Breast Ultrasound during Lactation: Benign and Malignant Lesions.

BACKGROUND: Structural changes during lactation make breast physical examination difficult. When breast problems occur, patients are often referred for an ultrasound (US) scan. Most breast lesions diagnosed in these patients are benign, but the diagnosis of breast cancer is a challenge. We aim to demonstrate the spectrum of US imaging findings in lactating women. METHODS: 77 breastfeeding patients who underwent breast US in our department between February 2012 and March 2017 were evaluated. Patients' electronic medical records were reviewed for the presenting complaint, US reports, pathology results if available, and clinical/radiologic follow-up. All examinations were performed by 2 radiologists. RESULTS: 28 of the 77 patients had normal US findings. Cysts were seen in 16 patients. 4 patients had stable fibroadenomas. 6 patients had US imaging findings suggestive of mastitis, 5 patients had galactoceles, 1 patient had an abscess, and 1 patient had unilateral hypertrophy without any accompanying lesion. In 13 patients, BI-RADS 3 solid masses were diagnosed. Invasive breast cancer was diagnosed in 3 patients. CONCLUSION: US can demonstrate or exclude a true mass against the background of a nodular breast parenchyma. Radiologists must be aware of malignant US features to avoid delays in the diagnosis of pregnancy-associated breast cancer.

Concurrent Septal and Right Ventricular Aneurysms Detected on Second Trimester Ultrasound Scan: A Case Report.

Congenital aneurysms and diverticula of the heart are rare anomalies and their prenatal diagnosis is challenging. Fetuses with suspected cardiac aneurysms on ultrasound (US) screening should undergo targeted fetal echocardiography, postnatal imaging, and follow-ups. Herein, we describe the second trimester US scan and postnatal cardiac magnetic resonance imaging (MRI) findings of a baby girl with concurrent septal and right ventricular cardiac aneurysms. Other cardiac and extra-cardiac structures were normal. Upon consultation about the prognostic uncertainty of the situation, the family chose to continue the pregnancy. The rest of the pregnancy and birth was without any complications. Follow-up postnatal echocardiograms showed no progression regarding the size of the aneurysms. The baby is still on follow-up without any medication and is thriving. To the best of our knowledge, this case report is the first to show the prenatal diagnosis of two concurrent rare cardiac aneurysms.

Typical MR imaging findings of perianal infections in patients with hematologic malignancies.

OBJECTIVE: We aimed to investigate the MR imaging findings of patients with hematologic malignancies who have symptoms suggesting perianal infection and to demonstrate the importance of imaging. SUBJECTS AND METHODS: The study included 36 patients with hematologic malignancies who underwent anorectal MR imaging in our department between September 2011-May 2016. Two radiologists experienced in abdominal radiology viewed the MR images in consensus. Abscesses, fistulous or sinus tracts, signal alterations and contrast enhancement in keeping with an inflammation and edema in the perianal region were recorded. RESULTS: Perianal abscess was found in 16 of the 36 patients. In 10 of these 16 patients there was also extensive inflammatory signal alterations in perianal and/or perineal soft tissues. In six of the 36 patients perianal fistula was detected. A sinus tract was seen at the level of subcutaneous external anal sphincter in one patient. Inflammatory signal alterations in the surrounding soft tissues were present in three of these seven patients. There were abscesses in labium majus in two patients and in one patient there were perineal abscesses with accompanying inflammatory signal alterations. In six of the 36 patients no abscess or fistula/sinus tract was seen. There were only inflammatory signal alterations with contrast enhancement in perianal or subcutaneous tissues. In two patients presenting with perianal pain and hemorrhoids, minimal inflammatory changes were detected on MR images. There were two patients with normal MR imaging findings. CONCLUSION: As digital examination of the anorectum and rectoscopy are avoided in neutropenic patients, MR imaging, which clearly demonstrates the perianal pathology should be preferential.

Determination of risk factors and perinatal outcomes of singleton pregnancies complicated by isolated single umbilical artery in Turkish population.

OBJECTIVE: To address the possible risk factors, eventual pregnancy outcomes, and probable troubles in follow-ups of pregnancies complicated by an isolated single umbilical artery and to provide data on Turkish cases in such an aspect that ethnic divergences may have influence. MATERIAL AND METHODS: A total of 16568 singleton pregnancies that were delivered between May 2006 and May 2013 were retrospectively screened. Ninety-three fetuses were found to have an isolated single umbilical artery. One-hundred pregnancies that did not show any structural or chromosomal abnormalities were randomly selected from the rest of the cases to establish the control group. IBM SPSS Statistics 20.0 software was utilized for statistical analysis. Non-parametric data were analyzed with Mann-Whitney U test and were presented as means±standard deviations. P values less than 0.05 were statistically significant. For the adjustment of confounding factors, odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by multiple logistic regression analysis. RESULTS: The incidence of small for gestational age (SGA) fetuses and hypertensive disorders in pregnancy was found to be significantly higher in cases with an isolated single umbilical artery (p<0.001 and p=0.022, respectively). Maternal smoking was found to be independently associated with the occurrence of an isolated single umbilical artery (OR: 3.556; 95% CI: 1.104-11.45). The risk of preterm birth was not higher in the study group (OR: 0.538; 95% CI: 0.576-2.873). The incidence of cases who underwent cesarean delivery because of non-reassuring fetal heart trace was similar in the study and control groups (p=0.499). CONCLUSION: Attention should be paid to the development of hypertensive disorders in cases with a diagnosis of an isolated single umbilical artery, and parents should be counseled properly, including the information on increased risk of SGA. Strict follow-up of pregnancies complicated with an isolated single umbilical artery in terms of preterm birth seems unfeasible except in cases with accompanying risk factors for preterm labor.

The effects of isolated single umbilical artery on first and second trimester aneuploidy screening test parameters.

OBJECTIVE: Reliability of first and second trimester screening tests largely depends on accurate estimation of maternal serum marker values. Reduced reliability could lead redundant invasive tests or misdiagnosis. Adjustments of serum marker values for confounding factors like insulin-dependent diabetes, maternal weight or maternal rhesus status are essential. We aimed to investigate whether isolated single umbilical artery alters first and second trimester test parameters or not. METHODS: Routine detailed obstetric ultrasonographies performed were retrospectively screened for this study. Among spontaneously conceived singleton pregnancies, women who were found to have single umbilical artery without any additional structural anomalies or aneuploidies were selected. First and second trimester screening test results were accessible for 98 and 102 of the cases with isolated single umbilical artery, respectively. RESULTS: Among first trimester screening test parameters, PAPP-A (pregnancy-associated plasma protein A) MoMs were found significantly higher in isolated single umbilical artery group. AFP MoMs were found significantly elevated in isolated single umbilical artery group in second trimester quadruple tests. CONCLUSION: Existence of single umbilical artery could alter the estimation of MoM values of maternal serum markers. Reliability of prenatal screening tests could be improved by adjusting these parameters in accordance with isolated single umbilical artery.

Changes in first trimester screening test parameters in pregnancies complicated by placenta previa and association with hyperemesis gravidarum.

OBJECTIVE: To assess the possible changes in first trimester screening test parameters in pregnancies complicated with placenta previa and to determine whether there is an association between hyperemesis gravidarum and placenta previa. MATERIAL AND METHODS: A total of 131 singleton spontaneously conceived pregnancies that were complicated by placenta previa and delivered between May 2006 and May 2013 were evaluated from birth charts. Ninety patients without placenta previa were selected amongst patients who delivered within the same period of time as the control group. Cases of low lying placenta (n=52) within the study group were assessed as a separate group. The rest of the cases was considered to be in a different group. RESULTS: Beta human chorionic gonadotropin (BhCG) multiples of medians (MoMs) and nuchal translucency (NT) MoMs were significantly higher in the placenta previa group in comparison with the low lying placenta and control groups. Apgar scores at both the 1st and 5th minutes were significantly lower in the placenta previa group. Hyperemesis gravidarum was found to be significantly more frequent in the placenta previa group. CONCLUSION: The prevalence of hyperemesis gravidarum in the first trimester is higher in pregnancies complicated by placenta previa. Paying more attention to the development of placenta previa in the routine pregnancy follow-up of patients with hyperemesis gravidarum could be considered.

Are caudate-right lobe ratio and splenic size correlated with the MELD score in cirrhotic patients?

AIM: To determine the relationship between caudate-right lobe ratio (C/R) and model for end-stage liver disease (MELD) score. METHODS: The study included 50 patients with cirrhosis and a control group of 20 patients. C/R was measured as described by Harbin et al. The size of the spleen was measured on coronal images. The Organ Procurement and Transplantation Network Web site was used for MELD score calculation. Aspartate to alanine aminotranferase (AST/ALT) ratio was calculated. RESULTS: There was statistically significant difference between the two groups. C/R, the size of the spleen, and AST/ALT values were significantly correlated with MELD score. CONCLUSIONS: There is a significant relationship between the C/R and MELD score.

Gray-scale and color Doppler US findings of amniotic sheets.

PURPOSE: To identify the gray-scale and color Doppler ultrasonography (US) findings of amniotic sheets. MATERIALS AND METHODS: Among 1201 pregnant patients who underwent detailed second trimester US, nine had amniotic sheets. An amniotic sheet was defined as a shelf-like structure in the uterine cavity with a free edge not attached to the fetus or umbilical cord. There was no major fetal anomaly observed in any patient. Eight patients had solitary amniotic sheets, and one patient had double sheets. All gray-scale and Doppler US features of amniotic sheets were noted. RESULTS: The incidence of an amniotic sheet was determined to be 0.75% (ten amniotic sheets were observed in nine patients). On gray-scale US images, amniotic sheets were observed as bands of tissue that originated from the uterine wall with a triangular-shaped base that tapered toward the free edge. A three-layered appearance was identified in seven amniotic sheets. Using Doppler US images, four of ten sheets showed a low-resistance arterial flow, and five of ten sheets showed non-pulsatile venous flows. No vascularization was observed in one patient with a thin, membranous sheet. CONCLUSION: Gray-scale US is sufficient for the diagnosis of amniotic sheets because of the typical US characteristics; however, Doppler US findings of amniotic sheets are highly variable. Thus, Doppler US may not be beneficial in the diagnosis of amniotic sheets.

The effect of nuchal cord on nuchal fold thickness measured in the second trimester.

PURPOSE: To find out whether nuchal cord causes an effect on the nuchal skin fold thickness (NFT) measurements, or not. PATIENTS AND METHODS: A total of 242 fetuses with normal outcomes that had undergone detailed second trimester US scan between 18 and 24 weeks of gestation were included in the study. NFT measurements were made on axial cranial US images passing through the cerebellum and cavum septi pellucidum. To detect nuchal cord, color Doppler imaging was performed on the axial views of the fetal neck. To investigate the differences in NFT measurements of the fetuses with or without nuchal cord, statistical analysis was performed using Mann-Whitney test. P < 0.05 was considered statistically significant. RESULTS: The study group was divided into two groups: nuchal cord (+) (n: 26) and nuchal cord (-) (n: 216) fetuses. Mean NFT measurements were 4.66 ± 0.64 mm and 4.36 ± 0.79 mm for nuchal cord (+) and nuchal cord (-) fetuses, respectively. Median NFT measurement for nuchal cord (+) fetuses was 4.6mm, whereas it was 4.4mm for nuchal cord (-) fetuses. Statistically significant difference was denoted between two groups, in terms of NFT measurements (P = 0.049). CONCLUSION: NFT measurements of fetuses with nuchal cord are higher than the NFT measurements of fetuses without nuchal cord. One can conclude that the nuchal cord (+) fetuses with no other anomalies but increased NFT should be re-scanned to see if the increased NFT resolves in the absence of nuchal cord.

MR imaging in diffuse-type hepatocellular carcinoma with synchronous portal vein thrombi.

BACKGROUND/AIMS: Diffuse or continuous multifocal tumors with accompanying portal vein thrombosis yield considerable changes in the magnetic resonance imaging findings of hepatocellular carcinoma. The overlapped imaging findings of these two co-existing pathologies may be confusing. We aimed to evaluate the magnetic resonance imaging findings of widespread hepatocellular carcinoma lesions complicated with portal vein thrombosis. METHODS: Twenty-two patients (20 male, 2 female; mean age: 57 years) with portal vein thrombosis and diffuse-type hepatocellular carcinoma who underwent contrast-enhanced hepatic magnetic resonance imaging in our department between August 2001 and November 2008 were evaluated retrospectively. The unenhanced axial T1-weighted, T2-weighted, and post-contrast early- and late-phase images were reviewed in each patient. RESULTS: On T2-weighted magnetic resonance images, tumors were seen mildly hyperintense in 11 patients and heterogeneously hyperintense in 11 patients. Unenhanced T1-weighted images demonstrated homogeneous hypointensity in 15 patients and heterogeneous hypointensity in 7 patients. Post-contrast early-phase magnetic resonance images showed patchy enhancement in 12 patients, moth-eaten enhancement in 6 patients, strong enhancement in 1 patient, and minimal enhancement in 3 patients. Post-contrast late-phase magnetic resonance images demonstrated heterogeneous washout in all patients. Portal vein thrombosis was present in all patients. The mean diameter of main portal vein thrombi was 27 mm (range: 25-30 mm). Serum alpha-fetoprotein levels were elevated in all patients. CONCLUSIONS: In patients with chronic parenchymal liver disease, when portal vein thrombosis and high serum alpha-fetoprotein values co-exist, careful attention must be paid to the hepatic parenchymal changes, especially on contrast-enhanced images, in order to not overlook diffuse-type hepatocellular carcinoma.

Frequencies of perianal fistula types using two classification systems.

PURPOSE: The aims of this study were to determine the frequencies of the perianal fistula subtypes according to the Parks and St. James's University Hospital (SJUH) classification systems and to evaluate the adequacy of these two systems for classifying and reporting perianal fistulas. MATERIALS AND METHODS: Magnetic resonance imaging examinations of 52 patients (44 men, 8 women) with perianal fistula were reviewed retrospectively. The fistulas were classified according to the Parks and SJUH classification systems. RESULTS: According to the Parks system, 13 patients had intersphincteric (25%), 36 had transsphincteric (69.23%), and 2 had (3.84%) extrasphincteric fistulas. Only one fistula (a subsphincteric fistula) (1.92%) could not be classified. According to the SJUH system, 10 patients had grade 1 (19.23%), 2 patients had grade 2 (3.84%), 13 patients had grade 3 (25%), 21 patients had grade 4 (40.38%), and 5 patients had grade 5 (9.61%) perianal fistulas. The one (and only) subsphincteric fistula was left unclassified. CONCLUSION: The most common types are transsphincteric and intersphincteric fistulas. Although the two most commonly used classification systems are adequate for describing most perianal fistulas, there is a small percentage that is left unclassified.

Pelvic retroperitoneal angioleiomyoma mimicking a uterine mass.

Angioleiomyoma (vascular myoma) is a rare type of leiomyoma originating from smooth muscle cells and containing thick-walled vessels. There are only a few cases of retroperitoneal angioleiomyoma reported in the literature. Herein, we present the ultrasonography, magnetic resonance imaging and histopathological findings of an asymptomatic patient with a pelvic retroperitoneal angioleiomyoma which radiologically mimicked a uterine mass.

An unusual case of neurobrucellosis presenting with unilateral abducens nerve palsy: clinical and MRI findings.

Brucellosis is an endemic zoonotic disease in which neurobrucellosis occurs in 5-10% of cases. Variable clinical and radiological manifestations of neurobrucellosis can mimic those of other diseases. In this report, we present unusual clinical and magnetic resonance imaging (MRI) findings in a patient with neurobrucellosis and unilateral abducens nerve palsy. Her MRI showed punctate leptomeningeal enhancement of the cerebellum on contrast-enhanced T1-weighted images, and a focal area of hyperintensity in the splenium of the corpus callosum on T2-weighted images.

Performance analysis of 8-channel MDCT angiography in detection, localization, and sizing of intracranial aneurysms identified on DSA.

PURPOSE: To retrospectively analyze the performance of 8-channel multi-detector computed tomographic angiography (MDCTA) in detecting, localizing, and sizing intracranial aneurysms using conventional intraarterial digital subtraction angiography (DSA) as the gold standard. MATERIALS AND METHODS: A retrospective search from November 2004 to August 2006 revealed subarachnoid hemorrhage (SAH) in 25 patients (13 females and 12 males, age range 21-73 years) who underwent both DSA and 8-channel MDCTA exams. Two independent reviewers compared both studies for the presence, location, and size of the aneurysm. RESULTS: A total of 35 aneurysms in 25 patients were identified on DSA, and 33 on MDCTA. MDCTA missed two 4-mm posterior communicating artery (PcoA) aneurysms. There was a mismatch in the location of two aneurysms. One aneurysm at PcoA on DSA was reported as a supraclinoid internal carotid artery (ICA) aneurysm on MDCTA. The other on M2 bifurcation was reported as on M1. No size mismatch was noted. MDCTA had a 94% (33/35) aneurysm detection rate, 88% (31/35) aneurysm localization rate and 100% (33/33) sizing rate. CONCLUSION: MDCTA correlated perfectly with DSA in the detection of intracranial aneurysms of anterior communicating artery and middle cerebral artery; however, slightly lower performance was noted in the PcoA and ICA supraclinoid segment aneurysms.

Post-treatment MRI findings of hepatocellular carcinoma.

In addition to surgery, ablative and transarterial therapies are widely accepted treatment options for hepatocellular carcinoma. Although post-treatment followup is usually done with both computed tomography and magnetic resonance imaging (MRI), MRI is found to be superior in detecting residual or recurrent tumors after treatment. Familiarity with post-treatment MRI findings is critical for the correct interpretation of these examinations, and for guiding further therapies.

Pancreatic changes in patients with primary sclerosing cholangitis: MR cholangiopancreatography and MRI findings.

PURPOSE: To evaluate the possible pancreatic changes and their frequencies in patients with primary sclerosing cholangitis (PSC) on MR cholangiopancreatography (MRCP), and conventional abdominal MRI. MATERIALS AND METHODS: Patient group consisted of 29 PSC (13 male, 16 female) cases, whereas cohort 1 consisted of 12 female patients with primary biliary cirrhosis, and cohort 2 consisted of 17 patients (6 male, 11 female) with non-immune chronic liver disease. Two radiologists retrospectively evaluated the MR examinations paying special attention to the pancreatic size (atrophy or enlargement), T1- and T2-signal intensity of the pancreas, focal pancreatic lesion, capsule-like rim, peripancreatic edema or fluid, fascial thickening, and pancreatic ducts (dilatation or narrowing). The results are expressed as percentages. Three groups were compared using Pearson chi-square test for each feature. However, only p-value for "dilatation of the pancreatic duct" was determined, whereas p-value could not be calculated because of the insufficient number of subjects/sequences for the other features. RESULTS: Twelve PSC patients (41.3%) had pancreatic abnormalities. The most common pancreatic changes in PSC patients were decreased T1-signal intensity (44%) and dilatation of the pancreatic duct (13.8%), respectively. Increased T2-signal intensity was also shown in 2 PSC patients (6.9%). CONCLUSION: Even PSC patients without any sign of pancreatitis, can show MR changes in the pancreatic parenchyma or the pancreatic duct. The etiologies of these changes, and whether they are unique to PSC, are still controversial. Histopathological studies bringing light to these pancreatic changes are needed.

Imaging features of portal biliopathy: frequency of involvement patterns with emphasis on MRCP.

PURPOSE: To investigate the imaging features of portal biliopathy with emphasis on MR cholangiopancreatography (MRCP). The ancillary vascular findings of portal biliopathy were also evaluated by accompanying MR portography, dynamic contrast-enhanced (CE) CT, and dynamic CE MRI studies. MATERIALS AND METHODS: Sixteen patients with portal cavernoma were included in the study. Patients had undergone MRCP (n=16) studies accompanied by MR portography (n=13), dynamic CE CT (n=3) or dynamic CE MRI (n=2) of the liver. Two patients had undergone both dynamic CE CT and dynamic CE MRI. Two radiologists evaluated all the examinations together, retrospectively. MRCP images were analyzed for the presence of biliary stenosis, upstream (prestenotic) dilatation, wavy appearance of the bile ducts, angulation of the common bile duct (CBD), and choledocholithiasis. MR portography, dynamic CE CT and dynamic CE MRI studies were evaluated for the existence of portal cavernomas, and the presence of gall bladder/choledochal varices. RESULTS: All patients had signs of portal biliopathy on MRCP. Frequencies of the biliary findings on MRCP were as follows: biliary stenosis, 93.7%; upstream dilatation, 68.7%; wavy appearance of the biliary tree, 87.5%; angulation of the CBD, 75%. None of the patients had choledocholithiasis. Frequencies of the ancillary vascular findings detected on CE studies were as follows: gall bladder varices, 100%, choledochal varices, 93.7%. CONCLUSION: MRCP features of portal biliopathy in order to their frequencies were as follows: biliary stenosis, wavy appearance of the bile ducts, angulation of the CBD, and upstream dilatation of the bile ducts.

Ruptured iliac aneurysm presenting as lumbosacral plexopathy.

Isolated internal iliac aneurysms are rare. Unless rupture occurs, they usually remain asymptomatic. In this paper, a patient with a ruptured internal iliac aneurysm that resulted in chronic stage hematoma causing lumbosacral plexopathy and erosion of the pelvic bony structures is presented, along with magnetic resonance imaging (MRI) and computed tomography (CT) findings. To expedite the diagnosis of extraspinal radicular pain, one should pay attention to the extraspinal structures involved in lumbar CT or MRI examinations. If necessary, further investigation can be made with pelvic CT or MRI.

Orbital wall infarction mimicking periorbital cellulitis in a patient with sickle cell disease.

Orbital wall infarction and subperiosteal haematomas are unusual manifestations of sickling disorders. Here we report an 11-year-old girl with sickle cell anaemia having multiple skull infarctions including the orbital bony structures associated with subperiosteal haematomas. The diagnosis was made by MRI, which showed bone marrow changes and associated haemorrhagic collections. The patient was successfully managed without surgical intervention.