Dermoscopic aspect of verrucous epidermal nevi: new findings

Background/aim: Verrucous epidermal nevi are cutaneous hamartomas with many clinical variants. Dermoscopic features of verrucous epidermal nevus have rarely been investigated. We aimed to identify dermoscopic findings of the entity which will facilitate the diagnostic process by reducing the use of invasive diagnostic methods. Materials and methods: The study included the patients with histopathologically approved verrucous epidermal nevus. Clinical, dermoscopic, and histopathological features of the patients were retrospectively reviewed and the findings identified were recorded. Dermoscopic examination was performed with a polarized-light handheld dermoscope with 10-fold magnification. Results: The most common dermoscopic features were thick brown circles, thick brown branched lines, and terminal hairs. The most common vessel pattern was dotted vessels. Branched thick brown lines, brown globules, brown dots forming lines, serpiginous brown dots, white and brown exophytic papillary structures, fine scale, thick adherent scale, and cerebriform structures were the other findings. Conclusion: We observed many vascular and nonvascular dermoscopic findings which were not described previously for the entity. Dermoscopic examination of the verrucous epidermal nevi may lead to more reliable clinical interpretation and thus may reduce the need for histopathological investigation.

Medical Infrared Thermography in back pain osteopathic management.

OBJECTIVES: The objective of this study was to provide proof-of-concept for the use of Medical Infrared Thermography to verify both diagnosis and osteopathic management accuracy in back pain. METHODS: A 50-year-old woman with acute back pain syndrome volunteered to participate in this study. RESULTS: Prior the treatment, thermal image reveals that in a sagittal plane, the inflammation extends from vertebra D8 to L3 with a maximum inflammation between vertebrae D10 to L1. Post-treatment, Medical Infrared Thermography only shows a slight inflammation along the lumbar furrow that does not induce pain in the patient. CONCLUSION: Medical Infrared Thermography has made it possible to scientifically support the osteopathic approach to back pain, both in the initial diagnostic phase and in the validation phase of treatment effectivess.

Cutaneous Manifestation of Sarcoidosis in Lower-Back Tattoo With Increased Uptake of 18F-FDG.

Sarcoidosis, a granulomatous T-cell-mediated multisystem disease with a yearly incidence of 10.9 to 35.5 cases per 100,000 in the United States, affects a variety of organ systems. Although the characteristic radiological finding of a bihilar lymphadenopathy still plays a diagnostic key role, FDG PET/CT is more sensitive in detecting and monitoring various manifestations. We present a rare case of a 37-year-old woman with bihilar, mediastinal, and abdominal lymphadenopathy in conjunction with a histologically proven cutaneous manifestation of sarcoidosis in a tattoo of the lower back exhibiting an increased uptake of FDG.

Lady with wings: a case report of giant neurofibromatosis type I.

RATIONALE: Neurofibromatosis type I (NF-I) accounts for approximately 90% of neurofibromatosis. NF-I is an autosomal dominant genetic disease which results from the gene mutation of NF-I situated in chromosome 17q11.2. PATIENT CONCERNS: A 32-year-old lady presented with a giant wing like structure on her back which started growing from her childhood. DIAGNOSIS: A diagnosis of NF-I was confirmed as she presented with multiple cutaneous nodules, multiple café-au-lait macules of different sizes, scoliosis deformity, and positive family history of neurofibroma. INTERVENTIONS: Surgical excision of tumor and multiple Z plasty reconstruction of the back was carried out. OUTCOMES: The excised neurofibroma weighed 6.7 kg containing thickened nerves, nerve roots, and circuitous vessels. The histopathological report confirmed plexiform and diffuse type cutaneous neurofibroma without any malignant transformation. Surgical excision and reconstruction with regular follow-up is an excellent choice of treatment for such a giant neurofibroma as in this case. LESSONS: NF-I is a genetic disease which could present as a giant cutaneous neurofibroma. One of the treatment options for giant neurofibromas causing deformity and physical disability is by surgical excision and histopathological examination with regular follow-up for NF-I recurrence.

Sentinel Node Mapping in Melanoma of the Back: SPECT/CT Helps Discriminate "True" and "False" in-Transit Lymph Nodes.

A 32-year-old man with melanoma on the right paramedian region of the lower back underwent lymphoscintigraphy for radioguided sentinel node (SN) biopsy. Planar imaging showed the presence of 2 sites of radioactivity accumulation corresponding to an axillary SN and to an "in-transit" SN, located on the right side of the upper trunk. A further "hot spot" placed on the left paramedian region of the lower back was identified by planar lymphoscintigraphy. This last finding could be mistaken for another "in-transit" SN, but SPECT/CT demonstrated it was actually a nonspecific radiopharmaceutical accumulation at the level of the right renal pelvis.

Reconstruction of the external auditory canal using the random flap technique and laser Doppler evaluation.

BACKGROUND: The external auditory canal is one of the most difficult sites to reconstruct after tumor resection. In general, fascia transplantation is used to reconstruct defects of the external auditory canal, but this method is associated with scar formation and prolonged wound healing. Scar tissue might cause stenosis in the external auditory canal and hypoacusis, and wound healing is further delayed by radiation and chemotherapy. OBJECTIVE: To examine the safety of a random flap for reconstruction of an external auditory canal based on blood flow evaluation using a laser Doppler system. METHODS: Ten healthy volunteers were enrolled in this study to compare blood flow in the face, back, and behind the ear using a laser Doppler system. Two cases of external auditory canal reconstruction are presented. RESULTS: Blood flow behind the ear was abundant compared with that in the back. Blood flow in the face was higher than that behind the ear or on the back. CONCLUSION: Blood flow in the random flap was easily evaluated using the laser Doppler method. Based on our findings, we propose the random flap to reconstruct the external auditory canal after tumor resection.

[Intrathoracic hibernoma]. / Intrathoracaal hibernoom.

BACKGROUND: A hibernoma is a rare, often asymptomatic benign tumour which usually develops in adults and resembles brown adipose tissue of foetal origin. They occur most often in the thigh. Intrathoracic hibernomas are rare and often discovered incidentally. Hibernomas can infiltrate to adjacent structures. CASE DESCRIPTION: A 29-year-old woman consulted her GP for left-sided thoracic pain. A chest X-ray showed scoliosis of the thoracic spine and a large mass. Further investigations showed a large intrathoracic soft tissue mass with compression of the right lung. Histological samples taken from an open biopsy confirmed the diagnosis of a hibernoma. CONCLUSION: For the correct diagnosis of a hibernoma, histopathological analysis is always necessary. Malignant transformation or metastases have not been described in the literature. Surgical excision of the tumour is always recommended and after complete excision the prognosis for patients is excellent.

Computed tomographic analysis of the quality of trunk muscles in asymptomatic and symptomatic lumbar discectomy patients.

BACKGROUND: No consensus exists on how rehabilitation programs for lumbar discectomy patients with persistent complaints after surgery should be composed. A better understanding of normal and abnormal postoperative trunk muscle condition might help direct the treatment goals. METHODS: A three-dimensional CT scan of the lumbar spine was obtained in 18 symptomatic and 18 asymptomatic patients who had undergone a lumbar discectomy 42 months to 83 months (median 63 months) previously. The psoas muscle (PS), the paraspinal muscle mass (PA) and the multifidus muscle (MF) were outlined at the L3, L4 and L5 level. Of these muscles, fat free Cross Sectional Area (CSA) and fat CSA were determined. CSA of the lumbar erector spinae (LES = longissimus thoracis + iliocostalis lumborum) was calculated by subtracting MF CSA from PA CSA. Mean muscle CSA of the left and right sides was calculated at each level. To normalize the data for interpersonal comparison, the mean CSA was divided by the CSA of the L3 vertebral body (mCSA = normalized fat-free muscle CSA; fCSA = normalized fat CSA). Differences in CSA between the pain group and the pain free group were examined using a General Linear Model (GLM). Three levels were examined to investigate the possible role of the level of operation. RESULTS: In lumbar discectomy patients with pain, the mCSA of the MF was significantly smaller than in pain-free subjects (p = 0.009) independently of the level. The mCSA of the LES was significantly smaller in pain patients, but only on the L3 slice (p = 0.018). No significant difference in mCSA of the PS was found between pain patients and pain-free patients (p = 0.462). The fCSA of the MF (p = 0.186) and of the LES (p = 0.256) were not significantly different between both populations. However, the fCSA of the PS was significantly larger in pain patients than in pain-free patients. (p = 0.012).The level of operation was never a significant factor. CONCLUSIONS: CT comparison of MF, LES and PS muscle condition between lumbar discectomy patients without pain and patients with protracted postoperative pain showed a smaller fat-free muscle CSA of the MF at all levels examined, a smaller fat- free muscle CSA of the LES at the L3 level, and more fat in the PS in patients with pain. The level of operation was not found to be of importance. The present results suggest a general lumbar muscle dysfunction in the pain group, in particular of the deep stabilizing muscle system.

Segmental acquisition method for stationary objects in (18)F-fluorodeoxyglucose positron emission tomography tests.

PURPOSE: We investigated whether images of stationary objects obtained by segmental acquisition with positron emission tomography using 2-deoxy-2-[(18)F]-fluoro-D: -glucose (FDG-PET) are of a quality equivalent to those obtained by conventional continuous acquisition. MATERIALS AND METHODS: Phantoms filled with FDG and mid-abdominal regions of 18 patients who underwent FDG-PET tests were imaged by both continuous and segmental acquisition methods. The total acquisition time was set to 3 min; in the segmental acquisition mode, imaging for 15 s was repeated 12 times. Segmental images (SIs) obtained by superimposition of the reconstructed images were compared quantitatively and visually with continuous images (CIs). RESULTS: In all the phantom and clinical studies, SIs were never worse than CIs. The variances of the background counts of SIs were 9.8% and 13.0% less those of CIs in phantom and clinical studies, respectively. Visual assessments showed that SIs provided better detection of hot areas and superior image quality when compared to CIs. CONCLUSION: For stationary objects, the quality of images obtained by the segmental method is equivalent to that of images obtained conventionally by continuous acquisition. Moreover, under some conditions SIs provide better results than CIs.

The effect of interspinous implant surgery on back surface shape and radiographic lumbar curvature.

BACKGROUND: Interspinous process implants, used to augment lumbar spine surgery, putatively induce a local segmental lumbar kyphosis yet few investigations outline the effect in vivo on thoracolumbar sagittal curvature. Changes in lumbar skeletal alignment and posture have traditionally relied upon radiographic and back surface spinal curvature measurements, respectively. METHODS: Lumbar lordosis curvature in 10 healthy subjects (6F, 4M; mean age 36 years) and 10 interspinous implant lumbar surgery patients (5F, 5M; mean age 51 years) was assessed with rasterstereography at baseline and at 6 weeks. Skeletal lumbar lordosis in standing was measured from lateral erect radiography pre- and 6 weeks post-operatively in the surgical cohort, and compared to angulation obtained for surface lordosis curvature derived from rasterstereography. FINDINGS: Repeatable measurement of standing lumbar lordosis from rasterstereographic back shape imaging in healthy volunteers and lumbar surgery cases was demonstrated. Reductions of 0.6 (NS) in healthy and 3.1 (significant, P<0.001) in surgical subjects were recorded for surface lumbar lordosis angle between the 6 week time-points. Slight flattening of the segmental angle and regional lordosis after DIAM surgery was revealed by radiography. Skeletal and surface lumbar lordosis changes were uncorrelated preoperatively (rho=0.28) and postoperatively (rho=0.26). INTERPRETATION: Rasterstereography is sensitive in assessing lumbar lordosis changes in healthy and lumbar surgical individuals over time. Surgery with DIAM for lumbar pathology may result in an initial mild flattening of lordosis. Serial investigations of spinal curvature after surgery with DIAM interspinous implant are warranted in order to better understand the time-course of spinal posture changes of such cases.

An unusual cause of low back pain: paravertebral muscle metastases of lung cancer.

Paravertebral muscle metastasis is an extremely rare cause of low back pain. Lipomas, haemangiomas, hibernomas and liposarcomas should be considered first in the aetiology of paravertebral muscle masses. Schwannoma, neurofibroma, ganglioneuroma and paraganglioneuromas that show contiguous spread should also be included in the differential diagnosis. Haematogenous metastases are most frequently caused by lung cancers. Lung cancers typically metastasize to liver, brain, bone, kidney, and adrenal glands. They rarely metastasize to skeletal muscles due to metabolism, high tissue pressure and blood flow of muscles. Our case was a 48-year-old male who had been smoking 40 cigarettes per day and presented to our clinic with low back pain and a mass in the lower back region. The mass in his lower back region was excised and histopathological examination confirmed metastasis of a neuroendocrine tumour. Further examinations revealed the lung as the primary source of the metastasis.

Comparative analysis of blood loss in suction-assisted lipoplasty and third-generation internal ultrasound-assisted lipoplasty.

BACKGROUND: Lipoplasty remains the most common cosmetic surgical procedure performed in the United States. In spite of its well documented clinical advantages, ultrasound-assisted lipoplasty (UAL) accounts for less than 20% of all lipoplasty procedures currently performed. OBJECTIVE: The purpose of this study is to determine the blood content of third-generation internal UAL aspirate and compare it to traditional lipoplasty aspirate. METHODS: The lipoplasty aspirate of 27 consecutive patients who underwent traditional suction-assisted lipoplasty (SAL) of their back and posterior flanks was compared to the aspirate of 30 consecutive patients who underwent third-generation internal UAL of their backs and posterior flanks using the VASER Internal Ultrasound Device (Sound Surgical Technologies; Louisville, CO). The volume and composition of the wetting solution used was the same for both groups. The aspirate analysis was performed by an independent laboratory on a Beckman Coulter LH 750 blood analyzer (Fullerton, CA) and consisted of complete blood counts after separation of the fat. RESULTS: The hemoglobin content of SAL aspirate was 7.5 times greater than in the aspirate. The hematocrit value of SAL aspirate was 6.5 times greater than in the VASER-assisted lipoplasty aspirate. Statistical analysis using an independent t test confirmed that the data was statistically significant with P values of < .0001 for both hemoglobin content and hematocrit values. CONCLUSIONS: We conclude that third-generation internal UAL should be considered for patients undergoing large-volume lipoplasty procedures or lipoplasty of tight, fibrous areas, such as the back and posterior flanks, where increased blood loss is expected.

Lesions arising in or involving the iliopsoas groove.

The purpose of this pictorial essay was to aid in the understanding of the anatomy of the iliopsoas groove by presenting imaging of various lesions affecting this region. Neurogenic tumors, lymphangiomas, lymphangioleiomyomatosis, and posterior iliac crest lymph node metastases may present as masses in the iliopsoas groove. Iliopsoas abscess secondary to infections of the adjacent structures, tumors of the iliopsoas muscle, and iliopsoas hematomas may directly extend to this region.

F-18 FDG uptake associated with Elastofibroma dorsi.

A patient with a history of colon carcinoma and computed tomography (CT) evidence suggestive of a liver metastasis underwent an F-18 FDG PET scan. The PET scan confirmed a metastasis in the left lobe of the liver. The study also demonstrated bilateral symmetric uptake involving the inferior subscapular regions. Correlation with the previous CT showed this to correspond to bilateral elastofibroma dorsi, which had been prospectively reported on the CT. Elastofibroma dorsi is a rare benign mass consisting of fibroelastic tissue and fat. It has been previously described on PET, CT, ultrasound, and magnetic resonance imaging (MRI). On CT, the masses are of soft tissue density, similar to adjacent musculature, and may contain linear areas of low density secondary to fat. On MRI, elastofibroma dorsi has been shown to have variable enhancement, which may reflect increased vascularity of the lesion. In this case, the masses demonstrated low-grade diffuse F-18 FDG uptake.

Incidental detection of pigmented villonodular synovitis on FDG PET.

18 Fluorine fluorodeoxyglucose (FDG) has been used extensively in positron emission tomographic (PET) imaging for oncology. FDG is a glucose analog demonstrating enhanced uptake in the majority of malignant as well as granulomatous lesions. Although a few cases of pigmented villonodular synovitis using bone scanning agents Tl-201 chloride, Ga-67 citrate, and Tc-99m pentavalent dimercaptosuccinic acid have been published, to our knowledge FDG PET imaging of pigmented villonodular synovitis has not.

Direct electrophilic radiofluorination of a cyclic RGD peptide for in vivo alpha(v)beta3 integrin related tumor imaging.

The association of the alpha(v)beta(3) integrin with tumor metastasis and tumor related angiogenesis has been suggested. Therefore, by imaging the alpha(v)beta(3) receptor with PET, information concerning the tumor status could be obtained. Cyclic peptides including the RGD sequence, were radiolabeled by direct electrophilic fluorination with [(18)F]AcOF. In tumor-bearing mice, the labeled peptides accumulated at the tumor with a high tumor to blood ratio. These findings suggest that an assessment of tumor characteristics may be obtained by using these (18)F-labeled peptides.

Subcutaneous fat layer in different donor regions used for harvesting microvascular soft tissue flaps in slender and adipose patients.

The aim of this study is to provide valid data concerning the thickness of the subcutaneous fat layer in seven donor regions which are most commonly used for soft tissue replacement in the head and neck region. Furthermore the study focuses on differences in thickness of this layer depending on the nutritional status and sex. In 100 volunteers the thickness of the subcutaneous fat layer was evaluated using ultrasound in seven potential donor regions: radial and ulnar forearm, lateral upper arm, scapular and parascapular region, abdominal/supra-umbilical region and the lateral calf. Volunteers were divided into 4 groups: male and female, slender (body mass index [BMI] < 25) and adipose (BMI > 30). Data obtained was compared and differences were proven to be statistically significant (Student's t-test, P<0.05). The largest thickness was found in the supra-umbilical region followed by the lateral upper arm whereas the ulnar forearm region had the smallest thickness. Depending on the BMI the supra-umbilical and the lateral upper arm regions showed the most wide variation. Depending on sex the most noticeable variation in thickness of the subcutaneous layer was seen in the lateral calf region with a significant larger tissue layer in females.