White out hemithorax secondary to salivary gland type of lung cancer with metastasis in liver and bone: a case report.

BACKGROUND: Salivary gland-type lung carcinomas are uncommon neoplasms of the lung, representing less than 1% of all lung tumors. The two most common among them are adenoid cystic carcinoma and mucoepidermoid carcinoma. Although they usually have an indolent behavior, adenoid cystic carcinomas can be more aggressive, with 5-year survival as low as 55%. Very few cases are reported in literature. We report a similar rare case of salivary gland type lung carcinoma that presented for the first time with unilateral opacification of left hemithorax. CASE PRESENTATION: A 38-year-old man of North Indian origin, who was a a nonsmoker, presented with complaints of shortness of breath and cough for 1 year, which has increased in the last 2 months and was associated with significant weight loss. A frontal radiograph of the chest and computed tomography of the chest were performed, which showed a mass in the left upper lobe of the lung with its epicenter in the left main bronchus. A bronchoscopic guided biopsy was performed, and histopathology confirmed the diagnosis of lung carcinoma of salivary gland type (adenoid cystic carcinoma). There was invasion of major vessels, hence the patient was offered and started on palliative management instead of surgical treatment. In spite of palliative management of two cycles of chemotherapy and radiotherapy, the patient succumbed to the disease within 2 months from the time of diagnosis. CONCLUSION: Lung carcinoma of the salivary gland type (especially adenoid cystic carcinoma) usually presents at a later stage. The resectability of the tumor depends on the involvement of the surrounding major vessels. Interestingly, these cancers have no association with smoking. The prognosis depends on the extent of the disease at the time of diagnosis. Hence, imaging plays a major role in deciding the further plan of management.

Utility of Diffusion Tensor Imaging in Assessing Corticospinal Tracts for the Management of Brain Tumors: A Cross-Sectional Observational Study.

Introduction Intra-axial brain tumors are a significant health problem and present several diagnostic and treatment challenges. Conventional magnetic resonance imaging (MRI) has posed several limitations, such as the inability to delineate the detailed anatomy of fibers in structures like the brainstem and the inability to accurately judge the extent of tumor infiltration. Diffusion tensor imaging (DTI), based on the concepts of isotropic and anisotropic diffusion, is capable of visualizing and segmenting white fiber bundles in high detail and providing crucial information about tumor boundaries, extent, neighboring tracts, and more. This information can be very useful in initial non-invasive diagnosis, preoperative tumor grading, biopsy planning, surgical planning, and prognosis. Methods and materials This is a cross-sectional observational study in a tertiary care setup, conducted over a one-year period. The study was performed in Seth Gordhandas Sunderdas Medical College (Seth G.S. Medical College) and King Edward VII Memorial Hospital (K.E.M. Hospital), a tertiary care hospital located in Mumbai, India. Fiber tractography was performed and was used to visualize the corticospinal tracts passing through the length of the brainstem. Changes in the degree of infiltration, destruction, and displacement of the corticospinal tracts were observed carefully. Adult patients who were diagnosed with brain tumors, willing to participate in the study, and capable of providing written informed consent prior to study registration were included. The DTI findings along with information from other investigations were used to decide the best course of management for each case. Results The study included 30 participants with a mean age of 46.0 ± 17.1 years, 63.3% and 37.7% being male and female, respectively. According to the lesion's location, the pons was found to be the most often affected area in 23.33% of cases, followed by the temporo-parietal region (13.3%) and the frontal region (13.3%). These lesions had heterogenous enhancement in 63.3% of the instances and homogeneous enhancement in 36.7% of the cases, according to a contrast study. According to their consistency, the lesions were further divided into two categories: solid lesions, which were present in 66.7% of instances, and cystic lesions, which were present in 90% of cases. Results from the diffusion tensor technique revealed that infiltration accounted for 40.0% of cases, displacement for 76.7%, and loss of white fiber tracts for 20.0%. DTI findings were significantly associated with the type of planned management and with the presence of post-management neurological deficit. Conclusion DTI played a complementary role in the assessment of tumors and can be used to improve surgical planning and therapeutic decision making. Preservation of corticospinal tracts is vital to prevent motor impairment. Availability of qualitative data with the depiction of corticospinal tracts in a three-dimensional projection and their relation with the brain tumors by DTI greatly helps in preoperative decision making and surgical approach.

Paediatric and adolescent ectopic Cushing's syndrome: systematic review.

OBJECTIVE: The data on clinical, biochemical, radiological characteristics, and outcomes in paediatric ectopic adrenocorticotropic hormone syndrome (EAS) are limited owing to rarity of the condition. We report three new cases and perform a systematic review of paediatric EAS. DESIGN AND METHOD: Case records of paediatric and adolescent EAS patient's ≤20 years presenting at our centre between 1997 and 2021 were retrospectively reviewed, and a systematic review of the literature published between January 1970 and December 2022 was performed. RESULTS: A total of 161 patients including 3 new patients from our centre were identified. Bronchial neuroendocrine tumours (NET) (28.5%), thymic NET (22.9%), primitive cell-derived tumours (18.6%), and gastro-entero-pancreatic-NET (13.7%) were the common causes. Primitive cell-derived tumours were the most common in the first decade (24/45, 53.4%) and were the largest (82 [60-100] mm), whereas bronchial NETs predominated during the second decade (42/116, 36.2%) and were the smallest (15 [10-25] mm). Computed tomography localized 92.9% (118/127) of paediatric EAS patients. Immediate postoperative remission was attained in 77.9% (88/113) patients, whereas 30.4% (24/79) relapsed over a median (IQR) period of 13 (8-36) months. Over a median (IQR) follow-up of 2 (0.6-4.6) years, 31.4% of patients died. The median survival was higher in bronchial NET than in other tumour groups. Distant metastasis and tumour size were independent negative predictors of survival. CONCLUSIONS: Aetiological profile of paediatric and adolescent EAS is distinct from that of adults. Bronchial NETs have the best long-term survival, whereas distant metastasis and tumour size predict poor survival.

Correlation Between Renal Calculus Disease and Iliac Bone Thickness on a Single Non-contrast CT Scan.

Background Renal calculi remain a major economic and health burden worldwide and are considered a systemic disorder associated with multiple other diseases. Several studies have observed that patients with idiopathic calcium renal stones show a reduction in bone mass. This study aimed to evaluate bone mass reduction on a non-contrast CT scan study in a group of idiopathic calcium-containing renal calculus disease patients in comparison with subjects without renal calculus disease. Methodology This non-interventional, cross-sectional study included a total of 300 patients with 150 cases (with renal calculi) and 150 controls (without renal calculi). Patients were divided according to age groups of 18-40, 40-60, and more than 60 years. The renal calculus size and the mean iliac bone thickness were calculated, and Spearman's correlation test was used to determine the correlation between them. Results The mean iliac bone thickness was significantly lower in the cases (3.29 mm) compared to the controls (9.73 mm with a standard deviation of 1.341 mm). There was a statistically significant negative correlation between the size of the renal calculus and the mean iliac bone thickness. Conclusions Renal calculus disease associated with hypercalciuria caused by increased bone resorption is reflected by the decreased iliac bone thickness on CT scans. Our study used the iliac bone (cancellous bone) in predicting bone mass reduction which shows changes early in the course of the disease compared to the neck of the femur and lumbar vertebrae (compact bones). It helps in predicting osteoporosis early and prevents the progression of the disease through early and appropriate clinical and urological intervention.

Laparoscopic transhiatal stapled closure of spontaneous pleuroesophageal fistula: A case report.

Pleuroesophageal (PE) fistula (PEF) is rare and usually presents secondary to tuberculous mediastinal lymphadenopathy, Boerhaave syndrome, penetrating foreign bodies, erosive oesophagitis, post-mediastinal and gastroesophageal surgeries and neoplasm. We present a case of spontaneous PEF, successfully treated laparoscopically with stapling done through the hiatus.

Slipped capital femoral epiphysis as primary presentation in an adolescent with primary hyperparathyroidism due to ectopic mediastinal parathyroid adenoma.

Key Clinical Message: Ectopic mediastinal parathyroid adenoma causes primary hyperparathyroidism presenting as hypercalcemia. When children with hypercalcemia present with slipped capital femoral epiphysis, a detailed evaluation for hypercalcemia must be done before surgery. Abstract: The association between slipped capital femoral epiphysis (SCFE) and hyperparathyroidism has been reported and is rare. Each is known to affect different age groups. We report a case of a 13-year-old boy with SCFE and primary HPT leading to hypercalcemia and skeletal deformities.

Age Estimation Based on CT Chest Analysis of Ossification of the Xiphisternal Joint in a Living Population Aged 35-50 in a Tertiary Setup.

Introduction Age estimation has been an area of special interest in the medicolegal context because of its necessity in various criminal and civil cases like assaults, murders, rapes, inheritance, insurance claims, etc. While legal documents are useful in daily activities that require age identity, they cannot be relied on for criminal and civil proceedings because of being falsifiable and inaccessible to some people. Scientific methods of age determination like physical, dental, and radiological examinations are used for reliable age estimation due to their universal and non-falsifiable nature. The skeletal examination is of great importance here because the human skeleton provides many sites for age estimation in different age groups. The xiphisternal joint between the xiphoid process and the body of the sternum provides one such opportunity in participants of 35-50 years of age. The ossification in this joint proceeds gradually in approximately the third to fifth decade of life; this natural variation in the morphology of the joint can be leveraged for age estimation. Previous studies showed that the mean age of fusion varied with the ethnicity of individuals and environmental factors. Thus, it is critical to have statistical information for the concerned population to avoid errors. Also, the relation of gender with the mean age of complete fusion remained ambiguous with the previous studies. The xiphisternal joint can be studied by radiological techniques like computed tomography (CT) and plain radiographs. Radiological methods have the benefit that they can be used on both living and dead participants and are non-invasive. The present study aims at gathering data relevant for use in India (Maharashtra) and to find out the reference age group in which there is complete ossification of the xiphisternal joint in males and females.  Methods and materials This was a cross-sectional observational study in a tertiary care setup over a period of one year. High-resolution computed tomography (HRCT) was used for assessing joint fusion due to its high spatial resolution. The participants were included in the study if they were referred for HRCT chest by a physician for some pathology, did not have any trauma or lesion of the sternum and consented to the use of their information for the purpose of this study. Results The study included a total of 384 participants, out of whom 195 (50.8%) were males and 189 (49.2%) were females. The mean age of participants was 42.87 years. The mean age of complete xiphisternal joint fusion was observed to be 46.31 years (95% CI: 45.61 to 47.00) in males and 45.57 years (95% CI: 44.73 to 46.42) in females. Similarly, the mean age of participants with an unfused xiphisternal joint was observed to be 38.42 years (95% CI: 37.47 to 39.39) in males and 37.85 years (95% CI: 37.14 to 38.57) in females. There was no statistically significant difference in the age above which males and females show complete ossification of the xiphisternal joint. Conclusion The xiphisternal joint fusion can be used to determine the chronological age of an individual. It can be estimated as lesser than or equal to 45 years if the xiphisternal joint is unossified and greater than or equal to 37 years if the joint is ossified, with a 95% level of confidence.

Uncommon Presentation of Craniopharyngioma: A Case Report of Post-traumatic Intratumoral Hemorrhage Leading to Cerebral Infarct.

Craniopharyngiomas emanate from squamous cell remnants in the hypophyseal/pharyngeal duct region. This report details the unprecedented case of a 29-year-old male with adamantinomatous craniopharyngioma, who, following a motor vehicle collision (MVC), presented with post-traumatic intratumoral hemorrhage leading to acute basal ganglia infarct. The patient, previously subjected to subtotal resection, exhibited focal neurological deficits attributed to compression of lenticulostriate arteries due to the sudden increase in tumor volume. The patient, ineligible for thrombolysis or thrombectomy, was conservatively managed post-MVC. Subtotal resection occurred four months later. After one year, persistent right-sided weakness (2/5 motor power) remained, and the recommended stereotactic radiotherapy was declined by the patient. Notably, this instance represents the first documented case of post-traumatic intratumoral hemorrhage in adamantinomatous craniopharyngioma. This report distinguishes between adamantinomatous and papillary subtypes, noting their prevalence in different age groups. While these tumors commonly present with gradual vision changes, fatigue, and endocrine dysfunction, complications such as intra-tumoral hemorrhage remain rare. This report serves as an educational tool, shedding light on potential complications and urging increased vigilance in managing craniopharyngiomas.

Rib osteochondroma presenting as acute paraparesis.

Osteochondromas are usually osseous outgrowths arising from the metaphyseal region of cortical bone. Moreover, osteochondroma can also arise from flat bones and the spine. However, their origin in the ribs is extremely rare and always near the costochondral junction. We present a 26-year-old male who presented with chief complaints of difficulty in walking for 2 weeks subsequently diagnosed with osteochondroma based on the presence of a cartilage cap on Magnetic resonance imaging.

Pulmonary artery pseudoaneurysm: an unsuspected cause of haemoptysis in post-COVID fungal infection of the chest.

Pulmonary Artery Pseudoaneurysm (PAP) is a rare but potentially fatal cause of haemoptysis, which often remains unsuspected by both clinicians and radiologists. Traditionally, infections like tuberculosis and bacterial endocarditis have been associated with the development of PAPs. However, additional causative factors like trauma, neoplasia, pulmonary hypertension and vasculitis are also to be considered. With the advent of the novel Coronavirus (COVID-19), attempts have been undertaken to study its multisystem implications. Also, a strong correlation has also been established between COVID-19 and fungal infestation of the paranasal sinuses and lung parenchyma. Hence, PAP should be suspected in post-COVID patients who develop new-onset haemoptysis or new focal consolidation on imaging. Imaging investigations like chest radiograph, CT chest, and CT Pulmonary Angiography help in the establishment of a diagnosis and assessment of the relevant anatomy, which aid in the classification of the PAP. Management strategies include endovascular treatment, surgical resection or conservative approach in form of prolonged antimicrobial therapy. Interventional radiological procedures like endovascular embolisation are especially useful in vitally unstable cases of massive haemoptysis who are poor surgical candidates. Our case highlights the unique presentation of pulmonary arterial pseudoaneurysm induced by a post-COVID-19 fungal infection.

Traumatic pseudocyst of the lung following blunt trauma to the chest.

Traumatic pseudocysts of the lung are a rare complication following blunt trauma to the chest. Differentiating them from other cystic lesions of the lung is important. Traumatic pseudocysts usually occur in children and young adults who present with haemoptysis and persistent pain. History of trauma and radiological evaluation with a chest radiograph and a CT scan help in making the diagnosis. Follow-up chest radiographs showing resolution of the pseudocyst can confirm thediagnostic confirmation. This is a report of one such patient, a young man who improved after conservative treatment, with spontaneous radiological resolution of the pseudocyst.

COVID-19 associated Rhino-Orbito-Cerebral Mucormycosis: Imaging spectrum and Clinico-radiological correlation- a single Centre experience.

PURPOSE: The study aims to depict the radiological features of Cov-ROCM, depict the common routes of spread to orbits and intracranial compartment and look for an association of the risk factors with radiological severity of the disease. METHODS: 96 patients who had COVID-19 infection in the past 3 months and were diagnosed with ROCM underwent CECT PNS examinations which were assessed by two experienced radiologists. They were divided into three groups based on the intraorbital and intracranial involvement and were correlated with various risk factors. RESULTS: The incidence of bony erosions which was the commonest finding (75%) was double in Cov-ROCM than the ROCM cases of pre COVID era (33-40%). The most common route of spread to orbit was through angioinvasion(52%) with intact orbital walls; and intracranial extension was via erosion of the cribriform plate(52%). Sphenoid sinus involvement is strongly associated with intracranial and intraorbital involvement.(p-value = .0004). History of longer ICU stays and being on mechanical ventilation as a part of COVID management is associated with aggressive disease pattern(p-value = .002). Similarly, poor glycaemic control signified by raised HbA1c levels showed statistically significant correlation with severe Cov-ROCM(intraorbital/intracranial extension) (p-value = .040). CONCLUSION: Amidst the COVID pandemic, it is pertinent to look at bony erosions in case of any sinusitis, especially bony maxillary walls and the turbinates. The intraorbital compartment must be viewed thoroughly even in the absence of bony erosions due to the angioinvasive nature of these fungi. Aggressive follow-up for patients with ICU stays for COVID and for glycaemic control would help reduce the morbidity.

Pseudomyxoma retroperitonei masquerading as a psoas abscess.

A 52-year-old woman was referred to our department with multiple discharging sinuses and swelling in the right flank and iliac region for the past year. Ultrasound revealed a large collection in the right psoas muscle with the sinus tract reaching up to the skin in the right iliac region. Despite repeated attempts at drainage, the collection continued to increase in size. CT was requested and revealed a large heterogeneous irregular collection in the right psoas with fistulous communication with the cecum and skin with the erosion of the overlying ilium. Because of lack of vertebral involvement, enhancing internal septations, non-visualisation of the appendix and feculent material admixed with mucinous discharge from the sinus, pseudomyxoma retroperitonei secondary to ruptured mucinous neoplasm of the appendix was suspected. Mucoid material at the local site was sent for histopathology, which confirmed our suspicion. Our treatment plan after ileostomy was cytoreductive surgery along with adjuvant radiotherapy (40 Gy in 20 fractions) with chemotherapy (5-fluorouracil and folinic acid given for 30 weeks, once a week). However, after ileostomy, the patient refused further treatment, citing financial reasons.

The Utility of 68Ga-DOTATATE PET/CT in Localizing Primary/Metastatic Pheochromocytoma and Paraganglioma: Asian Indian Experience.

Purpose: Pheochromocytoma and paraganglioma (PGL), together called PPGL, are rare tumors with a limited number of studies on the diagnostic performance of 68Ga-DOTA (0)-Tyr (3)-octreotate positron emission tomography-computed tomography (68Ga-DOTATATE PET/CT) from the Asian-Indian subcontinent. Materials and Methods: In this retrospective study, PPGL suspects (n = 87) who had undergone at least contrast-enhanced computed tomography (CECT) and 68Ga-DOTATATE PET/CT, were included. Lesion-wise, patient-wise, and region-wise sensitivities of 68Ga-DOTATATE PET/CT, 18F fluorodeoxyglucose positron emission tomography CT (18F-FDG PET/CT, n = 53), 131I-metaiodobenzylguanidine (131I-MIBG, n = 37), and CECT were compared, and diagnostic performance of 68Ga-DOTATATE PET/CT in the detection of PPGL was calculated. Results: 68Ga-DOTATATE PET/CT had significantly higher lesion-wise sensitivity than 131I-MIBG for both primary (94% vs 75%, P = 0.004) and metastatic disease (85% vs 59%, P = 0.001) and higher sensitivity than CECT for metastatic lesions (83% vs 43%, P = 0.0001). The lesion-wise sensitivity of 68Ga-DOTATATE PET/CT was similar to 18F-FDG PET/CT for both primary tumors (94% vs 85%, P = 0.08) and metastatic lesions (82% vs 84%, P = 0.76) in the whole cohort but tended to be inferior in the head to head comparison. Conclusion: 68Ga-DOTATATE PET/CT had higher sensitivity for detection of PPGL than 131I-MIBG (primary and metastatic) and CECT (metastatic) but similar to 18F-FDG PET/CT (primary and metastatic).

Oesophageal lung: a rare cause of complete hemithorax opacification.

Congenital bronchopulmonary foregut anomalies are uncommon group of disorders that reflect upon the embryological development of the foregut. These conditions represent the intimate embryological proximity of the foregut and tracheobronchial tree. The radiological findings are typically of segmental or lobar consolidation with abnormal vascular supply or foregut communication. We report a case of a breathless neonate with oesophageal origin of the right main bronchus. This communication was well demonstrated with the help of an oesophagogram. The radiologist plays an important role by identifying this communication on a CT done for non-resolving lung collapse. Contrast-enhanced CT of the chest is also useful in evaluating the vascular supply of the lung that helps in diagnosis and also directs treatment.

Sinonasal paraganglioma and Cushing's syndrome: A rare association.

In general, paragangliomas are symptomatic tumors, which may be clinically taken for other tumors, benign or malignant lesions. Paragangliomas of the nasal cavity and paranasal sinuses are an extremely rare entity and what is even rarer is its association with ectopic adrenocorticotropic hormone production. We report this very rare case to highlight the rare association of Cushing's syndrome with nasal paraganglioma and the importance of total surgical resection in its treatment.

Hysterosalpingography and ultrasonography findings of female genital tuberculosis.

Genital tuberculosis (TB) is an important cause of female infertility in the world, especially in developing countries. Majority of infertility cases are due to involvement of the fallopian tubes (92%-100%), endometrial cavity (50%), and ovaries (10%-30%); cervical and vulvovaginal TB are uncommon. Genital TB has characteristic radiological appearances based on the stage of the disease process (acute inflammatory or chronic fibrotic) and the organ of involvement. Hysterosalpingography (HSG) and ultrasonography (US) remain the main imaging modalities used in the diagnosis of genital TB. HSG is the primary modality for evaluating uterine, fallopian tube, and peritubal involvement and also helps in evaluating tubal patency. US, on the other hand, allows simultaneous evaluation of ovarian and extrapelvic involvement.