MDCT evaluation of Dorsal Pancreatic Artery and Intrapancreatic arcade anatomy.

OBJECTIVE: The purpose of the study was to analyze the anatomy and variations in the origin of the dorsal pancreatic artery, greater pancreatic artery and to study the various types of arterial arcades supplying the pancreas on multidetector CT (MDCT). METHODS: A retrospective analysis of 747 MDCT scans was performed in patients who underwent triple phase or dual phase CT abdomen between December 2020 and October 2022. Variations in origin of Dorsal pancreatic artery (DPA), greater pancreatic artery (GPA), uncinate process branch were studied. Intrapancreatic arcade anatomy was classified according to Roman Ramos et al. into 4 types-small arcades (type I), small and large arcades (type II), large arcades (type III) and straight branches (type IV). RESULTS: The DPA was visualized in 65.3% (n = 488) of cases. The most common origin was from the splenic artery in 58.2% (n = 284) cases. The mean calibre of DPA was 2.05 mm (1.0-4.8 mm). The uncinate branch was seen in 21.7% (n = 106) with an average diameter of 1.3 mm. The greater pancreatic artery was seen in 57.3% (n = 428) predominantly seen arising from the splenic artery. The most common arcade anatomy was of Type II in 52.1% (n = 63) cases. CONCLUSION: Pancreatic arterial variations are not very uncommon in daily practice. Knowledge of these variations before pancreatic surgery and endovascular intervention procedure is important for surgeons and interventional radiologist.

American college of radiology thyroid imaging reporting and data system score has high diagnostic value in the diagnosis of malignant thyroid nodules: A prospective single-center cross-sectional study.

Introduction: A palpable thyroid swelling is a very common finding and is seen in almost 12% of Asian Indian population. Thyroid imaging reporting and data system (TI-RADS) can be used as a risk stratification system to determine malignant or benign thyroid nodules and necessity of further intervention. Objective: The objective of this study was to determine the positive predictive value (PPV) of TI-RADS category/ultrasound using TI-RADS categories in the diagnosis of malignancy in clinically suspected thyroid nodule and necessity for further intervention in the case of malignant thyroid nodules. Materials and Methods: We conducted a prospective study evaluating 110 patients (140 thyroid nodules) from March 2018 to April 2020 including patients with thyroid swelling. Ultrasound was performed by a radiologist on the patients, and targeted fine-needle aspiration cytology from thyroid nodules was interpreted by an experienced pathologist. Ultrasound features and TI-RADS category were compared with cytology and surgical histopathology. Sensitivity, specificity, PPV, and positive likelihood ratio in different categories of TI-RADS nodules were calculated. Results: A total of 113 thyroid nodules were assessed. Out of 113 nodules (right lobe - 64, isthmus - 6, and left lobe - 43), 84 nodules were benign and 29 nodules were malignant. Eleven (10%) patients were found to have metastatic cervical lymphadenopathy. There was no significant difference in the occurrence of malignant nodules according to gender, location of the nodule, or size of the nodule. The mean anteroposterior and transverse diameter of benign nodule was 14.1 ± 6.9 mm and 20.9 ± 9.9 mm, respectively, whereas in the case of malignant nodules, it was 15.6 ± 7.1 mm and 19.5 ± 9.0 mm, respectively. A TI-RADS score of ≥4 had 84% PPV for malignancy. The PPV for malignancy was 32.2%, 49.1%, and 100% for TI-RADS 2, 3, and 5 categories. Conclusion: TI-RADS is a simple, practical, and cost-effective tool for assessing the malignancy rates of thyroid nodules. TI-RADS categories 4 and 5 have high PPV for malignancy in thyroid nodules.

Résumé Introduction: Un gonflement palpable de la thyroïde est une constatation très courante et est observé chez près de 12 % de la population indienne d'Asie. Le système de rapport et de données d'imagerie thyroïdienne (TI-RADS) peut être utilisé comme système de stratification des risques pour déterminer les nodules thyroïdiens malins ou bénins et la nécessité d'une intervention supplémentaire. Objectif: L'objectif de cette étude était de déterminer la valeur prédictive positive (VPP) de la catégorie/échographie TI-RADS à l'aide des catégories TI-RADS dans le diagnostic de malignité dans un nodule thyroïdien cliniquement suspecté et la nécessité d'une intervention supplémentaire dans le cas d'une tumeur maligne de la thyroïde. nodules. Matériels et méthodes: Nous avons mené une étude prospective évaluant 110 patients (140 nodules thyroïdiens) de mars 2018 à avril 2020 incluant des patients présentant un gonflement de la thyroïde. L'échographie a été réalisée par un radiologue sur les patients, et la cytologie par aspiration à l'aiguille fine ciblée des nodules thyroïdiens a été interprétée par un pathologiste expérimenté. Les caractéristiques échographiques et la catégorie TI-RADS ont été comparées à la cytologie et à l'histopathologie chirurgicale. La sensibilité, la spécificité, la VPP et le rapport de vraisemblance positif dans différentes catégories de nodules TI-RADS ont été calculés. Résultats: Au total, 113 nodules thyroïdiens ont été évalués. Sur 113 nodules (lobe droit - 64, isthme - 6 et lobe gauche - 43), 84 nodules étaient bénins et 29 nodules malins. Onze (10%) patients présentaient une lymphadénopathie cervicale métastatique. Il n'y avait pas de différence significative dans la survenue de nodules malins selon le sexe, la localisation du nodule, ou la taille du nodule. Le diamètre moyen antéropostérieur et transversal du nodule bénin était de 14,1 ± 6,9 mm et 20,9 ± 9,9 mm, respectivement, alors que dans le cas des nodules malins, il était de 15,6 ± 7,1 mm et 19,5 ± 9,0 mm, respectivement. Un score TI-RADS ≥ 4 avait une VPP de 84 % pour la malignité. La VPP pour la malignité était de 32,2 %, 49,1 % et 100 % pour les catégories TI-RADS 2, 3 et 5. Conclusion: TI-RADS est un outil simple, pratique et rentable pour évaluer les taux de malignité des nodules thyroïdiens. Les catégories TI-RADS 4 et 5 ont une VPP élevée pour la malignité des nodules thyroïdiens. Mots-clés : Nodule, système de rapport et de données d'imagerie thyroïdienne, thyroïde, échographie.

Thick crusted plaques on the periorificial area in a young woman.

We report a young woman with periorificial erosions and thick crusts mimicking pemphigus foliaceous, who was found to have an underlying pancreatic malignancy with normal blood glucose and glycosylated haemoglobin levels. Click here for the corresponding questions to this CME article.

Inhibin B Secreting Ovarian Fibroma.

Background: Nearly 90% of all the hormone-producing ovarian tumours are sex cord-stromal tumours (SCSTs). The Ovarian fibroma is a hormonally inactive variant of SCST. It is composed of spindle, oval, round cells producing collagen and accounts for approximately 4% of all ovarian neoplasms. Amongst the other SCSTs, Inhibin B is an important tumour marker. It is a heterodimeric glycoprotein hormone that is secreted primarily by the granulosa cells of the developing follicles. High levels of Inhibin-B can hamper follicular recruitment, leading to amenorrhea in a reproductive age woman. Finding: In this case report, we describe a rare case of a reproductive age female presenting with secondary amenorrhea, having an Ovarian Fibroma, producing massive amounts of Inhibin B. Significance: Although some pathological variants of ovarian fibromas like cyst-adeno-fibroma and ovarian fibro-thecoma are known to secrete inhibin B, benign /pure ovarian fibromas rarely do so.

A lumpy bumpy stomach: The more the murkier.

This report describes the radiological and endoscopic findings in a 54-year-old male who presented with epigastric pain. The patient underwent an upper gastrointestinal (GI) barium study followed by axial imaging, which demonstrated nodular gastric wall thickening. The classic findings of aggressive primary gastric diffuse large B-Cell lymphoma are presented with a brief review differentiating the pathological subtypes, important for patient prognostication and planning of therapy.

Computed tomography perfusion (CTP) in primary lung cancer: Results from a tertiary care centre.

Context: Lung cancer is the leading cause of cancer-related deaths in the world. Computed tomography perfusion (CTP) parameters can be used to evaluate the vascular flow dynamics of lung tumours. We set out to evaluate the CTP parameters in lung cancer and correlate them with histopathological subtype and other characteristics of patients with Lung Cancer. Settings and Design: This prospective study was conducted at a tertiary care referral hospital in western India. Methods: Between January 2019 and July 2020, CTP was performed in 46 patients of lung cancer with histopathological confirmation. The CTP parameters were evaluated in detail and correlated with histopathological subtypes, staging and immunohistochemistry (IHC) markers. Analysis of variance (ANOVA) test, receiver operator characteristic (ROC) curve, Box and whiskers plot graph and Pearson correlation tests were used for statistical analysis. Results: The most common subtype was adenocarcinoma (AC) in 21 patients, followed by squamous cell carcinoma (SCC) in 15 patients and others in 10 patients. Statistically significant difference in blood flow (BF) (f = 5.563, P = 0.007), blood volume (BV) (f = 3.548, P = 0.038) and permeability/flow extraction (FE) (f = 3.617, P = 0.036) were seen in different histopathological subtypes of lung cancer. BF is the main perfusion parameter for differentiation of AC from SCC. P63 positive lesions showed statistically significant lower BF, BV and FE parameters compared to P63 negative lesions (P = 0.013, 0.016 and 0.014, respectively). Different T stages showed statistically significant differences in BF (f = 3.573, P = 0.037), BV (f = 5.145, P = 0.010) and in FE (f = 4.849, P = 0.013). Conclusion: CTP is a non-invasive imaging method to assess the vascular flow dynamics of the tumours that may predict the histopathological subtypes in lung cancer. It can be used to target large-sized lesions during biopsy and to predict the chemotherapy response.

Eosinophilic Solid and Cystic Renal Cell Carcinoma: From Unclassified to Classified, A Case Report.

Eosinophilic solid and cystic renal cell carcinoma (ESC RCC) is a novel tumour with unique morphological and immunohistochemical features. It is a recently described entity after the 2016 World Health Organization Classification of Tumours of the Urinary System and Male Genital Organs and is characterised by a solid cystic tumour composed of polygonal cells with voluminous eosinophilic cytoplasm and CK20 positivity. This tumour has uncertain malignant potential and also has an association with tuberous sclerosis complex (TSC). Sarcomatoid differentiation has not been reported in ESC RCC till now. ESC RCC poses a diagnostic challenge as many eosinophilic/oncocytic renal tumours are included in the differentials. We present a case of ESC RCC with sarcomatoid differentiation in an elderly female without any clinical features of TSC and discuss the differential diagnosis of oncocytic renal tumours.

Rapid Response Preparedness for Management of Post-Covid Invasive Rhino-Orbito-Cerebral Fungal Infections: Experience from a Tertiary Care Government Institute in India.

Sudden surge of Post Covid-19 Rhino-orbito-mucormycosis cases has left entire ENT fraternity in the center of a war room. We present a quick administrative preparedness for this situation in a tertiary care Government Institute in India. This model may serve as a reference for other centers.

Neuroendocrine tumors of the urinary bladder - Report of two cases.

Primary paraganglioma and small cell neuroendocrine carcinoma of the urinary bladder are rare tumors, comprising 0.05% of all bladder tumors and <1% of all malignant bladder tumors, respectively. These tumors can be the cause of a diagnostic dilemma or misdiagnosis on morphology. Paraganglioma is often mistaken for urothelial carcinoma and small cell carcinoma for poorly differentiated carcinoma or lymphoma. Herein, we report a case of primary paraganglioma and another of a small cell carcinoma of the urinary bladder and discuss their closest differential diagnoses. The diagnostic pitfalls should be kept in mind so that correct, timely diagnosis of these entities can be made due to implications in the management and prognosis.

Adenocarcinoma of the fourth portion of duodenum presenting as intussusception: an unusual manifestation of rare pathology.

Primary adenocarcinoma of the fourth portion of the duodenum (D-IV) is reported infrequently than other parts of the duodenum. Its diagnosis is often late because of non-specific symptoms and signs. We encountered a 48-year-old male patient who was diagnosed as duodeno-duodenal intussusception, underwent segmental duodenal resection with duodenojejunal anastomosis and confirmed as adenocarcinoma of D-IV. He received adjuvant chemotherapy and is doing well at 1 year of follow-up. This report describes about the rare case of isolated adenocarcinoma of the D-IV presented as intussusception which is never reported before and successfully treated by segmental resection of the duodenum and jejunum.

Predictors of Clinical Outcomes in Adult COVID-19 Patients Admitted to a Tertiary Care Hospital in India: an analytical cross-sectional study.

BACKGROUND: The outbreak ofsevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted inexponential rise in the number of patients getting hospitalised with corona virus disease 2019 (COVID-19). There is a paucity of data from South East Asian Region related to the predictors of clinical outcomes in these patients. This formed the basis of conducting our study. METHODS: This was an analytical cross-sectional study. Demographic, clinical, radiological and laboratory data of 125 patients was collected on admission. The study outcome was death or discharge after recovery. For univariate analysis, unpaired t-test, Chi-square and Fisher's Exact test were used. Receiver operating characteristic (ROC) curves were plotted for Sequential Organ Failure Assessment (SOFA) score and few laboratory parameters. Logistic regression was applied for multivariate analysis. RESULTS: Elderly age, ischemic heart disease and smoking were significantly associated with mortality. Elevated levels of D-dimer and lactate dehydrogenase (LDH) and reduced lymphocyte counts were the predictors of mortality. The ROCs for SOFA score curve showed a cut-off value ≥ 3.5 (sensitivity- 91.7% and specificity- 87.5%), for IL-6 the cut-off value was ≥ 37.9 (sensitivity- 96% and specificity- 78%) and for lymphocyte counts, a cut off was calculated to be less than and equal to 1.46 x 109per litre (sensitivity-75.2%and specificity- 83.3%). CONCLUSION: Old age, smoking history, ischemic heart disease and laboratory parameters including elevated D-dimer, raised LDH and low lymphocyte counts at baseline are associated with COVID-19 mortality. A higher SOFA score at admission is a poor prognosticator in COVID-19 patients.

Can combined multiparametric magnetic resonance imaging of the prostate and prostate-specific antigen density improve the detection of clinically significant prostate cancer: A prospective single-center cross-sectional study.

OBJECTIVE: The objective of the study was to validate PIRADS v2 on 3T MRI with secondary assessment if combination of the PIRADS v2 and PSA density improves detection of clinically significant prostate cancer. MATERIALS AND METHODS: We conducted a prospective study evaluating 58 patients with PSA value of >4 ng/ml from July 2017 to December 2019. Transrectal ultrasonography (TRUS) guided targeted biopsy was performed via cognitive targeting followed by systemic 12 core biopsy. Two cognitive fusion-targeted biopsy cores were added for each lesion in patients who had suspicious or equivocal lesions on mpMRI. The PI-RADS scoring system version 2.0 (PI-RADS v2) was used to describe the MRI findings. RESULTS: Total of 112 lesions of 58 patients were assessed via mpMRI followed by TRUS guided biopsy. A PI-RADS v2 score of ≥4 irrespective of PSA density categories and a PI-RADS v2 score of 3 with PSA density of ≥0.15 ng/mL/cc, yielded the highest overall prostate cancer and clinically significant prostate cancer detection rate. Contrary to, a PI-RADS v2 score of ≤3 and a PSA densitay of <0.15 ng/ mL/mL(low risk group), which yielded no clinically significant prostate cancer. CONCLUSION: Both PIRADS v2 score and PSA density are eminently sensitive and specific in the detection of clinically significant prostate cancers individually. However the combination of PIRADS v2 and PSA density significantly improved the accuracy of clinically significant prostate cancer detection. Patients with combination of PIRADS v2 score 33 and PSA density 30.15 ng/ml/cc should undergo prostate biopsy.

Pseudo-pseudo Meigs' syndrome (PPMS) in chronic lupus peritonitis: a case report with review of literature.

Gastrointestinal involvement in systemic lupus erythematosus (SLE) usually occurs in the form of mesenteric vasculitis, protein-losing enteropathy, intestinal pseudo-obstruction, and pancreatitis. We describe a 23-year-old female, a known case of SLE presented with significant ascites and pleural effusion. Further evaluation showed elevated CA-125 levels without evidence of malignancy. The patient was treated with corticosteroids, hydroxychloroquine, and azathioprine resulting in the resolution of ascites in 2 weeks. The triad of ascites, pleural effusion, and increased CA-125 is known as pseudo-pseudo Meigs' syndrome, which is rarely reported in the literature. Clinicians should be aware of this entity while evaluating an SLE patient with low serum-ascites albumin gradient (SAAG) ascites.

MDCT evaluation of pancreatic contour variations in head, neck, body and tail: surgical and radiological significance.

OBJECTIVE: The purpose of the study was to investigate the incidence of pancreatic contour variations on multidetector CT (MDCT) for abdominal examinations. METHODS: A retrospective analysis of 700 MDCT scans was performed in patients who underwent triple phase CT abdomen between October 2018 and January 2021. After excluding 176 patients, finally total of 524 patients were included in the study. For simplification, we classified the pancreatic contour variations as classified by Ross et al. and Omeri et al. Pancreatic head-neck variations was classified into Type I-anterior, Type II-posterior and Type III-horizontal variety. Pancreatic body-tail variation was divided into Type Ia-anterior projection; Ib-posterior projection and Type IIa-globular, IIb-lobulated, IIc-tapered, and IId-bifid pancreatic tail. RESULTS: The most common type of variation in the head was Type II (n = 112, 21.3%) followed by Type III (n = 37, 7%) and Type I (n = 21, 4%). The most common type of variation in the body of pancreas was Type Ia (n = 33, 6.2%) followed by Type Ib (n = 13, 2.4%). In the tail region of pancreas, the most common variation was Type IIb (n = 21, 4%) followed by Type IIa (n = 19, 3.6%). CONCLUSION: Pancreatic contour variations are not very uncommon in daily practice. Knowledge of these variations is important for surgeons, radiologists and avoids misjudgement of normal pancreatic tissue as tumor or lymph node especially on unenhanced or single phase MDCT.

Neuroendocrine tumors of the urinary bladder - Report of two cases

Primary paraganglioma and small cell neuroendocrine carcinoma of the urinary bladder are rare tumors, comprising 0.05% of all bladder tumors and <1% of all malignant bladder tumors, respectively. These tumors can be the cause of a diagnostic dilemma or misdiagnosis on morphology. Paraganglioma is often mistaken for urothelial carcinoma and small cell carcinoma for poorly differentiated carcinoma or lymphoma. Herein, we report a case of primary paraganglioma and another of a small cell carcinoma of the urinary bladder and discuss their closest differential diagnoses. The diagnostic pitfalls should be kept in mind so that correct, timely diagnosis of these entities can be made due to implications in the management and prognosis.

Epithelioid angiomyolipoma with tumor thrombus in IVC and right atrium.

Epithelioid angiomyolipoma is an uncommon subtype of renal angiomyolipoma associated with potentially malignant behavior and is considered a distinct entity by the World Health Organization classification of renal tumors. We present a case of an epithelioid variant of angiomyolipoma with extension into the renal vein, inferior vena cava reaching up to the right atrium. Pre-operatively, a diagnosis of renal cell carcinoma was considered based on imaging findings. Intra-operatively due to extensive adhesions, surgical resection was not performed and only tissue sampling was performed for histopathology. Microscopic examination revealed short fascicles of spindle cells and perivascular epithelioid cells. A differential diagnosis of renal cell carcinoma with sarcomatoid differentiation was considered. The immunohistochemical profile showed tumor cells that express Melan-A and smooth muscle actin, while they were negative for pan-cytokeratin, PAX8, CK7, CD117 and CD34. Therefore a diagnosis of epithelioid angiomyolipoma was rendered. The presence of intravascular thrombi on radiological investigation and carcinoma-like growth pattern on light microscopy may compound an erroneous diagnosis of renal cell carcinoma. Hence, it is prudent for the urologist to consider differential diagnosis other than renal cell carcinoma when confronted with a renal neoplasm presenting with intravascular thrombi. In these cases, a core biopsy should be planned pre-operatively and diagnosis should be made with aid of appropriate immunohistochemical markers.

Preoperative diagnosis of pancreatic schwannoma - Myth or reality.

Pancreatic schwannoma is a rare, well-encapsulated tumor of the pancreas. Preoperative diagnosis of this tumor is uncommon due to marked degenerative change, its rarity, and overlapping clinical and imaging features with other pancreatic neoplasms. Here, we report two cases of pancreatic schwannoma, suspected preoperatively based on their multimodal imaging features, so that enucleation was possible. Extensive pancreatic surgeries can be avoided if imaging can provide clues about the benign nature of the pancreatic masses preoperatively.

Clinico-radiological-pathological correlation in eumycetoma spectrum: Case series.

Maduramycosis or mycetoma is one of the chronic granulomatous diseases commonly seen in tropical regions. Microbiological cultures and biopsy are carried out for the definitive diagnosis of the disease, but they are time-consuming methods. The present study aims to correlate clinical, radiological and pathological features in eumycetoma cases to emphasize the role of "dot in circle" sign leading to early imaging-based diagnosis. Imaging plays an important role in early diagnosis of mycetoma, which has therapeutic implications. "Dot in circle" sign is a recently described sign in mycetoma cases on ultrasound (USG) and magnetic resonance imaging (MRI). We diagnosed four cases of eumycetoma based on clinical and imaging features, which were confirmed with histopathology. The differential diagnosis, which may mimic this sign is also discussed. The "dot in circle" sign is seen on both ultrasound and MRI. This sign is highly specific for mycetomas. Knowledge of this sign can help in early diagnosis of mycetomas preventing misdiagnosis and further complications.

Quantitative diffusion-weighted magnetic resonance imaging for prediction of early infection in pancreatic collections: Results of a pilot study.

BACKGROUND/AIMS: The development of infection in pancreatitis increases the mortality rate up to 32%. Therefore, it is important to identify patients who are at high risk of developing infection, at an early stage. The objectives of the study were (a) to analyze the quantitative parameters of diffusion-weighted magnetic resonance imaging (DW-MRI) and apparent diffusion coefficient (ADC) in infected as well as sterile pancreatic collections (b) to establish "cut-off" values for ADC that can identify infected pancreatic collections. MATERIALS AND METHODS: Prospective observational study of pancreatitis cases who underwent DW-MRI from August 2018 to July 2019 were enrolled in the study. The collections were analyzed for diffusion restriction. The average of the three ADC values from the wall and center of collection was noted. RESULTS: Infected collections were seen in 7 and sterile collections observed in 11 cases. The optimal cut-off ADC value to differentiate sterile and infected collection in our study was 1.651 × 10-3 mm2/s (sensitivity of 81.8%; specificity of 100.0%). ROC curve for mean ADC from the wall showed a significant diagnostic accuracy with AUC: 0.91; 95% CI: 0.77-1.0 (P = 0.004). CONCLUSION: DW-MRI is a reliable noninvasive technique to differentiate sterile and infected pancreatic collections. ADC values from the periphery of the collection can predict infected pancreatic collections at an early stage. DW-MRI should not be considered as a substitute for aspiration cytology in patients with septic symptoms and absent diffusion restriction on MRI.