Atypical Cardiac Location of Melanoma of Unknown Origin.

The subject was a 66-year-old woman, suffering from the chest pain evoked by physical activity. Transthoracic echocardiography (TTE) revealed an abnormal structure, 41 × 29 mm. In MSCT, a hypodensic mobile tissue lesion that was infiltrating the whole thickness of left ventricle was confirmed. PET excluded the existence of other remote lesions. After surgical tumor removal, histopathological differential diagnosis revealed melanoma, myoepithelial cancer, and MPNST "high-grade" sarcoma. A control TTE detected a tumor that was 14 × 10 mm. After immunohistochemical results, immunotherapy with pembrolizumab was used, which resulted in complete tumor resolution. Presently, surgical resection and neoadjuvant targeted immunochemotherapy remain the treatment of choice for clinical stage III/IV melanoma.

Stress radiography in the diagnosis and assessment of the outcomes of surgical treatment of chronic anterolateral ankle instability.

BACKGROUND: In about 20-40% of patients, damage to the soft tissues surrounding the ankle leads to recurrent and chronic pain with signs of instability of the talus in the tibiofibular fork. PURPOSE: The aim of the study was to assess the usefulness of stress X-ray images in the diagnosis of long-term outcomes of conservative versus surgical treatment of anterolateral ankle instability. MATERIAL AND METHODS: Thirty patients with chronic ankle instability (CAI) were recruited for the study. The participants were divided into two groups. The first group consisted of 15 non-operatively treated individuals diagnosed with anterior talofibular ligament (ATFL) damage. The second group consisted of 15 patients who had undergone surgical reconstruction of the ATFL. In both groups of patients, the contralateral normal limb was used as a control. In all patients, anteroposterior and lateral view stress radiographs of both ankles were taken using the TELOS Stress Device (GA - III/E, Hungen, Germany). RESULTS: Statistical tests showed that the surgically treated patients had a significantly greater ankle stability compared to the non-surgically treated patients (P = 0.001 for talar tilt angle and P = 0.009 for anterior drawer distance). The results obtained in this study indicate that this method can also be used in postoperative assessment of the function of the reconstructed lateral ankle ligaments. CONCLUSIONS: Stress radiography is a reliable and safe tool for diagnosing CAI. This imaging method is an objective instrument that can be successfully used in postoperative assessment of the function of the reconstructed ATFL.

[Hypersensitivity pneumonitis and idiopathic pulmonary fibrosis - case report]. / Alergiczne zapalenie pecherzyków plucnych i samoistne sródmiazszowe wlóknienie pluc ­ opis przypadku.

Hypersensitivity pneumonitis (HP), called extrinsic allergic alveolitis, is a syndrome characterized by diffuse inflammation of lung parenchyma and airways in response to the inhalation of antigens to witch the patient has been previously sensitized. The clinical presentation of HP have been categorized as acute, subacute and chronic. The patient with chronic HP may lack a history of acute episodes and usually reports the insidious onset of cough, dyspnoea, fatigue, and weight los. Idiopathic pulmonary fibrosis (IPF) is a type of lung disease that results in scarring (fibrosis) of the lungs for an unknown reason. Symptoms of IPF are the same as in chronic hypersensitivity pneumonitis and differentiation may be difficult. We present a case of patient with chronic HP, in whom the course of the end stage of the disease mimic acute exacerbations idiopathic pulmonary fibrosis.

Total anomalous pulmonary vein drainage in a 60-year-old woman diagnosed in an ECG-gated multidetector computed tomography - a case report and review of literature.

PURPOSE: Total anomalous pulmonary vein drainage (TAPVD) is a congenital cardiac defect in which there is no connection between pulmonary veins and the left atrium. Pulmonary veins form a confluence independent of the left atrium and drain to a systemic vein. TAPVD types are: supracardiac, cardiac, infracardiac, and mixed. TAPVD accounts for approximately 1.5-2.2% of all congenital heart diseases. This anomaly is usually diagnosed in the neonatal period, and it coexists with atrial septal defect. Adult cases of TAPVD are rarely reported. CASE REPORT: We report a rare case of a 60-year-old woman with incidentally found, uncorrected TAPVD in ECG-gated multidetector computed tomography. In previous echocardiographic examinations partial anomalous pulmonary venous return and atrial septal defect were diagnosed. CONCLUSIONS: ECG-gated multidetector computed tomography is a valuable diagnostic method for adults with congenital heart disease. It enables evaluation of coronary arteries and simultaneously provides detailed anatomy of great vessels.

Two types of lateral extension in juvenile nasopharyngeal angiofibroma: diagnostic and therapeutic management.

Juvenile nasopharyngeal angiofibroma is a benign, locally aggressive nasopharyngeal tumor. Apart from anterior lateral extension to the pterygopalatine fossa, it may spread laterally posterior to the pterygoid process, showing posterior lateral growth pattern, which is less common and more difficult to identify during surgery. We analyzed the routes of lateral spread, modalities useful in its diagnosis, the incidence of lateral extension and its influence on outcomes of surgical treatment. The records of 37 patients with laterally extending JNA treated at our institution between 1987 and 2011 were retrospectively evaluated. Computed tomography was performed in all patients and magnetic resonance imaging in 17 (46 %) patients. CT and MRI were evaluated to determine routes and extension of JNA lateral spread. Anterior lateral extension to the pterygopalatine fossa occurred in 36 (97 %) patients and further to the infratemporal fossa in 20 (54 %) patients. In 16 (43 %) cases posterior lateral spread was observed: posterior to the pterygoid process and/or between its plates. The recurrence rate was 29.7 % (11/37). The majority of residual lesions was located behind the pterygoid process (7/11). Recurrent disease occurred in 3/21 patients with anterior lateral extension, in 7/15 patients with both types of lateral extensions and in 1 patient with posterior lateral extension. JNA posterior lateral extension may spread behind the pterygoid process or between its plates. The recurrence rate in patients with anterior and/or posterior lateral extension is significantly higher than in patients with anterior lateral extension only. Both CT and MRI allow identification of the anterior and posterior lateral extensions.

Diagnosis and management of multiple paragangliomas of the head and neck.

Paragangliomas (PGs) are slowly growing, usually benign neoplasms. The aim of the study was to analyze the incidence, diagnostic and therapeutic management of patients with multiple paragangliomas of the head and neck. A retrospective review of the records of 84 patients with head and neck PGs, diagnosed and treated in our institution was performed for the years 1983-2013 to identify patients with multiple tumors. Fourteen (16.6 %) patients developed multiple PGs, synchronous or metachronous, within 4-21 years of follow-up. Clinical data of these patients were reviewed to evaluate the diagnosis, location, stage and management strategy. There was a total number of 37 tumors in 14 patients. There were 20/37 (54.0 %) carotid PGs, 9/37 (24.3 %) jugular PGs and 8/37 (21.7 %) vagal PGs. Carotid PGs were observed in 12/14 (86 %) patients and in 8/14 (57 %) cases bilateral tumors occurred. Vagal PGs developed in 7/14 (50 %) patients and bilateral tumors were found in 1/14 (7 %) case. Jugular PGs occurred in 9/14 (64 %) patients. There were 30 synchronous tumors and seven metachronous PGs diagnosed 2-18 years after removal of the first tumor. Single metachronous mediastinal PG occurred. All patients had at least one tumor removed, with histopathological confirmation of the diagnosis. One patient had positive history of familial PGs. Carotid PGs are most common multiple paragangliomas. Radiological survey of the head and neck is required to detect multicentric tumors. Metachronous mediastinal and abdominal tumors may occur. Regular, prolonged follow-up is essential to identify metachronous PGs and possible postoperative gradual ICA occlusion.

Clinically relevant anatomical parameters of the replaced right hepatic artery (RRHA).

PURPOSE: Vascular anatomy of the liver is subjected to many variations. The most common hepatic artery (HA) replacement is the right hepatic artery (RRHA). Variations of the HA are particularly important consideration when choosing the best surgical procedure or if radiological abdominal intervention is required. In this study, we evaluated the anatomical details of the RRHA origin. METHODS: Retrospective investigation of clinical data from 1569 patients who underwent an abdominal MDCT was performed. The anatomy of RRHA origin was described based on four parameters measured: D--the distance between SMA origin and the RRHA origin, L--the lumen at the place of origin, AH--the origin angle from the SMA in horizontal plane, and AV--the origin angle from the SMA in vertical plane. RESULTS: RRHA arising from SMA was detected in 10.13 % of cases (159/1569) and its anatomy was subjected to variations. Mean (±SD) of parameters D, L, AH and AV was 27.34 mm ± 6.83, 3.29 mm ± 1.17, 97.27º ± 26.69 and 89.73º ± 20.81, respectively. Values of parameters D and L were significantly higher in males compared to females. CONCLUSION: Although radiologists are not always aware of the clinical significance of the RRHA origin, the evaluation of its anatomy is thought to help reduce the risk of inadvertent vascular injury, especially in pancreatoduodenectomy. Detection and evaluation of the RRHA does not necessarily require angio-CT examination. Our study demonstrated that the MDCT, the standard imaging modality for diagnosing the abdominal symptoms, is sufficient to provide the knowledge of the HA abnormalities.

Fatty foci within the heart diagnosed with ECG-gated multi-slice computed tomography: frequency and morphology.

BACKGROUND: The purpose of our study was to analyze the frequency of focal fatty replacement (FR) of the heart, as well as the distribution and detailed morphology of FR in a large group of patients referred to multi-slice computed tomography with ECG-gating examinations (ECG-MSCT) for various clinical reasons. MATERIAL AND METHODS: The ECG-MSCT examinations of 1830 consecutive patients were analyzed. The examinations were performed using 8-row (1015 patients) and 64-row (815 patients) MSCT, in pre- and post-contrast scanning. We analyzed the morphology of FR, the dimensions and densities of changes, as well as the morphology and localization of FR with regard to clinical diagnosis. RESULTS: 204 subjects (11.1%) had FR within the heart (113 men; 91 women; mean age 57.8 years); 66% of fatty foci were seen only in the native scanning. The distribution of the fat was: right ventricle (RV) 31.9%, left ventricle (LV) 21.5%, biventricular 39.7%, interventricular or atrial septum 5.9%, and atria 1%. In the RV, fat was localized mainly in the papillary muscles, while in the LV fat was mainly subendocardial (p<0.001). The morphology of the fat was: linear 61.6%, oval 14.8%, punctuate 10.6%, irregular 10.2%, and bilobular 2.8%. Fat was primarily located subendocardially in the LV in patients after myocardial infarction. In patients with suspected coronary artery disease, it was mainly observed subpericardially in the RV and in papillary muscles (p<0.001). CONCLUSIONS: The incidental frequency of FR within the heart in patients diagnosed with the ECG-MSCT examinations is about 11%. Pre-contrast scanning is the most valuable for FR assessment.

Invasive growth patterns of juvenile nasopharyngeal angiofibroma: radiological imaging and clinical implications.

Juvenile nasopharyngeal angiofibroma is a benign lesion with locally aggressive nature. Knowledge of its typical growth patterns is crucial for precise preoperative staging and adequate preoperative patient counseling. This pictorial essay focuses on characteristic radiological features and paths of invasive growth of this rare tumor. Also, the impact of accurate preoperative evaluation of tumor extensions on surgical planning and results of treatment are discussed.

Extranasopharyngeal angiofibroma: clinical and radiological presentation.

Nasopharyngeal angiofibroma (NA) is a rare, vascular tumor affecting adolescent males. Due to aggressive local growth, skull base location and risk of profound hemorrhage, NA is a challenge for surgeons. Angiofibromas have been sporadically described in extanasopharyngeal locations. We review ten cases of extranasopharyngeal angiofibroma (ENA) and discuss the incidence, clinical presentation and management of this pathology. The group consisted of 4 males and 5 females aged 8-49. There were 7 patients with nasal angiofibroma, 1 patient with laryngeal angiofibroma, 1 patient with oral angiofibroma and another patient with infratemporal fossa tumor. In patients with nasal angiofibroma most common presenting symptoms were nasal obstruction and epistaxis. Patients with laryngeal angiofibroma suffered from mild dysphagia and patients with the infratemporal fossa tumor had painless cheek swelling. In four patients with nasal tumor computed tomography (CT) demonstrated mass with strong to intermediate contrast enhancement. In one patient with nasal tumor carotid angiography demonstrated pathological vessels without intensive tumor blush. Infratemporal fossa tumor showed intensive contrast enhancement on CT and magnetic resonance imaging (MRI) scans, and abundant vascularity on angiography. Laryngeal and oral angiofibroma required no radiological imaging. Three nasal tumors were evaluated before introduction of CT to clinical practice. All patients underwent surgery. No recurrences developed. ENAs differ significantly from NAs regarding clinical and radiological presentations. They lack typical clinical and radiological features as they develop in all age groups and in females, may be less vascularised, arise from various sites and produce a variety of symptoms.

Outcomes of Open Repair Treatment for Acute Versus Chronic Achilles Tendon Ruptures: Long-Term Retrospective Follow-Up of a Minimum 10 Years-A Pilot Study.

The aim of the present study was to compare repaired Achilles tendon (AT) remodelling, whether its function was restored and what effects the surgery had on our patients' gait cycle in a long-term follow-up study. The study population comprised 30 human subjects treated acutely and chronically for AT ruptures, using the same surgical technique in all cases. The study group was divided into two subgroups regarding the age of their AT injury, i.e., how much time elapsed between the injury and when a correct diagnosis was made and when adequate treatment was applied. Following these criteria, persons presenting at less than 4 weeks postinjury were classified as acute rupture (AR) patients and those presenting at more than 4 weeks after injury were grouped as chronic rupture (CR) patients. Both patient groups were operated on using a surgical method favoured at least a decade ago, i.e., open repair through a posteromedial approach. The AT was augmented with a plantaris longus tendon autograft, followed by suturing using the pull-out suture technique. The results were measured using clinical, ultrasonographic (US) and pedobarographic methods. Our ultrasonographic and pedobarographic findings revealed differences between both patient groups, thus indicating that delayed surgery had negative impacts on treatment success, however, with good long-term functional score outcomes in both patient groups. Nevertheless, delayed treatment of AT ruptures did not leave individual gait phases unaffected, as it also affected the plantar surface and balance performance of the affected limb. As per the results, the Achilles tendon manifested decreased capacity following delayed treatment; however, its long-term functional outcomes were favourable, irrespective of whether it was for acute or chronic patients.

Takayasu arteritis as a cause of arterial hypertension. Case report and literature review.

UNLABELLED: We report a 16-year-old girl in whom Takayasu arteritis (TA) was manifested mainly by severe arterial hypertension on her right arm, which was detected during a routine examination at school. Her systolic blood pressure on the right arm was significantly higher than that on the left one. There was also a pressure difference between the right arm and legs. The pulse of the left external carotid artery and that of the left radial artery was absent. Vascular bruits over interscapular and right supra- and subclavian areas were heard on auscultation. The diagnosis of TA was confirmed by a spiral computed tomography angiography, which showed a thickened thoracic aortic wall and narrowing of its lumen. In addition, complete occlusion of the left common carotid artery and the left subclavian artery was observed. CONCLUSION: The rarity of the disorder and the heterogeneous nature of its clinical manifestation predispose to a late diagnosis and delayed treatment. Our report highlights the fact that the condition can and does occur in a pediatric population in Europe and hence must be considered in patients presenting with suggestive symptoms and signs, especially in young patients with unexplained hypertension. Clinical suspicion and proper imaging are crucial for the correct diagnosis and management of patients with TA. A brief review of literature completes this report.

Lipomatous hypertrophy of the interatrial septum in ECG-gated multislice computed tomography of the heart.

BACKGROUND: Lipomatous hypertrophy of the interatrial septum (LHIS) is a benign disorder characterized by fat accumulation in the interatrial septum (IAS). The purpose of the study was to analyze the incidental detection of LHIS in patients with various clinical conditions, referred to ECG-gated multislice computed tomography (ECG-MSCT) examinations of the heart. MATERIAL/METHODS: The ECG-MSCT examinations of 5786 patients (2839 women; 2947 men), were analyzed. The examinations were performed using 8-row (1015 patients) and 64-row (4771 patients) MSCT, in pre- and postcontrast scanning. We analyzed the shape of the IAS, density and maximal thickness of IAS, the thickness of the epicardial adipose tissue, and the degree of contact of IAS with the ascending aorta and superior vena cava. We also determined body mass index (BMI) in patients with LHIS. RESULTS: LHIS was detected in 56 (0.96%) patients, with an average age of 61.5±9.8 years. The mean BMI in the analyzed group was 30.1±4.86. During the end-diastolic phase the thickness of IAS was significantly higher (p<0.0001), and on average equaled 18.3 mm. The mean optical density of the IAS was conspicuously higher (p<0.0001) in post-contrast phase than in pre-contrast phase. The thickness of the epicardial adipose tissue in the region of the left atrioventricular groove was on average 15 mm. In all cases the dumbbell shape of IAS was observed. CONCLUSIONS: The incidental frequency of LHIS occurrence in patients diagnosed with the ECG-MSCT examinations is about 1%. In most subjects it is linked with a higher BMI and increased thickness of the epicardial adipose tissue.

[Malignant peripheral nerve sheath tumor associated with clear cell renal cell carcinoma - case report]. / Zlosliwy nowotwór oslonek nerwów obwodowych wspólwystepujacy z rakiem jasnokomórkowym nerki­ opis przypadku.

Malignant peripheral nerve sheath tumor (MPNST) is a rare malignant counterpart to benign neurogenes tumors such as schwannomas and neurofibromas and account for approximately 5-10 % of all soft tissue sarcomas. This neoplasm is also referred to older designations as a malignant schwannoma, malignant neurilemmoma or neurogenic sarcoma. A patient was a woman of 59 years old with a diagnosed malignant neurilemmoma, treated since 1993. Operated several times and subjected to radiotherapy due to the local recurrence of the tumors located in the soft tissues of the back until 2002; Treated with chemotherapy (doxorubicin) and operated due to a lung metastases. The therapy resulted in a total remission that lasted 12 months. In 2004 a new small tumor was diagnosed in the right lung, which had been followed up until 2006. The patient did not give permission to a second surgery, treated with ifosfamide. In 2006 she was operated for renal cell carcinoma of the left kidney. In 2009, due to a following progression of neurilemmoma and a worsening overall condition, she was subsequently treated with a combination of gemcitabine and docetaxel. The treatment resulted in a slight improvement, but was stopped due to complications (pancytopenia). In 2010 another progression of the disease occurred, which resulted in pleural metastases and osteolytic lesions in the vertebrae (Th6 and L2).

Dual-Energy Heart CT: Beyond Better Angiography-Review.

Heart CT has undergone substantial development from the use of calcium scores performed on electron beam CT to modern 256+-row CT scanners. The latest big step in its evolution was the invention of dual-energy scanners with much greater capabilities than just performing better ECG-gated angio-CT. In this review, we present the unique features of dual-energy CT in heart diagnostics.

Widening of coronary sinus in CT pulmonary angiography indicates right ventricular dysfunction in patients with acute pulmonary embolism.

OBJECTIVES: Right ventricular dysfunction (RVD) may occur in the course of acute pulmonary embolism (PE). Patients with RVD need more intensive treatment, and the prognosis is more severe. The aim of this study was to evaluate the usefulness of the measurement of the coronary sinus in the assessment of RVD in patients with acute PE and to compare it with other indicators of RVD. METHODS: Retrospective assessment of 55 CT pulmonary angiography examinations with signs of acute PE was performed. Pulmonary artery systolic pressure (PASP) was echocardiographically assessed in all patients, and RVD was defined as PASP values greater than 30 mmHg. CT measurements included the size of the heart ventricles, mediastinal vessels and the width of the coronary sinus. RESULTS: Median width of the coronary sinus was 16 mm (range 12-24 mm) in patients with increased PASP and 10 mm (range 7-22 mm) in patients with normal PASP (p = 0.001). Best cut-off value was assessed to be 12.5 mm, with sensitivity 94% and specificity 75%. It was characterised by the largest area under ROC curve (0.82) among analysed parameters. CONCLUSION: Width of the coronary sinus seems to be a promising parameter for identification of RVD in patients with acute PE. A prospective study should be undertaken to further assess its clinical and prognostic applicability.

Transvenous removal of endocardial leads with coexisting great vegetation (3.5 cm)--case report.

We discuss a case of transvenous removal of endocardial leads in a patient with initial contraindication for such a procedure due to the size of the vegetation in his right atrium. Simultaneously, the patient's progressive general poor condition during the course of infective endocarditis prognosed that cardiosurgical intervention with the use of cardiopulmonary bypass would be unsuccessful. Using an innovative solution, that is placing the Dotter's basket in the right ventricular outlet as a protection against massive pulmonary embolism, the leads were removed. An asymptomatic pulmonary embolism caused by defragmented vegetation was revealed after the procedure.

99mTc-EDDA/HYNIC-TOC somatostatin receptor scintigraphy in daily clinical practice.

BACKGROUND: This study aimed to assess the impact of 99mTc-EDDA/HYNIC-TOC (99mTc-TOC) somatostatin receptor scintigraphy (SRS) in clinical practice. MATERIAL/METHODS: One hundred seventeen patients were divided into 6 groups: 1, initial detection and localization of suspected neuroendocrine tumor (NET); 2, tumor staging before therapy; 3, staging of NET of unknown origin, 4, restaging after surgery of primary tumor; 5, diagnosis of solitary pulmonary nodules (SPNs), and 6, follow-up after "cold" somatostatin analogues treatment. RESULTS: In group 1, clinical suspicions were not confirmed in any of the patients; in group 2, most of the primary lesions showed overexpression of somatostatin receptors (SSRT); in group 3, the primary tumor was not identified in any of the patients; in group 4, recurrences were depicted in 7 out of 47 patients; in group 5, only 1 malignant SPN was detected, and in group 6, regression of primary mass and metastases were seen on follow-up SRS in 1 patient. CONCLUSIONS: 99mTc-TOC SRS is useful in staging of SSRT-overexpressing tumors of known and unknown primary origin, as well as in restaging after primary tumor surgery. This method is less effective in detecting suspected NET and assessing SPNs. Further investigation is necessary to evaluate the usefulness of SRS in monitoring patients after biological treatment.

Liposarcoma of the esophagus: case report and literature review.

BACKGROUND: Liposarcoma is one of the most common soft tissue sarcomas in adults, but it is exceedingly rare in the gastrointestinal tract. To the authors' knowledge, only 17 cases of esophageal liposarcomas have been described in the literature. CASE REPORT: The case of a 56-year-old woman is reported who complained of dyspnea and airway obstruction and was referred for multi-slice computed tomography (MSCT) with the suspicion of mediastinal tumor. MSCT revealed a heterogeneous mass within the esophagus. The density measurements from pre- and post-contrast scanning suggested a fatty tissue component of the lesion and a possible malignant nature. The patient underwent esophagotomy. The diagnosis of liposarcoma was established. Five months after the surgery, follow-up chest MSCT was performed which revealed an inhomogeneous mass behind the left atrium. Additional CT was performed with a perfusion protocol which suggested a malignant nature of the lesion. After thoracotomy with removal of the tumor, the patient underwent adjuvant radiotherapy. The patient is still being followed up and two years after the esophagotomy has been well, with no metastases in subsequent endoscopic and CT examinations. CONCLUSIONS: To the authors' knowledge this is the first case of liposarcoma of the esophagus detected and postoperatively monitored using MSCT. MSCT, even as the first examination, may enable a proper diagnosis of liposarcoma in patients with atypical clinical features.

Juvenile nasopharyngeal angiofibroma with intracranial extension - diagnosis and treatment.

INTRODUCTION: This retrospective study analyzes radiological findings, therapeutic management and outcomes of patients with intracranial extension of JNA. The routes of intracranial spread, incidence of intracranial disease and influence on therapeutic approach are discussed. MATERIAL AND METHODS: An evaluation on the records of 62 patients with JNA was performed and 10 patients with intracranial tumors were included in the study. All patients were males aged 10 to 19 years. R esults: According to Andrews' classification 8 patients presented with stage IIIb, 1 patient stage IVa and another patient stage IVb tumor. Intracranial invasion was extradural in 8 cases and intradural in 2 patient. Surgery was performed in 9 cases and the most common was combined approach: infratemporal fossa and sublabial transantral. One patient was referred for radiotherapy. Follow-up ranged from 8 to 26 years. There was extracranial recurrence in 2 (22%) of 9 operated patients. C onclusions: The superior orbital fissure is the most frequent route of intracranial spread in patients with extensive involvement of the infratemporal fossa. Due to high risk of recurrence and potential serious complications advanced cases of JNA should be managed by experienced multidisciplinary team, preferably in tertiary referral centers, with an access to modern diagnostic and therapeutic modalities.