Asymptomatic Patient With Incarcerated Gravid Uterus Diagnosed in the Third Trimester: A Case Report of a Rare Potential Obstetric Emergency.

Incarcerated gravid uterus (IGU) is a rare condition that occurs when a retropositioned gravid uterus becomes entrapped within the pelvic cavity. Most patients present around the 17th week of pregnancy with symptoms such as pelvic fullness, urinary incontinence, abdominal pain, constipation, and vaginal bleeding. Rarely, patients are asymptomatic throughout pregnancy, leaving IGU undiagnosed and untreated. Here, we present an asymptomatic 26-year-old female who presented at 30 weeks of gestation with severe intrauterine growth retardation (IUGR) on serial obstetric ultrasounds. Further evaluation with ultrasound and MRI revealed an incarcerated uterus. This was complicated by severe fetal IUGR, abnormal biophysical profile, and oligohydramnios. This case highlights the importance of early diagnosis and treatment of IGU in order to prevent complications associated with the condition. Clinicians should be aware that, although uncommon, patients with IGU may be asymptomatic and that diagnosis should depend primarily on imaging findings rather than symptoms.

Incidence and Fusion of Os Trigonum in a Healthy Pediatric Population.

BACKGROUND: Accessory ossicles off the talus (os trigonum) are a common radiographic finding seen within the foot with variable symptomatology in adult and pediatric patients. Although most studies have examined the incidence of these anatomic variants in a retrospective manner, few have longitudinally followed the behavior of os trigonum over time. The aim of this study was to investigate the incidence, mean age of appearance and fusion, and fusion rate of os trigonum in a large cohort of asymptomatic pediatric patients. METHODS: A total of 2620 serial digitized unilateral foot and ankle radiographs from 261 healthy white children (age range, 0.25 to 7 y at enrollment) were retrospectively reviewed. Radiographs were examined to determine the incidence of os trigonum, noting age of appearance and if present, the age of fusion. Skeletal maturity was graded based on ossification pattern of the calcaneal apophysis. RESULTS: Radiographic evidence of os trigonum was present in 18% of patients (n=16 females, n=15 males) with radiographs extending 1 SD beyond the average age of os trigonum appearance. There was no difference in incidence between females and males (P=0.27), and os trigonum was found to appear at a significantly younger age in females (9.1±1.8 y) than males (10.4±2.0 y, P=0.04). Overall, 70% (n=26) of subjects with os trigonum achieved fusion by age 17 (mean, 9.5±1.6 y in females, 11.2±1.6 in males) with no significant difference between sexes (P=0.61). Grading of skeletal maturity at the time of fusion showed that both male and female subjects underwent fusion on average between calcaneal stages 2 and 3 (P=0.5). CONCLUSIONS: This study confirms a relatively large prevalence of os trigonum in a random pediatric population, and clarifies both the average age of onset and high rate of fusion at a relatively narrow range of skeletal maturity. LEVEL OF EVIDENCE: Prognostic level II-retrospective study.

A Cadaveric Analysis of the Optimal Radiographic Angle for Evaluating Trochlear Depth.

Disorders of the patellofemoral joint are common. Diagnosis and management often involves the use tangential imaging of the patella and trochlear grove, with the sunrise projection being the most common. However, imaging protocols vary between institutions, and limited data exist to determine which radiographic projections provide optimal visualization of the trochlear groove at its deepest point. Plain radiographs of 48 cadaveric femora were taken at various beam-femur angles and the maximum trochlear depth was measured; a tilt-board apparatus was used to elevate the femur in 5-degree increments between 40 and 75 degrees. A corollary experiment was undertaken to investigate beam-femur angles osteologically: digital representations of each bone were created with a MicroScribe digitizer, and trochlear depth was measured on all specimens at beam-femur angles from 0 to 75 degrees. The results of the radiographic and digitizer experiments showed that the maximum trochlear grove depth occurred at a beam-femur angle of 50 degrees. These results suggest that the optimal beam-femur angle for visualizing maximum trochlear depth is 50 degrees. This is significantly lower than the beam-femur angle of 90 degrees typically used in the sunrise projection. Clinicians evaluating trochlear depth on sunrise projections may be underestimating maximal depth and evaluating a nonarticulating portion of the femur.

Brain metastasis from gastrointestinal clear cell sarcoma.

Clear cell sarcoma (CCS) of the gastrointestinal tract presents a diagnostic challenge to the pathologist due to its morphological and immunohistochemical similarity to melanoma. It usually metastasizes to regional lymph nodes, liver, and lungs. Herein, we report the first known metastasis of a gastrointestinal CCS to the central nervous system. Cytogenetic testing showed the t(12,22) translocation corresponding to the presence of the EWS/ATF1 hybrid consistent with CCS. The literature that compares melanoma to CCS is reviewed in the context of this rare presentation to differentiate between the two diseases.
.

Longitudinal radiographic behavior of accessory navicular in pediatric patients.

BACKGROUND: An accessory navicular is generally asymptomatic and discovered incidentally on radiographs. The natural history of an accessory navicular in the pediatric population is largely undescribed. METHODS: The medical charts of 261 pediatric subjects undergoing 2620 annual unilateral radiographs of the foot and ankle (age range 0.25-7 years at enrollment) were reviewed. Radiographs were examined to determine the incidence of accessory navicular, with focus on the age at appearance and, if present, the age at fusion. Skeletal maturity was graded based on ossification pattern of the calcaneal apophysis. RESULTS: Accessory navicular was identified in 19 subjects (n = 12 males, n = 7 females, p = 0.43), appearing significantly earlier in the female subjects than in the male ones (p = 0.03). Fusion was documented in 42% (n = 8) of subjects, occurring at a mean (±standard deviation) age of 12.5 ± 1.0 years in females and 14.1 ± 2.7 years in males. Skeletal maturity grading demonstrated comparable stages of maturity at the time of fusion between male and female subjects (p = 0.5). Based on an analysis of 160 subjects with serial images extending at least one standard deviation past the mean age of appearance, the overall incidence was 12%. CONCLUSION: Our review of pediatric subjects showed that accessory navicular appeared earlier in females than in males. Fusion occurred in 42% of patients at comparable levels of skeletal maturity between the male and female subjects. No significant differences in overall incidence, skeletal maturity, fusion rate, or age of fusion were noted between the male and female subjects.

Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma.

The diagnosis of a tumor-to-tumor metastasis in the central nervous system most commonly involves metastasis to a meningioma. These combined lesions are often radiographically unsuspected and mimic a meningioma. Most commonly, the source of metastatic disease are carcinomas from the lung and breast. To our knowledge, fewer than a half dozen cases of metastatic prostatic adenocarcinoma to a meningioma have been documented in the literature. This report documents a 67-year-old man who presented with worsening confusion and altered mental status, accompanied by symptoms of increased urinary frequency, incontinence, and difficulty urinating. Imaging revealed a mass at the base of the bladder and an intracranial lesion, surrounded by edema, which was initially suspicious for intracranial metastasis of prostate cancer. Due to worsening neurological symptoms, the patient underwent craniotomy to remove the intracranial mass. The mass was comprised of a meningothelial meningioma, World Health Organization Grade I, accompanied by atypical epithelioid cells which demonstrated immunoreactivity to prostate specific antigen, chromogranin and neuron specific enolase antibodies, consistent with a metastatic prostatic adenocarcinoma with neuroendocrine differentiation. The patient suffered severe neurological complications post-operatively, developed multiple metastases and expired 12months later. The report reviews current theories as to why meningiomas are the most common host tumor for tumor-to-tumor metastases in the brain and reviews the literature on previously reported cases involving metastatic prostatic adenocarcinoma.

Peripheral nerve sheath tumors arising in salivary glands: A clinicopathologic study.

Primary salivary gland peripheral nerve sheath tumors (PNST) are uncommon. This study is a retrospective, clinicopathologic review of 9 cases of PNST (5 neurofibromas, 3 schwannomas and 1 malignant peripheral nerve sheath tumor (MPNST)) arising from the salivary glands, encountered between 1990 and 2015. All patients with neurofibromas were male (ages 1-62 years) and had a single parotid lesion of which 2 were diffuse, 2 plexiform and one mixed diffuse/plexiform. Four had a history of neurofibromatosis I. Four of 5 presented with symptoms related to mass effect including facial swelling, facial drooping, and dysphagia. All underwent de-bulking surgery and recurred due to continued growth. Of the 3 patients with schwannomas, 1 was male and 2 were female (ages 19, 44 and 56 years). One tumor each arose in the sublingual, submandibular, and parotid glands. Two of 3 presented with soreness and swelling local to the affected gland, especially while chewing. There was no recurrence of these tumors after resection. An MPNST in a male presented as a tender mass in the patient's left parotid; the tumor was resected. There was no evidence of tumor elsewhere in the body. The tumor did not recur in 12 years of follow-up. The most common tumor type in the current series was neurofibroma; most arose in the background of neurofibromatosis type I and all of which recurred after initial subtotal resection. Most PNST arose in the parotid gland.