Differentiation of Borderline Epithelial Ovarian Tumors from Benign and Malignant Epithelial Ovarian Tumors by MRI Scoring

INTRODUCTION: The distinction between benign and borderline epithelial ovarian tumors is important because treatment and follow-up strategies differ OBJECTIVE: We aimed to evaluate benign, borderline, and malignant epithelial ovarian tumors using MRI features and contributed to the preoperative evaluation. METHODS: MRIs of 81 patients (20 bilateral), including 31 benign, 27 borderline, and 23 malignant, who had pelvic imaging between 2013-2020, were evaluated retrospectively. The evaluation was made blindly to the pathology result by two radiologists with MRI scoring and features that we determined. MRI evaluation was performed with T1 TSE, T2 TSE, fat-suppressed T2 TSE, and before and after contrast T1 fat-suppressed and non-fat-suppressed TSE images. The numbers and findings obtained in scoring were evaluated by Chi-Square, ordinal logistic regression, and 2 and 3 category ROC analysis. RESULTS: The total score varied between 7 and 24. Among the three groups, a significant difference was found in terms of T1, T2 signal intensity (p <0.01), size (p = 0.055), solid area (p <0.001), septa number (p <0.05), ovarian parenchyma (p = 0.001), ascites (p <0.001), peritoneal involvement (p <0.001), laterality (p <0.001), contrast enhancement pattern (p <0.001). On the other hand, no significant difference was found in terms of wall thickness, lymph node involvement and endometrial thickness (p> 0.05). Cut-off values were found as 11.5 and 18.5 in the 3-category ROC analysis performed for the score (VUS: 0.8109). Patients with a score below 11.5 were classified as benign, those between 11.5-18.5 as borderline, and those over 18.5 as malignant. CONCLUSION: The differentiation of borderline tumors from benign and malignant tumors by MRI scoring will contribute to the preoperative diagnosis.

Sunitinib-induced small bowel wall edema as a prognostic marker in metastatic renal cell carcinoma.

Aim: The aim of this study was to evaluate the presence of small bowel wall edema (SBWE) on computed tomography (CT) images in patients with metastatic renal cell carcinoma (mRCC) treated with sunitinib and to investigate the relationship between the presence of SBWE and survival. Materials and Methods: We retrospectively evaluated the presence of SBWE on CT images of 27 mRCC patients who received at least one cycle of sunitinib. Then, we analyzed the relationship between the presence of SBWE and progression-free survival (PFS) and overall survival (OS). RESULTS: All 27 patients had SBWE on at least one CT scan. The median value of SBWE thickness was 2.5 mm. SBWE thickness was ≤2.5 mm in 13 patients (group A) and >2.5 mm in 14 patients (group B). The median OS was significantly higher in group B (55 vs. 18 months, respectively, P = 0.02). Although it was not statistically significant (13 vs. 8 months, respectively, P = 0.69), the median PFS was longer in group B than in group A. CONCLUSIONS: This study showed that sunitinib treatment caused SBWE in all patients with mRCC who received the drug. Also, this study demonstrated an association between higher SBWE thickness and better survival outcomes.

Vaginal metastasis in solid tumours: our four cases and review of the literature.

BACKGROUND: Vaginal metastasis should be kept in mind when evaluating the staging tests of all cancers, especially endometrial cancer. CASE PRESENTATION: We present four patients with vaginal recurrence who recently applied to our clinic. Three cases were of endometrial cancer and one case of rectal cancer. All patients presented with vaginal bleeding. CONCLUSION: Standard treatment for vaginal metastasis has not yet been established. Therapeutic options for vaginal metastasis-separately or in combination-are surgical resection, radiotherapy, and chemotherapy.

Small bowel wall edema induced by regorafenib is associated with regorafenib intolerance and shorter survival in patients with metastatic colorectal cancer: A retrospective study.

INTRODUCTION: Regorafenib, a receptor tyrosine kinase inhibitor, is a routinely used targeted agent in the current treatment of patients with refractory metastatic colorectal carcinoma (mCRC). The aims of this study were to detect the presence of bowel wall edema during regorafenib treatment via computed tomography (CT) and to assess the relationship between survival and regorafenib-induced bowel wall edema in patients with mCRC receiving regorafenib. PATIENTS AND METHODS: We retrospectively evaluated the presence of bowel wall edema on CT of 25 mCRC patients who received regorafenib and analyzed its relationship with progression free survival (PFS) and overall survival (OS). RESULTS: Among the 25 patients, 25 had small bowel wall edema (SBWE) and 14 had large bowel wall edema (LBWE) on at least one CT examination. The median SBWE value was 4.85 milimeters (mm). Of the 25 patients, 14 had SBWE ≤4.85 mm and 11 had SBWE >4.85 mm. Regorafenib intolerance was significantly higher at SBWE >4.85 mm patients (p = 0.03). The median PFS was 4.6 months (95% CI: 2.4-6.8) and median OS was 9.3 months (95% CI: 3.1-15.4). Median PFS and OS were shorter in patients with SBWE > 4.85 mm than in those with ≤4.85 mm, but not statistically significant (median PFS: 3.9 vs 4.6 months, p: 0.523; median OS: 5.6 vs 9.3 months, p: 0.977). CONCLUSIONS: Regorafenib caused SBWE in patients with mCRC. Patients who developed more SBWE had a higher regorafenib intolerance and a shorter survival. Further studies are needed to confirm the predictor value of SBWE on the survival outcomes of patients with mCRC receiving regorafenib.

Frequency of potential causes of lower back pain and incidental findings in patients with suspected sacroiliitis: retrospective analysis of 886 patients with negative sacroiliac MRI examination for sacroiliitis.

BACKGROUND: In a majority of patients with suspected sacroiliitis (SI) who underwent sacroiliac magnetic resonance imaging (MRI), imaging studies may be normal, may depict other causes for pain, or may show clinically irrelevant incidental findings. PURPOSE: To determine the prevalence of possible etiologies other than SI and frequency of incidental findings demonstrated on sacroiliac MRI examinations in a cohort of patients with lower back pain and suspected SI. MATERIAL AND METHODS: Sacroiliac MRI examinations of 1421 patients with suspected SI were retrospectively reviewed. In patients without SI findings, other potential causes for lower back pain and incidental findings were documented. RESULTS: SI was present in 535 of 1421 patients (37.6%). In 886 of the patients whose MRI studies were negative for SI, other possible causes for lower back pain or incidental findings were seen in 386 (43.5%). The most common musculoskeletal (MSK) finding was lumbosacral transitional vertebra (8.6%) followed by findings suggesting piriformis syndrome (4.2%), spondylosis (3.7%), and sacral insufficiency fractures (1.8%). The most common non-MSK findings were follicular cysts (15.3%) and uterine fibroids (4.9%). CONCLUSION: In patients with suspected SI but negative MRI examinations for SI, some other possible causes for lower back pain and several incidental findings can be seen on imaging. The presence of these findings may explain the patient's symptoms, and awareness of these conditions may be helpful in patient management and individualizing treatment.

Case 269: Sacroiliac Joint Hydatid Disease.

HistoryA 20-year old woman living in Turkey presented with a 3-month history of lower back pain. She had no medical history of note and was taking no medications. Complete blood count, C-reactive protein level, sedimentation rate, and creatinine, alanine aminotransferase, and aspartate aminotransferase levels were within normal limits. Anteroposterior pelvic radiography and unenhanced pelvic CT were performed to rule out sacroiliitis. The imaging findings were abnormal, and the patient underwent contrast-enhanced sacroiliac MRI. A few days later, she underwent contrast-enhanced (100 mL iohexol, Omnipaque; GE Healthcare, Cork, Ireland) abdominal CT because of right upper quadrant pain.

Case 269.

History A 20-year old woman living in Turkey presented with a 3-month history of lower back pain. She had no medical history of note and was taking no medications. Complete blood count, C-reactive protein level, sedimentation rate, and creatinine, alanine aminotransferase, and aspartate aminotransferase levels were within normal limits. Anteroposterior pelvic radiography and unenhanced pelvic CT were performed to rule out sacroiliitis. The imaging findings were abnormal, and the patient underwent contrast-enhanced sacroiliac MRI. A few days later, she underwent contrast-enhanced (100 mL iohexol, Omnipaque; GE Healthcare, Cork, Ireland) abdominal CT because of right upper quadrant pain. Figure 1: Anteroposterior pelvic radiograph. Figure 2: Axial unenhanced pelvic CT image. Figure 3a: (a) Coronal T2-weighted fat-saturated fast spin-echo (repetition time msec/echo time msec, 2220/57; section thickness, 4 mm), (b) axial unenhanced T1-weighted fat-saturated, and (c) axial contrast-enhanced (20 mL gadoteric acid, Dotarem; Guerbet, Roissy, France) T1-weighted fat-saturated (400/20; section thickness, 4 mm) sacroiliac images from MRI. Figure 3b: (a) Coronal T2-weighted fat-saturated fast spin-echo (repetition time msec/echo time msec, 2220/57; section thickness, 4 mm), (b) axial unenhanced T1-weighted fat-saturated, and (c) axial contrast-enhanced (20 mL gadoteric acid, Dotarem; Guerbet, Roissy, France) T1-weighted fat-saturated (400/20; section thickness, 4 mm) sacroiliac images from MRI. Figure 3c: (a) Coronal T2-weighted fat-saturated fast spin-echo (repetition time msec/echo time msec, 2220/57; section thickness, 4 mm), (b) axial unenhanced T1-weighted fat-saturated, and (c) axial contrast-enhanced (20 mL gadoteric acid, Dotarem; Guerbet, Roissy, France) T1-weighted fat-saturated (400/20; section thickness, 4 mm) sacroiliac images from MRI. Figure 4: Axial contrast-enhanced CT image of the abdomen.

Hounsfield unit density in the characterisation of bile duct lesions.

PURPOSE: To study the density of lesions in the lumens of extrahepatic bile ducts through computed tomography examinations, and to compare their characterisations with the results of pathology and/or endoscopic retrograde cholangiopancreatography (ERCP). METHODS: The density of lesions along extrahepatic bile ducts were measured and compared with pathology and/or ERCP. The lesions were evaluated in two main groups: benign or malignant. The bile duct wall enhancement, intrahepatic bile ducts, and gallbladder were also evaluated. RESULTS: The study was conducted with computed tomography scans of 197 cases (93 females, 104 males) who had optimal imaging. The results regarding density of extrahepatic intraductal lesions that were studied at BT were compared with pathology and magnetic resonance cholangiopancreatography results. Of 197 lesions, 125 (63.5%) were reported as benign and 72 (36.5%) were reported as malignant. The results for benign lesions showed an average density of 66.67 ± 17.30 Hounsfield units (HU), and for malignant lesions the average density was 82.38 ± 13.67 HU. CONCLUSION: Lesion density level (HU) gives valuable information for the differentiation between benign and malign lesions in intraluminal extrahepatic bile ducts.

An important cause of pes planus: the posterior tibial tendon dysfunction.

Posterior tibial tendon dysfunction (PTTD) is an important cause of acquired pes planus that frequently observed in adults. Factors that play a role in the development of PTTD such as age-related tendon degeneration, inflammatory arthritis, hypertension, diabetes mellitus, obesity, peritendinous injections and more rarely acute traumatic rupture of the tendon. PTT is the primary dynamic stabilizer of medial arch of the foot. Plantar flexion and inversion of the foot occurs with contraction of tibialis posterior tendon, and arch of the foot becomes elaveted while midtarsal joints are locked and midfoot-hindfoot sets as rigid. Thus, during the walk gastrocnemius muscle works more efficiently. If the PTT does not work in the order, other foot ligaments and joint capsule would be increasingly weak and than pes planus occurs. We present a 10-year-old female patient diagnosed as PTTD and conservative treatment with review of the current literature.

Strain elastography in the characterization of renal cell carcinoma and angiomyolipoma.

INTRODUCTION: We evaluate the diagnostic performance of strain elastography to differentiate renal cell carcinoma (RCC) from angiomyolipoma (AML). METHODS: Strain elastography was performed in 65 patients (mean age 55.5 years; range: 32-81) who had renal lesions (24 AMLs and 41 RCCs) prospectively. Lesions were classified according to lesion size and histological subtypes. The strain ratios of the RCCs and AMLs were evaluated by a radiologist. The area under the curve and the cut-off point were used to assess diagnostic performance. Sensitivity, specificity, and positive and negative predictive values were obtained. RESULTS: In assessing the mean strain ratio, we divided the groups in 3 according to size: (1) <20-mm lesions; (2) 20- to 40-mm lesions; and (3) >40-mm lesions; the respective mean strain ratios were: 1.5 ± 0.5 (range: 0.06-5.92), 2.8 ± 0.4 (range: 0.17-9.92), 2.7 ± 0.3 (range: 0.08-6.15). When RCCs and AMLs were compared, there was a statistically significant difference in the strain ratio among the 3 groups divided per lesion size (p < 0.01). For the strain ratio, the mean ± standard deviation was 1.1 ± 0.1 for AMLs and 3.4 ± 0.3 for RCCs (p < 0.01). When lesion subtypes were compared, there was a statistically significant difference in the strain ratio between the AML and clear cell RCC (p < 0.01). CONCLUSIONS: For assessing renal lesions, strain elastography and strain ratio values may be useful in differentiating RCCs from AMLs.

Tuberculous bursitis of the greater trochanter mimicking ankylosing spondylitis.

Tuberculous trochanteric bursitis (TTB) is a rare condition that accounts for 1% of musculoskeletal tuberculosis cases. Extrapulmonary TB is usually diagnosed late because of reduced diagnostic suspicion, particularly in the absence of signs of systemic infection. Herein, we report a case of right hip pain that was misdiagnosed as ankylosing spondylitis. The patient had a history of inflammatory back pain with morning stiffness. However, HLA-B27 was negative. Sacroiliac magnetic resonance imaging (MRI) revealed a giant multiloculated collection (27×16×10 cm). Percutaneous drainage was performed and Mycobacterium tuberculosis was observed in fluid culture. The patient was treated by drainage along with antituberculosis therapy. After 1 year of antituberculosis therapy, control MRI revealed total resolution of the large fluid collection. It is important to emphasize that fever or general symptoms are absent in patients with TTB, as observed in the present case. In endemic countries, TTB should be kept in mind in the differential diagnosis of a patient presenting with chronic hip pain without fever, weight loss, and constitutional symptoms.

Giant cell tumour of humerus: an unexpected lesion in a skeletally immature patient with Hodgkin's disease.

Giant cell tumour (GCT) of bone is a benign aggressive tumour of the bone. It typically presents in persons aged 20 - 40 years. It is rare in adolescents and children. In most cases, GCT of bone occurs in the metaphyseal and epiphyseal regions of long bones. However, in children with open physes, GCT of bone may be centered in the metaphysis and may abut the physis. GCT is most commonly found in the distal femur, proximal tibia, and distal radius. It is not reported after treatment of a cancer in childhood. To the best of authors' knowledge, the coexistence of giant cell tumour of the bone and Hodgkin disease has not been reported in the literature. We report an atypical case of giant cell tumour of humerus in a skeletally immature child treated for Hodgkin's disease (HD), which had initially presented as a bone cyst radiologically.

Boron enhances strength and alters mineral composition of bone in rabbits fed a high energy diet.

An experiment was performed to determine whether boron had a beneficial effect on bone strength and composition in rabbits with apparent adiposity induced by a high energy diet. Sixty female New Zealand rabbits, aged 8 months, were randomly divided into five groups with the following treatments for seven months: control 1, fed alfalfa hay only (5.91 MJ/kg); control 2, high energy diet (11.76 MJ and 3.88 mg boron/kg); B10, high energy diet+10 mg/kg body weight boron gavage/96 h; B30, high energy diet+30 mg/kg body weight boron gavage/96 h; B50, high energy diet+50mg/kg body weight boron gavage/96 h. Bone boron concentrations were lowest in rabbits fed the high energy diet without boron supplementation, which suggested an inferior boron status. Femur maximum breaking force was highest in the B50 rabbits. Tibia compression strength was highest in B30 and B50 rabbits. All boron treatments significantly increased calcium and magnesium concentrations, and the B30 and B50 treatments increased the phosphorus concentration in tibia of rabbits fed the high energy diet. The B30 treatment significantly increased calcium, phosphorus and magnesium concentrations in femur of rabbits fed the high energy diet. Principal component analysis of the tibia minerals showed that the three boron treatments formed a separate cluster from controls. Discriminant analysis suggested that the concentrations of the minerals in femur could predict boron treatment. The findings indicate boron has beneficial effects on bone strength and mineral composition in rabbits fed a high energy diet.

Application of first-pass contrast bolus tracking sequence for the assessment of morphology and flow dynamics in cardiac MRI.

PURPOSE: There are two well-known indications for first-pass perfusion in the literature. First is the evaluation of myocardial ischemia, and the other is the evaluation of tumor vascularity. Our aim was to assess the value of a first-pass contrast bolus tracking sequence (FPCBTS) for cases unrelated to these pathologies. MATERIALS AND METHODS: A total of 35 patients (age range, 1 day to 66 years; mean age, 10.4±19.2 years; median age, 4.5 months) with suspected congenital (n=31) and acquired (n=4) heart and great vessel disease were included in the study. All the patients underwent cardiac magnetic resonance imaging (MRI) and FPCBTS, and 20 patients underwent contrast enhanced magnetic resonance angiography (CE-MRA). We used cardiac MRI and CEMRA for anatomic evaluation and FPCBTS for dynamic flow evaluation. RESULTS: Truncus arteriosus, double outlet right ventricle, tetralogy of Fallot, corrected transposition of great arteries, atrial and ventricular septal defect, aortic rupture, cardiac hydatid cyst, tricuspid atresia, anomalous pulmonary venous return, and interrupted aorta were detected using the technique described here. Septal defects in six patients and atrial aneurysm in two patients were excluded. The shunt gap and flow direction of the septal defects, a ruptured wall in a dissected aorta, a hydatid cyst, and the atrial relationship in two cases with paracardiac masses were diagnosed easily using this dynamic evaluation technique. CONCLUSION: FPCBTS can be performed in addition to cardiac MRI and CEMRA to reveal flow dynamics and morphology.

Radiofrequency ablation of phalangeal osteoid osteoma: technical challenges encountered in small bones.

Osteoid osteoma, a benign bone tumor, is characterized by a generally less than 1 cm nidus surrounded by a zone of reactive sclerosis. It is frequently located in the femur and tibia; on the other hand in up to 5% of cases it may be presented in upper extremities. In previous years, its treatment was usually open surgery with en-bloc resection or curettage of the tumor. Various minimal invasive percutaneous treatments including radiofrequency ablation became popular in last years. In this report, the difficulties encountered during radiofrequency ablation treatment in small bones is described in a 19-year-old female case of osteoid osteoma.

The effect of electrical stimulation in combination with Bobath techniques in the prevention of shoulder subluxation in acute stroke patients.

OBJECTIVE: To examine the efficiency of electrical stimulation in combination with Bobath techniques in the prevention of inferior and anterior shoulder subluxation in acute stroke patients. DESIGN: A prospective randomized controlled trial. SETTING: Intensive care unit and inpatient clinics of neurology in a university hospital. SUBJECTS: Forty-eight patients with acute stroke, divided equally into control and study groups. INTERVENTION: Subjects in both groups were treated in accordance with the Bobath concept during the early hospitalization period. In addition to Bobath techniques, electrical stimulation was also applied to the supraspinatus muscle, mid and posterior portions of the deltoid muscle of patients in the study group. MAIN MEASURES: Two radiological methods were used to measure the horizontal, vertical and total asymmetry and vertical distance values of the shoulder joint. Motor functions of the arm were evaluated with the Motor Assessment Scale. RESULTS: The hospitalization period was 12.62 ± 2.24 days for the control group and 11.66 ± 1.88 days for the study group. Shoulder subluxation occurred in 9 (37.5%) subjects in the control group, whereas it was not observed in the study group. All shoulder joint displacement values were higher in the control group than in the study group (horizontal asymmetry P = 0.0001, vertical asymmetry P = 0.0001, total asymmetry P = 0.0001, vertical range P = 0.002). CONCLUSION: Application of electrical stimulation combined with the Bobath approach proved to be efficient in preventing inferior and anterior shoulder subluxation in the acute stages of stroke.

Women with patellofemoral pain syndrome have quadriceps femoris volume and strength deficiency.

PURPOSE: the aim of this study was to assess muscle torque, total volume, and cross-sectional area, and lower limb function of the quadriceps muscle in women with unilateral patellofemoral pain syndrome (PFPS). METHODS: twenty-four women with unilateral patellofemoral pain participated in the study, with each subject acting as their own internal control by using the unaffected limb. quadriceps muscle torque was measured with the Isomed 2000. The total volume and cross-sectional area (CSA) of the quadriceps muscle were measured by using magnetic resonance imaging. Lower limb function was assessed by hop and step-down tests. RESULTS: there was a significant difference in the total volume (P < 0.05) and in the cross-sectional area (P < 0.05) of the quadriceps muscle between affected and unaffected sides. There was a significant difference in the peak torque of the quadriceps muscle at 60°/s between affected and unaffected sides (P < 0.05). There were significant correlations between quadriceps largest CSA and volume on the affected side (P < 0.05) and on the unaffected side (P < 0.05). There were significant negative correlations between the smallest CSA and the peak torque at 180°/s (P < 0.05) and at 60°/s (P < 0.05) on the affected side. CONCLUSIONS: decreased torque, total volume, and CSA of the quadriceps muscle are presented in unilateral with PFPS although cause or effect cannot be established. Large prospective longitudinal studies are needed to detect the changes in the muscle structure and to establish whether these features are a cause of PFPS.