Focal Mass Research Articles

Feasibility and effectiveness of image-guided percutaneous biopsy of the urinary bladder.

To evaluate the indications, technique, results, and complications of image-guided percutaneous biopsy of the urinary bladder. This retrospective study included 15 patients (10 male, 5 female) who underwent image-guided percutaneous biopsy of the urinary bladder between January 1999 and December 2013. The medical records, imaging studies, procedural details, and long-term follow-up of each patient were reviewed in detail to assess the feasibility of percutaneous bladder biopsy. Ten patients had focal bladder masses and 5 patients had asymmetric or diffuse bladder wall thickening. Eleven patients had either negative or unsatisfactory cystoscopies prior to the biopsy. Percutaneous biopsies were performed under computed tomography guidance in 12 patients and ultrasound in 3 patients. All procedures were technically successful and there were no procedural complications. Malignancy was confirmed in 8 patients, among whom 6 had transitional cell carcinoma, 1 cervical cancer, and 1 prostate cancer metastasis. Seven patients had a benign diagnosis, including 3 that were later confirmed by pathology following surgery and 2 patients with a false-negative result. The overall sensitivity was 80% and accuracy was 87%. Image-guided percutaneous biopsy of the urinary bladder is a safe and technically feasible procedure with a high sensitivity and accuracy rate. Although image-guided bladder biopsy is an uncommon procedure, it should be considered in selected cases when more traditional methods of tissue sampling are either not possible or fail to identify abnormalities detected by cross-sectional imaging.

Nodding Episodes and High Anion Gap in a 13 Year Old Child with Nodding Syndrome: A Case Report

Introduction: Nodding syndrome is an unknown neurological disorder affecting children in Northern Uganda, South Sudan and Southern Tanzania. The patient in our case report is, to the best of our knowledge, the first with the syndrome that has been serially followed up for more than three months and the information obtained provides important clue to the possible risk factor to the syndrome. Case Study Kitara et al.; BJMMR, 6(8): 851-858, 2015; Article no.BJMMR.2015.260 852 Case Presentation: A 13-year-old boy diagnosed in Atanga Health Centre III using World Health Organization (WHO) surveillance case definition as probable Nodding syndrome was referred to Gulu Regional Referral Hospital with pyomyositis of abdominal wall muscle and head nodding which was not responding to treatment. Serial anthropometry and laboratory investigations including, haematology, clinical chemistry, biochemistry and muscle biopsy were conducted in a period of 3 months and compared to the nodding episodes. Complete blood count showed leucocytosis with immature granulocytes and atypical lymphocytes mainly during the infective phase of the pyomyositis but returned to normal as a result of the surgical procedure, Incision, Drainage and Debridement (I, D & D) of pyomyositis of the anterior abdominal wall muscle combined with administration of antibiotics and analgesics. The liver enzymes were high throughout the period of admission in Gulu Hospital. The renal parameters and serum electrolytes were within normal ranges during the nodding free periods but it was deranged during the nodding episodes. Abdominal ultrasound scan showed a focal mass on the right internal and external oblique muscles of the abdominal wall. Histology of the muscle showed a non-specific inflammation of the abdominal muscles with mass necrosis of the muscle and thrombosed blood vessels. These findings highlight the concurrent existence of pyomyositis in a child with Nodding Syndrome but whose nodding episodes were pronounced during the periods with imbalanced electrolyte pattern and with high anion gap. In conclusion: Nodding syndrome is an unknown neurological disorder affecting children whose nodding episodes are probably related to the high Anion Gap metabolic acidosis.

Comparison of Intra-voxel Incoherent Motion Diffusion Magnetic Resonance Imaging and Apparent Diffusion Coefficient in the Evaluation of Focal Malignant Liver Masses

Aim: To compare the apparent diffusion coefficient (ADC) derived from conventional diffusion-weighted imaging (DWI), and parameters derived from intra-voxel incoherent motion (IVIM) diffusion, in the differentiation of common focal malignant liver masses. Methods: DWI of 53 patients with 85 focal liver masses (47 hepatocellular cancers [HCCs], 18 cholangiocarcinomas, and 20 metastases) were recruited to receive a 3.0T MR scanner with 2 b values (0, 700 s/mm [2] ) to measure the ADC values and with 7 b values (0, 50, 100, 250, 500, 750, 1000 s/mm [2] ) to measure IVIM derived parameters: true diffusion coefficient (D), perfusion related diffusion coefficient (D*) and perfusion fraction (f). The mean of each parameter was compared by the Dunnett multiple comparison test. Results: Both ADC and D were significantly higher in cholangiocarcinomas than in HCCs (ADC: 1.49 ± 0.27 × 10 −3 vs . 1.20 ± 0.26 × 10 −3 mm 2 /s and D: 0.94 ± 0.17 × 10 −3 vs . 0.53 ± 0.23 × 10 −3 mm 2 /s, respectively; P = 0.002 and P Conclusion: D improved the accuracy of differentiating HCCs and cholangiocarcinomas compared to ADC.

MR Imaging of Non-Traumatic Intrinsic Brachial Plexus Neuropathy: Spectrum of Findings

Objective: Non-traumatic intrinsic neuropathy of the brachial plexus (BP) could be because of focal or diffuse involvement. The purpose of this article is to focus on MR imaging spectrum and illustrate key features of a variety of pathologic entities based on review of 21 imaging studies. This paper highlights the detailed MR anatomy, the imaging techniques and the spectrum of MR imaging appearances of focal and diffuse form of non-traumatic intrinsic brachial neuropathy. Materials and methods: We retrospectively reviewed 140 consecutive BP MR examinations performed at our institution over a period of four years from August 2006 to August 2010. We excluded cases of diverse clinical data including both traumatic and non-traumatic extrinsic compressive brachial neuropathies occuring along the course of the BP. Of 140 MR imaging studies of the BP, 75 were excluded and remaining 65 imaging studies were included for review. BP was assessed for the calibre, continuity, presence and distribution of signal changes (focal or diffuse) and focal masses. Results: 21 of the 65 included imaging studies showed features of non-traumatic intrinsic BP neuropathy. The diagnosis was made on the basis of MR findings, electromyographic (EMG), clinical patient information and histopathological findings. The diagnosis included spectrum of neoplastic and non-neoplastic conditions like perineurioma, radiation plexitis, chronic inflammatory demyelinating polyneuropathy (CIDP) and hereditary motor sensory neuropathy (HMSN).

Head mass in chronic pancreatitis: Inflammatory or malignant.

Chronic pancreatitis increases the risk of developing pancreatic cancer. This often presents as a mass lesion in the head of pancreas. Mass lesion in the head of pancreas can also occur secondary to an inflammatory lesion. Recognising this is crucial to avoid unnecessary surgery. This is sometimes difficult as there is an overlap in clinical presentation and conventional computed tomography (CT) abdomen findings in inflammatory and malignant mass. Advances in imaging technologies like endoscopic ultrasound in conjunction with techniques like fine needle aspiration, contrast enhancement and elastography as well as multidetector row CT, magnetic resonance imaging and positron emission tomography scanning have been shown to help in distinguishing inflammatory and malignant mass. Research is ongoing to develop molecular techniques to help characterise focal pancreatic mass lesions. This paper reviews the current status of imaging and molecular techniques in differentiating a benign mass lesion in chronic pancreatitis and from malignancy.

Localized pulmonary histiocytic sarcomas in Pembroke Welsh Corgi.

Nineteen cases of histiocytic sarcomas in Pembroke Welsh Corgi were examined histopathologically. Focal or multiple masses were detected in the lung or in regional lymph nodes, or in both lung and nodes. All neoplastic lesions had common histological features characterized by the proliferation of pleomorphic histiocytic cells combined with various inflammatory cells. Most of the pleomorphic neoplastic cells were immunopositive for human leukocyte antigen (HLA)-DR and Iba-1. The median survival time for all dogs was 133 days. In the present study, several prognostic factors, such as gender, age, single or multiple lesions, lymph node involvement at the time of diagnosis, surgical resection status and additional chemotherapy, were examined, although none of these factors approached statistical significance. Histiocytic sarcoma must be considered in the differential diagnosis of dogs with pulmonary masses, especially in the canine breed.

Opportunities of magnetic resonance imaging in differential diagnosis of focal liver masses

Opportunities of magnetic resonance imaging in differential diagnosis of focal liver masses

Application of an Advanced Image-Based Virtual Monoenergetic Reconstruction of Dual Source Dual-Energy CT Data at Low keV Increases Image Quality for Routine Pancreas Imaging.

To compare image quality on contrast-enhanced dual-energy computed tomography (DECT) during the pancreatic parenchymal phase of pancreatic masses between linearly-blended simulated 120 kVp images (routine) and advanced image-based virtual monoenergetic reconstructions at 55 keV. This was a retrospective evaluation of 24 nonconsecutive adults found to have a focal pancreatic mass on a multiphasic abdominal dual-source DECT (12 adenocarcinoma, 5 neuroendocrine, 7 cystic tumors). For pancreatic-parenchymal phase images, subjects had routine and 55 keV images reconstructed at the time of clinical evaluation. Quantitative evaluation by contrast-to-noise ratio and qualitative evaluations of image quality by (1) direct comparison of image pairs (preference) and (2) blinded assessment of image quality measures based on Likert scores were performed. Mean patient weight was 205.8 ± 26.6 lbs. Mean pancreatic lesion contrast-to-noise ratio was significantly higher at 55 keV (6.8 ± 4.1) compared to the routine image series (5.8 ± 3.8; P = 0.0002). All 3 readers preferred the 55-keV images over routine blended images in 70.1% to 95.8% of cases. No significant differences were observed for subjective sharpness of the mass, visualization of internal mass structures, or image noise. Use of a single advanced image-based virtual monoenergetic reconstruction at 55 keV in pancreatic DECT showed improved objective image quality and reader preference compared to routine images. As this image reconstruction can be incorporated into the scan protocol, this technique should be considered for routine clinical use.

Ultrasound for breast condition monitoring in females using levonorgestrel-containing intrauterine systems for 5 years

Aim. To assess the breast condition in females using levonorgestrel-containing intrauterine system (20 μg) for 5-year period, by repeated ultrasound monitoring. Methods. Results of regular clinical examination and breast ultrasound repeated during 5 years of follow up in 118 women aged 30 to 55 years, continuously using levonorgestrel-containing intrauterine system (20 μg) for 5-year period, were analyzed. Results. According to the results of 5-year sonographic monitoring of breast condition in females using levonorgestrel-containing intrauterine system, breast cancer was diagnosed in 2 (1.7%) patients during the first 6 months of the research; no other cases were discovered during the subsequent follow-up. Fibroadenoma of the breast was diagnosed in 3 (2.5%) women, which was lower compared to statistical prevalence in general population (5%). By the end of the follow-up period, no mammary gland adenosis foci were found at ultrasound. The number of patients with breast cysts decreased, as well as the number of breast cysts in single patient, which were found in 41 (34.7%) female patients before the treatment and in 13 (11.0%) patients after a year of treatment with levonorgestrel-containing intrauterine system. No mammary gland dilatation was diagnosed before levonorgestrel-containing intrauterine system was administered, during the first year of treatment it was revealed in 16 (13.5%) patients. According to the results of ultrasonography, maximal size of fibrous glandular complex after 5 years of treatment was 16.2 mm, mean - 10.2 mm (before the treatment - 18.2 and 14.2 mm respectively, after 1 year of treatment - 17.4 and 13.3 mm respectively. Conclusion. The use of levonorgestrel-containing intrauterine system was associated with favorable effects on breast condition. No adenosis foci were further found, the number of patients with mammary gland cysts decreased as well as the number of the cysts, the fibrous glandular complex thickness has decreased, revealing the downward trend for breast focal masses formation.

Gross Hematuria and Focal Renal Masses as Initial Features of a Mature B-cell Leukemia in an Adolescent Male

We report a case of a 14-year-old boy who presented with gross hematuria and focal bilateral renal masses as presenting features of a mature high-grade B-cell leukemia, Burkitt subtype. The patient was treated with standard chemotherapy with the addition of rituximab and has no evidence of disease on completion. To our knowledge, this is the first case to describe gross hematuria in conjunction with focal bilateral renal masses as presenting features in a pediatric patient with Burkitt leukemia. This unique presentation suggests that early leukemic infiltration of the urinary collecting system may occur but is extremely unusual.

Two Diseases, One Treatment: The Challenges Faced When Treating an Overlap Syndrome

Introduction: A 53-year-old female with arterial hypertension and bronchial asthma complained of abdominal pain for the past 4 months. The pain was epigastric, stabbing, 10/10, irradiating to the lower abdomen, lasting hours to days, not associated to food, and without any improving or worsening factors. This was accompanied by nausea and 2-3 episodes of vomiting per day, of gastric content without blood or bile. She had anorexia with an 8-pounds loss in 6 months, general malaise, weakness, fatigue, itching, joint pain (wrist, elbow, and knee), dry mouth and eyes, and occasional swelling of her legs. She also complained of a red rash throughout the body, and hyperpigmentation of the arms. She used alcohol daily for 30 years and smoked 10-15 cigarettes each day, but quit both 5 years ago. Physical exam showed an overweight patient with a body mass Index of 28.7 kg/m2. Scattered bilateral forearm hyperpigmented areas and erythematous blanching papules were present in the chest and extremities. The abdomen showed no distention, normal bowel sounds, diffuse tenderness to deep palpation, no rebound tenderness, no palpable spleen, resonant percussion, a liver span of 11 cm, and no shifting dullness. Laboratories showed normal CBC, prothrombin time, and partial thromboplastin time. Aspartate and alanine aminotransferases were 308 and 407 IU/L respectively, alkaline phosphatase was 467 IU/L, total bilirubin was 1.25 mg/dL, and globulins were 8.3 g/dL. Hepatitis serology, lipid panel, iron studies, and anti-nuclear antibody were normal. Anti-mitochondrial antibody titers were 1:640 and immunoglobulin M was 425 mg/dL. Abdominal sonogram showed a liver normal in size, echotexture, and echogenicity without any focal mass. Liver biopsy showed chronic portal inflammation (confluent necrosis) with lymphocytes and plasma cells suggestive of autoimmune hepatitis, and bile duct destruction and loss suggestive of primary biliary cirrhosis. The diagnosis of overlap syndrome was made. On follow-up, improvement of liver enzymes without any therapy was noted. It was decided to start the patient only on ursodiol 15 mg/kg. After 4 months, there was a complete normalization of all liver chemistry. Deciding whether to target the autoimmune hepatitis or the biliary component is a challenging decision for the clinician. Individual features usually guide the decision, and close observation of the response is necessary. Adequate response to therapy is not always obtained, even when combined therapy is given. Randomized clinical trials comparing single versus combined therapy for both diseases are necessary to define therapeutic guidelines for the overlap syndrome. Disclosure - Dr. Torres - Advisory board: AbbVie.

IgG4-Related Autoimmune Pancreatitis Presenting With Multiple Extrapancreatic Manifestations

Introduction: A 43-year-old male presented with a 1-year history of an asymptomatic left inguinal mass. CT scan demonstrated a 5.3-cm well-circumscribed round heterogeneous mass in the left inguinal region, but also demonstrated a conglomerate nodal 13-cm mass surrounding the infrarenal aorta and proximal common iliac arteries, as well as pulmonary micronodules. Excisional biopsy of the inguinal mass demonstrated a benign reactive lymph node. One year later, the patient presented with an acute onset of epigastric abdominal pain and obstructive jaundice. His labs demonstrated an elevated total bilirubin of 5.6 mg/dL, alkaline phosphatase of 210 IU/mL, and ALT of 504 IU/mL, with normal previous values 3 months prior. Serum lipase was 70 units/L. MRI demonstrated a diffusely enlarged pancreas. There was also intra- and extrahepatic biliary ductal dilatation to 10 mm and mucosal enhancement of the bile duct and gallbladder. His symptoms did improve on antibiotics. His serum IgG4 eventually returned at 851 mg/dL with the remainder of IgG subclasses being normal. One month later, he was readmitted for recurrent painless jaundice. Labs demonstrated a serum total bilirubin of 14.7 mg/dL, alkaline phosphatase of 698, AST of 120, and ALT of 224. CT demonstrated worsened diffuse bile duct dilatation to 2.4 cm and complete effacement of the common bile duct at the pancreatic head with distal decompression. The pancreas was also persistently enlarged. The patient was started on prednisone 40 mg once daily. One week later, endoscopic ultrasound demonstrated heterogeneous pancreatic parenchyma with findings consistent with chronic pancreatitis with no focal pancreatic mass. The bile duct dilation improved to 12.5 mm. ERCP demonstrated a smooth stricture in the distal common bile duct with no filling defects. A sphincterotomy was performed and a plastic stent was placed. Fine needle aspiration of the pancreas was nondiagnostic. On follow-up 3 weeks later, the patient’s jaundice and laboratory abnormalities completely resolved. A serum IgG4 and repeat imaging have been ordered and are currently pending. His corticosteroid dose was tapered. This case illustrates interesting findings of type 1 IgG4-related autoimmune pancreatitis along with extra-pancreatic involvement consisting of IgG4-related autoimmune cholangitis, periaortitis, pulmonary nodules, and inguinal lymphadenopathy, and hence his clinical picture meets 4 out of the 5 Mayo Clinic “HISORt criteria.” With corticosteroids, his symptoms of pancreatitis and cholestasis did resolve, as did his laboratory abnormalities. Follow-up imaging and serum IgG4 is currently pending and will be available to report by the time of presentation of this clinical vignette.

IgG4-Related Focal Autoimmune Pancreatitis and Küttner’s Tumour

Introduction: Type 1 autoimmune pancreatitis (AIP) or chronic sclerosing sialadenitis (Küttner’s tumour) is an uncommon disorder that has recently been confirmed as an IgG4-related disease (IgG4-RD). Here, we report a rare case of a patient with IgG4-related focal type of AIP (f-AIP) accompanied with Küttner’s tumour manifesting itself as a mass in the neck and several lumps in the lower lip, which was originally misdiagnosed of being PC with neck metastasis. Methods: A 53-year-old male from northeast China was admitted for abdominal distension and diarrhea lasting for 4 years. He presented a painless, hard left neck mass with slight dysfunction of salivary secretion and a 20-pound weight loss over 6 months. One year prior to admission, CT imaging identified a possible pancreatic body carcinoma resulting in surgical resection of the pancreatic body and tail with en-bloc splenectomy at that time. The patient denied any history of alcohol, tobacco, or illicit drug use. On examination, several firm 0.3-cm non-tender lumps were seen in the mucosa of his lower lip. He also had a painless, hard, fixed mass in the left submandibular area (suspected cervical metastasis). Abdominal examination revealed mild epigastric tenderness to deep palpation without rebound. The laboratory test data on admission revealed high levels of IgG4 (32.7 g/L) and positive reaction with anti-nuclei antibody. An ultrasound scan of the neck showed left swollen submandibular gland (4.2 cm length × 2.8 cm width × 2.1 cm height), suggesting the possibility of chronic sialadenitis. An enhanced CT scan of the abdomen revealed a relatively low density of the pancreatic head as well as extra- and intrahepatic bile duct dilatation, suggesting the possibility of pancreatic head cancer. The patient underwent labial gland lumps resection and an ultrasound-guided biopsy of the left neck mass. He was diagnosed with IgG4-related f-AIP and Küttner’s tumour on the basis of numerous IgG4-positive plasma cells in excisional pancreatic body mass sample and labial gland specimen. The patient responded well to corticosteroid therapy and remains healthy, with no signs of recurrence at 1-year follow-up. Conclusion: IgG4-RD is a recently recognized multi-organ fibro-inflammatory condition with a propensity to manifest itself as a mass-forming lesion characterized by the presence of abundant IgG4+ plasma cells, elevation of serum IgG4 levels, and a dramatic steroid responsiveness. Since the differentiation of f-AIP from PC is very difficult and their treatment and prognosis are quite different, we suggest that AIP should always be considered in case of a focal pancreatic mass.

Dynamic contrast-enhanced MRI findings of acute pancreatitis in ectopic pancreatic tissue: case report and review of the literature.

Acute pancreatitis in ectopic pancreatic tissue is an uncommon cause of acute abdominal pain and can be difficult to diagnose on imaging. Our aim is to raise awareness and aid in the diagnosis of this entity by highlighting helpful dynamic contrast-enhanced MRI imaging findings.We report a 51-year-old man with acute onset epigastric pain presented to ER. With the presence of elevated serum lipase, the clinical diagnosis of acute pancreatitis was made. Contrast enhanced CT demonstrated normal pancreas and a focal mass at the duodenojejunal flexure, mimicked a neoplasm. Subsequent dynamic contrast enhanced MR images demonstrated enhancement pattern of the lesion similar to the native pancreatic tissue enhancement, a finding raised the possibility of acute pancreatitis in ectopic pancreatic tissue, but tumor was not excluded. Finally, patient undergone surgical bowel resection including the suspected mass that was proved as an ectopic pancreatic tissue on microscopic examination.We concluded that findings on dynamic contrast enhanced MR imaging can be characteristic and diagnostic of acute pancreatitis in ectopic pancreatic tissue in the appropriate clinical setting.

Primary adnexal angiosarcoma masquerading as periorbital hematoma

We report an elderly woman who was anticoagulated and presented with a recent history of right-sided orbital contusion and a periorbital hematoma without clinical or radiological evidence of focal mass or orbital involvement. She was initially treated conservatively. Continued progression of adnexal swelling and erythema prompted further investigation, however. There was no improvement with surgical drainage alone; biopsy revealed angiosarcoma. The discovery of this vascular tumor underscores the importance of a reconsideration of the diagnosis in the face of counterintuitive findings. Additionally, we emphasize the need to consider malignancy in the differential diagnosis of prolonged periorbital swelling, regardless of a history of recent trauma.

IgG4‐related disease: a new kid on the block or an old aquaintance?

IgG4-related systemic disease is a recently recognized systemic condition characterized by unique pathological features that can affect a variety of organs. It includes a growing number of medical conditions which have the following features in common: diffuse organ swelling or focal mass formation, sclerosing storiforme (whirl-shaped) fibrosis with a lymphoplasmacytic infiltrate rich in IgG4-bearing plasma cells, as well as elevated levels of serum IgG4. It invariably responds to steroid treatment and is mostly diagnosed in elderly men. Well-known syndromes like Mikulicz's disease of the salivary or lacrimal gland, Küttner's tumour of the submandibular gland, Riedel's thyroiditis, or retroperitoneal fibrosis, as well as novel entities such as autoimmune pancreatitis type 1, are now regarded to be manifestations of this systemic disease. This article provides an overview of the epidemiology, concepts of pathogenesis, clinical presentation, proposed diagnostic approaches, treatment options, and differential diagnosis of IgG4-related disease.

Patterns of presentation and failure in patients with gliomatosis cerebri treated with partial-brain radiation therapy.

The patterns of lobar involvement, optimal treatment, and disease course among patients with gliomatosis cerebri (GC) have not been fully characterized. The current study evaluates the clinical presentations and outcomes for patients with GC treated with radiation therapy (RT) at our institution. A total of 26 patients (25 with follow-up) with GC were diagnosed and treated between January 2004 and June 2012. Inclusion criteria consisted of brain magnetic resonance imaging and neuroradiology confirmation of contiguous involvement of ≥ 3 lobes/lobar equivalents with preservation of neural architecture. Patients were treated with either partial-brain RT to involved tumor (25 patients) or whole-brain RT (1 patient). The median RT dose was 54.0 Gray. The median follow-up was 17.3 months. The median age of the patients at the time of diagnosis was 57 years. Twenty-one patients (81%) and 5 patients (19%) had 3 to 6 and ≥ 7 involved lobes/lobar equivalents, respectively. The median progression-free survival and overall survival were 7.4 months and 14.9 months, respectively. Fifteen patients experienced radiographic disease progression after partial-brain RT, 14 of whom (93%) developed infield disease recurrence. On univariate analysis, higher tumor grade and type II GC (with focal mass) were associated with a poorer progression-free survival. The extent of lobar involvement and chemotherapy were not associated with overall survival. Even with partial-brain RT, nearly all disease recurrences were infield and clinical outcomes were similar to previous GC series, thereby suggesting that whole-brain RT is not necessary for this patient population. A greater number of involved lobes did not correlate with inferior outcomes. Further studies are necessary to establish more uniform and optimal treatments for this rare disease.

Double-Duct Sign in the Era of Endoscopic Ultrasound: The Prevalence of Occult Pancreaticobiliary Malignancy

Simultaneous dilatation of the common bile duct and pancreatic duct, "double-duct sign" (DDS), is an ominous finding concerning for pancreaticobiliary malignancy. Little evidence exists to guide the initial evaluation and subsequent follow-up for patients with DDS in the absence of jaundice or focal mass noted on computed tomography (CT)/ magnetic resonance imaging (MRI). Endoscopic ultrasound (EUS) is often recommended in the evaluation of such patients, however, the prevalence of malignancy remains unclear. We sought to determine the prevalence of pancreaticobiliary neoplasm in this patient group on initial EUS evaluation and on subsequent clinical follow-up. We performed a retrospective analysis of a prospective database at a tertiary-care academic medical center between 2010 and 2012. Eighty-two patients were identified who underwent EUS evaluation for DDS without evidence of a mass on CT/MRI and without jaundice. Sixty-eight of 82 patients had confirmed DDS on EUS with biductal dilation. Six (9 %) of 68 patients were found to have a mass lesion on EUS. In these patients, final diagnoses were pancreatic carcinoma (n = 4), ampullary carcinoma (n = 1) and ampullary adenoma (n = 1). In the 62 patients without evidence of a focal mass on initial EUS, the most common diagnoses were benign ductal dilation (n = 42), chronic pancreatitis (n = 9) and choledocholithiasis (n = 8). Fifty-eight (94 %) of 62 patients had documented median follow-up of 13 months, and none developed subsequent evidence of previously unrecognized malignancy. The presence of double-duct sign on EUS in patients without jaundice or mass lesion on CT/MRI is most frequently associated with benign conditions. When a mass is not detected on EUS, subsequent evidence of malignancy is unlikely.

Enlargement of the Infraorbital Nerve: An Important Sign Associated with Orbital Reactive Lymphoid Hyperplasia or Immunoglobulin G4–Related Disease

To describe the clinical, histopathologic, and radiologic features of a recently identified cause for enlargement of the infraorbital canal. Retrospective, noncomparative case series. Consecutive patients were identified from the orbital databases at Moorfields Eye Hospital, London, England, and the Royal Victorian Eye and Ear Hospital, Melbourne, Australia. A retrospective, noncomparative review of the clinical case notes, radiology, and histopathology was performed. The English-language medical literature was reviewed for reports of enlargement of the infraorbital canal or nerve. Extent of clinical and radiologic changes in patients with enlargement of the infraorbital canal. A total of 14 patients (10 male) presented between the ages of 29 and 76 years with proptosis, eyelid swelling or a mass (10/14 cases), and periocular ache (5/14 cases). Clinical evidence of bilateral involvement was present in 6 of 14 patients. None had impairment of visual functions or facial sensation, but 4 of 14 patients had some reduction in ocular motility. Imaging showed a focal orbital mass in 10 of 14 patients (16/28 orbits), and all patients (22/28 orbits) had enlargement of some extraocular muscles. The infraorbital canal was enlarged in 20 of the 28 orbits, with associated ipsilateral orbital changes in 19 of 20 (all 14 patients) and ipsilateral maxillary sinus changes in 12 of 20 (11 patients). Biopsy-proven chronic orbital inflammation was present in all patients; this resembled reactive lymphoid hyperplasia (RLH) in 7 patients and immunoglobulin (Ig) G4-related sclerosing inflammation in 7 patients. When tested, serum IgG4 was elevated in 6 of 7 patients. Clinical or histologically proven enlargement of cervical lymph nodes was present in 7 of 14 patients. All patients responded well to systemic corticosteroid therapy, although some had a relapse upon withdrawal. One patient developed diffuse large B-cell lymphoma and subsequently leukemia, of which he later died 20 years after presentation. Enlargement of the infraorbital nerve and canal is rare and strongly suggests a diagnosis of RLH or IgG4-related disease, especially in the presence of ipsilateral extraocular muscle enlargement, sinus disease, or focal orbital disease.

Accuracy of Transvaginal Ultrasonography for Detecting Intrauterine Lesions at a Taiwan Medical Center: A Correlation with Ultrasound and Hysteroscopic Histopathology

Transvaginal ultrasound (TVUS) can detect intrauterine benign focal pathological mass lesions such as polyps and measure endometrial thickness (ET) in patients with or without abnormal uterine bleeding (AUB). Our study assessed TVUS images for evaluating and measuring benign focal intrauterine lesions. This study retrospectively analyzed symptoms, ultrasound findings, and final histopathological reports for 184 women who underwent operative hysteroscopy in 2011 at a single medical center in Taiwan. Patients were chosen if their TVUS images showed benign focal intrauterine pathological masses. Sonographic reports corresponding with hysteroscopic pathologic examinations were reported in 184 patients. There were 36 patients with positive sonographic reports that did not correlate with their pathologic examination results. Another 36 patients, however, had negative sonographic reports but positive pathologic examination results, with a sensitivity of 72.9% and positive predictive value of 72.9%. An ET cut-off value above 9 mm had a poorer sensitivity (74.4%) for detecting focal benign intrauterine lesions and an ET cut-off value above 8 mm had a higher sensitivity of 86.5% for detecting focal benign intrauterine lesions. In the AUB status group, calculated Chi-square test (χ 2 ) results showed that the intrauterine benign focal lesion detection rate did not change statistically even after controlling ET. TVUS had a sensitivity of 72.9% for diagnosing focal lesions. An ET ≥ 8 mm had a lower sensitivity for diagnosing benign intrauterine focal lesions. In our retrospective study group, AUB was not a good predictor for diagnosing focal intrauterine lesions even after treating ET as a fixed variance.