An Extraordinary Location of Sentinel Lymph Nodes in a Patient with Endometrial Cancer.

OBJECTIVE: To show dissection of sentinel lymph nodes. DESIGN: A step-by-step demonstration of the technique with narration. SETTING: Endometrial cancer (EC) is the most common gynecologic malignancy worldwide. Sentinel lymph node biopsy with indocyanine green (ICG) has become more widely used and has been featured in recently published guidelines for EC [1]. Minimally invasive approaches with the sentinel lymph node concept (conventional laparoscopy, laparoscopic-assisted vaginal surgeries or robotic) to EC staging have resulted in lower rates of peri- and postoperative complications than conventional staging procedures [2]. INTERVENTIONS: No video article has been published in the literature about high pelvic, para-aortic sentinel lymph node dissection. An informed consent form was obtained from the patient. An institutional review board approval was not required. A 45-year-old female with gravidity 0, parity 0, and body mass index of 23.4 kg/m2 presented with complaints of abnormal uterine bleeding (spotting). Increased endometrial thickness was detected on transvaginal ultrasound (10 mm) in the postmenstrual period. Endometrioid-type endometrial adenocancer with focal squamous differentiation International Federation of Gynecology and Obstetrics grade I was detected on endometrial biopsy. The patient had hepatitis B virus positivity and no other chronic disease. A laparotomic myomectomy had been performed in 2016. Laparoscopic high pelvic, low para-aortic sentinel lymph node dissection with ICG and hysterectomy (without uterine manipulator) + bilateral salpingo-oophorectomy were performed (Supplemental Video 1). The operation time for the procedure was 110 minutes and the estimated blood loss was <20 mL. No major complications occurred during or after the surgery. The patient stayed in the hospital for 1 day. The final pathology result showed an International Federation of Gynecology and Obstetrics grade I, endometrioid-type endometrial adenocancer with focal squamous differentiation, as a 1.5 × 1 cm tumorous mass invading less than one-half of the myometrium. Neither lymphovascular invasion nor sentinel lymph node metastasis was detected. A multicenter, prospective study showed that sentinel lymph node dissection with ICG in clinical stage 1 EC is feasible and has a high degree of diagnostic accuracy in detecting EC metastases. In that study, isolated para-aortic sentinel lymph node was detected in 3 of 340 patients (<1%) [2]. Another study reported the detection rate of isolated para-aortic sentinel lymph node to be 1.1% in patients with intermediate- and high-risk EC [3]. CONCLUSION: There are in some cases 2 distinct channels emanating from one side, and it is important to follow each and to acknowledge there may be more than one sentinel, one of which is lower in a typical location and one higher as in this case. This video article is the first video demonstration of bilateral isolated high pelvic, para-aortic sentinel lymph node dissection in EC.

Interstitial lung disease in patients with systemic lupus erythematosus: a cohort study.

BACKGROUND: Systemic lupus erythematosus (SLE) is an autoimmune disease with a variety of organ/system involvement. Respiratory system involvement is common in these patients and usually manifests itself by disorders of the lung parenchyma, pleura, pulmonary vasculature or diaphragm. In this study, we sought to determine the frequency of interstitial lung disease (ILD) in patients with SLE and associated risk factors. METHODS: Three hundred randomly chosen patients with SLE were included. Chest x-ray (CXR), lung spirometry and carbon monoxide diffusion test (DLCO) were performed. High-resolution thorax computed tomography (HRCT) was performed for a definite diagnosis of ILD. . RESULTS: Of 300 patients, 16% had ILD. At the start of the study, the prevalence obtained from the patients' records showed that 4% had ILD. The median age, mean duration of disease, and follow-up time were significantly higher and longer in patients with ILD compared to patients without (p < 0.05). Forced expiratory volume (FEV1), forced vital capacity (FVC), DLCO and total lung capacity (TLC) were significantly lower in patients with ILD (p < 0.001). Patients with ILD had a significantly higher frequency of arthritis, serositis, Raynaud's phenomenon, myositis, and anti-Scl70 positivity (p = 0.01, 0.001, 0.02, 0.004, and 0.001, respectively). A significantly higher number of patients had stopped using hydroxychloroquine (HCQ) in the ILD group (p = 0.04).

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients After Anterior Myocardial Infarction.

BACKGROUND: The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction (MI). Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential. We aimed to compare the two-dimensional echocardiography (2DE), contrast-2DE and real-time three-dimensional echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior. METHODS: The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (< 40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and magnetic resonance imaging (MRI) were performed on all patients within one month after anterior MI. RESULTS: Transthoracic 2DE detected thrombi in 29 patients, contrast-2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast-2DE and RT-3DE, respectively. CONCLUSIONS: We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.

Use of Diffusion-Weighted Magnetic Resonance Imaging and Apparent Diffusion Coefficient in Gastric Cancer Staging.

BACKGROUND: The apparent diffusion coefficient (ADC), the quantitative parameter of diffusion-weighted magnetic resonance imaging (DW-MRI), is a measure for this restricted diffusion, and its role in gastric cancer (GC) including distinguishing malignant segments from healthy gastric wall, metastatic perigastric lymph nodes from benign nodes and evaluating response of GC to neoadjuvant chemotherapy has been investigated in previous studies. Evidence suggests that ADC may also be of help in assessment of aggressiveness and preoperative staging of gastric cancer, which needs to be explored in further studies. OBJECTIVE: To investigate the role of DW-MRI and its quantitative parameter, ADC in staging of gastric cancer. METHODS: Forty-six patients (28 male, 18 female, mean age 62 years) with non-metastatic biopsy- proven GC who underwent abdominal DW-MRI before surgery were included in this retrospective study. Tumor invasion depth (T-stage) and nodal involvement (N-stage) were evaluated using signal increase on DW-MRI, and tumor ADC was measured. Diagnostic performance of these results was assessed by comparing them with postsurgical histopathology based on 8th TNM classification. RESULTS: Sensitivity, specificity, and accuracy of DW-MRI in T-staging were 92.1%, 75%, 89.1% for ≤T2 vs. ≥T3; and 75%, 88.5%, 82.6% for ≤T3 vs. T4. However, sensitivity, specificity, and accuracy of DW-MRI in N-staging were 89.3%, 88.9%, 89.1% for ≤N1 vs. ≥N2; and 73.7%, 96.3%, 86.9% for ≤N2 vs. N3, respectively. Relative preoperative ADC values correlated with pT staging (r=-0.397, p=0.006). There was also a statistically significant difference of relative ADC values between ≤T3 and T4 stages, and a cut-off of 0.64 s/mm2 could differentiate these stages with an odds ratio of 7.714 (95% confidence interval, 1.479-40.243). The area under the receiver operating characteristic curve for differentiating ≤T3 and T4 stages was 0.725. CONCLUSION: DW-MRI may contribute to the clinical staging of non-metastatic GC. In particular, relative ADC of DW-MRI can distinguish T4 gastric cancer from less advanced T-stages.

Multimodality imaging findings of visceral myopathy in a child presenting with palpable abdominal mass.

Bayramoglu Z, Yilmaz R, Demir AA, Ataizi-Çelikel Ç, Kombak FE, Ikinci A, Yekeler E. Multimodality imaging findings of visceral myopathy in a child presenting with palpable abdominal mass. Turk J Pediatr 2019; 61: 120-125. Visceral myopathy is a rare cause of intestinal obstruction characterized by intestinal dysmotility and constipation. Patients often present with recurrent abdominal pain, vomiting and abdominal distension. We report a rare case of visceral myopathy in a child presenting with intraabdominal mass. We aimed to describe ultrasound, computed tomography and magnetic resonance enterography findings of this rare disease that has not been demonstrated before. Differential diagnosis of mural thickening with distinguishable layers in addition to intestinal dilatation in the absence of mesenteric inflammation includes visceral myopathy.

Can MR Enterography and Diffusion-Weighted Imaging Predict Disease Activity Assessed by Simple Endoscopic Score for Crohn's Disease?

PURPOSE: Monitoring Crohn's disease (CD) activity has a crucial importance, especially for evaluating treatment efficacy. Magnetic resonance enterography (MRE) and diffusion-weighted imaging (DWI) or their combination may represent potential non-invasive tools for this purpose. This study aimed to examine DWI and MRE for their potential to differentiate between different grades of ileocolonic CD activity. MATERIALS AND METHODS: This retrospective study included 54 adult patients with a diagnosis of CD who underwent ileocolonoscopy and MRE including the DWI sequence. The severity of CD inflammation was categorized by Simple Endoscopic Score for Crohn's Disease (SES-CD) as inactive, mild, moderate and severe. In addition, following conventional MRE and DWI parameters were examined: bowel wall thickness, mural T2 hyperintensity, contrast enhancement, DWI signal intensity, and apparent diffusion coefficient (ADC) values. RESULTS: In patients with moderate to severe disease based on SES-CD, T2 hyperintensity score [1.68 ± 0.77 (1-3) vs. 2.19 ± 0.69 (1-3); p = 0.013] and mean DWI score [2.42 ± 0.58 (1-3) vs. 2.04 ± 0.69 (1-3); p = 0.037 ] were higher and mean ADC values [1.5 ± 0.4 (0.9-2.5) vs. 1.2 ± 0.3 (0.6-1.8)] were lower compared to patients with inactive to mild CD. ADC had a moderate diagnostic accuracy in predicting moderate to severe disease (AUC = 0.729, 95% CI = 0.591-0.841, p = 0.001), with a cut-off value of ≤1.47 × 10-3 mm2/sec yielded 88.5% (23/26) sensitivity, 57.1% (16/28) specificity. CONCLUSION: DWI, ADC and T2 signal appear to differentiate moderate to severe CD from inactive to mildly active CD, based on SES-CD evaluation and may be useful in monitoring disease activity, particularly when evaluating treatment response.

Superselective Transarterial Chemoembolization as an Alternative to Surgery in Symptomatic/Enlarging Liver Hemangiomas.

BACKGROUND: Transarterial embolization of liver hemangiomas has not been considered to be consistently effective. METHODS: The charts of 25 patients who underwent superselective transarterial chemoembolization with the bleomycin-lipiodol emulsion were evaluated retrospectively. RESULTS: Twenty-two patients had abdominal pain; asymptomatic/vaguely symptomatic enlargement was the treatment indication in three patients. A single session was conducted in 17 patients, two sessions in 7 and three sessions in one. After the first session, lesion volume decreased by median (range) 51% (10-92%) from median (range) 634 (226-8435) to 372(28-4710) cm3 (p < 0.01), after a median period of 4 months (range 2-8). A second session was performed in eight patients (median (range) initial volume 1276 (441-8435) cm3) with persistent complaints and/or large lesions receiving feeders from both right and left hepatic arteries (staged treatment). Median (range) lesion size decreased further from 806 (245-4710) to 464 (159-2150) cm3 (p < 0.01). Three patients experienced a postembolization syndrome that persisted after the first week. Seventeen of the 22 symptomatic patients (77%) reported resolution or marked amelioration of complaints. Regrowth after initial regression was not observed during median (range) 14 (8-39) months of follow-up (n:18). CONCLUSION: Transarterial chemoembolization with the bleomycin-lipiodol emulsion is a potential alternative to surgery for symptomatic/enlarging liver hemangiomas. Volume reduction is universal, and symptom control is satisfactory. Centrally located and very large (>1000 cm3) lesions may require two sessions.

Frequency of abnormal pulmonary computed tomography findings in asylum seeking refugees in Turkey.

Background: Lungs are particularly vulnerable to both acute infections, including TB, and chronic diseases such as chronic obstructive pulmonary disease, as well as to malignancies, all of which require particular attention during war times in which health conditions are far from optimal. Methods: This retrospective cross-sectional study included 1149 refugees that underwent thoracic computed tomography (CT) for respiratory symptoms between March 2013 and February 2015 in Turkey. Results: At least one positive CT finding was seen in 231 (20.1%) of the patients. The most common findings were chronic pulmonary changes (n=197, 17.2%), followed by findings suggestive of infections (n=39, 3.4%), and mass/nodular lesions (n=16, 1.4%). The rates of the lesions suggestive of active TB and malignancy were 1.0% (n=11) and 0.7% (n=8), respectively. Age 55-64 years was an independent significant predictor for any CT lesion, chronic changes, mass lesions, and lesions suggestive of malignancy. Age>65 years was predictive of any CT lesion and chronic changes. Conclusions: The findings of this study indicate the need for implementation of cost-effective screening strategies in refugees, particularly during war times. Screening for TB would improve disease control among both refugees and the host populations. Middle aged and older individuals, in particular, would benefit from more proactive screening tools and strategies for the early diagnosis of pulmonary malignancies and chronic lung diseases.

Adrenal mass of unusual etiology: Ewing sarcoma in a young man.

Ewing sarcoma and peripheral primitive neuroectodermal tumor belong to the Ewing sarcoma (ES) family of tumors originating from a primitive neural tube. We report a 31-year-old man who was admitted to the urology clinic with complaints of fever, nausea, and dysuria. A right-sided adrenal mass was detected during ultrasonography. The lesion was then evaluated with magnetic resonance imaging, which showed areas of necrosis amid heterogeneous solid areas. Whole body scan with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography and bone scan studies showed pulmonary and osseous metastatic foci. The mass and right kidney were removed by an open approach. An immunohistochemical and molecular workup enabled the diagnosis of ES. The patient also underwent radiotherapy and chemotherapy. The patient remained in fairly good health during the 18-month follow-up period, but showed progression of all metastatic foci and died 26 months after treatment. In conclusion, adrenal ES should be included in the differential diagnosis of nonfunctional adrenal lesions despite its rare occurrence.

Cardiac calcified amorphous tumors: CT and MRI findings.

PURPOSE: We aimed to evaluate computed tomography (CT) and magnetic resonance imaging (MRI) findings of cardiac calcified amorphous tumors (CATs). METHODS: CT and MRI findings of cardiac CATs in 12 patients were included. We retrospectively examined patient demographics, location, size, shape configuration, imaging features, calcification distribution of tumors, and accompanying medical problems. RESULTS: There was a female predominance (75%), with a mean age at presentation of 65 years. Patients were mostly asymptomatic on presentation (58.3%). The left ventricle of the heart was mostly involved (91%). CT findings of CATs were classified as partial calcification with a hypodense mass in four patients or a diffuse calcified form in eight. Calcification was predominant with large foci appearance as in partially calcified masses. On T1- and T2-weighted magnetic resonance images, CATs appeared hypointense and showed no contrast enhancement. CONCLUSION: The shape and configuration of cardiac CATs are variable with a narrow spectrum of CT and MRI findings, but large foci in a partially calcified mass or diffuse calcification of a mass on CT is very important in the diagnosis of cardiac CATs. Masses show a low signal intensity on T1- and T2-weighted images with no contrast enhancement on MRI.

Magnetic resonance imaging features of idiopathic granulomatous mastitis: is there any contribution of diffusion-weighted imaging in the differential diagnosis?

PURPOSE: To identify the magnetic resonance imaging (MRI) appearance of idiopathic granulomatous mastitis, and the usefulness of diffusion-weighted magnetic resonance imaging (DW-MRI) in distinguishing idiopathic granulomatous mastitis (IGM) from malignant breast lesions. MATERIAL AND METHODS: A total of 37 women (mean age 36 + 8; range 20-67 years) with histopathologic diagnoses of idiopathic granulomatous mastitis were enrolled in the study. Five patients had bilateral IGM, which were evaluated as ten cases. Dynamic MRI findings were categorized as enhancing mass lesion, non-mass enhancement, or both together. The frequency of quadrant involvement, retroareolar involvement, accompanying abscess, ductal ectasia, skin thickening, breast edema, extension to pectoral muscle, and presence of fistula were investigated. The mean apparent diffusion coefficient (ADC) values for lesions, contralateral normal breast parenchyma, pectoralis major muscle, and sternum were measured in patients with invasive cancers (n = 42) and those with mastitis (n = 42). The ADC ratio of the lesions to the contralateral normal breast parenchyma, pectoralis major muscle, and sternum were determined. RESULTS: The findings of idiopathic granulomatous mastitis on MRI were total (in all quadrants) or wide (2 or 3 quadrants) in 30 (71.5 %), retroareolar space involvement in 28 (66.7 %), skin thickening in 21 (50 %), breast edema in 21 (50 %), extension to pectoral muscle in 18 (42.9 %), accompanying abscess formation in 33 (78 %), ductal ectasia in 17 (40.5 %), and fistulas in 13 (31 %). On dynamic contrast-enhanced MRI, 69 % of the patients had mass appearance of IGM. The most frequent enhancement patterns were rim enhancement in 20 (78 %) in masses and clustered ring in 11 (48 %) in non-mass lesions. Early enhancement pattern of IGM was obtained as 'slow' in 29 cases (69 %), 'medium' in 11 cases (26.1) and 'rapid' in 2 (5 %) cases. Time-signal intensity curves were detected as Type-1 in 27 cases (64 %) and Type-2 in 15 cases (36 %). IGM showed significantly lower mean ADC values when compared with the normal parenchyma. When IGM was compared with malignancy, mastitis ADC was 0.98 ± 0.188 × 10-3, and invasive cancer ADC was 0.95 ± 0.229 × 10-3. The difference in ADC values of mastitis and invasive cancers proved not to be significant (P = 0.185). Our results had no discriminatory power for IGM versus malignant lesions for either ADC values and ADC ratios of normal breast parenchyma, pectoralis major muscle, and sternum. CONCLUSION: Although not characteristic for idiopathic granulomatous mastitis, masses with rim enhancement or clustered-ring non-mass lesions with segmental distribution on MRI are the most common features of the disease. Ductal ectasia and periductal enhancement were commonly accompanying; this and kinetic analysis are valuable findings for distinguishing IGM from invasive cancer. IGM shows similar ADC values to invasive cancers despite being benign, DW-MRI is not helpful in the differentiation with malignant lesions.

Fibroadenomatosis involving bilateral breasts and axillary accessory breast tissues in a renal transplant recipient given cyclosporin A.

We present the mammographic and sonographic findings in a case of fibroadenomatosis involving both breasts and axillae in a renal transplant patient after 16 years of treatment with cyclosporin A. Awareness of the fact that cyclosporin A may induce the formation of fibroadenomas, including in accessory breast tissue, is important for correct diagnosis and preventing unnecessary intervention.