A case of Muir-Torre syndrome on [18F]FDG PET/CT.

Muir-Torre syndrome (MTS) is a rare genetic disorder, considered a subtype of Lynch syndrome, that causes sebaceous cutaneous tumors and increases the risk of internal visceral tumors. We present a case of a 63-year-old male with a history of MTS with sebaceous tumors, colorectal, and urothelial cancers who underwent fluorine-18-deoxyglucose positron emission tomography/ computed tomography [18F]FDG PET/CT to follow-up on multiple [18F]FDG avid skin lesions and right pelvic lymph nodes. Although few reports are available detailing the utility of [18F]FDG PET/CT in this rare disease, this modality appears useful, and superior, to computed tomography in the diagnosis and follow-up of MTS.

Should sacrouterine plication be added to lateral suspension surgery? A prospective study.

AIM: Laparoscopic lateral suspension is a novel approach for repairing anterior and apical pelvic organ prolapse (POP). According to integral theory, urinary symptoms and pelvic pain are believed to originate from suspensory ligaments. We aimed to investigate the objective and subjective outcomes of adding sacroterine plication to apical prolapse surgery. METHODS: Sixty patients with Grade 2 or higher symptomatic apical POP were included in the study. The study sample was categorized into two groups: Group 1 underwent lateral suspension and Group 2 underwent lateral suspension and sacroterine plication. Anatomical cure was defined separately for the apical and anterior compartments as POP-Q scores for sites C and Ba of less than -1 cm for each compartment. A subjective cure was defined as the absence of bulge symptoms. Patient satisfaction, sexual function, prolapse-related quality of life, voiding dysfunction, nocturia, and constipation were assessed. RESULTS: In Group 1, anatomical cure rates for apical and anterior prolapse were 100% and 70%, respectively (p <0.001). In Group 2, these rates were 100% for apical prolapse and 73.3% for anterior prolapse (p <0.001). The subjective cure was 96.6% in both groups. Furthermore, improvement in sexual and urinary symptoms was more significant in the group that underwent sacroterine plication (p <0.001). CONCLUSIONS: The additional sacroterine plication (shortening) procedure with lateral suspension proved to be an effective and successful surgical approach for apical prolapse. Its routine addition to existing lateral suspension surgery can contribute significantly to the improvement of urinary and prolapse symptoms.

Recurrent invasive ductal carcinoma of the breast with metastasis to the uterine cervix: A case report.

This article presents a case of cervical metastasis from recurrence of invasive ductal carcinoma of the breast >20 years after initial diagnosis. The diagnosis was made after the patient presented with three months of intermittent post-menopausal vaginal spotting. She underwent palliative radiotherapy combined with chemotherapy and was disease free at the time of writing. Cervical metastasis of a primary breast cancer is extremely rare and can present with a variety of symptoms. This case report highlights the importance of life-long gynecologic care and surveillance in patients with a history of breast cancer.

Beneficial effects of IVIG treatment on experimental-induced osteoporosis.

Objective: Estrogen (E2) plays a significant role in postmenopausal osteoporosis, and its deficiency is related to chronic low-grade inflammation. Intravenous immunoglobulin (IVIG) is composed of immunoglobulins derived from the plasma of healthy donors. Numerous anti-inflammatory pathways are responsible for IVIG's anti-inflammatory action The aim of this study is to investigate the effects of IVIG on experimental-induced osteoporosis. Materials and methods: Forty adult female Wistar rats were included in the study. Thirty rats underwent bilateral dorsal ovariectomy. Rats were grouped as Group 1 (n = 10, ovariectomy and saline); Group 2 (n = 10, ovariectomy and E2); Group 3 (n = 10, ovariectomy and IVIG), and Control group (n = 10, no oophorectomy). Histopathological examination of bone tissue, and biochemical analysis for beta-catenin, plasma Tumor Necrosis Factor-α, IL-6, receptor activator of nuclear-κB ligand (RANKL), and osteoprotegerin (OPG) levels were made. Results: The IVIG group had increased trabecular number, area, and thickness with increased bone mineral density as well as decreased trabecular separation compared with the saline group. IVIG group had lower serum RANKL and higher serum OPG levels when compared with the saline group. The bone marrow beta-catenin level was significantly higher in the control and ovariectomy + IVIG groups. Conclusion: IVIG has beneficial effects on experimentally induced osteoporosis with a possible action on inflammation and RANKL-ß-catenin pathway.

Objetivo: El estrógeno juega un papel importante en la osteoporosis posmenopáusica y su deficiencia está relacionada con la inflamación crónica de bajo grado. La inmunoglobulina intravenosa (IGIV) está compuesta por inmunoglobulinas derivadas del plasma de donantes sanos. El objetivo de este estudio es investigar los efectos de IVIG en la osteoporosis inducida experimentalmente. Materiales y métodos: 30 ratas se sometieron a ovariectomía dorsal bilateral. las ratas se agruparon como: Grupo 1 (n = 10, ovariectomía y solución salina); Grupo 2 (n = 10, ovariectomía y estrógeno); Grupo 3 (n = 10, ovariectomía e IVIG) y Grupo Control (n = 10, sin ovariectomía). Se realizó un examen histopatológico del tejido óseo y un análisis bioquímico de los niveles de beta-catenina, factor de necrosis tumoral α (TNF-α), IL-6, RANKL y osteoprotegerina (OPG) en plasma. Resultados: El grupo IVIG había aumentado el número, el área y el grosor trabecular con una mayor densidad mineral ósea, así como una menor separación trabecular en comparación con el grupo de solución salina. El nivel de beta-catenina en la médula ósea fue significativamente mayor en los grupos de control y de ovariectomía + IVIG. Conclusión: IVIG tiene efectos beneficiosos sobre la osteoporosis inducida experimentalmente con una posible acción sobre la inflamación y la vía RANKL-ß-catenina.

MRI-based radiomic features for identifying recurrent prostate cancer after proton radiation therapy.

PURPOSE: Magnetic Resonance Imaging (MRI) evaluation of recurrent prostate cancer (PCa) following proton beam therapy is challenging due to radiation-induced tissue changes. This study aimed to evaluate MRI-based radiomic features so as to identify the recurrent PCa after proton therapy. METHODS: We retrospectively studied 12 patients with biochemical recurrence (BCR) following proton therapy. Two experienced radiologists identified prostate lesions from multi-parametric MRI (mpMRI) images post-proton therapy and marked control regions of interest (ROIs) on the contralateral side of the prostate gland. A total of 210 radiomic features were extracted from lesions and control regions on the T2-weighted (T2WI) and Apparent Diffusion Coefficient (ADC) image series. Recursive Feature Elimination with Cross-Validation method (RFE-CV) was used for feature selection. A Multilayer Perceptron (MLP) neural network was developed to classify three classes: cancerous, benign, and healthy tissue. The 12-core biopsy results were used as the gold standard for the segmentations. The classifier performance was measured using specificity, sensitivity, the area under receiver operating characteristic curve (AUC), and other statistical indicators. RESULTS: Based on biopsy results, 10 lesions were identified as PCa recurrence while eight lesions were confirmed to be benign. Ten radiomic features (10/210) were selected to build the multi-class classifier. The radiomics classifier gave an accuracy of 0.83 in identifying cancerous, benign, and healthy tissue with a sensitivity of 0.80 and specificity of 0.85. The model yielded an AUC of 0.87, 95% CI [0.72-1.00] in differentiating cancer from the benign and healthy tissues. CONCLUSIONS: Our proof-of-concept study demonstrates the potential of using radiomic features as part of the differential diagnosis of PCa on mpMRI following proton therapy. The results need to be validated in a larger cohort.

MRI-based nomograms and radiomics in presurgical prediction of extraprostatic extension in prostate cancer: a systematic review.

PURPOSE: Prediction of extraprostatic extension (EPE) is essential for accurate surgical planning in prostate cancer (PCa). Radiomics based on magnetic resonance imaging (MRI) has shown potential to predict EPE. We aimed to evaluate studies proposing MRI-based nomograms and radiomics for EPE prediction and assess the quality of current radiomics literature. METHODS: We used PubMed, EMBASE, and SCOPUS databases to find related articles using synonyms for MRI radiomics and nomograms to predict EPE. Two co-authors scored the quality of radiomics literature using the Radiomics Quality Score (RQS). Inter-rater agreement was measured using the intraclass correlation coefficient (ICC) from total RQS scores. We analyzed the characteristic s of the studies and used ANOVAs to associate the area under the curve (AUC) to sample size, clinical and imaging variables, and RQS scores. RESULTS: We identified 33 studies-22 nomograms and 11 radiomics analyses. The mean AUC for nomogram articles was 0.783, and no significant associations were found between AUC and sample size, clinical variables, or number of imaging variables. For radiomics articles, there were significant associations between number of lesions and AUC (p < 0.013). The average RQS total score was 15.91/36 (44%). Through the radiomics operation, segmentation of region-of-interest, selection of features, and model building resulted in a broader range of results. The qualities the studies lacked most were phantom tests for scanner variabilities, temporal variability, external validation datasets, prospective designs, cost-effectiveness analysis, and open science. CONCLUSION: Utilizing MRI-based radiomics to predict EPE in PCa patients demonstrates promising outcomes. However, quality improvement and standardization of radiomics workflow are needed.

Magnetic Resonance Imaging Virtual Biopsy of Common Solid Renal Masses-A Pictorial Review.

ABSTRACT: The expanded application of radiologic imaging resulted in an increased incidence of renal masses in the recent decade. Clinically, it is difficult to determine the malignant potential of the renal masses, thus resulting in complex management. Image-guided biopsies are the ongoing standard of care to identify molecular variance but are limited by tumor accessibility and heterogeneity. With the evolving importance of individualized cancer therapies, radiomics has displayed promising results in the identification of tumoral mutation status on routine imaging. This article discusses how magnetic resonance imaging features can guide a radiologist toward identifying renal mass characteristics.

18 F-FDG PET/CT Findings of Leptomeningeal Metastasis in Nasopharyngeal Carcinoma.

ABSTRACT: Nasopharyngeal carcinoma (NC) is an epithelial tumor with distinctive prevalence in East and Southeast Asia. Most patients with NC only experience regional metastasis. In cases of distant metastasis, prognosis is grim. Leptomeningeal spread of the disease is a rare occurrence, which is sparsely described in the literature. We present a case of a 33-year-old man with a history of high-grade NC with leptomeningeal metastasis. Initial MRI lumbar spine demonstrated subtle findings consistent with leptomeningeal disease. These findings are easily discernible on 18 F-FDG PET/CT.

The Role of Pelvic Ultrasound in Evaluating the Success of Tension-free Vaginal Tape (TVT).

Objectives: This study aims to assess the lack of response to treatment in individuals undergoing mid-urethral sling surgery for stress urinary incontinence (SUI) using ultrasound findings of the pelvic floor. Methods: The study included patients who underwent the tension-free vaginal tape (TVT) procedure for stress urinary incontinence within the period spanning from January 2016 to January 2021. The physical examination involved maintaining bladder filling at an average volume of 200-400 mL, and treatment failure was determined by the presence of SUI during the Valsalva maneuver. Results: The study comprised a total of 214 patients, where it was observed during the stress test that 32 patients (25.8%) had an unsuccessful outcome following mid-urethral sling surgery. In the unsuccessful group, the distance of the mesh-posterior urethra was lower (4.09±0.39 vs. 4.91±0.51; p<0.001), the posterior urethrovesical angle was lower when at rest, but the angle increased more significantly during the Valsalva maneuver, and the bladder neck angle was narrower (p<0.001). Conclusion: We obtained lower mean values of mesh-posterior urethral distance in unsuccessful patients compared to those found in the group of cured patients. Pelvic floor ultrasound can predict the success of TVT surgeries but there is as yet little data and there is a need to find in the near future more standard and objective parameters for the diagnosis of urinary incontinence.

Breast cancer in a Hispanic patient with Werner syndrome.

Werner Syndrome is a rare autosomal recessive condition characterized by premature aging and increased risk of malignancies due to gene mutations associated with DNA stability. We present the first case report of a 29-year-old Hispanic female with WS diagnosed with breast cancer. Diagnostic mammography and ultrasound, breast MRI and PET examinations revealed two lesions biopsy proven as invasive ductal carcinoma. The patient underwent neoadjuvant chemotherapy and radical mastectomy. Recurrence occurred 10 months postoperatively with molecular analysis demonstrating TP53 mutations. The multifactorial assessment of breast cancer in this case study is crucial towards optimizing screening, diagnosis and management of this disease in patients with WS.

Association of Obesity and Surgery Outcomes in Patients with Endometrial Cancer: A Single-Center Analysis.

OBJECTIVE: Although obesity can result in high morbidity and mortality in surgical outcomes because of multiple comorbidities, determinants of outcome in obese patients who underwent endometrial cancer surgery remain unclear. The aim of this study is to assess the relationship between body mass index (BMI) and surgical outcomes in obese patients with endometrial cancer. METHODS: An institutional retrospective review of the demographic details, clinical characteristics, and follow-up data of 142 patients with endometrial cancer who underwent surgery during a 72-month period was performed. The patients were divided into three groups based on their BMI; patients with BMI < 25 were identified as normal weight, patients with BMI between 25 and 30 were accepted as overweight, and those with BMI ≥ 30 kg/m2 were identified as obese. The groups' demographic and clinical variables were compared. RESULTS: Of the 142 patients, 42 were in the normal weight group, 55 in the overweight group, and 45 in the obese group. Age, surgical procedures, blood loss, preoperative health status, and metastatic lymph nodes did not show a significant difference between groups. However, surgery time and total lymph nodes were higher in the obese group. (p = 0.02, p = 0.00, and p = 0.00, respectively). Common complications were anemia, fever, intestinal injury, deep vein thrombosis, fascial dehiscence and urinary infection. There was no significant difference according to the complications. CONCLUSION: Our results indicated that higher BMI was significantly associated with a longer duration of endometrial cancer surgery. Minimally invasive surgeries and conventional laparotomy could be performed safely in obese patients.

Association of Obesity and Surgery Outcomes in Patients with Endometrial Cancer: A Single-Center Analysis

Abstract Objective Although obesity can result in high morbidity and mortality in surgical outcomes because of multiple comorbidities, determinants of outcome in obese patients who underwent endometrial cancer surgery remain unclear. The aim of this study is to assess the relationship between body mass index (BMI) and surgical outcomes in obese patients with endometrial cancer. Methods An institutional retrospective review of the demographic details, clinical characteristics, and follow-up data of 142 patients with endometrial cancer who underwent surgery during a 72-month period was performed. The patients were divided into three groups based on their BMI; patients with BMI < 25 were identified as normal weight, patients with BMI between 25 and 30 were accepted as overweight, and those with BMI ≥ 30 kg/m2 were identified as obese. The groups' demographic and clinical variables were compared. Results Of the 142 patients, 42 were in the normal weight group, 55 in the overweight group, and 45 in the obese group. Age, surgical procedures, blood loss, preoperative health status, and metastatic lymph nodes did not show a significant difference between groups. However, surgery time and total lymph nodes were higher in the obese group. (p = 0.02, p = 0.00, and p = 0.00, respectively). Common complications were anemia, fever, intestinal injury, deep vein thrombosis, fascial dehiscence and urinary infection. There was no significant difference according to the complications. Conclusion Our results indicated that higher BMI was significantly associated with a longer duration of endometrial cancer surgery. Minimally invasive surgeries and conventional laparotomy could be performed safely in obese patients.

Pericardial Effusion during Proton Therapy in a Patient with Chemorefractory Hodgkin Lymphoma.

We present a case of recurrent pericardial effusion presenting during proton therapy in a 24-year-old female receiving mediastinal treatment for classical Hodgkin lymphoma. Pericardial effusion is typically considered an event accompanying lymphoma diagnosis or as a subacute or late effect of radiotherapy. Rarely has it been described as occurring during radiation treatment with photon-based radiotherapy, let alone proton therapy. It is unclear what underlying cause triggered recurrent effusion in this patient. Identifying and managing pericardial effusion during treatment delivery is important to consider as it may affect radiation dosimetry, particularly with proton therapy. Doing so will help ensure patients receive optimal treatment and minimize the risks of morbidity and mortality.

A Practical Technique to Improve Visualization of Sentinel Nodes in Axillary Region on Breast Lymphoscintigraphy: Medial Breast Traction by Patient.

A standard method of performing breast lymphoscintigraphy is anterior and lateral views after periareolar intradermal injection of a radiotracer. However, a sentinel lymph node may be obscured by the activity at injection site, especially on anterior view. Also, breast tissue may cause attenuation to prevent sentinel node visualization. Repeat images during medial traction of breast by patient is an effective technique to improve visualization of sentinel lymph nodes in axillary region.

Pancreatic metastasis from papillary thyroid carcinoma: Case report and literature review.

Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy. Papillary thyroid carcinoma generally spreads locally to the cervical lymph nodes, but distant metastases are seen in 5%-7% of cases. Most distant metastases occur in the bone, lung, and brain. Pancreatic metastases of PTC are extremely rare. Herein we present a patient with PTC treated with total thyroidectomy and two rounds of radioactive iodine (RAI) ablation that was subsequently found to have a pancreaticmetastasis detected on fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG PET/CT) imaging 3 years from the initial diagnosis.

Recurrent Metastatic Breast Cancer in Internal Mammary Lymph Nodes along the Translocated Left Internal Mammary Artery Bypass Graft.

Internal mammary lymph node (IMLN) is the second most common site for nodal metastases in breast cancer. The authors present a case of a 58-year-old woman with a history of coronary artery bypass graft surgery 1 year prior who presented with a neck mass. Imaging showed an enlarged IMLN along the course of the translocated left internal mammary artery (LIMA) bypass graft on the surface of the heart, and the patient was later proven to have recurrent breast cancer. To the authors' knowledge, this is the first case report in the literature of a breast cancer recurrence in an IMLN along the postoperative translocated LIMA bypass graft. Keywords: Adults, CT, PET/CT, Breast, Thorax, Lymphatic, Metastases © RSNA, 2021.

Whole-Body versus Routine Skull Base to Mid-thigh 18F-Fluorodeoxyglucose Positron Emission Tomography/ Computed Tomography in Patients with Malignant Melanoma.

OBJECTIVES: The objectives of this study are to assess the utility of whole-body 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) (skull vertex to toes) imaging relative to the standard field of view (skull base to mid-thigh) in patients with primary melanoma site that is not located in the lower extremities. MATERIAL AND METHODS: The primary site of the melanoma and metastatic disease was determined based on 18F-FDG PET/CT findings in 26 patients. The FDG avid sites were tabulated as the primary site, lower extremity, brain, and other sites. The hypothesis is that routine skull base to mid-thigh versus whole-body 18F-FDG PET/CT in patients with malignant melanoma will not change management. RESULTS: Patients (26) were divided into those with primary melanoma site in either the lower extremities (six patients) or other site (20 patients). Four of the six patients with the primary site in the lower extremities also had positive findings in the ipsilateral inguinal lymph nodes. One of the patients with a positive inguinal lymph node had metastatic sites in the external iliac region and lungs on the initial study. On follow-up imaging, this patient also exhibited diffuse metastatic disease, including a lower extremity. None of the remaining patients in this group had positive findings other than the primary site in the lower extremity. Of the remaining 20 patients with the primary site not in the lower extremity, one had diffuse metastatic disease that included a lower extremity. However, lower extremity involvement would not change patient management in this case. A second patient in this group had diffuse metastatic disease that also involved the brain. However, no metastatic disease was present in the lower extremities in this patient. None of the remaining 18 patients in this group had metastatic disease in a lower extremity. Two patients in the entire study group of 26 had brain metastasis on contrast-enhanced head CT, with one having multiple brain metastasis. PET failed to demonstrate some of the brain lesions. In the other patient with solitary brain metastasis detected on contrast-enhanced head CT, PET was negative. CONCLUSION: 18F-FDG PET/CT imaging of the lower extremity may not be justified if the primary neoplasm is not located in the lower extremities. Elimination of lower extremity imaging will reduce scanning time and additional radiation exposure. Similarly, PET/CT imaging of the brain may not be justified if contrast-enhanced CT or magnetic resonance imaging of the head is already obtained since these are more sensitive.

Importance of baseline PET/CT imaging on radiation field design and relapse rates in patients with Hodgkin lymphoma.

PURPOSE: This study analyzed the impact of pretreatment positron emission tomography/computed tomography (PET/CT) scans on involved site radiation therapy (ISRT) field design and pattern of relapse among patients with Hodgkin lymphoma (HL). METHODS AND MATERIALS: Thirty-seven patients with stage I or II HL who received first-line chemotherapy followed by consolidative ISRT to all initial sites of disease were enrolled in an institutional review board-approved outcomes-tracking protocol between January 2009 and December 2014. Patients underwent standard-of-care follow-up. Relapse-free survival (RFS) was evaluated using a Kaplan-Meier analysis and cohort comparisons using a χ2 test. RESULTS: Thirty-one patients underwent (PET/CT) scans before chemotherapy and 6 did not because of a lack of insurance (n = 2), inpatient chemotherapy administration (n = 2), scheduling conflicts (n = 1), and unknown reasons (n = 1). The median follow-up was 46 months, and the 4-year RFS rate was 92%. Patients without pretreatment PET imaging were more likely to experience disease relapse (4-year RFS, 97% vs. 67%; P = .001). Among the 6 patients who did not receive a baseline PET/CT scan, all 3 recurrences occurred in lymph node regions outside of, but immediately adjacent to, the radiation field. CONCLUSIONS: Patients with stage I/II HL who receive ISRT without pretreatment PET/CT scans appear to have an increased risk for relapse in adjacent nodal stations just outside the radiation field. A larger cohort with a longer follow-up is needed to confirm these findings.

Unexpected Bone Metastases from Thyroid Cancer.

Objective. To present a complicated case of differentiated thyroid carcinoma (DTC) with metastases to the skull that was evident on I-131 whole body scan (WBS) but negative on other imaging modalities in a low risk patient. Methods. We will discuss clinical course, imaging, pathological findings, and treatment of the patient with skull metastasis from DTC. Pertinent literature on imaging and pathology findings as well as radioactive iodine (RAI) treatment impact on quality of life and survival in patients with bone metastases from DTC will be reviewed. Results. The patient is a 37-year-old woman with a diagnosis of DTC who had focal areas of increased uptake in the head on WBS with no correlative findings on CT and MRI. Initially, false positive findings were suspected since patient had a low risk for developing metastases. However, the persistent findings on post-RAI treatment WBS, following two courses of treatment, were highly concerning for metastatic bone disease. WBC performed 6 months following the second RAI treatment revealed resolution of the findings. Conclusions. False positive findings in WBS are frequent and may be due to contamination, perspiration, or folliculitis of the scalp as well as benign lesions such as meningioma, hematoma, cavernous angioma, and metallic sutures. However, metastatic disease should always be considered even if the patient has low risk of distant metastatic disease and correlative images do not support the diagnosis. RAI therapy appears to improve the survival rates and quality of life of thyroid cancer patients with bone metastases based on retrospective studies.