The Role of 4D-CT for Pre-Operative Localization in Patients with Primary Hyperparathyroidism with Negative Ultrasonography and/or Sestamibi SPECT/CT.

Objectives: The major cause of primary hyperparathyroidism (pHPT) is parathyroid adenoma. Today, minimally invasive parathyroidectomy (MIP) has become the standard treatment for patients in whom the pathological gland can be localized with pre-operative imaging methods. In this study, we aimed to evaluate the role of 4D-CT in pre-operative localization in patients with pHPT who are negative for ultrasonography (USG) and/or sestamibi single-photon emission computed tomography/CT (SPECT/CT) and will undergo primary surgery. Methods: Patients whom were operated between 2018 and 2023 were included to this study. 4D-CT results of patients with one- or two-negative USG and SPECT/CT results were evaluated retrospectively. Results: In this study, 19 patients (5 men and 14 women) with a mean age of 57.1±8.5 years were evaluated. Pathology results were consistent with parathyroid adenoma in 18 patients (94.7%) and parathyroid hyperplasia in 1 patient (5.3%). USG was negative in six patients, SPECT/CT was negative in 14 patients, and both were negative in four patients. In 4D-CT, positive images were detected in 15 patients and these results were finalized as true positive in 14 patients and false positive in 1 patient. The sensitivity of 4D-CT was 82.4% (95% CI: 60.4-95.3%), positive predictive value was 93.3% (95% CI: 73.8-99.6%), accuracy was 78.9%, and localization rate was 73.7%. In 14 (73.7%) patients, the pathological glands were removed by MIP. Conclusion: In approximately 75% of patients with negative USG and/or SPECT/CT, the pathological gland can be localized with 4D-CT and MIP can be applied in these patients.

Management of Thyroid Nodules.

Thyroid nodules are common and the prevalence varies between 4 and 7% by palpation and 19-68% by high-resolution USG. Most thyroid nodules are benign, and the malignancy rate varies between 7 and 15% of patients. Thyroid nodules are detected incidentally during clinical examination or, more often, during imaging studies performed for another reason. All detected thyroid nodules should be evaluated clinically. The main test in evaluating thyroid function is thyroid stimulating hormone (TSH). If the serum TSH level is below the normal reference range, a radionuclide thyroid scan should be performed to determine whether the nodule is hyperfunctioning. If the serum TSH level is normal or high, ultrasonography (US) should be performed to evaluate the nodule. US is the most sensitive imaging method in the evaluation of thyroid nodules. Computed tomography (CT) and magnetic resonance imaging are not routinely used in the initial evaluation of thyroid nodules. There are many risk classification systems according to the USG characteristics of thyroid nodules, and the most widely used in clinical practice are the American Thyroid Association guideline and the American College of Radiology Thyroid Imaging Reporting and Data System. Fine needle aspiration biopsy (FNAB) is the gold standard method in the evaluation of nodules with indication according to USG risk class. In the cytological evaluation of FNAB, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is the most frequently applied cytological classification. TBSRTC is a simplified, 6-category reporting system and was updated in 2023. The application of molecular tests to FNAB specimens, especially those diagnosed with Bethesda III and IV, is increasing to reduce the need for diagnostic surgery. Especially in Bethesda III and IV nodules, different methods are applied in the treatment of nodules according to the malignancy risk of each category, these are follow-up, surgical treatment, radioactive iodine treatment, and non-surgical ablation methods.

Interobserver Variability of Ultrasound Features Based on American College of Radiology Thyroid Imaging Reporting and Data System Lexicon in American College of Radiology Thyroid Imaging Reporting and Data System System: A Single-Center Study With Radiologists and Radiology Residents.

ABSTRACT: The aim of this study is to evaluate the variability of selecting the ultrasound features used in American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS) and in assigning the ACR-TIRADS level in a single center among radiologists and radiology residents. The study cohort consisted of 108 thyroid nodules in 102 patients who had definite cytology results after thyroid fine needle aspiration biopsy (Bethesda category II, VI) or surgery. Seven observers including 3 radiologists and 4 radiology residents evaluated the nodules according to 5 ultrasound feature categories. The evaluation process was performed after a joint meeting session, in which the "white papers" of the ACR-TIRADS committee were discussed regarding the thyroid ultrasound reporting lexicon, and final TIRADS system. Variability of ultrasound features and assigning ACR-TIRADS level was measured using Fleiss kappa statistics. Agreement for ultrasound features was "substantial" to "almost perfect" among all observers, with composition (κ = 0.86), macrocalcification (κ = 0.89) and peripheral calcification (κ = 0.92) at the highest level of agreement. The level of agreement for large comet tail artifacts and punctate echogenic foci was "moderate" in residents, whereas in radiologists, that level was "substantial." The agreement for assigning ACR-TIRADS level was moderate in resident as well as in radiologist subgroup. Agreement of thyroid ultrasound features was "substantial to almost perfect" among all observers. Although the level of agreement among resident group decreased to "moderate" level, ACR-TIRADS is a useful system in thyroid nodule management.

Giant parathyroid adenoma associated with severe hypercalcemia in an adolescent patient.

BACKGROUND: The objective of this study is to bring attention to the importance of differential diagnosis in adolescent patients with skeletal involvement and hypercalcemia. CASE: A 17-year-old male patient with a complaint of severe leg pain was admitted to our hospital. Seven months before he had a fracture of his distal humerus after falling on to his left shoulder and was treated conservatively. Five months previously, he had a rupture of his quadriceps tendon. Magnetic resonance imaging (MRI) was performed for the quadriceps tendon rupture and was evaluated as polyostotic fibrous dysplasia (PFD). Doctors decided to operate for the ruptured tendon but they detected severe hypercalcemia in the pre-operative blood tests and noticed that the main disease was primary hyper-parathyroidisim (PHPT) which was caused by a giant parathyroid adenoma. Conclusions Giant parathyroid adenoma can present in adolescent patients with multiple bone lesions and severe hypercalcemia. PHPT should be considered in the differential diagnosis of pathological bone fractures and benign bone tumors in every age. This may prevent patients from miss or delayed diagnosis of PHPT.

Sonographic scoring of solid thyroid nodules: effects of nodule size and suspicious cervical lymph node / Escore ultrassonográfico de nódulos sólidos de tireoide: efeitos do tamanho do nódulo e de linfonodo cervical suspeito

Abstract Introduction Ultrasound is the most frequently used imaging method to evaluate thyroid nodules. Sonographic characteristics of thyroid nodules which are concerning for malignancy are important to define the need for fine needle aspiration biopsy or open surgery. Objective To evaluate malignancy risk of solid thyroid nodules through sonographic scoring. The effects of nodule size ≥2 cm and associated pathologic cervical lymph node in scoring were examined in addition to generally excepted suspicious features. Methods Medical data of 123 patients underwent thyroid surgery were reviewed, and 89 patients (58 females, 31 males) were included in the study. The presence and absence of each suspicious sonographic feature of thyroid nodules were scored as 1 and 0, respectively. Total ultrasound score was obtained by adding the positive ultrasound findings. Differently from the literature, nodule size ≥2 cm and associated pathologic cervical node were added in scoring criteria. The diagnostic performance of nodule characteristics for malignancy and the effect of total US score to discriminate malignant and benign disease were calculated. Results A significant relationship was found between malignancy and hypoechogenity, border irregularity, intranodular vascularity, and microcalcification (p < 0.05). Pathologic cervical node was observed predominantly in association with malignant nodules. Positive predictive value of suspicious cervical node for malignancy was 67%, similar to microcalcification. Nodule size ≥2 cm was not distinctive for diagnosis of malignancy. The number of suspicious sonographic features obtained with receiver operating characteristic analysis to discriminate between malignant and benign disease was three. Conclusion Sonographic scoring of thyroid nodules is an effective method for predicting malignancy. The authors suggest including associated pathologic node in the scoring criteria. Further studies with larger cohorts will provide more evidence about its importance in sonographic scoring.

Resumo Introdução A ultrassonografia é o método imagiológico mais frequentemente usado na avaliação de nódulos tireoidianos. As características ultrassonográficas dos nódulos tireoidianos que dizem respeito à malignidade são importantes para a definição da necessidade de uma biópsia por aspiração com agulha fina ou uma cirurgia aberta. Objetivo Avaliar o risco de malignidade de nódulos tireoidianos sólidos por meio de escore ultrassonográfico, verificar os efeitos de nódulos ≥ 2 cm, em associação com linfonodo cervical patológico, além de características suspeitas geralmente omitidas. Método Foram revisados dados médicos de 123 pacientes tratados com cirurgia da tireoide. Foram incluídos no estudo 89 pacientes (58 mulheres, 31 homens). Presença e ausência de cada característica ultrassonográfica suspeita de nódulo tireoidiano receberam pontuações de 1 e 0, respectivamente. O escore ultrassonográfico total foi obtido pela soma dos achados ultrassonográficos positivos. Diferentemente da literatura, nódulos ≥ 2 cm e nodo cervical patológico associado foram acrescentados nos critérios de pontuação. Foram calculados o valor diagnóstico das características dos nódulos para malignidade e o efeito do escore ultrassonográfico total na diferenciação entre doença maligna vs. benigna. Resultados Foi encontrada uma associação significante entre malignidade e hipoecogenicidade, irregularidade das margens, vascularidade intranodular e microcalcificação (p < 0,05). Nodo cervical patológico foi observado predominantemente em associação com nódulos malignos. O valor preditivo positivo de nodo cervical suspeito para malignidade foi de 67%, similar ao achado para microcalcificação. Diâmetro de nódulo ≥ 2 cm não foi fator diferenciador para diagnóstico de malignidade. O número de características ultrassonográficas suspeitas obtido com a análise da curva de características de operação do receptor (receiver operating characteristic, ROC) para discriminação entre doença maligna vs. benigna foi igual a 3. Conclusão O escore ultrassonográfico dos nódulos tireoidianos é método efetivo para predição de malignidade. Sugerimos a inclusão de nódulo patológico associado aos critérios de pontuação. Futuros estudos com coortes maiores proporcionarão mais evidências sobre sua importância no escore ultrassonográfico.

Sonographic scoring of solid thyroid nodules: effects of nodule size and suspicious cervical lymph node.

INTRODUCTION: Ultrasound is the most frequently used imaging method to evaluate thyroid nodules. Sonographic characteristics of thyroid nodules which are concerning for malignancy are important to define the need for fine needle aspiration biopsy or open surgery. OBJECTIVE: To evaluate malignancy risk of solid thyroid nodules through sonographic scoring. The effects of nodule size ≥2cm and associated pathologic cervical lymph node in scoring were examined in addition to generally excepted suspicious features. METHODS: Medical data of 123 patients underwent thyroid surgery were reviewed, and 89 patients (58 females, 31 males) were included in the study. The presence and absence of each suspicious sonographic feature of thyroid nodules were scored as 1 and 0, respectively. Total ultrasound score was obtained by adding the positive ultrasound findings. Differently from the literature, nodule size ≥2cm and associated pathologic cervical node were added in scoring criteria. The diagnostic performance of nodule characteristics for malignancy and the effect of total US score to discriminate malignant and benign disease were calculated. RESULTS: A significant relationship was found between malignancy and hypoechogenity, border irregularity, intranodular vascularity, and microcalcification (p<0.05). Pathologic cervical node was observed predominantly in association with malignant nodules. Positive predictive value of suspicious cervical node for malignancy was 67%, similar to microcalcification. Nodule size ≥2cm was not distinctive for diagnosis of malignancy. The number of suspicious sonographic features obtained with receiver operating characteristic analysis to discriminate between malignant and benign disease was three. CONCLUSION: Sonographic scoring of thyroid nodules is an effective method for predicting malignancy. The authors suggest including associated pathologic node in the scoring criteria. Further studies with larger cohorts will provide more evidence about its importance in sonographic scoring.

A Rare Presentation of Autonomously Functioning Papillary Thyroid Cancer: Malignancy in Marine-Lenhart Syndrome Nodule.

Objective. Marine-Lenhart Syndrome (MLS) is defined as concomitant occurrence of autonomously functioning thyroid nodule (AFTN) with Graves' disease (GD). Malignancy in a functional nodule is rare. We aimed to present an extremely rare case of papillary thyroid cancer in a MLS nodule with lateral lymph node metastases. Case. A 43-year-old male presented with hyperthyroidism and Graves' ophthalmopathy. On Tc99m pertechnetate scintigraphy, a hyperactive nodule in the left upper thyroid pole was detected and the remaining tissue showed a mildly increased uptake. The ultrasonography demonstrated 15.5 × 13.5 × 12 mm sized hypoechoic nodule in the left upper pole of the thyroid and round lymph nodes on the left side of the neck. Fine needle aspiration biopsy (FNAB) of the nodule and lymph node revealed cytological findings consistent with papillary cancer. Total thyroidectomy with central and left modified radical neck dissection was performed. On pathologic examination, two foci of micropapillary cancer were detected. The skip metastases were present in three lymph nodes on the neck. Conclusion. AFTN can be seen rarely in association with GD. It is not possible to exclude malignancy due to the clinical and imaging findings. In the presence of suspicious clinical and sonographic features, FNAB should be performed.

IS BIOCHEMICAL ASSESSMENT OF PHEOCHROMOCYTOMA NECESSARY IN ADRENAL INCIDENTALOMAS WITH MAGNETIC RESONANCE IMAGING FEATURES NOT SUGGESTIVE OF PHEOCHROMOCYTOMA?

OBJECTIVE: Currently, it is unclear whether pheochromocytomas can be ruled out based on low intensity on T2-weighted sequences and signal loss on out-of-phase magnetic resonance imaging (MRI) sequences. Hence, in this study, we investigated whether biochemical screening for pheochromocytoma in patients with adrenal incidentalomas (AIs) showing MRI features not suggesting pheochromocytoma would prove beneficial. METHODS: We performed MRI for 300 AIs in 278 consecutive patients. All patients were screened for pheochromocytoma with plasma metanephrine and normetanephrine. Patients with high plasma levels of metanephrine and/or normetanephrine were also assessed for pheochromocytoma by urinary metanephrines. RESULTS: Hyperintensity was detected on T2-weighted MRI sequences in 28 (9.3%) of the 300 AIs. Among these 28 incidentalomas, pheochromocytoma was diagnosed in 13 (46.4%) of the cases by histopathologic analysis. Hyperintensity on T2-weighted MRI was significantly higher in pheochromocytomas compared to the remaining AIs (P<.001). All 13 pheochromocytomas were characterized by hyperintensity on T2-weighted sequences and the absence of signal loss on out-of-phase MRI sequences. Pheochromocytoma was not detected in any of the 272 AIs that appeared hypointense or isointense on T2-weighted MRI sequences or in the 250 cases with signal loss on out-of-phase sequences. CONCLUSION: The results of this study suggest that AIs that appear hypointense or isointense on T2-weighted MRI sequences and those with signal loss on out-of-phase sequences may not require routine biochemical screening for pheochromocytoma. Further studies including a higher number of pheochromocytomas are required to confirm our results.

Ectopic cervical thymus as a rare cause of pediatric neck mass: the role of ultrasound and MRI in the diagnosis. Case report.

Ectopic cervical thymus (ECT) is an uncommon cause for cervical mass in the pediatric age group. Ultrasound and magnetic resonance imaging findings of the mass (located along the thymic descent pathway along the thymopharyngeal tract and has identical echostructure and signal intensities to the native thymus in the superior mediastinum) would lead to the diagnosis. The diagnosis is confirmed by fine needle aspiration biopsy or histopathology after resection. The management of ECT is a conservative follow up, except in symptomatic cases with tracheal compression and histologically confirmed neoplasia where surgery is indicated. We present the case of ECT presenting as a left upper neck mass in a 12 year old girl.

Effects of totally extraperitoneal (TEP) and Lichtenstein hernia repair on testicular blood flow and volume.

BACKGROUND: Laparoscopic totally extraperitoneal hernia repair (TEP) has been compared with the open technique in several studies in terms of technical properties and perioperative outcomes. There are few studies that compare the long-term effects of each technique on testicular structure and function on the side of the hernia repair. The objective of this study is to investigate the effects at 6 months of the TEP and the Lichtenstein technique on testicular volume and arterial flow by the use of Doppler ultrasonography. METHODS: A total of 148 men with a unilateral hernia were randomized prospectively to undergo TEP or Lichtenstein repair. In both groups, unilateral resistive indices, pulsatile indices of capsular and intratesticular artery flow, and testicular volume (in milliliters) were measured preoperatively and 6 months postoperatively by the use of grayscale and color Doppler ultrasonography (CDUS). The primary outcomes of the study were postoperative findings from history, physical examination, and CDUS measurements at 6 months postoperatively. Demographics, clinical and operative data, CDUS measurements, and recurrence patterns were analyzed. RESULTS: Of 148 procedures, 134 cases consisting of 64 TEP and 70 Lichtenstein repairs were evaluated. Pre- and postoperative CDUS findings, rates of complications, and recurrence in both groups did not show any difference. Operative time was greater with a Lichtenstein repair (36 vs 30 minutes; P = .01). CONCLUSION: Complications and recurrence rates and effects on testicular perfusion and testicular volume in both laparoscopic and open techniques are similar, whereas the laparoscopic approach has shorter operative time than open hernia repair.

Diffusion tensor imaging of cysts, hemangiomas, and metastases of the liver.

BACKGROUND: Although diffusion-weighted magnetic resonance imaging imaging (DW-MRI) is commonly used to characterize hepatic lesions, the literature is sparse about the use of MR diffusion tensor imaging (DTI) in this regard. By using DTI, one is able to obtain not only apparent diffusion coefficients (ADCs) but also fractional anisotropy (Fa) values. PURPOSE: To evaluate DTI using ADC and Fa values in the imaging of hepatic cysts, hemangiomas, and metastases. MATERIAL AND METHODS: Sixty-six patients with 77 lesions were examined with DTI. There were 32 metastases, 13 cysts, and 32 hemangiomas. Two radiologists performed ADC and Fa measurements. Inter-observer agreement was evaluated using Bland-Altman plots. ADCs and Fa values were correlated using Pearson correlation. The differences were compared using ANOVA and Tukey tests. A ROC analysis was applied; sensitivities and specificities were calculated. RESULTS: The inter-observer agreement was very good. The correlation between ADC and Fa was negative, weak, and significant (r = -0.36). The mean ADC value of cysts (3.30 ± 0.8 × 10(-3) mm(2)/s) was significantly higher than that of hemangiomas (2.23 ± 0.5 × 10(-3) mm(2)/s) and metastases (1.62 ± 0.4 × 10(-3) mm(2)/s). The mean Fa value of cysts (0.2 ± 0.05) was significantly lower than hemangiomas (0.37 ± 0.1) and metastases (0.46 ± 0.1). The Az values for discriminating metastases from benign hepatic lesions for ADC and Fa value were 0.885 and 0.731, respectively. The sensitivity and specificity of ADC and Fa were 87.5% and 84.4%, and 78.1% and 57.8%, respectively. The Az value for discriminating cysts from hemangiomas for Fa was 0.96. The sensitivity and specificity were 90.6% and 92.3%, respectively. CONCLUSION: Fa values may play a supportive role in the imaging of liver lesions. Whereas metastases tend to have low ADCs and high Fa values, cysts have high ADCs and low Fa values and hemangiomas have high ADCs and high Fa values.

FGF-23 associated with the progression of coronary artery calcification in hemodialysis patients.

BACKGROUND: Disordered mineral metabolism is implicated in the pathogenesis of vascular calcification in hemodialysis (HD) patients. Fibroblast growth factor 23 (FGF-23) is the main regulator of phosphate metabolism. In this prospective study, we aimed to investigate the association of serum FGF-23 with progression of coronary artery calcification in HD patients. METHODS: Seventy-four HD patients (36 male/38 female, mean age: 52 ± 14 years) were included. Serum FGF-23 levels were measured by ELISA. Coronary artery calcification score (CACS) was measured twice with one year interval. Patients were grouped as progressive (PG) (36 patients-48%) and non-progressive (NPG). RESULTS: Age, serum phosphorus, baseline and first year CACS were found to be significantly higher in the PG compared to NPG group. Serum FGF-23 levels were significantly higher in PG [155 (80-468) vs 147 (82-234), p = 0.04]. Patients were divided into two groups according to baseline CACS (low group, CACS ≤ 30; high group, CACS > 30). Serum FGF-23 levels were significantly correlated with the progression of CACS (ΔCACS) in the low baseline CACS group (r = 0.51, p = 0.006), but this association was not found in high baseline CACS group (r = 0.11, p = 0.44). In logistic regression analysis for predicting the PG patients; serum FGF-23, phosphorus levels and baseline CACS were retained as significant factors in the model. CONCLUSIONS: Serum FGF-23 was found to be related to progression of CACS independent of serum phosphorus levels. FGF-23 may play a major role in the progression of vascular calcification especially at the early stages of calcification process in HD patients.

Osteoprotegerin/RANKL axis and progression of coronary artery calcification in hemodialysis patients.

BACKGROUND AND OBJECTIVES: Vascular calcification is associated with increased cardiovascular mortality in chronic hemodialysis patients. This prospective study investigated the relationship between serum osteoprotegerin, receptor activator of NF-κB ligand, inflammatory markers, and progression of coronary artery calcification score. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Seventy-eight hemodialysis patients were enrolled. Serum IL-1ß, IL-6, TNF-α, osteoprotegerin, receptor activator of NF-κB, fetuin A, and bone alkaline phosphatase were measured by ELISA. Coronary artery calcification score was measured two times with 1-year intervals, and patients were classified as progressive or nonprogressive. RESULTS: Baseline and first-year serum osteoprotegerin levels were significantly higher in the progressive than nonprogressive group (17.39±9.67 versus 12.90±6.59 pmol/L, P=0.02; 35.17±18.35 versus 24±11.65 pmol/L, P=0.002, respectively). The ratio of serum osteoprotegerin to receptor activator of NF-κB ligand at 1 year was significantly higher in the progressive group (0.26 [0.15-0.46] versus 0.18 [0.12-0.28], P=0.004). Serum osteoprotegerin levels were significantly correlated with coronary artery calcification score at both baseline (r=0.36, P=0.001) and 1 year (r=0.36, P=0.001). Importantly, progression in coronary artery calcification score significantly correlated with change in serum osteoprotegerin levels (r=0.39, P=0.001). In addition, serum receptor activator of NF-κB ligand levels were significantly inversely correlated with coronary artery calcification scores at both baseline (r=-0.29, P=0.01) and 1 year (r=-0.29, P=0.001). In linear regression analysis for predicting coronary artery calcification score progression, only baseline coronary artery calcification score and change in osteoprotegerin were retained as significant factors in the model. CONCLUSIONS: Baseline coronary artery calcification score and serum osteoprotegerin levels were significantly associated with progression of coronary artery calcification score in hemodialysis patients.

The diagnostic efficiency of ultrasound in characterization for thyroid nodules: how many criteria are required to predict malignancy?

OBJECTIVE: The purpose of this study was to define the criteria for use in differentiating benign and malignant nodules with the help of the receiver operating characteristic analysis and to increase the objective diagnostic accuracy of ultrasonography. MATERIALS AND METHODS: A total of 363 patients (307 women, 56 men) with 363 nodules (22 malignant and 341 benign nodules) were included in the study. The presence and absence of each US feature of the evaluated nodule - shape taller than wide, irregular margin, hypoechogenicity, microcalcification, and intranodular vascularity - were scored 1 and 0, respectively. The total ultrasound score was obtained by the summing up of each positive ultrasound findings for malignancy. The effect of the total US score in the discrimination of benign and malignant nodules was analysed using ROC analysis. RESULTS: The cut off values of US score at maximum sensitivity and specificity for nodules larger and smaller than one centimeter were two (Az: 0.783) and three (Az: 0.935), respectively. For nodules greater than one centimeter, the calculated diagnostic performances including sensitivity, specificity, positive predictive value and negative predictive value, and accuracy were 62.5%, 91.5%, 30.3%, 97.7%, and 89,9%, respectively. For nodules smaller or equal to one centimeter; the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 83.3%, 94.9%, 62.5%, 98.2% and 93.8%, respectively. CONCLUSION: Using ultraound, thyroid nodules can be characterized effectively. The number of the US features used in this distinction varies in respect to the nodule size.

Sonographic diagnosis of choledochocele.

We present a case of a 48-year-old female with a history of cholecystectomy and recurrent attacks of pancreatitis whose initial abdominal sonography (US) revealed multiple conglomerated stones in the descending part of the duodenum. Abdominal CT, MRI, and magnetic resonance cholangiopancreatography showed the same findings. The distended sacciform distal intramural segment of the common bile duct was protruding into the duodenum. The imaging findings explained the etiology of the patient's recurrent attacks of pancreatitis and led to surgical excision of the choledococele.

Is the measurement of inferior thyroid artery blood flow velocity by color-flow Doppler ultrasonography useful for differential diagnosis between gestational transient thyrotoxicosis and Graves' disease? A prospective study

OBJECTIVE: To determine the role of peak systolic velocity, end-diastolic velocity and resistance indices of both the right and left inferior thyroid arteries measured by color-flow Doppler ultrasonography for a differential diagnosis between gestational transient thyrotoxicosis and Graves' disease during pregnancy. METHODS: The right and left inferior thyroid artery-peak systolic velocity, end-diastolic velocity and resistance indices of 96 patients with thyrotoxicosis (41 with gestational transient thyrotoxicosis, 31 age-matched pregnant patients with Graves' disease and 24 age- and sex-matched non-pregnant patients with Graves' disease) and 25 ageand sex-matched healthy euthyroid subjects were assessed with color-flow Doppler ultrasonography. RESULTS: The right and left inferior thyroid artery-peak systolic and end-diastolic velocities in patients with gestational transient thyrotoxicosis were found to be significantly lower than those of pregnant patients with Graves' disease and higher than those of healthy euthyroid subjects. However, the right and left inferior thyroid artery peak systolic and end-diastolic velocities in pregnant patients with Graves' disease were significantly lower than those of non-pregnant patients with Graves' disease. The right and left inferior thyroid artery peak systolic and end-diastolic velocities were positively correlated with TSH-receptor antibody levels. We found an overlap between the inferior thyroid artery-blood flow velocities in a considerable number of patients with gestational transient thyrotoxicosis and pregnant patients with Graves' disease. CONCLUSIONS: This study suggests that the measurement of inferior thyroid artery-blood flow velocities with colorflow Doppler ultrasonography does not have sufficient sensitivity and specificity to be recommended as an initial diagnostic test for a differential diagnosis between gestational transient thyrotoxicosis and Graves' disease during pregnancy.

Wound complications and clinical results of electrocautery versus a scalpel to create a cutaneous flap in thyroidectomy: a prospective randomized trial.

PURPOSE: The use of electrocautery for tissue dissection is becoming increasingly popular, despite the associated risk of poor wound healing and excessive scarring. We conducted this study to compare the wound complications and early and late clinical results resulting from electrocautery versus the scalpel to create a cutaneous flap during thyroidectomy. METHODS: The subjects of this study were 100 patients, randomized prospectively to either a scalpel group (group S, n = 50) or an electrocautery group (group E, n = 50). RESULTS: Thickness of tissue damage, postoperative thickness of the flap, discomfort in the neck 7 days after surgery, and hypoesthesia and paresthesia in the neck 3 months after surgery were significantly higher in group E than in group S. There were no significant differences in overall postoperative wound complications, postoperative pain, satisfaction with the cosmetic result, or overall outcome of the operation between the groups. Although the incidence of seroma was higher in group E (20%) than in group S (8%), the difference was not significant. CONCLUSION: Although electrocautery was associated with increased histological tissue damage, postoperative flap edema, discomfort, and other complications in the early stage, the clinical and cosmetic results of flaps made using electrocautery or a scalpel were similar and satisfactory 6 months after surgery.

Rare presentation of pediatric acute lymphoblastic leukemia: nephromegaly at time of diagnosis.

Renal involvement is a fairly frequent development in children with acute lymphoblastic leukemia, but palpable renal enlargement at time of diagnosis is very unusual. We report the case of a young girl who presented with enlarged kidneys and was diagnosed with this form of leukemia. This case is of interest because of the rarity of this presentation. The importance of renal biopsy in identifying the etiology of this patient's nephromegaly is emphasized.

Comparison of multislice computed tomography angiography and digital subtraction angiography in the detection of residual or recurrent aneurysm after surgical clipping with titanium clips.

PURPOSE: To determine the diagnostic accuracy of 3D-CTA using volume rendering (VR) in the detection of residual or recurrent cerebral aneurysms after clipping. MATERIAL AND METHODS: Between January 2006 and November 2007, 45 patients (20 female, 25 male) with 50 intracranial aneurysms treated using titanium clips were enrolled in this study. IADSA and 3D-CTA were performed within 1 month after surgery in 27 (60%) patients, after 1 year in 12 (26%) patients and after 5 years in six (13%) patients. In blinded fashion, CTA and DSA images were independently interpreted by two senior neuroradiologists with 7 years of experience in vascular diagnostic neuroradiology. The diagnostic performance of MDCTA compared with DSA for the detection of aneurysm remnants was measured by receiver operating characteristic (ROC) analysis. The area under the ROC curve, 95% confidence interval (CI), sensitivity, and specificity were calculated. RESULTS: For the detection of residue-recurrent aneurysm; the sensitivity and specificity of MDCTA were 87.5% (95% CI = 52.9-97.8%) and 97.4% (95% CI = 86.5-99.5%) for the first reader and 87.5% (95% CI = 52.9-97.8%) and 100% (95% CI = 90.8-100%) for the second reader respectively. Receiver operating characteristic (ROC) analysis revealed good diagnostic performance for 3D-CTA (mean area under ROC curve (Az) = 0.98 and 0.99 for the first and the second observer, respectively) The kappa values extracted from the interobserver concordance analysis for agreement observers regarding the use of MDCTA for assessment of a remnant neck was 0.62. CONCLUSION: Using MDCTA, it is possible to demonstrate the status of intracranial aneurysms after surgical clipping in the immediate postoperative period as well as long-term follow-up with an high sensitivity and specificity when comparing with the findings of DSA.

Duodenal duplication cyst: a rare cause of acute pancreatitis in children.

Duodenal duplication is a rare cause of acute pancreatitis in children. We report a case of acute pancreatitis in which abdominal sonography revealed an enlarged hypoechoic edematous pancreas with mildly dilated main pancreatic duct and a cystic structure with layered wall in the second part of duodenum. Abdominal CT yielded similar findings. The diagnosis of duodenal duplication was confirmed at surgery and subsequent histopathologic examination.