Pitfalls in imaging of musculoskeletal infections

In musculoskeletal infections, imaging helps in the diagnosis and identification of disease extent. Musculoskeletal infections have variable clinical presentations related to host immune responses and virulence of pathogens. Occasionally, infectious process may mimic other entities such as autoimmune inflammatory diseases, tumors, or traumatic injuries, both clinically and radiologically. Identification of the disease extent is sometimes difficult, particularly when infection occurs in the damaged tissue. The key imaging feature of infection is formation of abscesses. Familiarity of the imaging patterns of the infectious process leads to correct diagnosis and appropriate treatment.

Clinics in diagnostic imaging (149). Bilateral testicular epidermoid cysts

A 33-year-old man presented with a painless, non-growing left testicular mass for five years. Preoperative ultrasonography (US) of the scrotum showed a small, circumscribed calcific mass in the right testis and another well-defined heterogeneous echoic mass with a partially calcified wall in the left testis, with avascularity on colour Doppler US. These imaging findings in a clinical setting of non-growing testicular masses were highly suggestive of epidermoid cysts, thus leading to testis sparing surgery. Histopathology confirmed bilateral epidermoid cysts. To the best of our knowledge, only 15 cases of bilateral epidermoid cysts have been reported. We discuss the US features of epidermoid cyst and its surgical management, as well as various cases of testicular masses.

Musculoskeletal melioidosis

Melioidosis is an infectious disease caused by Burkholderia pseudomallei, mostly affecting patients in Southeast Asia and northern Australia. The disease has been increasingly recognized around the world due to the increased levels of travel and population movement. Clinical manifestations of melioidosis range from fulminant septicemic illness to an indolent local infection. The disease often involves multiple organs, including the lung, spleen, liver, and other visceral organs. Musculoskeletal infection is usually seen as a part of multiorgan involvement, but localized musculoskeletal involvement may occur. The most common manifestation of musculoskeletal melioidosis is septic arthritis, followed by osteomyelitis, pyomyositis, and soft tissue abscesses. The clinical and radiological manifestations of musculoskeletal melioidosis are nonspecific, and the diagnosis needs a high level of suspicion. Associated infection of lungs and visceral organs is suggestive of melioidosis. The disease requires special laboratory facilities and treatment. Inappropriate or inadequate treatment leads to high mortality rate or long-term relapse of the disease. The causative organism of melioidosis, clinical manifestations, and imaging features of musculoskeletal melioidosis are reviewed.

Clinics in diagnostic imaging (135). Cystic renal cell carcinoma

A 45-year-old man presented with right flank pain and haematuria for one month. Computed tomography showed a large, well-circumscribed exophytic complex cystic mass with enhanced, irregular thickened walls arising from the upper pole of the right kidney, which was associated with bilateral renal stones. Partial right nephrectomy with removal of the right renal stones was performed. Histopathology revealed papillary cell carcinoma confined to the kidney. The patient made good postoperative recovery. The Bosniak classification system of renal cystic lesions and cystic renal cell carcinoma are discussed. Various cases of renal cystic lesions and cystic renal cell carcinoma are shown.

Clinics in diagnostic imaging (134). Testicular lymphoma

A 55-year-old man presented with a painless right scrotal mass for the past three months. Scrotal ultrasonography showed a large circumscribed hypoechoic mass with marked hypervascularity occupying almost the entire right testis. The epididymis and scrotal skin were normal. Right radical orchiectomy was performed. Histopathology revealed lymphoma, diffuse large B-cell type confined within the tunica albuginea. The patient made a good postoperative recovery. No evidence of lymphoma in other organs was demonstrated. We discuss the differential diagnosis of ultrasonographic intratesticular masses and highlight various cases of intratesticular lesions in this article.

Breast calcifications: which are malignant?

Most calcifications depicted on mammograms are benign. However, calcifications are important because they can be the first and earliest sign of malignancy. For detection and analysis of microcalcifications, high-quality images and magnification views are required. The American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) classifies calcifications on mammograms into three categories: typical benign, intermediate concern and higher probability of malignancy, according to types and distribution of calcifications. Benign calcifications are typically larger, coarser, round with smooth margins and have a scattered or diffuse distribution. Malignant calcifications are typically grouped or clustered, pleomorphic, fine and with linear branching. It is important for radiologists to detect, evaluate, classify and provide appropriate recommendations for calcifications perceived on mammograms to provide proper management.

Spectrum of imaging findings in melioidosis

This pictorial review aims to highlight the clinical and imaging features of melioidosis in various organ systems. The patients were from two centres: one in Thailand and one in Singapore. The annual average incidence of melioidosis is estimated to be 4.4 in 100 000 in north-eastern Thailand and 1.7 in 100 000 in Singapore. Melioidosis affects many different organs and produces a spectrum of imaging features. The lung is the most frequently involved organ and, on radiographs and computed tomography, melioidosis may manifest as acute pulmonary consolidation, multiple nodules and abscesses. The finding of multiple small discrete abscesses in both the liver and the spleen is highly suggestive of visceral melioidosis and is best diagnosed on ultrasonography and computed tomography. Bone and soft tissue musculoskeletal involvement is usually part of disseminated melioidosis, with changes being seen on radiographs and MRI. Although imaging findings of melioidosis are not specific, this infection requires a high index of clinical suspicion, particularly in patients with pre-disposing comorbidities, such as diabetes mellitus, chronic renal failure, alcoholism or malignancy, those who are immunosuppressed as the result of either diseases or drug treatment, and those living in or with a history of travel to endemic areas.

Clinics in diagnostic imaging (125). Diagnosis: Suspicious right breast carcinoma with axillary node metastases

A 61-year-old woman who had a known history of ovarian carcinoma presented with a palpable painless mass in the right axilla. Mammograms showed segmental-distributed pleomorphic microcalcifications in the upper outer quadrant of the right breast with marked enlargement of the right axillary nodes. The biggest node contained microcalcifications. Right axillary node dissection showed metastatic adenocarcinoma which was likely to be metastasis from the primary breast carcinoma. Unfortunately, she was then lost to follow-up and came back again with a right breast mass. Histopathology of the right breast mass revealed invasive ductal carcinoma. The causes and differential diagnosis of axillary adenopathy are discussed. In a patient with known primary extramammary malignancy and axillary adenopathy, it is important to differentiate if it is metastasis from the primary breast carcinoma or extramammary malignancy to provide proper management.

Urachal abnormalities: clinical and imaging features

INTRODUCTION

The clinical manifestation of urachal abnormalities may mimic many intraabdominal or pelvic diseases. We present clinical, imaging and pathological findings of a spectrum of complicated urachal abnormalities and determine whether imaging can be used to differentiate tumour from infection.

METHODS

From January 1993 to December 2006, seven patients with surgically-proven complicated urachal abnormalities had their clinical, imaging and pathological features reviewed.

RESULTS

There were three men and four women, aged 12-73 years. Four patients had infected urachal remnants and three had urachal carcinoma. The main clinical findings in infected urachal remnants were dysuria, abdominal pain and mass. The patients of urachal carcinoma presented with abdominal mass and haematuria. Computed tomography (CT) was performed in all cases, and ultrasonography (US) was performed in four cases. CT in all cases showed a mass located extraperitoneally in the midline just beneath the rectus abdominis muscle and extending from the umbilicus to the dome of the urinary bladder. There were one well-defined cystic mass and six ill-defined solid masses. US showed one cystic mass and three echogenic masses. Cystography was performed in one patient and it showed indentation to the dome of the urinary bladder with mucosal irregularity. The cystic mass and one ill-defined solid mass were pathologically-proven to be xanthogranulomatous inflammation. The other five solid masses were found to be adenocarcinoma in three and chronic non-specific inflammation in two cases.

CONCLUSION

Preoperative diagnosis of urachal abnormalities may be suggested by clinical presentation and imaging features. However, it is difficult to differentiate tumour from infection based on imaging features alone.

Imaging features of hepatic angiomyolipomas

We review the imaging appearances of hepatic angiomyolipomas in patients with and without tuberous sclerosis. Sporadic hepatic angiomyolipomas have a varied appearance because of the inconstant proportion of fat, making confident imaging diagnosis difficult and necessitating biopsy in many cases. In patients with tuberous sclerosis, hepatic angiomyolipomas have a more consistent imaging appearance and, together with other features of the syndrome, can be more easily diagnosed. Preoperative diagnosis helps obviate unnecessary surgery.

Benign breast lesions mimicking carcinoma at mammography

Many benign breast lesions pose diagnostic challenges. These lesions include abscess, haematoma, radial scar, post surgical scar, diabetic mastopathy, focal fibrosis, sclerosing adenosis, granular cell tumour, extra-abdominal desmoid tumour, medial insertion of pectoralis muscle and sternalis muscle, and axillary lymphadenopathy (due to HIV infection, collagen vascular lesions, tuberculous and bacterial lymphadenitis). Radiologists should be familiar with the characteristic imaging features of these benign lesions, and should include these benign lesions in the differential diagnosis whenever malignant-appearing findings are encountered. Correlation of the patient's clinical features with the mammographical findings and additional use of ultrasonography, fine-needle aspiration biopsy or core biopsy are helpful in establishing the final diagnosis and obviating unnecessary surgical intervention. In some of these lesions, surgery may be avoided while in others, the appropriate surgical procedure may be planned. This pictorial essay aims to illustrate the mammographical features of these lesions in a group of proven cases.

Cystic echinococcosis in Thailand with a special note on detection by serology in one family

Thailand is a nonendemic area of echinococcosis. We report, herein, 3 cases with a special note on the use of serology in detection of the disease in one family. All cases were Thais. The first case was a man, having a cystic mass in the liver. He was subsequently diagnosed as having echinococcosis following positive serology. The second case, a male, had a renal hydatid cyst revealed by histopathology, and a positive serological test. The third case, a wife of case 2, was positive by serological screening for echinococcosis and subsequently proven to have splenic and liver echinococcal cysts. The present findings support the use of serology in the case detection of echinococcosis in Thailand.

Clinics in diagnostic imaging (114). Rupture of the right testis

A 22-year-old man, who was kicked in the scrotum during Thai kickboxing, presented with a painful swelling of the right hemiscrotum. Scrotal ultrasonography (US) showed an enlarged right testis with heterogeneous echogenicity and irregular contours. Colour Doppler US showed vascularity in the upper pole of the right testis and avascularity in the lower pole. Emergency exploration of the right hemiscrotum revealed laceration of the lower pole of the right testis. Debridement and repair of the right testis were performed. The clinical manifestations, role of US and US findings of scrotal trauma are discussed.

Breast carcinomas: why are they missed?

INTRODUCTION

Mammography has proven to be an effective modality for the detection of early breast carcinoma. However, 4-34 percent of breast cancers may be missed at mammography. Delayed diagnosis of breast carcinoma results in an unfavourable prognosis. The objective of this study was to determine the causes and characteristics of breast carcinomas missed by mammography at our institution, with the aim of reducing the rate of missed carcinoma.

METHODS

We reviewed the reports of 13,191 mammograms performed over a five-year period. Breast Imaging Reporting and Data Systems (BI-RADS) were used for the mammographical assessment, and reports were cross-referenced with the histological diagnosis of breast carcinoma. Causes of missed carcinomas were classified.

RESULTS

Of 344 patients who had breast carcinoma and had mammograms done prior to surgery, 18 (5.2 percent) failed to be diagnosed by mammography. Of these, five were caused by dense breast parenchyma obscuring the lesions, 11 were due to perception and interpretation errors, and one each from unusual lesion characteristics and poor positioning.

CONCLUSION

Several factors, including dense breast parenchyma obscuring a lesion, perception error, interpretation error, unusual lesion characteristics, and poor technique or positioning, are possible causes of missed breast cancers.

Artifacts in mammography: ways to identify and overcome them

High-quality mammography images enhance a radiologist's ability to interpret mammograms because they have greater sensitivity and specificity. Artifacts may create pseudo-lesions or mask abnormalities leading to misinterpretation. Familiarity with the numerous artifacts encountered will enable radiologists to provide accurate diagnoses. We reviewed all the artifacts in mammography encountered at our centres and classified the causes of these artifacts into four categories. They are: 1. patient-related; 2. technologist-related; 3. related to the mammographic unit; and 4. related to processing and the processor. Implementation of a well-organised quality control programme will reduce the occurrence of artifacts. Recognition of artifacts in mammography is instructive and will help to improve the mammographic diagnostic quality.

Mammographic changes related to different types of hormonal therapies

OBJECTIVES

To determine the effects of different types of hormone therapies (HT) on mammographic breast density changes.

MATERIAL AND METHOD

Between 1999 and 2002, mammograms obtained before and 12-18 months after different types of HT in 170 women were evaluated Estrogen alone (n = 66), or estrogen in cyclic (n = 59) or continuous (n = 45) combination with progesterone were used. The baseline mammographic density was classified according to the Breast Imaging Reporting and Data Systems (BI-RADS). The serial changes observed mammographically were categorized as follows; no change, minimal change (10-25% increased density), moderate change (26-50% increased density), and marked change (> 50% increased density).

RESULTS

Twelve (7%) of the women developed an increase in parenchymal density after HT: Mammographic changes were minimal change in five (2.9%) of the women, moderate change in four (2.3%), and marked change in three (1.8%). No mammographic change was observed in women receiving cyclic estrogen-progesterone. A greater percentage of women who had undergone continuous estrogen-progesterone therapy (22.2%, 10 of 45) demonstrated more change than those who had estrogen alone (3%, 2 of 66). The difference was statistically significant (p < 0.01).

CONCLUSION

Changes of increased density after HT was seen in only 7% of mammograms and depended on the selected hormone regimen.

Atypical and suspicious categories in fine needle aspiration cytology of the breast: histological and mammographical correlation and clinical significance

INTRODUCTION

This study aims to correlate fine-needle aspiration specimens diagnosed as C3 (atypical, probably benign) and C4 (suspicious, probably malignant) with histology and mammography, and to evaluate these two cytology categories in terms of diagnostic usefulness and patient management.

METHODS

All fine-needle aspiration (FNA) specimens in categories C3 or C4 at the Maharaj Nakorn Chiang Mai Hospital, Thailand between 2000-2004 were reviewed. Results were correlated with available histological and mammographical studies.

RESULTS

148 FNA specimens were identified, comprising 43 category C3 and 105 category C4. Histology was available in 90 cases. 14 (64 percent) C3 cases showed benign histology on biopsy and eight (36 percent) were malignant. 13 (19 percent) C4 cases were benign on biopsy, whereas 55 (81 percent) were malignant. Mammographical studies were available in 56 of the histologically-proven cases. All seven cases with benign mammograms had benign histology, and all 26 cases called "highly suggestive of malignancy" were malignant on histology (five C3 and 21 C4). Of the 23 cases called "suspicious abnormality" on mammography, 14 turned out to be malignant on biopsy (one C3 and 13 C4).

CONCLUSION

Our study supports maintaining cytology categories C3 and C4. About two-thirds of C3 cases were benign on biopsy whereas 81 percent of C4 cases were malignant (p-value is less than 0.001). There was complete correlation between histological and mammographical studies except those with equivocal mammograms. Our study supports the combined use of clinical, mammographical and cytological findings for optimal patient management. This is especially important for patients with C3 aspiration results, in order to avoid unnecessary surgery for benign lesions.

Tuberculosis of the genitourinary tract: imaging features with pathological correlation

The prevalence of pulmonary and extrapulmonary tuberculosis (TB) has been increasing over the past decade, due to the rising number of people with acquired immunodeficiency syndrome and the development of drug-resistant strains of Mycobacterium tuberculosis. The genitourinary tract is the most common site of extrapulmonary TB. Diagnosis is often difficult because TB has a variety of clinical and radiological findings. It can mimic numerous other disease entities. A high level of clinical suspicion and familiarity with various radiological manifestations of TB allow early diagnosis and timely initiation of proper management. This pictorial essay illustrates the spectrum of imaging features of TB affecting the kidney, ureter, bladder, and the female and male genital tracts.

The painful scrotum: an ultrasonographical approach to diagnosis

Many disease processes, including inflammation, testicular torsion, testicular trauma, and testicular cancer, may have a similar clinical presentation as a painful scrotum. Differentiation of these disease processes is important for proper management. High-resolution ultrasonography (US) combined with colour Doppler ultrasonography (CDUS) is the imaging modality of choice in evaluating these patients. Gray-scale US helps to better characterise scrotal lesions. CDUS demonstrates testicular perfusion which aids in reaching a specific diagnosis. This pictorial essay is intended to review the causes, US appearances of disease processes causing the painful scrotum, and examination pitfalls of scrotal US.

Painless scrotal swelling: ultrasonographical features with pathological correlation

Scrotal swelling may be due to extratesticular and intratesticular lesions. The majority of extratesticular lesions are benign while the majority of intratesticular lesions are malignant. Ultrasonography (US) is helpful in separating extra- from intratesticular lesions. US can show whether a mass is cystic, solid or complex, and also features such as associated calcifications, epididymal involvement, scrotal skin thickening and colour Doppler flow pattern. Extratesticular lesions include hydrocoele, spermatocoele, varicocoele, epididymal cyst, hernia and tumours of the epididymis and cord structures. Intratesticular lesions include primary tumour, metastases, lymphoma and leukaemia. Tuberculous epididymitis or epididymo-orchitis may also present with painless scrotal swelling. US features of these disease patterns, with pathological correlation, are presented in this pictorial essay.

Noninvasive assessment of patency of internal ureteral stent: role of colour Doppler ultrasound

OBJECTIVE

To compare colour Doppler ultrasonography (CDU) and retrograde cystography in the assessment of the patency of internal ureteral stents.

PATIENTS AND METHODS

Thirty-two patients with 33 internal ureteral stents were evaluated for patency of the internal ureteral stent using both CDU and retrograde cystography. Real-time ultrasonography and CDU were performed before retrograde cystography. Stent patency was defined as seeing flow from the distal end of the stent in the urinary bladder or iodinated contrast in the renal pelvis. The two investigators had no prior knowledge of the other's results. After completion of both investigations, stent patency was proved by direct inspection of the stent after removal.

RESULTS

Both investigations showed the same result in 27 of the 33 stents. Stent patency was found if either investigation was positive. The accuracies of retrograde cystography, CDU and both were 73%, 79% and 85%, respectively.

CONCLUSIONS

CDU is a noninvasive method with high accuracy. Detection of flow at the distal end of the stent is helpful, but absence of flow may or may not indicate an obstructed stent and further investigation should be performed.

Imaging features of unusual adrenal masses

The widespread use of cross-sectional imaging techniques has resulted in increased detection of adrenal masses. The imaging characteristics of common adrenal masses such as adenoma, phaeochromocytoma and metastasis are well established. In this pictorial essay, the imaging features of unusual adrenal masses including cyst, lymphoma, adrenal carcinoma, myelolipoma, haemangioma, smooth muscle tumour, haematoma, and infection (acute tuberculous adrenitis and histoplasmosis) are presented. Computed tomography permits a diagnosis of cyst, acute or subacute haematoma and myelolipoma. Although the imaging features of other lesions are non-specific, imaging has an important role in the detection of these unusual adrenal masses, and in aiding their diagnosis and management.

Role of mammography in diagnosis of axillary abnormalities in women with normal breast examination

The mammograms of 43 patients presenting with palpable unilateral masses in the axilla and normal breasts on physical examination were retrospectively reviewed to determine the cause and imaging characteristics of axillary abnormalities, and the usefulness of mammography in detecting occult breast carcinoma. Cytological or histological confirmation was obtained in all patients. Forty of 43 patients had axillary lymphadenopathy while three had lipoma, fibroadenoma and haematoma, respectively. Causes of malignant lymphadenopathy (n = 22) were metastatic diseases from non-mammary primary malignancy (n = 8), occult ipsilateral breast carcinoma (n = 5), and previous contralateral breast carcinoma (n = 9). Causes of benign lymphadenopathy (n = 18) were reactive nodal hyperplasia (n = 6), collagen vascular diseases (n = 2), and acute bacterial (n = 2) and tuberculous (n = 8) lymphadenitis. Nodal size was not significantly different between benign and malignant lymph nodes. Benign and malignant nodal margins were variable. Intranodal microcalcifications were found in two cases of breast carcinoma metastasis. Intranodal macrocalcifications were found in three cases of tuberculous lymphadenitis. Occult primary breast carcinoma was detected on mammograms in four of five patients with axillary lymphadenopathy due to ipsilateral breast carcinoma. Mammographical features of benign and malignant lymphadenopathy may be indistinguishable, but presence of intranodal calcifications is helpful. Mammography is also valuable in depicting occult primary breast carcinoma.

Clinics in diagnostic imaging (99). Left emphysematous pyelonephritis

A 57-year-old woman, known to have diabetes mellitus, presented with a one-week history of fever, dysuria, and left flank pain. Computed tomography showed extensive left renal parenchymal destruction and a large gas collection. Urine culture revealed growth of Escherichia coli. The diagnosis of emphysematous pyelonephritis was confirmed at left nephrectomy. The clinical manifestations of emphysematous pyelonephritis, types of gas-forming renal infection, and their radiological findings are discussed.

Clinics in diagnostic imaging (97). Right renal tuberculous autonephrectomy

A 50-year-old man presented with recurrent episodes of right flank pain and dysuria for many years. Abdominal radiograph and intravenous urography showed extensive right renal parenchymal calcification in a lobar distribution and a non-functioning right kidney, characteristic of end-stage tuberculosis. The pathology, clinical manifestations, and radiological findings of renal tuberculosis are discussed.

Imaging of giant breast masses with pathological correlation

Ultrasonography (US) and mammography are the two basic techniques for routine imaging in the diagnosis of breast diseases. A wide variety of breast conditions such as lipoma, hamartoma, cyst, fibroadenoma, phyllodes tumour, haematoma, abscess and carcinoma can result in solitary or multiple giant masses. These conditions may appear similar on physical examination. The clinical significance of these entities is that some lesions necessitate mastectomy but some lesions may require only local excision, aspiration or even conservative management. Imaging has enhanced our ability to characterise these lesions. The purpose of this pictorial review is to illustrate the causes of giant breast masses, and the role of US and mammography in diagnosis of these lesions.

Malignant germ cell tumours of undescended testes: imaging features with pathological correlation

AIM

To illustrate the imaging features of malignant germ cell tumours complicating undescended testes, emphasizing the importance of recognizing this condition and providing a correct diagnosis to facilitate appropriate management.

METHODS

The clinical presentation, ultrasonography (US) and computed tomography (CT) features of eight consecutive patients with malignant germ cell tumours of undescended testes were reviewed.

RESULTS

CT performed in seven patients showed well-circumscribed soft-tissue masses with inhomogeneous enhancement in all cases. US in four patients showed circumscribed masses with inhomogeneous echogenicity. On pathological examination, there were two cases of embryonal carcinoma and six cases of seminoma. All tumours showed necrosis that correlated to inhomogeneous areas on imaging.

CONCLUSION

The radiologist has an important role as he may be the first physician to suggest the diagnosis.

Mammographic change in hysterectomized women on 0.625 mg/day of conjugated equine estrogen

OBJECTIVE

To compare the mammographic change before and after conjugated equine estrogen (CEE) 0.625 mg/day in hysterectomized women.

DESIGN

A retrospective descriptive study.

SETTING

Menopause clinic, Maharaj Nakorn Chiang Mai Hospital.

MATERIAL AND METHOD

Dedicated mammograms and demographic data of 66 women who had been hysterectomized were reviewed. Post surgical menopausal women were recruited for the study. CEE 0.625 mg/day was given just after the operation. The baseline mammography was done before the initiation of HRT and they were compared with the follow-up mammography performed 12-18 months after therapy. The degree of increase in mammographic density was classified as follows: minimal changes (10-25% increased density), moderated change (26-50% increased density), and marked change (> 50% increased density).

RESULTS

The mean age +/- SD was 47 +/- 4.3 years old. The mean duration +/- SD of hormone used was 13.5 +/- 2.4 months. The most common indication for operation was myoma uteri (43.9%). On the baseline mammogram, 5 cases had cystic change and one case had a small circumscribed solid mass suspected to be fibroadenoma. On the follow-up mammograms, there were 2 cases (3.0%) detected to have significantly increased breast density. One was moderately increased and the other was markedly increased, but cystic changes and one fibroadenoma were not changed.

CONCLUSION

CEE has little effect on increased mammographic density.

Clinics in diagnostic imaging (93)

A 63-year-old woman was found to have pathological fracture of the right lower tibia through a brown tumour, hypercalcemia, and a soft tissue mass at the lower pole of the right lobe of thyroid gland. US scan of the neck showed a well-circumscribed heterogeneously-hypoechoic mass with displacement of the right lobe of thyroid gland. Diagnosis of parathyroid adenoma was confirmed on histopathological examination of the excised specimen. The cause and clinical manifestations of primary hyperparathyroidism are discussed. Imaging methods of parathyroid gland are presented.

Clinics in diagnostic imaging (88). Gynaecomastia of the right breast and carcinoma of the left breast

An 83-year-old man presented with a painless lump in his left breast for one year. Mammograms showed an ill-defined uncalcified high-density subareolar mass in the left breast and minimal fibroglandular density radiating beneath the nipple into the fatty tissue of the right breast. US showed an irregular, heterogeneously-hypoechoic mass with mild posterior transmission. The differential diagnosis of breast enlargement in men is discussed. Mammographical and US features of gynaecomastia and male breast carcinoma are presented.

Breast cancer in women under 40 years: preoperative detection by mammography

INTRODUCTION

This article assesses the diagnostic sensitivity of mammography in the preoperative detection of breast cancer in young women.

MATERIALS AND METHODS

We retrospectively reviewed 1010 women with breast carcinoma between January 1996 and September 2002. The patients were identified from pathological reports. Of these, 237 women were below 40 years of age, accounting for 23.5% of all breast cancers. Only 76 of 237 patients had mammograms performed prior to surgery. Seventy-five of the 76 patients also had ultrasonography performed. Histological types were reviewed and the proportions of each type were compared with those found in a consecutive series of 773 breast carcinomas in women above 40 years of age seen during the same period in our hospital. The breast patterns, as seen on mammograms, were classified as follows: fatty, scattered fibroglandular, heterogeneously dense and homogeneously dense. Specific features of a mass, microcalcifications, architectural distortion and asymmetrical density were evaluated.

RESULTS

Of the 76 patients who had mammograms performed prior to surgery, 81 cancers were found. The patients' age ranged from 25 to 40 years, with a mean of 36.4 years. The breast parenchymal patterns were homogeneously dense in 6.6%, heterogeneously dense in 67.1% and had scattered fibroglandular density in 26.3%. Abnormal mammographical findings were present in 93.8%. The most common mammographical findings were mass in 60% and microcalcifications, with or without associated breast abnormality, in 28.7%. The most frequent tumour (82.7%) was invasive ductal carcinoma, which is not significantly different to those found in older women (P = 0.895). Ultrasonography showed solid masses in 73 patients and was negative in the other 2 patients.

CONCLUSION

Mammography is a useful imaging technique in providing preoperative detection and diagnosis of breast carcinoma in women below 40 years of age with clinical suspicion of malignancy. Mass and microcalcifications are the most common abnormal mammographical findings and invasive ductal carcinoma is the most common tumour found in our study.

Clinics in diagnostic imaging (84). Galactocoele

A 37-year-old woman who was six months postpartum presented with a painless lump in her left breast for three months. Mammograms showed a mixed fat and soft density mass on the craniocaudal and mediolateral views. A fat-fluid level was seen within the mass, typical of a galactocoele. Needle aspiration yielded milky fluid. The differential diagnosis of breast masses presenting in women with pregnancy or lactation is briefly discussed. The other causes of fat containing breast masses, such as oil cyst, hamartoma, lipoma and intramammary lymph nodes, are illustrated with additional examples.

Clinics in diagnostic imaging (82). Lesser trochanter metastasis

A 73-year-old woman who had previous mastectomy for breast carcinoma presented with persistent pain over the left hip area for two to three months. Pelvic radiograph showed an expanded osteolytic lesion involving the lesser trochanter of the left femur, with adjacent ill-defined destructive changes. She subsequently developed a displaced pathological fracture through the lesser trochanteric metastasis. The clinical features and pathophysiology of bone metastases are discussed. The role of imaging, with additional illustrative examples, is emphasised.

Clinics in diagnostic imaging (79). Ampulla of Vater carcinoma

A 58-year-old man presented with signs of obstructive jaundice for two weeks. Ultrasonography showed dilatation of the intrahepatic ducts and common bile duct, due to a distal common bile duct mass. ERCP showed a papillary mass. A Whipple's operation was done for the ampulla of Vater carcinoma. The role of imaging in the diagnosis and treatment of obstructive jaundice is reviewed. The common causes of distal extrahepatic obstructive lesions are also discussed.

Mammographic features of tuberculous axillary lymphadenitis

The clinical and mammographic findings of 10 patients with pathologically proven tuberculous axillary lymphadenitis were reviewed. The cases were identified from 10 173 mammograms performed over 6 years at Maharaj Nakorn Chiang Mai University Hospital. The 10 patients were aged 31-65 years. All cases were initially diagnosed to have breast carcinoma with axillary nodal metastases. Eight patients presented with axillary swelling, while two presented with breast enlargement. None of these cases had a palpable breast mass. Associated supraclavicular, cervical or groin nodes were found in seven cases, and two patients had evidence of pulmonary tuberculosis. All lesions were unilateral, affecting the right side in eight cases and left side in two cases. On mammogram, the axillary nodes were enlarged and homogeneously dense. The nodes were sized 2.5-5 cm. Nodal margins were variable. Some nodes were matted. Macrocalcifications were noted in three cases. Ipsilateral breast oedema without mass or microcalcifications was present in two cases. Patients with tuberculous axillary lymphadenitis have large homogeneously dense nodes with either well- or ill-defined margins. It is impossible to differentiate tuberculous from malignant nodes. The presence of macrocalcifications might suggest tuberculous axillary lynphadenitis. Biopsy of enlarged axillary nodes is necessary to determine its aetiology.

Preoperative diagnosis of bilateral tuberculous epididymo-orchitis following intravesical Bacillus Calmette-Guerin therapy for superficial bladder carcinoma

We report a case of bilateral tuberculous epididymo-orchitis following intravesical Bacillus Calmette-Guerin (BCG) therapy for superficial bladder carcinoma in which the diagnosis was made by ultrasonography prior to surgery. The US findings include heterogeneous enlargement of the epididymis and testis, associated with scrotal-skin thickening and scrotal sinus track. Patients with bladder carcinoma treated with intravesical BCG therapy, the presence of scrotal swelling with scrotal-skin thickening and epididymal involvement suggests tuberculous epididymo-orchitis rather than testicular tumour. It is important to be aware of this rare complication and to be familiar with the ultrasonographic features so that appropriate treatment can be given.

Evaluation of the contralateral breast in patients with ipsilateral breast carcinoma: the role of mammography

OBJECTIVE

To assess the value of mammography in the detection of cancer in the contralateral breast in women with ipsilateral breast carcinoma.

MATERIALS AND METHODS

From February 1994 through May 2001, a total of 500 patients with unilateral mastectomy from breast carcinoma had mammograms performed for the first time following mastectomy. We retrospectively reviewed the clinical findings and mammograms of these patients. Four hundred and sixty-four patients were asymptomatic and 36 patients presented with palpable breast or axillary masses. Specific mammographic features of a mass, microcalcifications, architectural distortion and asymmetric density were evaluated. Diagnosis was confirmed by fine needle aspiration biopsy or surgical excision in all patients.

RESULTS

Four hundred and sixty-four patients had screening mammograms and 36 patients had diagnostic mammograms. All 36 symptomatic patients had abnormal mammograms. Of these, 12 (33.33%) patients were found to have second primary breast carcinoma, 12 (33.33%) had metastases to the contralateral breast or axillary lymph nodes, six (16.66%) had fibroadenomas, two (5.55%) had abscesses, three (8.33%) had fibrocystic change, and one (2.77%) had axillary node reactive hyperplasia. Of the 464 asymptomatic patients, five (1.07%) had second primary breast carcinoma, five (1.07%) had fibrocystic change, and two (0.43%) had fibroadenomas. The mean age at the time of diagnosis of the first primary carcinoma in the symptomatic patients was 41.9 years (range 35-60 years), and was 43.4 years (range 36-56 years) in the screening group. The mean time interval between the two carcinomas was four years (range one to 13 years) in symptomatic group and 3.4 years (range one to four years) in screening group. The tumour stage in the screened group was in situ (n = 2), stage I (n = 3) and in the symptomatic group was stage I (n = 2), stage II (n = 5), stage III (n = 5).

CONCLUSION

Patients who have ipsilateral breast carcinoma have a strong risk to develop a second primary carcinoma in the contralateral breast. Close follow-up of the second breast with careful clinical examination and mammography are necessary for the early detection of cancer.

Clinics in diagnostic imaging (71). Left iliopsoas abscess secondary to vertebral osteomyelitis

A 26-year-old woman presented with a progressively painful lump at her left groin and upper thigh for five months. She also had intermittent back pain for three years. Radiographs and CT showed osteolytic destruction of the several contiguous thoracolumbar vertebrae with a large left iliopsoas abscess that extended to involve the left gluteus maximus and adductor magnus muscles. She responded well to a course of antibiotics. The role of imaging and imaging features of iliopsoas abscesses are discussed, together

Multiple bilateral giant fibroadenomas associated with cyclosporine A therapy in a renal transplant recipient

A 31-year-old woman developed a right breast mass following cyclosporine A therapy after a renal transplant. Several large breast masses continued to grow bilaterally. Mammography and ultrasonography showed features of giant fibroadenomas. The diagnosis was confirmed by biopsy of one of the masses. Awareness of the association between cyclosporine A therapy and fibroadenoma development in renal transplant recipients is highlighted.

Clinics in diagnostic imaging (62). Gallstones with acute cholecystitis

A 75-year-old man presented with right upper quadrant pain and fever. Ultrasonography showed gallstones, gallbladder enlargement, gallbladder wall thickening and pericholecystic fluid collection. Cholecystectomy confirmed the diagnosis of acute cholecystitis. The differential diagnosis of right upper quadrant abdominal pain and fever is discussed, and the role of imaging in its evaluation is emphasised.

Clinics in diagnostic imaging (59). Crossed-fused renal ectopia

A 62-year-old man was incidentally found to have a palpable right paraumbillcal mass. Ultrasonography and intravenous urogram showed cross-fused renal ectopia. The embryology and clinical features of renal ectopia are discussed.

CT of unusual iliopsoas compartment lesions

The authors reviewed the anatomy of the iliopsoas compartment and a spectrum of unusual lesions affecting structures in this compartment, with emphasis on the role of computed tomography (CT). Lesions in the iliopsoas compartment are caused by acute infection, tumor, or hemorrhage. The knowledge of detailed clinical data can help improve the diagnostic accuracy, particularly with regard to primary iliopsoas lesions. CT is useful for delineating the source of secondary iliopsoas lesions, guiding biopsy, and performing follow-up of treated lesions. Nonenhanced CT can help detect fresh hemorrhage, fat-containing tumor, and calcification, whereas contrast material enhanced CT optimizes imaging of infection, tumor, and aneurysm.