Clinico-radiological Diagnosis Research Articles

Diagnosis of diffuse parenchymal lung diseases using transbronchial cryobiopsy guided by endobronchial ultrasound compared to clinicoradiological diagnosis.

This study aimed to evaluate the safety and effect of transbronchial cryobiopsy guided by radial probe endobronchial ultrasound (RP-EBUS) compared with clinicoradiological diagnoses in diffuse parenchymal lung diseases (DPLDs). A total of 60 patients with DPLDs confirmed by chest computed tomography (CT) who underwent transbronchial lung cryobiopsy guided by RP-EBUS were enrolled. The ultrasound images were obtained and identified together with corresponding chest CT characteristics. The cryobiopsy samples were evaluated histopathologically and compared with CT imaging, and the complications were analyzed. The multidisciplinary diagnosis was clear in 51 (85%) participants but unclear in the remaining 9 (15%) participants. In transbronchial cryobiopsy guided by RP-EBUS, 36 (60%) participants had the biopsy in 1 lobe while 24 (40%) had a biopsy in 2 different lobes, with a mean biopsy specimen size of 43.17±15.25 mm2. The histopathologic diagnosis based on biopsy confirmed the preprocedural clinicoradiological diagnosis in 51 (85%) patients and clarified the diagnosis in the other 9 patients with unclear clinicoradiological diagnosis, including alveolated lung parenchyma with interstitial chronic inflammation in 4 (6.7%) cases and chronic bronchiolitis and interstitial lymphocytic infiltrates in the other 5 (8.3%). Intraprocedural complications occurred in 57 (95%) patients, including pneumothorax in 9 (15%), bleeding in 47 (78.3%), and hypoxemia in 1 (1.7%). The ultrasound images of DPLDs were normal, mesh (n=24), nodular (n=9), and alveolar type (n=27). Transbronchial cryobiopsy guided by RP-EBUS is safe and effective and can supply additional information to the clinicoradiological approach for correct diagnosis of DPLDs.

Clinico-radiological diagnosis of silent Choroid plexus papilloma in a child

Background: Choroid plexus papillomas (CPPs) are benign slow-growing tumors with the most common site as the choroid plexus of the lateral ventricle in children. These are highly vascular solid tumors which have classical diagnosis in contrast-enhanced computerized tomography (CECT) and contrast-enhanced magnetic resonance imaging (CEMRI). These require early management because of their secondary symptoms related to hydrocephalus and others due to tumoral compression. Case Report: We present a 10-month-old male child with abnormal eye movements and fever following head trauma seventeen days before. Ultrasound of the brain revealed the hyperechoic mass in the right lateral ventricle. CECT and CEMRI diagnosed as a case of choroid plexus papilloma with gross hydrocephalus. This was a silent CPP which came to limelight following head trauma. Ventriculoperitoneal shunt was placed for the decompression of the ventricular system and was advised for subsequent surgical management. Conclusion: Atypical presentations of CPP can confuse in making the diagnosis and this delay can be harmful to the patient. Early diagnosis of CPP is very important as these are slow-growing tumors which can lead to various complications if late diagnosis is made. Cross-sectional modalities such as CECT and CEMRI are the most valuable diagnostic modality tools for the early diagnosis

Clinico-Radiological assesment of lumbar spinal canal stenosis and evaluation of its surgical treatment

Objective: This study aimed to predict the absolute criteria for surgical intervention and study the outcome of surgical intervention. Materials and Methods: A prospective study was conducted from June 2002 to July 2003. A total of 35 patients were included in the study. Pre- and postoperative Oswestry Disability Index (ODI) scores were evaluated for all the patients. All patients underwent magnetic resonance imaging (MRI). The surgical indications were disabling backache with radicular pain, limited walking capacity, and neurological deficits leading to a poor ODI score. Surgical procedures done were discectomy and laminectomy with or without fixation with pedicle screws on a case-to-case basis. Follow-up was done for up to 1 year at three-monthly intervals. The final ODI score was taken at the last follow-up and was compared with preoperative scores. Results: A 50 ± 10 years was the average age of patients included in the study. The average walking capacity was 40 m; the average duration of symptoms was 41 months. ODI improved from average score of 71% ± 4% preoperatively to 22% ± 6% postoperatively. L4–L5 was the level most severely narrowed, with a mean cross-sectional area of 75 mm2. The most common surgical interventions done were discectomy and laminectomy, which were performed in 54% of the cases. We had good-to-excellent results in all our cases. None of the cases deteriorated after surgery. Conclusion: The findings in this study have important implications in clinical practice. The radiological findings in the MRI correlated well with the clinical signs and symptoms of the patients, i.e., patients with significant findings in the MRI had profound clinical symptoms and neurological deficits. Clinical Significance: Lumbar canal stenosis is a clinicoradiological diagnosis. ODI score is related to canal narrowing on MRI. Clinical improvement is related to preoperative disability and canal narrowing on MRI.

Retroperitoneal Sarcoma Mimicking a Testicular Malignancy

Low grade fibromyxoid sarcoma is a rare soft tissue sarcoma with typical histological findings. Growing as a painless mass, it is commonly seen in proximal extremities and trunk. Absence of strict protocols in diagnosis causes difficulty in its approach. Present case is a 52year male who presented with abdominal lump and absent right testis. Clinico-radiological diagnosis suggested a testicular malignancy. Histology showed low grade fibromyxosarcoma. A brief case report with review of literature is presented.

Screening success: A virtual MDT can reduce the number of patients requiring respiratory follow-up post-COVID-19 pneumonia in line with British Thoracic Society guidance

We reviewed all patients with a clinico-radiological diagnosis of COVID-19 admitted to hospital during a 3-month period and assigned a follow-up stream based on British Thoracic Society guidance. We changed the follow-up pathway in 71% (277/392) and refined the pathway in 67% (261/392) of indeterminate cases. We also created an automated process for the general practitioner to book follow-up imaging and will use this process going forward. These findings highlight the importance of the MDT review of cases with suspected COVID-19 pneumonia prior to clinic attendance to ensure appropriate patients are followed up and to optimise utilisation of outpatient imaging and clinics.

Role of Concurrent use of Thoracic Section Ultrasonography with 2D Echocardiography among Patients with Commonly Diagnosed Respiratory Illnesses- A Cross-sectional Study

Introduction: Respiratory diseases may affect the functioning of the heart, lung and heart work synchronously. Clinical assessment and work-up of patients with pulmonary problems may need an extension to cardiac disease. Thoracic Ultrasonography (TUS) is a diagnostic modality being used to assess respiratory conditions as it carries the inherent advantages of ultrasonography such as being reliable, inexpensive, safe, reproducible, and having no radiation hazard. Aim: To assess the usefulness of performing Thoracic Ultrasound (TUS) and 2D echocardiography in the same sitting, so as to confirm the respiratory diagnosis and to early identify various cardiac dysfunctions in patients with respiratory illnesses. Materials and Methods: This cross-sectional study was conducted in the Outpatient Department of Respiratory Medicine at Netaji Subhash Chandra Bose Medical College (tertiary care hospital), Jabalpur, Madhya Pradesh, India, from January 2019 to March 2020. Patients hospitalised with clinico-radiological diagnosis of pleural effusion, pneumonia, pulmonary fibrosis of interstitial lung disease, pulmonary oedema and Chronic Obstructive Pulmonary Disease (COPD) were subjected to TUS and echocardiography. Sonological findings and cardiac abnormalities were recorded. Data was analysed by applying descriptive statistics, t-test, and Chi-square test. Results: A total of 133 patients were enrolled with diagnosis of pleural effusion (n=46), pneumonia (n=22), pulmonary fibrosis (n=18), pulmonary oedema (n=14), and COPD (n=33). Out of total 46 patients,36 patients with pleural effusion had cardiac findings. The presence of pleural effusion showed a significant association with cor-pulmonale (p-value=0.012), dilated Right Ventricle (RV) (p-value=0.012), septal deviation (p-value=0.012), Pulmonary Hypertension (PH) (p-value=0.0002), Left Ventricular (LV) dysfunction (p-value=0.02) and Left Ventricular Ejection Fractions (LVEF) (p-value=0.006). The focal B-lines were seen in patients with pneumonia. Patients with Pulmonary fibrosis had scattered B-Lines, and patients with pulmonary oedema had bilateral diffuse B-lines. Among patients with pulmonary fibrosis, 11 (61.1%) had cor-pulmonale and dilated RV, whereas 10 (55.5%) had septal deviation. Patients with scattered B-lines more commonly had PH. A statistically significant association was found between lung ultrasound detected B-lines and cor-pulmonale, dilated RV, septal deviation, RV hypertrophy, Pulmonary Artery Systolic Pressure (PASP), and LVEF (p-value <0.005). In patients with COPD, cor-pulmonale was detected in 21 (68.8%), LV dysfunction in 5 (14.7%), mild PH in 14 (41.2%), moderate PH in 7 (20.6%), and severe PH in 5 (14.7%) using echocardiography. Conclusion: This study reveals the importance of performing a combination of TUS with 2D echocardiography and suggests its usefulness in early diagnosis of cardiac dysfunctions in patients with various respiratory illnesses.

Multi-disciplinary team meetings with specialist radiologists may improve pre-operative clinico-radiological diagnostic accuracy in patients requiring orbital biopsy and offer reciprocal educational opportunities.

Accurate pre-operative diagnosis of orbital lesions supports appropriate prioritisation of patients into available theatre time. We examine the accuracy of pre-operative clinico-radiological diagnosis in a tertiary centre with weekly dedicated orbital clinics and associated multi-disciplinary team meetings. A retrospective case notes review was undertaken for all patients who had an orbital biopsy performed at Bristol Eye Hospital between 2007 and 2017. In this centre, pre-operative clinico-radiological differential diagnoses are discussed during multi-disciplinary team meetings including two orbital specialist ophthalmologists and a specialist neuro-radiologist. Clinico-radiological diagnoses were compared with histopathological outcomes. Subcategory analysis according to histopathological diagnosis was undertaken to look for trends. 172 biopsies were taken from 156 patients, median age 59 years (range 3 months to 91 years). 60.9% of patient were females, with equal numbers of right and left-sided biopsies. 11 patients had inconclusive histopathology. 15 patients did not have a documented preoperative diagnosis or differential offered in available notes. 71 patients (49.0%) demonstrated an exact match between clinico-radiological and histopathological diagnosis, 93 (64.1%) demonstrated a category match (e.g. inflammatory, lymphoproliferative) and for 111 (76.6%), the histopathological diagnosis was considered within the list of proffered clinico-radiological differential diagnoses. Accuracy of pre-operative diagnosis of orbital lesions undergoing biopsy was higher in our series than previously reported by Koukoulli et al. Specialist head and neck radiology input via regular orbital multi-disciplinary meetings might be reciprocally educational and explain this difference. The authors recommend all surgeons who perform orbital surgery should have access to such multi-disciplinary meetings.

Accuracy of central neuro-imaging review of DIPG compared with histopathology in the International DIPG Registry.

Diffuse intrinsic pontine glioma (DIPG) remains a clinico-radiologic diagnosis without routine tissue acquisition. Reliable imaging distinction between DIPG and other pontine tumors with potentially more favorable prognoses and treatment considerations is essential. Cases submitted to the International DIPG registry (IDIPGR) with histopathologic and/or radiologic data were analyzed. Central imaging review was performed on diagnostic brain MRIs (if available) by two neuro-radiologists. Imaging features suggestive of alternative diagnoses included nonpontine origin, <50% pontine involvement, focally exophytic morphology, sharply defined margins, and/or marked diffusion restriction throughout. Among 286 patients with pathology from biopsy and/or autopsy, 23 (8%) had histologic diagnoses inconsistent with DIPG, most commonly nondiffuse low-grade gliomas and embryonal tumors. Among 569 patients with centrally-reviewed diagnostic MRIs, 40 (7%) were classified as non-DIPG, alternative diagnosis suspected. The combined analysis included 151 patients with both histopathology and centrally-reviewed MRI. Of 77 patients with imaging classified as characteristic of DIPG, 76 (99%) had histopathologic diagnoses consistent with DIPG (infiltrating grade II-IV gliomas). Of 57 patients classified as likely DIPG with some unusual imaging features, 55 (96%) had histopathologic diagnoses consistent with DIPG. Of 17 patients with imaging features suggestive of an alternative diagnosis, eight (47%) had histopathologic diagnoses inconsistent with DIPG (remaining patients were excluded due to nonpontine tumor origin). Association between central neuro-imaging review impression and histopathology was significant (p < 0.001), and central neuro-imaging impression was prognostic of overall survival. The accuracy and important role of central neuro-imaging review in confirming the diagnosis of DIPG is demonstrated.

Mild Encephalitis with Reversible Splenial Lesion Associated with COVID-19

Coronavirus disease-2019 (COVID-19) is an emerging pandemic disease with high morbidity and mortality. The area primarily affected in COVID-19 is the pulmonary system, where the most destructive effect occurs. Symptoms range from asymptomatic illness to mild-to-moderate (mild pneumonia), severe (dyspnea, hypoxia), and critical illness symptoms (acute respiratory distress syndrome, respiratory failure, shock, or multiorgan system dysfunction) in patients with COVID-19. Neurological manifestations, such as acute ischemic stroke, intracerebral hemorrhage, cerebral venous sinus thrombosis, conscious disturbance, febrile seizures, convulsions, mental status change, and encephalitis are observed in severe patients. Mild encephalitis/encephalopathy with reversible splenial (MERS) lesions is a clinicoradiological diagnosis that is associated with a prominent reversible lesion in the corpus callosum (SCC) splenium, infectious agent, and mild encephalopathy. In this case report, the key clinical and radiological features of MERS were highlighted in an adult patient presented to the emergency department with nausea, vomiting, and unconsciousness and admitted to the neurology clinic due to diffusion restriction in the SCC splenium.

MRI characteristics of brain edema in preeclampsia/eclampsia patients with posterior reversible encephalopathy syndrome

BackgroundThe neuroimaging manifestations of eclampsia and preeclampsia often overlap, mainly presenting as posterior reversible encephalopathy syndrome (PRES). The purpose of this retrospective study was to compare the extent and nature of brain edema in eclampsia and preeclampsia patients with PRES based on MRI characteristics.MethodsOne hundred fifty women diagnosed with preeclampsia-eclampsia and undergoing cranial MRI were enrolled; 24 of these were diagnosed as having eclampsia. According to clinicoradiologic diagnosis of PRES, eligible patients were classified as having eclampsia with PRES (group E-PRES) and preeclampsia with PRES (group P-PRES). A scale on T2W FLAIR-SPIR images was established to evaluate the extent of brain edema, and the score of brain edema (SBE) of both groups was compared. In patients of the two groups who also underwent DWI sequence, the presence or absence of hyperintensity on DWI and hypointensity on ADC maps were determined to compare the nature of brain edema. Furthermore, clinical and biochemical data of the two groups were compared.ResultsThe incidence of PRES in eclampsia patients was significantly higher than that in preeclampsia patients (87.50% vs. 46.03%, P<0.001). The SBE of all regions and typical regions in group E-PRES patients were significantly higher than those in group P-PRES patients (15.88±8.72 vs. 10.90±10.21, P=0.021; 8.52±3.87 vs. 5.01±4.19, P=0.002; respectively). The presence of hyperintensity on DWI was determined more frequently in group E-PRES patients than group P-PRES patients (71.43% vs. 32.00%, P=0.024). Age, systolic blood pressure, white blood cell count, neutrophil count and percentage of neutrophils were significantly different between the two groups (P<0.05).ConclusionsCertain MRI characteristics that reflect the extent and nature of brain edema were different between eclampsia and preeclampsia patients with PRES. Additional prospective studies are still required to explore whether these MRI characteristics of brain edema may further become a potential predictor for eclamptic seizures in preeclampsia patients with PRES.

Jarcho-Levin syndrome term baby with recurrent apnea

Jarcho-Levin syndrome or spondylocostal dysostosis, is a rare axial skeleton anomaly due to mutation in genes involved in somitic segmentation during embryogenesis. We describe a term, newborn baby with antenatally detected midthoracic lordotic deformity with skeletal features of multiple rib anomalies and vertebral defects, but with normal limb lengths. Baby had recurrent apnea requiring non-invasive ventilation and was successfully weaned to room air within 2 days. This syndrome is underdiagnosed and we wish to highlight the simple process involved in making a clinico-radiological diagnosis.

English

BACKGROUND Osteoid osteoma is a benign bone tumour which eventually undergoes spontaneous resolution but causes distress due to severe inflammatory pain and sleep loss. Major goal of ablative procedure is alleviation of symptoms. Long term follow up studies on pain remission and complications are less commonly available for microwave ablation. We wanted to assess alleviation of symptoms and long term complications in CT guided microwave ablation of osteoid osteoma. METHODS CT (Computed tomography) guided microwave ablation was performed on 10 patients referred with clinicoradiological diagnosis of osteoid osteoma and their preoperative and 6 month postoperative numerical pain scale, frequency of pain, disability and analgesic uses were compared. Subjects were between 13 and 30 years of age. RESULTS Pain scale dropped to 0 in 9 out of 10 patients. The single remaining patient had partial remission at 6 month follow up. The only complication encountered was wound site infection. All patients were free of analgesic use, disability due to pain, and sleep loss, on follow up. CONCLUSIONS Microwave ablation as an ablative procedure offers many potential benefits and appears to have good treatment response rate with minimal complications. KEY WORDS Osteoid Osteoma, Microwave Ablation, Bone, Interventional Radiology

What is the current clinico-radiological diagnostic accuracy for intracranial tumours?

To determine the diagnostic accuracy of routine clinico-radiological workup for a population-based selection of intracranial tumours. In this prospective cohort study, we included consecutive adult patients who underwent a primary surgical intervention for a suspected intracranial tumour between 2015 and 2019 at a single-neurosurgical centre. The treating team estimated the expected diagnosis prior to surgery using predefined groups. The expected diagnosis was compared to final histopathology and the accuracy of preoperative clinico-radiological diagnosis (sensitivity, specificity, positive and negative predictive values) was calculated. 392 patients were included in the data analysis, of whom 319 underwent a primary surgical resection and 73 were operated with a diagnostic biopsy only. The diagnostic accuracy varied between different tumour types. The overall sensitivity, specificity and diagnostic mismatch rate of clinico-radiological diagnosis was 85.8%, 97.7% and 4.0%, respectively. For gliomas (including differentiation between low-grade and high-grade gliomas), the same diagnostic accuracy measures were found to be 82.2%, 97.2% and 5.6%, respectively. The most common diagnostic mismatch was between low-grade gliomas, high-grade gliomas and metastases. Accuracy of 90.2% was achieved for differentiation between diffuse low-grade gliomas and high-grade gliomas. The current accuracy of a preoperative clinico-radiological diagnosis of brain tumours is high. Future non-invasive diagnostic methods need to outperform our results in order to add much value in a routine clinical setting in unselected patients.

Incidentalomas of the female genital tract on 64-slice MDCT: a clinico-radiological pictorial review.

Sonography is the imaging modality of choice for diagnosing diseases of the female genital tract due to its high resolution, easy availability, low cost and lack of radiation. CT is not advocated for the primary evaluation of the female pelvis. However, with the advent of Multidetector CT (MDCT), females of all ages undergo CT scan of the abdomen and pelvis for myriad non-gynaecological diseases, e.g. subacute intestinal obstruction, abdominal lump, abdominal tuberculosis, appendicitis, ureteric colic, pancreatitis, oncological staging, follow-up, etc. Incidental female genital tract disorders were seen on these scans that are a dilemma for both, the radiologists and the clinicians. The objective of this pictorial review is to characterise the incidentally detected lesions of the female genital tract observed on 64-slice MDCT by correlating with sonography, if necessary, and establishing a clinico-radiological diagnosis. Our aim is to emphasise that the radiologist may be the first person to recognise a gynaecologic disorder and hence can play a significant role in patient management.

Multidisciplinary team obviates biopsy in most patients with diffuse parenchymal lung diseases—A retrospective study from India

The inflammation and fibrosis in diffuse parenchymal lung diseases (DPLDs) in varied proportions give rise to different patterns in radiology and histopathology. The radiological pattern on CT of the thorax most often allows us to make a diagnosis with varying levels of confidence, to optimize management. With a multidisciplinary team bringing the strengths of their individual domains of knowledge, clinical, radiological, histopathological, and in many cases rheumatological, the level of confidence in making this diagnosis increases, often to the stage where the diagnosis is most often right, is concordant with the diagnosis achieved at histopathology and therefore obviates the need for lung biopsy which carries its own costs and risks of complications. Our study emphasizes the role of the multidisciplinary team (MDT) in the management of DPLDs at a tertiary care referral center. Every case of DPLD presenting to our pulmonology department was discussed in an MDT meeting before subjecting them to any diagnostic intervention or therapy. A clinico-radiological diagnosis was made according to the 2002 ATS/ERS guidelines initially. Later an official ATS/ERS/JRS/ALAT statement on idiopathic pulmonary fibrosis and a 2013 ATS/ERS consensus for the classification and diagnosis of idiopathic interstitial pneumonia was used. The concordance in our study was defined as the percentage of histopathological diagnoses that were identical to the clinico-radiological MDT diagnosis prior to the biopsy. A total of 434 patients with DPLDs were evaluated. The MDT suggested biopsy for only 38.7% (168/434) patients since the pattern was very clear in 266 (61.3%) cases. As not all patients consented to undergo the biopsy procedure when recommended, histopathology was obtained in 102 patients. The histological diagnosis was concordant with the initial MDT diagnosis in 80.3% (82/102) of samples. On an individual basis, connective tissue disease-interstitial lung disease and sarcoidosis showed the best concordance (87%). In idiopathic non-specific interstitial pneumonitis (NSIP) cases, the histopathological diagnosis concurred in only 53.3% (8/15), out of which 8 were NSIP, 4 were usual interstitial pneumonia, and 3 were reported as inadequate sampling on histopathology. The MDT plays a crucial role in the diagnosis of DPLDs. Not every pattern requires biopsy confirmation. However, an idiopathic non-specific interstitial pneumonitis diagnosis by the MDT should probably be better confirmed by biopsy.

A Step-by-Step Sonographic Approach to Vascular Anomalies in the Pediatric Population: A Pictorial Essay.

Vascular anomalies are a common cause of soft-tissue masses in children and often referred for ultrasonographic (USG) evaluation. They are broadly classified as vascular tumors (hemangiomas, hemangioendotheliomas, and angiosarcomas) or vascular malformations (venous malformations, lymphatic malformations, and arteriovenous malformations). Findings on USG and Doppler imaging can be used to categorize vascular anomalies into high- or low-flow lesions, which forms the basis for further workup, diagnosis, and management. On careful evaluation of various sonographic features, in conjunction with clinical findings, an accurate clinicoradiological diagnosis can be made in most cases. Further imaging with magnetic resonance (MR) imaging or computed tomography (CT) helps in delineation of lesion extent, whereas MR or CT angiography is useful to map the vascular supply of high-flow lesions. We have illustrated and discussed a step-by-step approach to diagnose vascular anomalies using ultrasound and Doppler imaging.

Mc Cune Albright Syndrome - Clinicoradiological Diagnosis of a Rare Case

Mc Cune Albright Syndrome (MAS) is a rare, sporadic disorder characterized by a triad of symptoms: fibrous dysplasia, cafe-au-lait spots, and endocrinopathy. It is thought to be caused by the mutation of the GNAS1 gene and is predominantly a disease of females. We hereby report a case of a 40-year-old man who presented with suppuration and mobility of teeth in the maxillary left posterior region. The patient also had a history of recurrent fractures of limbs since childhood. Clinical examination revealed asymmetry of the face, brownish-tan macules on the nape of the neck, back, and bilateral buccal mucosa as well as lower labial mucosa. The radiological investigation confirmed the presence of polyostotic fibro-osseous lesion while the biochemical investigations revealed endocrinopathy (hyperparathyroidism). This case report emphasizes the role of an oral physician in arriving at the diagnosis of a complex disorder like MAS.

Prenatal Ultrasonographic and Magnetic Resonance Imaging Diagnosis of Occipital Meningio-Encephalocele- An Interesting Case Report

Meningo encephalocele is a congenital anomaly and is a neural tube defect with occipital meningo encephalocele being the most common and is a result of a failure of the surface ectoderm to separate from the neuroectoderm. This condition can be identified in 1st trimester in 80% of cases and almost all by 2nd trimester. A 20-year-old third gravida was referred for antenatal Ultrasonography at five months of amenorrhoea to rule out fetal anomalies. On targeted imaging, for fetal anomalies, a defect was seen in occipital bone with herniation of posterior fossa contents with overlying meningeal covering. No other fetal anomalies were noted. A diagnosis of isolated occipital meningoencephalocele was made with additional fetal MRI correlation. The mother underwent termination of her pregnancy by Department of Obstetrics and Gynecology because of the grim fetal prognosis. The mother was advised to plan the subsequent pregnancies and was advised pre-conceptional folic acid supplementation. We present a case of isolated occipital meningoencephalocele- a rare congenital anomaly which was diagnosed prenatally in our hospital. This case provides an opportunity for identifying such neurological defects early and prompt termination of pregnancy to prevent comorbidity to mother. This study also helps to establish occipital meninigioencephalocele as an isolated clinicoradiological diagnosis and to distinguish it from syndrome associated occipital meninigioencephalocele or those associated with other neural tube defects like Chiari III malformations. It also allows us to stress once again the role of periconceptional folic acid in preventing the occurrence of neural tube defects.

Adnexal Mass with an Unknown Histology

Background: Ovarian malignancy is a common malignancy in women. Most malignancies are adenocarcinoma. However, adnexal metastases from squamous cell carcinoma (SCC) of the cervix are uncommon. Case: We present a 53-year-old nulliparous postmenopausal woman who presented with pain in abdomen, adnexal mass, and high CA125 levels. On local examination, vagina and cervix were apparently healthy with retroverted uterus of normal size, and bilateral (B/L) forniceal thickening was present. Pouch of Douglas and rectal mucosa were free. Clinicoradiologic diagnosis was an ovarian malignancy. Results: Intraoperatively, ∼150 mL mucinous ascites and omental caking with subcentimeter deposits on right subhepatic peritoneum were noted. Uterus was apparently normal and B/L adnexal masses with stretched and dilated B/L tubes were seen, ovaries could not be visualized separately (right = 6 × 5 cm, left = 7 × 4 cm). B/L pelvic lymph nodes were grossly enlarged with pelvic peritoneal deposits. A total abdominal hysterectomy with B/L pelvic lymph node dissection with total omentectomy with excision of pelvic and subhepatic peritoneal deposits with appendicectomy was done and a Sugarbaker's completeness cytoreduction score 0 (CC-0) was achieved. Final histopathologic examination postsurgery revealed disseminated SCC of the cervix. Conclusions: Before confirming a diagnosis of primary SCC of the ovary, a consideration of possible origin from a cervical tumor should be made, unless overt features of primary neoplasia are immediately obvious.

The Use of Treatment Response Assessment Maps in Discriminating Between Radiation Effect and Persistent Tumoral Lesion in Metastatic Brain Tumors Treated with Gamma Knife Radiosurgery

Traditional imaging modalities are not useful in the follow-up of irradiated metastatic brain tumors, because radiation can change imaging characteristics. We aimed to assess the ability of treatment response assessment maps (TRAMs) calculated from delayed-contrast magnetic resonance imaging (MRI) in differentiation between radiation effect and persistent tumoral tissue. TRAMs were calculated by subtracting three-dimensional T1 MRIs acquired 5 minutes after contrast injection from the images acquired 60-105 minutes later. Red areas were regarded as radiation effect and blue areas as persistent tumoral lesion. Thirty-seven patients with 130 metastatic brain tumors who were treated with Gamma Knife radiosurgery and who underwent TRAMs perfusion-weighted MRI were enrolled in this retrospective study. The median age was 58 years and the most common primary diagnosis was lung cancer (n= 21). The median follow-up period of patients was 12 months. The overall local control rate was 100% at 1 year and 98.9% at 2 years. The median progression-free survival was 12 months. The mean overall survival was 27.3 months. The radiologic and clinical follow-up showed a clinicoradiologic diagnosis of a persistent tumoral lesion in 3 tumors (2.3%) and radiation effect in 127 tumors (97.7%). There was a fair agreement between clinicoradiologic diagnosis and TRAMs analysis (κ= 0.380). The sensitivity and positive predictive value of TRAMs in diagnosing radiation effect were 96.06% and 99.2%, respectively. TRAMs showed comparable results to perfusion-weighted MRI, with a diagnostic odds ratio of 27.4 versus 20.7, respectively. The presented results show the ability of TRAMs in differentiating radiation effect and persistent tumoral lesions.