most common lesions were renal cysts, liver hemangiomas, liver cysts, thyroid nodules, and uterine leiomyomas.

CONCLUSIONS

WB-MRI is able to cover area from head to toes in one diagnostic work-up, and besides the anatomic regions evaluated by conventional radiological modalities, i.e. brain parenchyma, bones and extremities, can be evaluated in one examination.

Leiomyosarcoma of the Inferior Vena Cava Confirmed by Aspiration Biopsy With a Catheter During Digital Subtraction Angiography

Leiomyosarcoma of the vascular origin is a rare malignant tumor. It originates from the smooth muscle cells of the media with intra- or extraluminal growth, and in most cases it arises in the inferior vena cava. The diagnosis is often delayed because the clinical symptoms of this disease are often nonspecific. Accurate diagnosis of inferior vena cava leiomyosarcoma (IVCLMS) needs histologic confirmation. We report a case of IVCLMS histologically confirmed by aspiration biopsy with a catheter during digital subtraction angiography presenting with pulmonary emboli in a 65-year-old man.

Susceptibility-weighted imaging in migraine with aura

We report 2 patients with migraine with aura, in whom SWI showed transient prominence of the venous vasculature within areas of impaired perfusion. The findings resolved spontaneously in both patients. This imaging technique may play a helpful role in assessing the vascular events in migraine with aura.

Intrathecal gadolinium-enhanced MR cisternography in the evaluation of CSF leakage

BACKGROUND AND PURPOSE

Radiologic identification of the location of the CSF leakage is important for proper surgical planning and increases the chance of dural repair. This article describes our experience in analyzing clinically suspected cranial CSF fistulas by using MR imaging combined with the intrathecal administration of a gadolinium-based contrast agent.

MATERIALS AND METHODS

A total of 85 consecutive patients with suspected CSF fistulas who presented with persistent or intermittent rhinorrhea or otorrhea lasting for more than 1 month between 2003 and 2007 were included in this study.

RESULTS

We observed objective CSF leakage in 64 of 85 patients (75%). The CSF leak was located in the ethmoidal region in 37 patients (58%), in the superior wall of the sphenoid sinus in 8 patients (13%), in the posterior wall of the frontal sinus in 10 patients (15%), in the superior wall of the mastoid air cells in 6 patients (9%), and from the skull base into the infratemporal fossa in 1 patient (2%). Two patients (3%) showed leakage into >1 paranasal sinus.

CONCLUSIONS

MR cisternography after the intrathecal administration of gadopentate dimeglumine represents an effective and minimally invasive method for evaluating suspected CSF fistulas along the skull base. It provides multiplanar capabilities without risk of radiation exposure and is an excellent approach to depict the anatomy of CSF spaces and CSF fistulas.

Pain & resistance in patients with adhesive capsulitis during contrast material injection phase of MR arthrography

BACKGROUND & OBJECTIVE

Adhesive capsulitis of the shoulder is a condition of unknown aetiology that results in the development of restricted active and passive glenohumeral motion. It has been reported that magnetic resonance (MR) imaging is useful in diagnosing adhesive capsulitis. We carried out this study to assess how pain and/or resistance during contrast material injection affects the diagnosis of adhesive capsulitis on magnetic resonance (MR) arthrography.

METHODS

The study included MR arthrography examinations of 21 patients with a diagnosis of adhesive capsulitis. The control group consisted of 20 patients who presented clinically with rotator cuff tear. The pain (visual analog scale, VAS), resistance to injection and the amount of contrast material that could be injected during injection phase of MR arthrography was assessed and compared between groups.

RESULTS

The patients in adhesive capsulitis group (mean VAS score 66.5+/-25.5) experienced more pain when compared with the control group (mean VAS score 34.9+/-27.7, P<0.001). A statistically significant difference (P<0.001) in terms of the amount of the injected fluid (4.3+/-2.6 ml for adhesive capsulitis group, and 10.9+/-4.1 ml for control group) was seen into the joint cavity. Resistance to injection was significantly more (P<0.001) in patients with adhesive capsulitis when compared to control group.

INTERPRETATION & CONCLUSION

Experience of pain during injection, a decreased amount of contrast material injected and resistance to injection in patients during injection phase of MR arthrography may suggest adhesive capsulitis.

Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration

BACKGROUND

Foreign body aspiration is common in children, especially those under 3 years of age. Chest radiography and CT are the main imaging modalities for the evaluation of these children. Management of children with suspected foreign body aspiration (SFBA) mainly depends on radiological findings.

OBJECTIVE

To investigate the potential use of low-dose multidetector CT (MDCT) and virtual bronchoscopy (VB) in the evaluation and management of SFBA in children.

MATERIALS AND METHODS

Included in the study were 37 children (17 girls, 20 boys; age 4 months to 10 years, mean 32 months) with SFBA. Chest radiographs were obtained prior to MDCT in all patients. MDCT was performed using a low-dose technique. VB images were obtained in the same session. Conventional bronchoscopy (CB) was performed within 24 h on patients in whom an obstructive abnormality had been found by MDCT and VB.

RESULTS

Obstructive pathology was found in 16 (43.25%) of the 37 patients using MDCT and VB. In 13 of these patients, foreign bodies were detected and removed via CB. The foreign bodies were located in the right main bronchus (n = 5), in the bronchus intermedius (n = 6), in the medial segment of the middle lobe bronchus (n = 1), and in the left main bronchus (n = 1). In the remaining three patients, the diagnosis was false-positive for an obstructive pathology by MDCT and VB; the final diagnoses were secretions (n = 2) and schwannoma (n = 1), as demonstrated by CB. In 21 patients in whom no obstructive pathology was detected by MDCT and VB, CB was not performed. These patients were followed for 5-20 months without any recurrent obstructive symptomatology.

CONCLUSIONS

Low-dose MDCT and VB are non-invasive radiological modalities that can be used easily in the investigation of SFBA in children. MDCT and VB provide the exact location of the obstructive pathology prior to CB. If obstructive pathology is depicted with MDCT and VB, CB should be performed either for confirmation of the diagnosis or for the diagnosis of an alternative cause for the obstruction. In cases where no obstructive pathology is detected by MDCT and VB, CB may not be clinically useful.

Traumatic bilateral vertebral artery dissection at the dural entry point site in a 10-year-old boy

We present a 10-year-old boy who was admitted with headache and neurological symptoms after a trauma in the school yard. Cerebral MRI revealed an extensive ischaemia in the bilateral cerebellar hemispheres, left middle cerebellar peduncle, and right vermis. Digital subtraction angiography demonstrated bilateral vertebral artery dissections at the dural entry point site. This case emphasises the management of patients with traumatic vertebral artery dissection.

A combination of small bowel imaging methods: conventional enteroclysis with complementary magnetic resonance enteroclysis

AIM

The aim of this prospective study was to evaluate the overall findings of conventional enteroclysis (CE) with complementary magnetic resonance enteroclysis (MRE) in small bowel disease.

METHODS

The study included 32 patients referred from various clinical departments, with known or suspected small bowel disease and abnormalities on CE. Immediately after CE, true fast imaging with steady-state precession (true FISP), and unenhanced and gadolinium-enhanced T1-weighted fast low-angle shot (FLASH) sequences with fat saturation were obtained. Mucosal, mural and luminal changes of the small bowel were evaluated by each technique. In addition, bowel wall thickening, bowel wall enhancement and perienteric changes were assessed by MRE. The radiological findings obtained were evaluated together as a combination, and the role of MRE in the determination of the activity and complications of the small bowel disease was assessed. Radiological findings were correlated with clinical evaluation and follow-up in all cases, including endoscopy in 14 cases and surgery in 5 cases.

RESULTS

MRE provided important supplementary mural and extramural information, including degree of pathological wall thickness, mural enhancement pattern associated with disease activity, perivisceral collection, abscess formation, mesenteric fibrofatty proliferation, lymphadenopathy and increase in perienteric vascularity. Short strictures were not revealed on MRE; however, for patients with a history of abdominal malignancy, MRE helped characterize the level of any obstruction and the extent of the disease.

CONCLUSION

We recommend MRE for patients who have findings of advanced inflammatory bowel disease or neoplasm on CE examination. The combination of these two techniques can provide important information on the degree and extent of the disorder.

Pedunculated Localized Fibrous Tumor of the Pleura Presenting as a Moving Chest Mass

Localized fibrous tumor of the pleura is a rare primary pleural neoplasm. The tumors are usually discovered incidentally on routine chest radiography. A change in the lesion's position with respiration and/or posture of the patient indicates a pedunculated pleural lesion. Computed tomography and magnetic resonance imaging reveal the relation of the lesions to adjacent structures. Magnetic resonance imaging is also useful for the characterization of the lesions on the basis of signal features. These tumors usually consist of mature fibrous tissue.

Gray scale and power Doppler US in the preoperative evaluation of axillary metastases in breast cancer patients with no palpable lymph nodes

The purpose of this study is to evaluate the accuracy of gray scale and Doppler US findings in the detection of axillary metastases in breast cancer patients with no palpable lymph nodes. One-hundred and ninety-eight lymph nodes detected in 83 women were evaluated. The size and longitudinal/transverse axis ratios of each node were documented. Absence of echogenic hilum, asymmetrical cortical thickening, and presence of peripheral flow were prospectively considered signs of malignancy. Histopathologically, there were 93 malignant and 105 benign nodes. The above criteria and a low longitudinal-transverse axis ratio were statistically significant for malignancy. In lymph nodes smaller than 1 cm, only asymmetric cortical thickening and presence of peripheral flow were significant. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of US were 86.49, 93.62, 91.43, 89.8 and 90.48%, respectively. In conclusion, US is successful and reliable in the determination of axillary metastatic involvement in nonpalpable and small lymph nodes. Inclusion of axillary US in the preoperative diagnostic evaluation would be complimentary to sentinel node biopsy, and also could eliminate the need for it in patients with positive US results, after confirmation with biopsy.

Endovascular treatment of a congenital dural caroticocavernous fistula

Carotico-cavernous sinus fistula is a rare anomaly in infancy. We report a 3-month-old boy with progressive symptoms and threatened visual loss requiring urgent therapeutic intervention. Embolization using n-butyl 2-cyanoacrylate was performed with immediate and dramatic results.