Substernal goitre presenting with upper and lower extremity oedema.

Substernal goitre is characterised by compressive symptoms of the airway and oesophagus. Chronic, progressive symptoms usually result in surgical removal. We report a rare presentation of substernal goitre in a male in his early 70s who suffered from severe bilateral lower extremity (LE) lymphoedema, resulting in immobility and nursing home placement, and left upper extremity lymphoedema. Our initial assessment led to a filariasis work-up, which was negative, due to the patient's prior 2-year residence in India and service overseas. Chest CT scan revealed an incidental substernal goitre extending posterior to the left innominate vein and aortic arch to the level of the left mainstem bronchus. The patient underwent a left hemithyroidectomy via cervical excision and sternotomy and had an uneventful recovery with resolution of lymphoedema and mobility. Despite extensive literature regarding clinical presentations of substernal goitre, severe lymphoedema of the LE is not a well-established association.

Differentiation of High-Grade Glioma and Intracranial Metastasis Using Volumetric Diffusion Tensor Imaging Tractography.

OBJECTIVE: A reliable, noninvasive method to differentiate high-grade glioma (HGG) and intracranial metastasis (IM) has remained elusive. The aim of this study was to differentiate between HGG and IM using tumoral and peritumoral diffusion tensor imaging characteristics. METHODS: A semiautomated script generated volumetric regions of interest (ROIs) for the tumor and a peritumoral shell at a predetermined voxel thickness. ROI differences in diffusion tensor imaging-related metrics between HGG and IM groups were estimated, including fractional anisotropy, mean diffusivity, total fiber tract counts, and tract density. RESULTS: The HGG group (n = 46) had a significantly higher tumor-to-brain volume ratio than the IM group (n = 35) (P < 0.001). The HGG group exhibited significantly higher mean fractional anisotropy and significantly lower mean diffusivity within peritumoral ROI than the IM group (P < 0.05). The HGG group exhibited significantly higher total tract count and higher tract density in tumoral and peritumoral ROIs than the IM group (P < 0.05). Tumoral tract count and peritumoral tract density were the most optimal metrics to differentiate the groups based on receiver operating characteristic curve analysis. Predictive analysis using receiver operating characteristic curve thresholds was performed on 13 additional participants. Compared with correct clinical diagnoses, the 2 thresholds exhibited equal specificities (66.7%), but the tumoral tract count (85.7%) seemed more sensitive in differentiating the 2 groups. CONCLUSIONS: Tract count and tract density were significantly different in tumoral and peritumoral regions between HGG and IM. Differences in microenvironmental interactions between the tumor types may cause these tract differences.