Ciliary body malignant melanoma: A dilemma on staging / Melanoma maligno do corpo ciliar: um dilema no faseamento

Abstract Choroidal melanomas are the most common primary intraocular malignant tumor in adults. They tend to be more malignant; because of their location hidden behind the iris they can not be detected until they become larger. Therapeutic strategy is related by size, extension, number and location of tumor and growth patterns. High frequency ultrasound biomicroscopy (UBM) gives high resolution, cross-sectional images of the anterior segment lesions. Postequatorial lesions and intracranial extension of the melanomas are scanned by magnetic resonance imaging (MRI). We report a case of bilobed tumor with confusing appereance in preoperative imaging studies and macroscopy following enucleation. MRI is the perfect imaging method to reveal extension and size of the tumor in the posterior chamber. Combined use of UBM and MRI provides appropriate staging of ocular melanomas.

Resumo Melanomas coroidais são os tumores malignos intra-oculares primários mais comuns em adultos. Eles tendem a ser mais malignos; devido à sua localização ser escondida por detrás da íris eles não podem ser detectados até se tornarem maiores. A estratégia terapêutica está relacionada com tamanho, extensão, número e localização dos padrões tumorais e de crescimento. O biomicroscopio ultra-sónico de alta frequência (BMU) fornece imagens transversais de alta resolução das lesões do segmento anterior. Lesões pós-equatoriais e de extensão intracraniana dos melanomas são digitalizadas em ressonância magnética (RM). Relatamos um caso de tumor com dois lóbulos, com aparência confusa em exames de imagem pré-operatórios e macroscopia após enucleação. A RM é o método de imagem perfeito para revelar a extensão e o tamanho do tumor na câmara posterior. O uso combinado de BMU e MRI fornece o faseamento apropriado dos melanomas oculares.

Unilateral cervical and petrosal segment agenesis of the internal carotid artery with rete mirabile.

The carotid rete mirabile (RM) is a physiological network between the internal and external carotid arterial systems. In this paper, an extremely rare case is presented, in which internal-external carotid artery anastomoses and a dilated ascending pharyngeal artery, due to unilateral agenesis of the cervical and petrous segments of the internal carotid artery (ICA), is presented.

The Vertebral Artery Convergence to the Cervical Spine in Elders.

BACKGROUND: In the older population, tortuosity of the vertebral artery (VA), uncovertebral joint (UVJ) osteoarthritis, and abnormal vertebral alignment may alter the normal anatomy. AIM: We aimed to determine the anatomical variations and relationships between the cervical segment of the VA and the cervical spine with regard to ageing. MATERIALS AND METHODS: In this retrospective cross-sectional study, the computed tomography angiography scans of 110 subjects were reviewed. Any variations in the VA, UVJ degeneration were identified. The distance between the VA and uncinate process (UP) was measured electronically. The distance between the VA and UP were compared according to the age group (group A < 45, group B = 45-65, and group C > 65 years-old). RESULTS: With regard to the transverse foramen, 7.2% of the cases had entering abnormalities of the VA, while in one case (0.83%), the right VA had an exiting abnormality (exiting from the C2 instead of the C1). UVJ degeneration was found to be significantly higher in the older age group (p < 0.05). Furthermore, at the C4-C7 levels, the distances between the VA and UP were significantly smaller in the older age group (p < 0.01). CONCLUSIONS: The VA-UP distance has been shown to decrease due to increasing UVJ osteoarthritis in the elderly. The convergence of the VA toward the spine occurs at the most mobile segment of the cervical spine, and this anatomical alteration may predispose temporary and/or permanent vertebral artery occlusion clinically, and be dangerous during cervical spine surgery.

Diffusion-weighted magnetic resonance imaging in the assessment of choroid plexus aging.

Recent studies have pointed out dysfunction and histopathological changes of the choroid plexuses (CPs) with aging. This paper reviews apparent diffusion coefficient (ADC) values of the CPs for age-related changes. All the brain MR images of the patients between January 2013 and June 2014 in our Radiology Department were retrospectively investigated. Patients with major cranial abnormalities (brain tumors, hyperacute or acute ischemia, developmental anomalies, hemorrhage, hydrocephaly) were excluded. Diffusion-weighted images were obtained at the parameter values of b = 1000 s/mm2 in the axial plane. The transverse diameters of the lateral ventricles (LVs) and ADC values of both CPs were measured. Brain MRIs of 202 individuals, 97 men (48%), 105 women (52%), were studied. There were statistically significant positive correlations between the ADC values of CP and patient ages. (Right CP: r = 0.623; p < 0.05. Left CP: r = 0.654; p < 0.05). There were positive correlations between LV diameters and age ( r = 0.624, p < 0.05 for the right LV; r = 0.621, p < 0.05 for the left LV). The ADC values of age groups significantly differed ( p < 0.05); the ≥61-year-old group was significantly higher compared to younger individuals. There is a progressive increase of water diffusivity in the CPs during aging. ADC values should be considered as a neuroimaging quantitative biomarker in normal aging-dementia syndromes.

Right Liver Lobe Hypoplasia and Related Abnormalities.

BACKGROUND: Hypoplasia and agenesis of the liver lobe is a rare abnormality. It is associated with biliary system abnormalities, high location of the right kidney, and right colon interposition. These patients are prone to gallstones, portal hypertension and possible surgical complications because of anatomical disturbance. CASE REPORT: Magnetic resonance imaging features of a rare case of hypoplasia of the right lobe of the liver in a sigmoid cancer patient are presented. CONCLUSIONS: Hypoplasia of the right liver should not be confused with liver atrophy; indeed, associations with other coexistent abnormalities are also possible. Awareness and familiarity with these anomalies are necessary to avoid fatal surgical and interventional complications.

Age-related morphologic changes of the vertebral artery in the transverse process. Analysis by multidetector computed tomography angiography.

BACKGROUND CONTEXT: The V2 segment of the vertebral artery (VA) ascends and passes through the transverse foramen (TF) of the C6-C1 vertebrae. Atherosclerosis of the VA and degenerative changes in the cervical spine are likely to occur with aging, and subsequent morphologic changes may alter the normal anatomy. PURPOSE: The aim was to determine the morphologic changes of TF and VA in relation to aging. STUDY DESIGN/SETTING: This was a retrospective cross-sectional study. PATIENT SAMPLE: One hundred ten consecutive patients who had undergone computed tomography angiography were included. METHODS: The subjects were then divided into three groups according to age: Group A, less than 45 years; Group B, from 45 to 65 years; and Group C, older than 65 years. Cases with stenosis and dissection of the VA were excluded from the quantitative analysis. The areas of the VA and TF were measured, and the VA/TF occupation ratio (OR) was calculated accordingly. The presence of VAs tortuosity within the TF was also noted. RESULTS: The TF was larger in the oldest group, but the difference was not statistically significant. There was also no significant statistical difference among the age groups in terms of the VA and VA/TF ORs (p>.05). In the Group C, the rate of overall tortuosity of the VA was 73%, and arterial tortuosity in the TF was 28.6%. In cases with tortuous VA, C6 and C4 TFs were found to be significantly larger. CONCLUSIONS: Tortuous VAs tend to be associated with enlargement of C6 and C4 TFs. Knowledge of such changes in the anatomy is crucial during instrumentation used for cervical spine surgeries, to prevent serious complications in patients aged older than 65 years.

Polysplenia syndrome detected after chest symptoms in two adult patients: case report and review of literature.

BACKGROUND: Polisplenia syndrome (PSS) is a rare subtype of heterotaxy syndrome and means ambiguous location of the major thoracic and abdominal organs with vascular anomalies and multiple spleens. We reported on the findings of computed tomography (CT) of PSS in adults, detected incidentally. CASE REPORT: Two woman underwent a CT examination of the thorax for different thoracic pathologies. There were common abnormalities such as hyparterial bronchi and absence of middle lobe fissure on CTscans suggesting heterotaxy syndrome. Therefore, the abdominal CTs were performed to detect the accompanying abdominal anomalies. Our two cases defined as PSS were diagnosed with multiple spleens in the normal location in the abdomen. The left-dominant liver and short pancreas with agenesis of the pancreatic tail and lateral part of the body were detected on CT scan. In the first case, the vascular abnormalities were as follows: variant entrance of the main portal vein into the liver and atypically located superior mesenteric vein (SMV) joining with the splenic vein to form the portal vein. In the second case, the preduodenal portal vein and hemiazygos continuation with interruption of the hepatic segment of the inferior vena cava (IVC) were the vascular anomalies. The bowels were malrotated in the second case. CONCLUSIONS: Although such cases are usually admitted as abdominal emergency, our two cases were detected during examinations for thoracic and cardiac pathologies. The knowledge and awareness of PSS can be helpful to diagnose pathology and plan surgical procedures.

The subpubic angle in sex determination: anthropometric measurements and analyses on Anatolian Caucasians using multidetector computed tomography datasets.

INTRODUCTION AND AIM: The investigation of new anatomical criteria and revalidation of existing ones in sex determination for different populations are among main research foci of forensic anthropometry. In that context, the pelvis is the most extensively studied bone. A number of qualitative classifications, dimensional measurements and indices have been proposed for investigative anthropometry and forensic studies. Independent use of these parameters generally provided an accuracy rate of 70-75%. In this study, the accuracy rate of the subpubic angle in sex determination was investigated in living Anatolian Caucasians. MATERIAL AND METHOD: The subpubic angle was identified and measured on three-dimensional computed tomographic images of pelves. Data were obtained using 64-detector computed tomography (MDCT) with an isotrophic resolution of 500 µm. The sample included 66 males (41.6 ± 14.9 years of age) and 43 females (41.1 ± 14.2 years of age). Measurements were taken on a dedicated three-dimensional image analysis workstation. The subpubic angle was electronically measured. The technique and methodology was validated on a standard skeletal model. Intraobserver agreement was analyzed with intraclass correlation coefficient, and intraobserver variability was evaluated with technical error of measurement (inter- and intra-observer TEM), relative technical error of measurement (rTEM) and coefficient of reliability (R) measures. The subpubic angle for the study group and for both sexes was reported as minimum-maximum (mean ± SD). Independent-Samples T Test for equality of means was used to determine the difference between the two sexes regarding the subpubic angle. The correlation between the subpubic angle and the age of subjects were using Pearson Correlation Coefficients in males and in females. Logistic regression model was used to classify subjects according to their sex. Receiver operating characteristic curve analysis was performed to determine a cut-off value for further studies and to test the performance of the binary classification test. RESULTS: Intraclass correlation for the subpubic angle (0.990), TEM (1082), rTEM (1.492), and R (0.990) represented almost complete reliability and accuracy of the measurement method. The subpubic angle was between 48° and 81° (65.9° ± 7.2°) in males and was between 64° and 100° (82.6° ± 7.7°) in females. Statistically significant difference was found between males and females regarding the subpubic angle (p < 0.0001). The subpubic angle was not significantly correlated with age in males (p = 0.953), or in females (r = 0.975). The accuracy of the subpubic angle in sex determination was 90.8%. With a cut-off value of 74°, sensitivity of subpubic angle to detect female phenotype was 88% and its specificity was 95%. CONCLUSION: The subpubic angle is an accurate parameter in sex determination with high sensitivity and specificity.

Utility of semiquantitative parameters to differentiate benign and malignant focal hepatic lesions.

OBJECTIVE: Any distinction and the usefulness of semiquantitative parameters derived from dynamic-contrast-enhanced (DCE) MRI obtained with extracellular gadolinium contrast agent in hemangiomas, hepatocellular carcinomas (HCC) and metastases of the liver was studied prospectively. METHODS: Seventy-four focal liver lesions (consisted of 34 hemangiomas, 23 HCC, and 17 metastases) of the 37 patients underwent DCE-MRI (six phases). Functional coloured maps and subsequently semiquantitative parameters were obtained using the FuncTool. Maximum and average (avg) values of mean time to enhancement (MTE), positive enhancement integral (PEI), time to peak (TP), maximum slope of increase (MSI), maximum slope of decrease (MSD) values were measured by placing the region of interest. The diagnosis of HCC and metastases were proven histopathologically and/or clinically. RESULTS: The mean values of the paremeters were: In hemangiomas, avgMTE: 271.2 ± 4.7; avgPEI: 840.3 ± 77.3; avgTP: 146.6 ± 13.1; avgMSI: 999.1 ± 108.4; avgMSD: 254.1 ± 30.4. In HCC, avgMTE: 246 ± 3.6; avgPEI: 424.9 ± 31.6; avgTP: 132.8 ± 9.5; avgMSI: 484.1 ± 36.5; avgMSD: 109.1 ± 13.3. In metastases, avgMTE: 248.1 ± 8.2, avgPEI: 453.9 ± 39.6; avgTP: 142.8 ± 13.9; avgMSI: 472.6 ± 50.4 and avg MSD: 200.1 ± 38.2. Both maximum and avg values of MTE, PEI, MSI, and MSD were significantly higher in hemangiomas (P<.05). The most significant difference was found in avgPEI with 82.1% sensitivity and 67.6% specificity when 570 cutoff value was considered. The values however were not significantly different among HCC and metastases (P>.05). CONCLUSIONS: Semiquantitative DCE-MRI parameters provide useful, complementary, and quantitative information. This technique increases diagnostic value of extracellular gadolinium contrast agent to characterize focal liver lesions and may be useful for follow-up after local-regional therapies.

Magnetic resonance imaging predictors of surgical outcome in degenerative lumbar spinal stenosis.

PURPOSE: To identify any MRI predictors for surgical outcomes of patients with degenerative lumbar spinal stenosis (DLSS) having instrumented posterior decompression (IPD) surgery. MATERIALS AND METHODS: Seventy patients with DLSS who underwent IPD were reviewed retrospectively. The clinical score of each patient was assessed using the JOAS (Japanese Orthopedics Association Scoring) system, which is mainly based on the subjective symptoms and physical signs of the patients before (JOAS-I) and after (JOAS-II) surgery. Healing rate (HR) was calculated as: [(JOAS-II) - (JOAS-I)] × 100/[15 - (JOAS-I)]. HR >50 % was considered clinical improvement. Radiological stenosis was assessed on MRI and was graded from 0 to 3 at the laminectomy level in terms of thecal sac-nerve root compression, foraminal stenosis, and facet degeneration. RESULTS: Mean HR of the improved patients (n = 39) was 81.94; HR of the unimproved patients (n = 31) was 34.75 (p < 0.05). There was no statistical difference in radiological stenosis parameters between the two groups (p > 0.05). HR was worse in patients with severe facet degeneration. CONCLUSIONS: Surgical outcomes of DLSS depend on multiple variables. It is not possible to predict the outcomes by assessing only one parameter. The possible outcomes should be analyzed by considering all the factors individually.

Gastrointestinal stromal tumor mimicking gynecological mass: A case report.

► GISTs do not have a unique appearance on ultrasound examination. ► If a pelvic mass is detected, the possibility of a non-gynecological tumor like GISTs has to be considered.

Total body height estimation using sacrum height in Anatolian Caucasians: multidetector computed tomography-based virtual anthropometry.

OBJECTIVE: Estimation of total body height is a major step when a subject has to be identified from his/her skeletal structures. In the presence of decomposed skeletons and missing bones, estimation is usually based on regression equation for intact long bones. If these bones are fragmented or missing, alternative structures must be used. In this study, the value of sacrum height (SH) in total body height (TBH) estimation was investigated in a contemporary population of adult Anatolian Caucasians. MATERIALS AND METHODS: Sixty-six men (41.6 ± 14.9 years) and 43 women (41.1 ± 14.2 years) were scanned with 64-row multidetector computed tomography (MDCT) to obtain high-resolution anthropometric data. SH of midsagittal sections was electronically measured. The technique and methodology were validated on a standard skeletal model. RESULTS: Sacrum height was 111.2 ± 12.6 mm (77-138 mm) in men and 104.7 ± 8.2 (89-125 mm) in women. The difference between the two sexes regarding SH was significant (p < 0.0001). SH did not significantly correlate with age in men, whereas the correlation was significant in women (p < 0.03). The correlation between SH and the stature was significant in men (r = 0.427, p < 0.0001) and was insignificant in women. For men the regression equation was [Formula: see text] (r = 0.54, SEE = 56.9, p < 0.0001). CONCLUSION: Sacrum height is not susceptible to sex, or to age in men. In the presence of incomplete male skeletons, SH helps to determine the stature. This study is also one of the initial applications of MDCT in virtual anthropometric research.

The morphometric analysis of crista phallica in identification of sexes / El análisis morfométrico de cresta fálica en la identificación de los sexos

Crista phallica (CP) is used to determine sex in anthropology and criminal forensic medicine; however, it does not exist in anatomic and radiological terminology. The purpose of this retrospective study is morphometric analysis of the CP. We studied radiographs displaying several different clinical indications from patients whose bone maturation were fully complete. The crista phallica located on both sides of the medial portion of ischiopubic ramus (IPR) were localized and their peak points were determined. The distance from these peak points to the inner cortex of IPRs were measured, as well as the angles between the tangents passing the peak points from both sides. We determined the distance of the IPR (DIPR) for males and females sequentially as 21.3 +/- 3.5 mm, and 17 +/-2.8 mm, angle of CP (ACP) as 149.1 +/-15.7, and 163.5 +/-13.4. It was identified that ACP for females is less than ACP for males (p<0.001). ACP and DIPR alone are not sufficient criteria to determine sex. Therefore, the results of our findings show that it would be more useful to study other specifications and their metric analysis in order to determine sex.

La cresta fálica (Crista phallica, CP) se utiliza para determinación de sexo en antropología y la medicina forense, sin embargo, no existe en la terminología anatómica y radiológica. El objetivo de este estudio retrospectivo es el análisis morfométrico de la CP. Estudiamos radiografías que muestran varias indicaciones clínicas diferentes de pacientes cuya maduración ósea fue totalmente completa. La cresta fálica se situó a ambos lados de la porción medial de la rama isquio-pubiana (RIP), donde su localización y sus puntos más altos fueron determinados. La distancia desde estos puntos más altos a la corteza interna de la RIP fueron medidos, así como los ángulos entre las tangentes que pasaron por los puntos más altos de ambos lados. Se determinó la distancia de la RIP (DRIP) para hombres y mujeres de forma secuencial como 21,3 +/- 3,5 mm, y 17 +/- 2,8 mm, ángulo de la CP (ACP) como 149,1 +/- 15,7 y 163,5 +/- 13,4. Se identificó que los ACP para mujeres fueron menores que las ACP para los hombres (p <0,001). ACP y DRIP por sí solas no son criterios suficientes para determinar el sexo. Por lo tanto, los resultados de nuestros hallazgos muestran que sería más útil para estudiar otras especificaciones y sus análisis métricos a fin de determinar el sexo.

Bilateral anterior inferior iliac spine avulsion in an adolescent soccer player: a typical imitator of malignant bone lesions.

Avulsion fractures are usually diagnosed easily in acutely presented cases. The diagnosis becomes definite if clinical and radiological follow up reflect the fracture's healing phase. A 13-year-old soccer player with bilateral anterior inferior iliac spine (AIIS) avulsion, who had been examined in other institutions with a prediagnosis of malignancy, is reported. Clinically, such cases display the importance of medical management of athletic injuries by specially trained physicians. From the perspective of preventive medicine, the high incidence of AIIS injuries during soccer games, and the bilateral nature of the damage mandate a review of the training programs and shooting techniques for adolescent players.

Absence of infrarenal inferior vena cava is not a congenital abnormality.

The absence of inferior vena cava (IVC) is one among infrequent subtypes of IVC abnormalities that are rarely seen in general population. The absence of IVC involves either that of entire IVC or that of infrarenal segment. These two entities are relatively similar but their etiopathogeneses are still controversial. The absence of the entire IVC is thought to be a result of an embryologic disorder, whereas perinatal thrombosis is hypothesised to lead to the development of absent infrarenal IVC, thus the latter is a developmental disorder and the former occurs due to embryologic disorder. We report an adult man with renal-infrarenal absence of IVC, as well as missing common iliac veins. He clinically presented with extensive varicose collateral circulation on the thoracoabdominal wall, right varicocele and severe varices on lower limbs. Calcifications of adrenal glands indicate a hematologic disorder during perinatal period. The etiopathogenesis of this unusual abnormality is emphasized in this case report (Fig. 5, Ref. 10). Full Text (Free, PDF) www.bmj.sk.

Spinal leptomeningeal metastasis in a patient with squamous cell lung cancer.

Spinal leptomeningeal metastasis occurs rarely in solid tumors, and the prognosis is extremely poor. Adenocarcinomas and small-cell carcinomas are the most common histological type detected among lung tumors. A 58-year-old man with a history of squamous-cell lung carcinoma with mediastinal invasion and brain metastasis was examined because of his low back pain and weakness in both lower limbs. Spinal MRI revealed subpial enhancement in the spinal cord; and innumerable nodules with thickening of the cauda equina fibres. To our knowledge, this is the second reported case of squamous cell lung cancer with spinal leptomeningeal metastasis.