CT and 18FDG-PET/CT findings in progressive mediastinal idiopathic fibrosis as a benign mimicker of esophageal carcinoma: a case report.

Idiopathic mediastinal fibrosis, also called sclerosing or fibrosing mediastinitis, is a very rare and aggressive fibroinflammatory process characterized by fibrous tissue proliferation in the mediastinal region. Herein, we present a rare case of idiopathic mediastinal fibrosis presenting with esophageal obstruction, most likely associated with immunoglobulin G (IgG4)-related disease, affecting the posterior mediastinum with intrapulmonary infiltration. Computed tomography revealed a narrowed lumen and thickened wall of the distal esophagus surrounded by a necrotic mass with infiltration into the nearby structures, suggesting a locally advanced malignant process. Positron emission tomography revealed intense accumulation of 18F-fluorodeoxyglucose, indicating an active inflammatory component, which complicates further differential diagnosis of mediastinal masses. Thoracoscopic biopsy and immunohistochemical analysis confirmed a fibroinflammatory process with perivascular lymphoid cell infiltration that was cluster of differentiation (CD)3 (++) and CD20 (++), with massive numbers of IgG4-immunoreactive plasma cells. Although a benign condition, sclerosing mediastinitis is a close mimicker of esophageal carcinoma, which cannot be differentiated by computed tomography or positron emission tomography and must be considered in a differential diagnosis.

MRI Tumor Regression Grade Combined with T2-Weighted Volumetry May Predict Histopathological Response in Locally Advanced Rectal Cancer following Neoadjuvant Chemoradiotherapy-A New Scoring System Proposal.

Modern studies focus on the discovery of innovative methods to improve the value of post-treatment magnetic resonance imaging (MRI) in the prediction of pathological responses to preoperative neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC). The aim of this study was to assess the potential benefits of combining magnetic resonance tumor regression grade (mrTRG) with T2-weighted volumetry in the prediction of pathological responses to nCRT in LARC. This was a cohort study conducted on patients with histopathologically confirmed LARC in a period from 2020 to 2022. After histopathological verification, all patients underwent initial MRI studies, while the follow-up MRI was performed after nCRT. Tumor characteristics, MRI estimated tumor regression grade (mrTRG) and tumor volumetry were evaluated both initially and at follow-up. All patients were classified into responders and non-responders according to pathological tumor regression grade (pTRG) and mrTRG. A total of 71 patients, mostly male (66.2%) were included in the study. The median tumor volume reduction rate was significantly higher in nCRT-responders compared to non-responders (79.9% vs. 63.3%) (p = 0.003). Based on ROC analysis, optimal cut-off value for tumor volume reduction rate was determined with an area under the curve (AUC) value of 0.724 (p = 0.003). Using the tumor volume reduction rate ≥75% with the addition of response to nCRT according to mrTRG, a new scoring system for prediction of pTRG to preoperative nCRT in LARC was developed. Diagnostic performance of prediction score was tested and the sensitivity, PPV, specificity, and NPV were 81.8%, 56.3%, 71.4%, and 89.7%, respectively. The combination of mrTRG and T2-weighted volumetry increases the MRI-based prediction of pTRG to preoperative nCRT in LARC. The proposed scoring system could aid in distinguishing responders to nCRT, as these patients could benefit from organ-preserving treatment and a "watch and wait" strategy.

Morphometric and volumetric analysis of lacrimal glands in patients with thyroid eye disease.

Assessment of morphometric and volumetric changes in lacrimal glands in thyroid eye disease, its clinical manifestations in relation of disease progression. Retrospective volumetric analysis included both genders and was performed on total of 183 patients - 91 patients with diagnosed Grave's disease and thyroid eye disease and 92 patients without Grave's disease and thyroid eye disease who underwent multidetector computed tomography (MDCT) examination in routine daily work according to other medical indications. In the group of females, there was statistical significance between patients with thyroid eye disease and controls who were smoking and had body weight gain. We found statistical significance in volumetric enlargements for both orbits in both genders for the patients group when compared to controls. There was also statistical significance in morphometric characteristics for the lacrimal gland diameters measured. Determination planimetric morphometric parameters of importance were coronary height of lacrimal gland of the right eye, coronary height of lacrimal gland of the left eye and coronary width of lacrimal gland of the left eye for the group of males. In a group of females the established determination parameters of importance were the coronary height of lacrimal gland of the left eye, the axial width of lacrimal gland of the left eye, volume of lacrimal gland of the right eye and the volume of lacrimal gland of the left eye. When we compared the displaced lacrimal gland coming forward (proptosis) in time progressing disease between group of patients and controls, we also found statistical significant connection. Evaluation of lacrimal gland volumetric and morphometric data may increase validity of defining this anatomical substrate and its morphology disruption as liable tool for thyroid eye disease progression follow up and treatment planning and outcome.

The Utility of Conventional CT, CT Perfusion and Quantitative Diffusion-Weighted Imaging in Predicting the Risk Level of Gastrointestinal Stromal Tumors of the Stomach: A Prospective Comparison of Classical CT Features, CT Perfusion Values, Apparent Diffusion Coefficient and Intravoxel Incoherent Motion-Derived Parameters.

Background: The role of advanced functional imaging techniques in prediction of pathological risk categories of gastrointestinal stromal tumors (GIST) is still unknown. The purpose of this study was to evaluate classical CT features, CT-perfusion and magnetic-resonance-diffusion-weighted-imaging (MR-DWI)-related parameters in predicting the metastatic risk of gastric GIST. Patients and methods: Sixty-two patients with histologically proven GIST who underwent CT perfusion and MR-DWI using multiple b-values were prospectively included. Morphological CT characteristics and CT-perfusion parameters of tumor were comparatively analyzed in the high-risk (HR) and low-risk (LR) GIST groups. Apparent diffusion coefficient (ADC) and intravoxel-incoherent-motion (IVIM)-related parameters were also analyzed in 45 and 34 patients, respectively. Results: Binary logistic regression analysis revealed that greater tumor diameter (p < 0.001), cystic structure (p < 0.001), irregular margins (p = 0.007), irregular shape (p < 0.001), disrupted mucosa (p < 0.001) and visible EFDV (p < 0.001), as well as less ADC value (p = 0.001) and shorter time-to-peak (p = 0.006), were significant predictors of HR GIST. Multivariate analysis extracted irregular shape (p = 0.006) and enlarged feeding or draining vessels (EFDV) (p = 0.017) as independent predictors of HR GIST (area under curve (AUC) of predicting model 0.869). Conclusion: Although certain classical CT imaging features remain most valuable, some functional imaging parameters may add the diagnostic value in preoperative prediction of HR gastric GIST.

COVID-19-Associated Pulmonary Aspergillosis in Patients with Acute Leukemia: A Single-Center Study.

Patients with coronavirus disease 19 (COVID-19) have increased susceptibility to secondary respiratory infections including invasive pulmonary aspergillosis (IPA). COVID-19-associated pulmonary aspergillosis (CAPA) is difficult to diagnose and can be associated with increased mortality especially in severe immunodeficiency such as hematological malignancies. Our study evaluates IPA in COVID-19 patients defined as COVID-19-CAPA among patients with acute leukemia (AL). A retrospective single-center study analyzed 46 patients with COVID-19 infection and acute leukemia, admitted to the Clinic for Haematology, Clinical Center of Serbia, Belgrade between the 2 April 2020 and 15 May 2021. During hospitalization, all participants were diagnosed with probable IPA according to the previous consensus definitions. Positive serology and galactomannan (GM) detection values in bronchoalveolar lavage (BAL) and serum were used as microbiological criteria. COVID-19 associated probable IPA was found in 22% (9/41) tested patients, where serum GM and IgM anti-Aspergillus antibodies were positive in 12% (5/41) and 10% (4/41) had positive serology for aspergillosis. One patient died while eight recovered during follow-up. Our study showed that COVID-19 might be a risk factor for IPA development in patients with AL. Early diagnosis and prompt treatment are required as reported mortality rates are high.

Aggressive fibromatosis of the right colon mimicking a gastrointestinal stromal tumour: a case report.

Aggressive fibromatosis is a rare type of intra-abdominal desmoid tumour that usually involves the small bowel mesentery. It is a locally-invasive lesion, with a high rate of recurrence, but without metastatic potential. Aggressive fibromatosis is seen more often in young female patients. This case report presents the radiological, intraoperative and histopathological findings from a 37-year-old female patient that presented with epigastric pain and a palpable mass in the right hemiabdomen. Histological and immunohistochemical examinations of the resected tumour, including positive staining for beta-catenin, confirmed a postoperative diagnosis of desmoid type fibromatosis. This specific case showed that desmoid type fibromatosis of the colon can mimic gastrointestinal stromal tumours (GIST) based on its clinical presentation, computed tomography and magnetic resonance imaging findings. Differential diagnosis between desmoid type fibromatosis and GIST is clinically very important due to the different treatments and follow-up protocols that are implemented for these lesions.

Value of Multidetector Computed Tomography in the Assessment of Achalasia Subtypes and Detection of Pulmonary and Thoracic Complications.

OBJECTIVE: To evaluate multidetector computed tomography (MDCT) findings in patients with achalasia, to assess its role in differentiating subtypes in detecting lung involvement and extra-esophageal thoracic complications. SUBJECTS AND METHODS: This clinical retrospective study included 51 patients with manometrically confirmed achalasia who underwent chest X-ray and MDCT in diagnostic work-up. Esophageal wall thickness and morphology, luminal dilatation, lung changes, and extra-esophageal manifestations were analyzed on MDCT by 2 readers. Wilcoxon, Kruskal-Wallis and Mann-Whitney test were used for assessing the differences among the achalasia subtypes, and intra-class correlation coefficients (ICC) assessing the inter-observer agreement between the measurements of 2 readers. RESULTS: Fourteen (27.5%) patients had achalasia subtype I, 21 (60.8%) had subtype II while 6 (11.8%) had subtype III. Esophageal wall thickness of the esophageal body (EB) and distal esophageal segment (DES) as well as nodular/lobulated appearance of DES were found significantly more often in subtype III (p = 0.024, p < 0.001, p = 0.009, respectively). Esophageal dilatation gradually decreased from subtype I to III (p = 0.006). Chest X-ray revealed lung changes in 9 (17%) and MDCT in 21 (41%) patients (p = 0.001), most frequently in subtype I, with predominance of ground-glass opacities. Tracheal/carinal compression was detected in 27 (52.9%) and left atrial compression in 17 (33.3%) patients. Excellent inter-observer agreement was observed in measuring the EB and DES wall thickness, and diameter of EB (ICC 0.829, 0.901, and 0.922). CONCLUSION: MDCT is a useful tool for detecting lung and extra-esophageal thoracic complications in patients with achalasia, and could be a valuable additional imaging modality in the differentiation of achalasia subtypes.

Analyzing the post-contrast attenuation of the esophageal wall on routine contrast-enhanced MDCT examination can improve the diagnostic accuracy in response evaluation of the squamous cell esophageal carcinoma to neoadjuvant chemoradiotherapy in comparison with the esophageal wall thickness.

PURPOSE: To evaluate the accuracy of the multidetector computed tomography (MDCT) in the response evaluation of the esophageal squamous cell carcinoma (ESCC) to neoadjuvant chemoradiotherapy (nCRT) by analyzing the thickness and post-contrast attenuation of the esophageal wall after the nCRT. METHODS: Contrast-enhanced (CE)-MDCT examinations in portal venous phase of one hundred patients with locally advanced ESCC who received nCRT and underwent esophageal resection and histopathology assessment of tumor regression grade (TRG) were retrospectively analyzed by measuring the maximal thickness and mean density of the esophageal wall in the segment involved by tumor and visually searching for hyperdense foci within it. Diagnostic performance was evaluated using the ROC analysis. RESULTS: Average attenuation of the esophageal wall had stronger diagnostic performance for predicting pathologic complete regression (pCR) (AUC = 0.994; p < 0.001) in relation to maximal esophageal wall thickness (AUC = 0.731; p < 0.001). Maximal esophageal wall thickness ≤ 9 mm and average attenuation of the esophageal wall ≤ 64 HU predicted pCR with the sensitivity, specificity, and overall accuracy of 62.5%, 77.9%, and 73%, and 96.9%, 98.5%, and 98%, respectively. Combination of both cutoff values enabled correct assessment of pCR with the 100% accuracy. Visual detection of the hyperdense focus within the esophageal wall predicted pCR with the sensitivity, specificity, and overall accuracy values of 100%, 94.1%, and 96%, respectively. CONCLUSION: Visual analysis and measurement of post-contrast attenuation of the esophageal wall after the nCRT can improve diagnostic accuracy of MDCT in the response evaluation of the ESCC to nCRT in comparison with measuring the esophageal wall thickness.

p21 does, but p53 does not predict pathological response to preoperative chemoradiotherapy in locally advanced rectal cancer.

PURPOSE: Preoperative chemoradiotherapy (CRT) is the standard treatment option in locally advanced rectal cancer. The tumor response is assessed through tumor and nodal downstaging and the tumor regression grade. Currently, there is no method to predict a tumor response to CRT. We aimed to evaluate whether p21 and p53 expressions could be a reliable predictors of pathological response to CRT. METHODS: Fifty patients with locally advanced rectal cancer were treated with preoperative radiotherapy combined with mitomycin C and capecitabine. p21 and p53 immumohistochemical staining was performed on pretreatment biopsies and the results were compared with tumor regression according to grading systems by Dworak (TRG grades) and by Wheeler (RCRG grades). RESULTS: Testing RCRG grades in relation to p21 expression showed statistically significant difference (p=0.021). RCRG 3 (poor response) was more frequent in the group of patients with low p21. According to Dworak, grade 4 (complete regression) was more frequent in the group of patients with positive p21 expression (p=0.032). Significant difference in p21 expression in grade 4 group compared with all other grade groups was also found (p=0.007). Patients with immune expression of p21 had significantly higher percentage of complete regression in comparison to the patients with low expression of p21. We haven't found any correlation between p53 expression and histopathological (HP) as well as regression grades. CONCLUSION: According to both grading systems, our results suggest that p53 expression does not, but p21 expression does predict pathological response to preoperative CRT.

Gastroduodenal Lipomatosis in Familial Multiple Lipomatosis.

OBJECTIVE: To present a case of gastroduodenal lipomatosis associated with familial multiple lipomatosis (FML). CLINICAL PRESENTATION AND INTERVENTION: A 58-year-old male presented with FML that manifested as multiple, painless, subcutaneous lipomas on his body; his mother had subcutaneous lipoma without a diagnosis of gastroduodenal lipomatosis. His lipid profile was normal. Abdominal computed tomography showed multiple, submucosal, polypoid lesions (of uniform density) of fat in the stomach and duodenum, and a small, similar lesion in the ileum. CONCLUSION: This case shows that gastrointestinal lipomatosis can manifest as FML.

Follow-Up Imaging of Inflammatory Myofibroblastic Tumor of the Uterus and Its Spontaneous Regression.

Inflammatory myofibroblastic tumor (IMT) is an aggressive benign mass that may arise from various tissues and organs with a great variability of histological and clinical appearances. Due to variable and nonspecific imaging findings, diagnosis of IMT is not obtained before surgery. The aim of this paper is to present CT and MRI findings during four-year follow-up of complete, spontaneous regression of IMT of the uterus. The diagnosis was made by histology and immunohistochemistry analysis of the open excisional biopsy specimen. At that time, the organ of origin was not specified. After analysis of the follow-up imaging findings and the mode of tumor regression, the uterus was proclaimed as the probable site of origin. IMT of the uterus is extremely rare and has been reported in ten cases up to now. The gradual, complete regression of uterine IMT documented by CT and MRI may contribute to understanding of its nature.

Does the computed tomography perfusion imaging improve the diagnostic accuracy in the response evaluation of esophageal carcinoma to the neoadjuvant chemoradiotherapy? Preliminary study.

PURPOSE: To estimate whether the computed tomography (CT) perfusion imaging could be useful to predict the pathological complete response (pCR) of esophageal cancer to the neoadjuvant chemoradiotherapy (NACRT). METHODS: Twenty-seven patients with the advanced squamous cell esophageal carcinoma, who were treated with concomitant CRT (CIS/5-FU/LV and 45-50 Gy total radiation dose), were re-evaluated using CT examination, which included the low-dose CT perfusion study. CT perfusion series were analysed using the deconvolution-based CT perfusion software (Perfusion 3.0, GE), and color parametric maps of the blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability surface area product (PS) were displayed. All patients were operated and histopathological analysis of the resected esophagus considered the gold standard for pathologic complete response (pCR). RESULTS: BFpost-NACRT, BVpost-NACRT, and PSpost-NACRT were significantly lower, and MTTpost-NACRT significantly higher in the pCR group. Mean (±SD), or median perfusion parameter values in the pCRs (11 patients) vs non-pCRs (16 patients) were: BFpost-NACRT- 21.4±5.0 vs 86.0±29 ml/min/100 g (p<0.001), BVpost-NACRT- 1.3 vs 3.9 ml/100 g (p<0.001), MTTpost-NACRT- 5.5 vs 3.7 s (p=0.018), and PSpost-NACRT- 5.9 vs 9.8 ml/min/100 g (p=0.006). ROC analysis revealed that BFpost- NACRT (AUC=1.000), BVpost-NACRT (AUC=0.932), MTTpost-NACRT (AUC=0.801), and PSpost-NACRT (AUC=0.844) could predict the pCR (p<0.01), while maximal esophageal wall thickness could not (AUC=0.676, p=0.126). If we set a cut-off value of BFpost-NACRT<30.0 ml/min/100 g, pCR was predicted with sensitivity and specificity of 100%. CONCLUSION: CT perfusion imaging enables accurate prediction of pCR of esophageal carcinoma to neoadjuvant chemoradiotherapy.

The utility of 18F-FDG PET/CT for diagnosis and adjustment of therapy in patients with active chronic sarcoidosis.

UNLABELLED: The purpose of this study was to assess the utility of (18)F-FDG PET/CT for detection of inflammation in granulomatous sites and management of patients with chronic sarcoidosis. The 3 specific aims were to assess differences between (18)F-FDG PET/CT and multidetector CT (MDCT) findings, to compare (18)F-FDG PET/CT results with serum levels of angiotensin-converting enzyme (ACE), and to determine whether (18)F-FDG PET/CT findings are associated with the decision to change therapy. METHODS: We studied 90 sarcoidosis patients (mean age ± SD, 47 ± 12 y; 32 men and 58 women) with persistent symptoms who were referred for (18)F-FDG PET/CT evaluation to assess the extent of inflammation. They also underwent MDCT and measurement of serum ACE level. After the follow-up (12 ± 5 mo after (18)F-FDG PET/CT), the clinical status and changes in therapy were analyzed. RESULTS: (18)F-FDG PET/CT detected inflammation in 74 patients (82%) (maximum standardized uptake value, 8.1 ± 3.9). MDCT was positive for sarcoidosis in 6 additional patients (80, 89%). The difference between the 2 methods was not significant (P = 0.238, McNemar test), and their agreement was fair (κ = 0.198). Although ACE levels were significantly higher in patients with positive than negative (18)F-FDG PET/CT results (P = 0.002, Mann-Whitney test), 38 patients (51%) with positive (18)F-FDG PET/CT results had normal ACE levels. The therapy was initiated or changed in 73 out of 90 patients (81%). Both univariate and multivariate logistic regression analyses indicated that positive (18)F-FDG PET/CT results were significantly (P < 0.001) associated with changes in therapy, with no contribution from age, sex, ACE level, CT results, or previous therapy. CONCLUSION: Our results indicate that (18)F-FDG PET/CT is a useful adjunct to other diagnostic methods for detecting active inflammatory sites in chronic sarcoidosis patients with persistent symptoms, especially those with normal ACE levels. (18)F-FDG PET/CT proved advantageous for determining the spread of active disease throughout the body and influenced the decision to adjust the therapy.

Preliminary experience with 18f-fluoro-deoxy-glucose positron emission tomography/computed tomography in pediatric oncology patients.

The aim of this study was to present preliminary experience with FDG PET/CT in pediatric oncology patients in National PET Center, Clinical Center of Serbia and to asses its impact on management of malignancies in children. 33 FDG PET/CT scans were performed on 30 pediatric patients. PET/CT imaging was performed for staging the disease, assessing therapy efficacy and diagnosing recurrent or metastatic disease. FDG PET/CT changed the stage of the disease in 60.6% (20/33) of the cases. 14 patients were down-staged after PET/CT, mostly patients with Hodgkin's disease, were in 7/10 cases PET/CT showed no activity in residual masses. Six scans led to upstage of the disease. In three cases PET/CT did not change the stage of disease, but has showed new distant metastases. In conclusion, FDG PET/CT showed important role in managing pediatric patients with different malignancies and was useful complementary diagnostic tool to conventional imaging methods.

Endoanal ultrasound evaluation of anorectal diseases and disorders: technique, indications, results and limitations.

Imaging of the rectum, anorectal junction and surrounding tissues is both difficult and technically challenging. CT and conventional barium studies offer limited information in local staging of rectal and perirectal neoplasms, anal carcinomas and extension perianal fistulas in patients with inflamamatory bowel disease, or in evaluating patients with fecal incontinence. During past decade, sonography and MR imaging have resulted in significant improvement in the imaging of rectal and perirectal and anal and perianal disease. The aim of this article is to review possibility of the EAUS in the evaluation both normal anal anatomy and anorectal disease and disorders (anal carcinoma, sphincter defects, anal fistulas, perianal abscesses and other pathological conditions).

Intraoperative endoscopy in obstructive hypopharyngeal carcinoma.

AIM: To demonstrate the necessity of intraoperative endoscopy in the diagnosis of secondary primary tumors of the upper digestive tract in patients with obstructive hypopharyngeal carcinoma. METHODS: Thirty-one patients with hypopharyngeal squamous cell carcinoma had been operated, with radical intent, at our Institution in the period between 1978 and 2004. Due to obstructive tumor mass, in 7 (22.6%) patients, preoperative endoscopic evaluation of the esophagus and stomach could not be performed. In those patients, intraoperative endoscopy, made through an incision in the cervical esophagus, was standard diagnostic method for examination of the esophagus and stomach. RESULTS: We found synchronous foregut carcinomas in 3 patients (9.7%). In two patients, synchronous carcinomas had been detected during preoperative endoscopic evaluation, and in one (with obstructive carcinoma) using intraoperative endoscopy. In this case, preoperative barium swallow and CT scan did not reveal the existence of second primary tumor within esophagus, despite the fact that small, but T2 carcinoma, was present. CONCLUSION: It is reasonable to use intraoperative endoscopy as a selective screening test in patients with obstructive hypopharyngeal carcinoma.