Heterogeneous Lesion Research Articles

Effectiveness of super-selective digital subtraction angiography and 3D rotational digital subtraction venography for a developmental venous anomaly with an arteriovenous malformation: A case report and literature review

Background: Arteriovenous malformation (AVM) and developmental venous anomaly (DVA) rarely coexist. Developing a surgical strategy to treat this co-occurrence is difficult due to the unclear pathogenesis. We report the use of super-selective digital subtraction angiography (DSA) and Three-dimensional (3D) rotational digital subtraction venography (DSV) to develop a surgical strategy for complex AVM draining into a DVA. Case Description: A 58-year-old woman presented with left hemiparesis and unconsciousness. Plain and contrast computed tomography showed a right frontal subcortical hematoma and a heterogeneous contrast lesion anterior to the hematoma, leading to a dilated vessel. The hematoma was removed due to worsening unconsciousness. DSA revealed a right frontal AVM of Spetzler-Martin grade 2 with superficial drainage into a DVA, and 3D-DSV revealed that the intermediate part of the DVA involved normal parenchyma. Interventional transarterial embolization and surgical nidus removal were planned. Preoperative super-selective DSA showed two medullary veins draining from the AVM into the DVA. Thus, we decided to separate the two medullary veins from the nidus. Postoperative angiography revealed complete removal of the AVM and preservation of the DVA. Conclusion: Treating a complex AVM draining into a DVA is challenging; surgeons have to remove only the AVM portion and preserve the DVA. Super-selective DSA and 3D rotational DSV were performed to develop the surgical strategy.

Abstract 4131838: Heart’s Deception: A Venous Villain Hiding in the Heart

A 66-year-old male presented with 5 months of worsening left flank and lower back pain. Three weeks prior to this presentation, he was seen at an outside facility where he was found to have a left renal mass that was not further worked up. CT Abdomen and Pelvis showed an enhancing heterogenous lesion at the left superior renal pole, left adrenal gland lesion, and a pulmonary artery filling defect. This defect, along with concern for metastasis, led to a CT chest angiogram that reported small left upper and lower lobe pulmonary emboli. A transthoracic echocardiogram (TTE) was ordered and showed a linear highly mobile mass in the right atrium that was intermittently protruding into the right ventricle and into the main pulmonary artery through the pulmonic valve. There was no visible evidence of tumor extension of the renal mass into the inferior vena cava. Based on this, the highest differential was a clot-in-transit. After collaboration with the pulmonary embolism response team and echo team, the patient underwent aspiration thrombectomy via AngioVac system with transesophageal echocardiography (TEE) guidance. Most of the mass was removed, but there was a residual small portion adherent to the superior vena cava that was not amenable to aspiration. Grossly, the removed mass did not have the classic appearance of thrombus. The specimen was sent to pathology and returned as poorly differentiated carcinoma with spindle cell pattern positive for PAX8, CK7, CD10, pancytokeratin, and vimentin concerning for renal cell carcinoma. Post procedural transthoracic echo found to have new basal septal globular mass with vascularity seen on echo contrast imaging concerning for vascular involvement consistent with myocardial metastatic invasion. Cardiac magnetic resonance imaging could have aided in more precise tissue characterization to differentiate between clot or tumor prior to aspiration thrombectomy. This case demonstrates the significance of a detailed history and physical exam, use of multimodality imaging, and multidisciplinary collaboration to manage a rare cardiac condition.

Roles of MRI evaluation of pelvic recurrence in patients with rectal cancer.

Developments in the multidisciplinary treatment of rectal cancer with advances in preoperative magnetic resonance imaging (MRI), surgical techniques, neoadjuvant chemoradiotherapy, and adjuvant chemotherapy have had a significant impact on patient outcomes, increasing the rates of curative surgeries and reducing pelvic recurrence. Patients with pelvic recurrence have worse prognoses, with an impact on morbidity and mortality. Although local recurrence is more frequent within 2 years of surgical resection of the primary tumor, late recurrence may occur. Clinical manifestations can vary from asymptomatic, nonspecific symptoms, to pelvic pain, bleeding, and fistulas. Synchronous metastatic disease occurs in approximately 50% of patients diagnosed with local recurrence. MRI plays a crucial role in posttreatment follow-up, whether by identifying viable neoplastic tissues or acting as a tool for therapeutic planning and assessing the resectability of these lesions. Locally recurrent tissues usually have a higher signal intensity than muscle on T2-weighted imaging. Thus, attention is required for focal heterogeneous lesions, marked contrast enhancement, early invasive behavior, and asymmetric appearance, which are suspicious for local recurrence. However, postsurgical inflammatory changes related to radiotherapy and fibrosis make it difficult to detect initial lesions. This study therefore aimed to review the main imaging patterns of pelvic recurrence and their implications for the surgical decision-making process. CRITICAL RELEVANCE STATEMENT: MRI plays a crucial role in the posttreatment follow-up of rectal cancer, whether by identifying viable neoplastic tissues or by acting as a tool for therapeutic planning. This study reviewed the main imaging patterns of pelvic recurrence. KEY POINTS: MRI aids in surgical planning and the detection of pelvic recurrence and postoperative complications. Being familiar with surgical techniques enables radiologists to identify expected MRI findings. Patterns of rectal cancer recurrence have been categorized by pelvic compartments. Neoplastic tissue may mimic postsurgical and postradiotherapy changes. Resectability of pelvic recurrence is highly related to lesion location.

A Case Report on Congenital Mesoblastic Nephroma

Aims: This study aims to provide a comprehensive review of the epidemiology, genetic underpinnings, clinical presentation, and management strategies of congenital mesoblastic nephroma (CMN), with a focus on the diagnostic and therapeutic challenges that distinguish it from other neonatal renal tumors such as Wilms’ tumor. By presenting a unique case of a neonate diagnosed with CMN and undergoing tumor resection, we seek to highlight the complexities of perinatal care in such cases and the potential for life-threatening complications despite early intervention. Furthermore, the study underscores the importance of early and accurate differentiation between CMN subtypes, as well as the role of histopathology in guiding treatment approaches. Presentation of Case: A female neonate was born at 34+2 weeks gestation, presenting with a retroperitoneal mass on the left kidney, identified prenatally via ultrasound. Delivered by cesarean section due to polyhydramnios and anemia, a palpable intraabdominal mass was noted during examination. Imaging confirmed a heterogeneous solid lesion suggestive of nephroblastoma. The patient underwent nephroureterectomy, with histopathology confirming congenital mesoblastic nephroma. Despite successful resection, the patient died at 9 days of age from refractory catecholamine septic shock, with complications including neonatal sepsis, gastrointestinal bleeding, and femoral artery thrombosis. Discussion: Congenital mesoblastic nephroma is the most common renal tumor in neonates, often misdiagnosed as Wilms’ tumor. It typically presents before 2 months of age and is associated with translocation (12;15)(p13;q25). The prognosis for classical CMN is excellent, while the cellular variant is more aggressive. Surgical excision is the primary treatment, but the neonate's age necessitates careful management to mitigate risks. In this case, multiple complications contributed to the poor outcome despite timely intervention. Conclusion: CMN is a rare renal tumor in neonates, requiring accurate diagnosis through histopathology. While prognosis is generally favorable, complications from prematurity can adversely affect survival.

Presacral glomangioma: a rare localization of glomus tumors: case report

Introduction and importance: Deep located glomangiomas are rarely reported. Because of their scarcity, treatment strategie is hard to establish. Herein, we report the first case to our knowledge of presacral glomangioma. Case presentation: A 34-year-old female patient, with no previous medical history, consulted for 2-month-old pelvic abdominal pain, vomiting and delayed menstruation. Her physical and biological parameters were with no abnormalities. MRI of the pelvis demonstrated a 14 cm mixed heterogeneous pre-sacral lesion pushing the rectum anteriorly. She was operated on via a laparoscopic approach. Division of Douglas’ pouch and pelvic peritoneum laterally to the bladder showcased a cystic lesion of 13×8 cm occupying the pelvis while deviating the rectum anteriorly. Its content was aspirated and left membrane was extracted in a sac. The postoperative course was uneventful. Discussion: Presacral masses are hard to treat because of their large heterogeneity. Surgical resection should be tempted to retrieve the definitive histological diagnosis and relieve the patient. However, the surgical route is controversial as each approach has its advantages. Thus, the surgical route should take into consideration the lesion’s size, height and surrounding contacts, the patient’s functional state and surgeon’s expertise. Conclusion: Presacral glomangiomas carries low malignant pattern but should be resected to offer histological diagnosis. The surgical route remains at the surgeon’s decision, with the main objective to totally resect the encountered lesion without causing functional and sexual complications or harm to surrounding viscera.

Clinical relevance of paramagnetic rim lesion heterogeneity in multiple sclerosis.

Previous studies reveal heterogeneity in terms of paramagnetic rim lesions (PRL) associated tissue damage. We investigated the physiopathology and clinical implications of this heterogeneity. In 103 MS patients (72 relapsing and 31 progressive), brain lesions were manually segmented on 3T 3D-FLAIR and rim visibility was assessed with a visual confidence level score (VCLS) on 3D-EPI phase. Using T1 relaxation time maps, lesions were categorized in long-T1 and short-T1. Lesion age was calculated from time of first gadolinium enhancement (N = 84 lesions). Results on clinical scores were validated in an extended cohort of 167 patients using normalized T1w-MPRAGE lesion values. Rim visibility (VCLS analysis) was associated with increasing lesional T1 (P/PFDR < 0.001). Of 1680 analyzed lesions, 427 were categorized as PRL. Long-T1 PRL were older than short-T1 PRL (average 0.8 vs. 2.0 years, P/PFDR = 0.005/0.008), and featured larger lesional volume (P/PFDR < 0.0001) and multi-shell diffusion-measured axonal damage (P/PFDR < 0.0001). The total volume of long-T1-PRL versus PRL showed 2× predictive power for both higher MS disability (EDSS; P/PFDR = 0.003/0.005 vs. P/PFDR = 0.042/0.057) and severity (MSSS; P/PFDR = 0.0006/0.001 vs. P/PFDR = 0.004/0.007). In random forest, having ≥1 long-T1-PRL versus ≥4 PRL showed 2-4× higher performance to predict a higher EDSS and MSSS. In the validation cohort, long-T1 PRL outperformed (~2×) PRL in predicting both EDSS and MSSS. PRL show substantial heterogeneity in terms of intralesional tissue damage. More destructive, likely older, long-T1 PRL improve the association with MS clinical scales. This PRL heterogeneity characterization was replicated using standard T1w MRI, highlighting its potential for clinical translation.

7202 CPP with Rapid Pubertal Progression in a 9-Year-Old Boy with Hypothalamic Teratoma

Abstract Disclosure: R. Robilliard: None. G. Tung: None. K. Svokos: None. R. Lulla: None. J.Q. Quintos: None. Background: Central Precocious Puberty (CPP) in males is rare, with incidence of 0.01-2/10,000. The most common identifiable cause of CPP in young children is hypothalamic hamartoma. No case hypothalamic teratoma has been reported to cause CPP in males. Clinical Case: At the age of 10-years and 5-months, a boy presented to the pediatric endocrinology with signs of precocious puberty including facial hair development, voice deepening, and increased growth velocity that began at 9 years old. There was no significant past medical history and he denied headache, blurry vision, or diplopia. Physical examination showed height of 140.4 cm (47%), Tanner 4 genitalia, Tanner 3 pubic hair, and testicular volumes of 15 cc (left) and 12-15cc (right). Bone age (BA) determined by radiography was 13.5 years with a predicted adult height (PAH) of 63 inches. The mid-parental target height was 67 +/- 4 inches. Evaluation including TSH, glucose, serum and CSF β-HCG, DHEA, CSF AFP was normal. Serum LH was 2.9 IU/L and testosterone level was 109 ng/dl, consistent with CPP. MRI of the pituitary showed a small, heterogeneous and fat-containing lesion extending inferiorly from the tuber cinereum consistent with teratoma. Treatment included GnRH agonist Lupron (30mg) every 3 months. Laboratory evaluation 8 months after initial presentation showed suppressed LH of 0.9 IU/L and FSH 0.5 mIU/mL, and testosterone of 57 ng/dL. Repeat radiography for BA one year after GnRHa suppression showed BA of 14 years at CA of 11 years 6 months and PAH of 64.4 inches. Growth velocity slowed to 5.3 cm/year. At the most recent follow-up visit at CA of 12 years, height was 151.5 cm (61%), growth velocity 6.3 cm/year (74% for age), Tanner 5 penis and pubic hair, left testicular volume of 15-20cc and right testicular volume of 15 cc. Most recent radiographic BA is14 years, and PAH is 65.9 inches. Given response to GnRH agonist injections every 3 months, the absence of CNS symptoms referable to the teratoma and no change in MR imaging, no surgical intervention is recommended. Conclusion: This is the first case of a hypothalamic teratoma reported in a male associated with CPP. Despite this rare cause, the patient has responded to standard treatment with GnRH agonist therapy alone. Presentation: 6/1/2024

12243 The Case of a Metastatic Papillary Thyroid Cancer Presenting as an Unresectable Pelvic Mass

Abstract Disclosure: M. Tucktuck: None. Y. El Soufi: None. O.G. Adeniran: None. A.A. Gliwa: None. Background: Papillary thyroid cancer (PTC) represents around 85% of all thyroid cancers, of which 2-10% of patients will present with metastasis distant to the neck. The frequency of bone metastasis in PTC occurs in only 1-4% of patients. Studies have shown that distant and multi-organ metastasis is associated with higher mortality rates. Clinical case: A 69-year-old woman with diabetes mellitus, cerebrovascular accident, and right lower extremity deep venous thrombosis, presented with right foot and hip pain for 1 week after a mechanical fall. She had a 50 pound weight loss over a year without personal or family history of thyroid cancer or disease or radiation exposure. A soft and nontender mass in the right lower abdomen was noted during a physical exam. Imaging revealed a large heterogeneous lesion (16.3 x 13.3 x 15.5 cm) in the right bony pelvis with internal necrosis, destructing the right iliac bone, and extending into the right sacrum, acetabulum, and musculature, with mass effect on the surrounding vasculature, and enlarged lymph nodes suspicious for metastasis. Thyroid imaging showed a hypervascular hyperechoic 1.3 cm nodule within the right thyroid gland and a large 2 cm left thyroid nodule with scattered microcalcifications. Thyroid function tests were within normal limits. The patient underwent an initial ultrasound guided biopsy of the pelvic mass with indiscriminate results, and later a laparoscopic excisional biopsy of the pelvic mass showed neoplastic papillary proliferation with typical nuclear features, without necrosis or associated ovarian tissue. The immuno-histopathological profile was positive for PAX-8, TTF-1, thyroglobulin, and CK7, and the Ki-67 proliferation index was ∼20-30%. The patient was diagnosed with papillary thyroid cancer with metastasis to the pelvic bone, and was classified as stage IV, cT1bN0M1. As the pelvic mass was inoperable, the patient completed total thyroidectomy and was started on hormone replacement therapy. Subsequent thyroid pathology report was negative for papillary carcinoma. Further review of imaging did not show ectopic thyroid tissue in the neck or an ovarian pathology. Before the patient’s next visit to evaluate for struma ovarii, she passed away. Conclusion: Thyroid cancer is usually treated through thyroidectomy or lobectomy, with radioiodine (RAI) therapy as an effective treatment for differentiated cancers. Our patient, who presented with extremity pain revealing a distant metastasis, completed thyroidectomy with plans to undergo RAI therapy. Our case highlighted the importance of recognizing musculoskeletal presentations as an initial and possibly only finding of a distant metastasis. It also emphasized the utility of multidisciplinary collaboration in detecting and recognizing PTC as a primary thyroid cancer, as early management can reduce mortality and lead to more favorable outcomes. Presentation: 6/2/2024

8385 Coexistence of Parathyroid Adenoma &amp; Papillary Thyroid Cancer: A Rare Case Report

Abstract Disclosure: K. Dash: None. S. Verma: None. U. Ayyagari: None. M. Roy: None. S. Rathore: None. Prevalence of primary hyperparathyroidism (pHPT) ranges from 0.1- 0.4% in general population. Nodular thyroid disease is an increasingly common incidental diagnosis due to widespread use of ultrasound. Papillary thyroid cancer (PTC) is the most common cancer of thyroid gland. Here we report a 53 year old post-menopausal woman presented with weight loss, generalised body aches, arthralgia, myalgia, and proximal muscle weakness. She was hypertensive and clinically euthyroid. Physical examination revealed generalized tenderness all over the body but no thyroid or parathyroid nodules on palpation. Biochemical evaluation showed hypercalcemia 12.1mg/dl (8.4-10.2mg/dl), PTH&amp;gt;2000pg/ml (14-72pg/ml), ALP-1855 U/L (40–125 U/L), decreased phosphorous of 2.4mg/dl (25-4.6 mg/dl), and vitamin-D of 46 nmol/L ( 75-250 nmol/L). USG neck revealed a heterogeneous lesion at the lower pole of right lobe of thyroid gland &amp; two small hypoechoic nodules seen in the right lobe of thyroid gland. FNAC from nodules was inconclusive. USG abdomen revealed nephrocalcinosis. DEXA scan showed severe osteoporosis. Tc99mSestamibi SPECT-CT showed uptake at lower pole of right lobe of thyroid. On exploration, two nodules were palpated in the right lobe of the thyroid and simultaneous right hemi-thyroidectomy was performed. Histopathologic report confirmed parathyroid adenoma (figure 1) as well as presence of carcinoma in the two nodules: one was a papillary thyroid cancer (Classic variant) and the other a follicular variant of papillary thyroid carcinoma (figure 2). Margins were negative for malignancy. She was treated with levothyroxine to maintain TSH &amp;lt;0.1U/L and followed up with annual ultrasound screening. At 2 year follow up, patient was symptom free with improved T score on DEXA scan and no nodule over residual thyroid gland. Discussion: Co-existence of pHPT and PTC ranges from 2.3-4.3%. The use of ultrasound neck as a routine imaging modality for localisation of parathyroid adenoma allows detection of thyroid nodules. Benign and/or malignant thyroid nodules are commonly seen in patients with pHPT and this can range from 2-15%. Women have higher risk for co-existence. The relationship between the two diseases is thought to be incidental. Some authors have suggested possible role of shared genes, embryological factors, transcription factors, vitamin-D deficiency and hyperparathyroidism that could lead to activation of angiogenic factors and carcinogenesis. Fig. 1. Parathyroid adenoma. (a)Tc99m sestamibi scan showing right inferior parathyroid adenoma (b) Parathyroid adenoma (400x high power) comprising predominantly of Chief cells with mild pleomorphism. Fig. 2. Histopathology of PTC. (a)Papillary Carcinoma thyroid. 10xPhotomicrograph showing areas of calcification. (b) Papillary Carcinoma thyroid. Photomicrograph showing thyroid with papillary pattern with areas of infiltration. Presentation: 6/1/2024

8744 Genomic Variant Landscape In Aggressive &amp; Treatment Resistant Prolactin-Secreting Tumors

Abstract Disclosure: D. Marrero-Rodríguez: None. K. Taniguchi-Ponciano: None. F. Martinez-Mendoza: None. E. Peña-Martinez: None. S. Vela-Patiño: None. S. Hinojosa-Alvarez: None. J. Hernandez-Perez: None. R. Chavez-Santoscoy: None. E. Sosa-Eroza: None. P.E. Espinosa Cardenas: None. M. Mercado: None. Pituitary tumors (PT) represent the second most frequent intracranial tumor and this neoplasm arises from adenohypophyseal cells. Prolactin-secreting tumor (PRL-tumors) are the most commonly neoplasm of the pituitary gland and arises from lactotrophs, and account for 50% of all pituitary tumors. Pituitary tumors are highly heterogeneous lesions and many of them are invasive in up to 45%, with up to 15% being clinically aggressive. Aggressive PRL-tumors are defined as invasive tumors with unusually rapid growth rate despite maximal tolerated dopamine agonist dose and requiring additional therapy and presenting multirecurrent potential. Predicting pituitary tumor behavior remains a challenge, therefore we performed whole exome sequencing to identify genomic variant landscape from aggressive and treatment-resistant prolactin-secreting pituitary tumors. Interestingly one tumor showed one hotspot mutation in splicing factor gene SF3B1 (c.C1873T:p.R625C), a second tumor showed an stop codon in SF3B1 (c.C496T:p.R166*). We then evaluated known hereditary-related pituitary tumor genes, identifying three patients with two different GNAS allelic variants the first one showed c.A3059G:p.N1020S and two tumors with c.C1307A:p.A436D variants. PRKAR1A gene did not showed any allelic variants in our cohort, while all tumors presented c.A1636G:p.T546A variant in MEN1 gene, in AIP gene allelic variant c.C682A:p.Q228K was present in all tumors. PAX6 gene is related to pituitary gland development and function, we found a deletion (c.980delA:p.K327Rfs*29) causing frameshift present in all tumors. The target coding-gene for cabergoline, first line of treatment, DRD2 di not showed any allelic variant. Also XRCC1 and ABCB1 genes, which are related to drug and therapy response showed c.A1196G:p.Q399R and c.T2887G:p.S963A allelic variants in 100% and 88% of tumors, respectively. Together this genomic landscape could represent higher risk to harbor aggressive non-responsive PRL secreting tumor. Presentation: 6/1/2024

A rare presentation of nasopharyngeal mass: a case report

A Thornwaldt's cyst develops in the nasopharynx, which is the region where the throat and nasal passageways converge, extending from the back of the nasal tube to above the soft palate. A painful throat, obstruction of the eustachian tube, and pus with an unpleasant taste and odour might result from an infection of the cyst. Here in our study, we report a case of a 27-year-old male presented with symptoms of nasal obstruction and voice change for the past 1 year. On zero-degree endoscopic examination, a nasopharyngeal mass was seen arising from the roof of the nasopharynx without bony erosion of skull base. Further based on his radiological investigations, heterogeneous hyperintense lesion in T1/T2 weighted images of size 5×5 mm noted in nasopharynx most likely to be the Thornwaldt’s cyst. Thus, the surgical removal of the nasopharyngeal mass has been performed through a transoral and trans nasal endoscopic technique with no remnants at the surgical site. The histopathological findings revealed respiratory-type epithelium with underlying lymphoid tissue confirming Thornwald’s cyst as diagnosis. The patient was discharged with no complications and have been periodically advised for a follow-up. The differential diagnosis should include a meningocele or meningo-encephalocele. Various therapeutic approaches, including endoscopic, transoral, or trans palatal surgical interventions, can be used for treatment of symptomatic cysts.

Spermatic cord liposarcoma presented as scrotal swelling: a case report

BackgroundLiposarcoma is considered the most common among spermatic cord sarcomas. It usually presents as a progressively enlarging inguinoscrotal mass. The resemblance between the spermatic cord liposarcoma and the inguinal hernia allows the swelling to be tolerated for a long duration giving time for hematogenous dissemination. In this article, we share the experience of a unique case of metastatic liposarcoma of the spermatic cord that showed a stationary course of the lower abdominal satellite lesions on follow-up following palliative resection.Case presentationWe present a case of a 53-year-old male with progressively enlarging painless scrotal swelling over 1-year duration. A heterogeneous lesion of the right hemiscrotum and spermatic cord with non-specific radiological features was described by imaging. Two lower abdominal skip lesions were also discovered synchronously in addition to the primary one and were designated inoperable as they were adherent to the nearby bowel loops. The patient underwent cytoreductive surgery of the primary tumour which was proven to be an undifferentiated liposarcoma with free safety margins based on histopathology. Finally, the patient was referred for adjuvant chemotherapy and sequential follow-up.ConclusionsDespite being a rare tumour, the radiologist should always consider the liposarcoma of the spermatic cord in the differential diagnosis of inguinoscrotal lesions even in the absence of typical imaging features. The diagnosis and management of spermatic cord liposarcoma remain a challenge with no clear accepted guidelines.

Radiomic and deep learning analysis of dermoscopic images for skin lesion pattern decoding

This study aims to explore the efficacy of a hybrid deep learning and radiomics approach, supplemented with patient metadata, in the noninvasive dermoscopic imaging-based diagnosis of skin lesions. We analyzed dermoscopic images from the International Skin Imaging Collaboration (ISIC) dataset, spanning 2016–2020, encompassing a variety of skin lesions. Our approach integrates deep learning with a comprehensive radiomics analysis, utilizing a vast array of quantitative image features to precisely quantify skin lesion patterns. The dataset includes cases of three, four, and eight different skin lesion types. Our methodology was benchmarked against seven classification methods from the ISIC 2020 challenge and prior research using a binary decision framework. The proposed hybrid model demonstrated superior performance in distinguishing benign from malignant lesions, achieving area under the receiver operating characteristic curve (AUROC) scores of 99%, 95%, and 96%, and multiclass decoding AUROCs of 98.5%, 94.9%, and 96.4%, with sensitivities of 97.6%, 93.9%, and 96.0% and specificities of 98.4%, 96.7%, and 96.9% in the internal ISIC 2018 challenge, as well as in the external Jinan and Longhua datasets, respectively. Our findings suggest that the integration of radiomics and deep learning, utilizing dermoscopic images, effectively captures the heterogeneity and pattern expression of skin lesions.

Dissecting the heterogeneity of craniofacial lesions in patients with fibrous dysplasia/McCune–Albright Syndrome

Fibrous dysplasia/McCune–Albright Syndrome (FD/MAS) frequently involves the craniofacial skeleton. Craniofacial fibrous dysplasia lesions exhibit diverse imaging characteristics on multimodality evaluation, utilizing radiographs, computed tomography (CT), magnetic resonance imaging (MRI), and 18F-sodium fluoride positron emission tomography (18F-NaF PET). A multimodal imaging classification of craniofacial fibrous dysplasia lesions may offer clinical insights into the types of lesions that are (1) prone to progression, (2) amenable to intervention (i.e., pharmacological or surgical), or (3) associated with symptoms such as pain. In this prospective, preliminary single site study of 15 patients with FD/MAS, the heterogeneity of craniofacial lesions (N = 35) was assessed using a combination of 18F-NaF PET, MRI, and CT. A k-means clustering algorithm was used to categorize lesions based on imaging characteristics. Clustering analysis revealed three types of lesion based on the magnitude of the regional 18F-NaF standardized uptake values (SUV), signal intensities on T1-weighted and fluid-sensitive sequences, and appearance on CT (lucent, sclerotic, and/or ground glass). This preliminary study provides a foundation for future longitudinal natural history or treatment studies, where the prognostic value of baseline craniofacial fibrous dysplasia imaging characteristics and clinical symptomatology can be further evaluated.

Textural heterogeneity of liver lesions in CT imaging - comparison of colorectal and pancreatic metastases

PurposeTumoral heterogeneity poses a challenge for personalized cancer treatments. Especially in metastasized cancer, it remains a major limitation for successful targeted therapy, often leading to drug resistance due to tumoral escape mechanisms. This work explores a non-invasive radiomics-based approach to capture textural heterogeneity in liver lesions and compare it between colorectal cancer (CRC) and pancreatic cancer (PDAC).Materials and methodsIn this retrospective single-center study 73 subjects (42 CRC, 31 PDAC) with 1291 liver metastases (430 CRC, 861 PDAC) were segmented fully automated on contrast-enhanced CT images by a UNet for medical images. Radiomics features were extracted using the Python package Pyradiomics. The mean coefficient of variation (CV) was calculated patient-wise for each feature to quantify the heterogeneity. An unpaired t-test identified features with significant differences in feature variability between CRC and PDAC metastases.ResultsIn both colorectal and pancreatic liver metastases, interlesional heterogeneity in imaging can be observed using quantitative imaging features. 75 second-order features were extracted to compare the varying textural characteristics. In total, 18 radiomics features showed a significant difference (p < 0.05) in their expression between the two malignancies. Out of these, 16 features showed higher levels of variability within the cohort of pancreatic metastases, which, as illustrated in a radar plot, suggests greater textural heterogeneity for this entity.ConclusionsRadiomics has the potential to identify the interlesional heterogeneity of CT texture among individual liver metastases. In this proof-of-concept study for the quantification and comparison of imaging-related heterogeneity in liver metastases a variation in the extent of heterogeneity levels in CRC and PDAC liver metastases was shown.

Augmenting CT-Guided Bone Biopsies Using 18F-FDG PET/CT Guidance.

Computer tomography (CT)-guided percutaneous core biopsies are currently the gold standard in diagnostic procedures for patients with bone lesions of unknown kind. CT-guided biopsies can lead to misdiagnosis or repetition of biopsies in case of small or heterogeneous lesions. We hypothesize that molecular image guidance could be used to optimize the biopsy strategy, by supporting the detection of heterogeneous lesions or lesions without radiographic substrate. To evaluate this hypothesis, we investigated if and how the addition of 2-deoxy-2-18F-fluoro-D-glucose-positron emission tomography (18F-FDG-PET)/CT could augment routine CT-guided bone biopsies. To this end, 106 patients who underwent a CT-guided bone biopsy between April 2019 and April 2020, obtained from either a vertebral or peripheral bone, were included. Patients were divided into 2 groups: 36 patients received an 18F-FDG-PET/CT scan prior to their CT-guided bone biopsy (PET group), while 70 patients only had a morphological CT scan (CT group). Histopathology was used to categorize biopsies into five subgroups (inconclusive, benign, malignant or infectious disease, or normal tissue). In the PET group, the number of conclusive biopsies was significantly higher compared to the CT group (N = 33/36 (92%) versus N = 53/70 (76%); p < 0.05). Furthermore, the number of first-try biopsies was lower in the PET group compared to the CT group (1.9 vs. 2.54, p = 0.051). In conclusion, 18F-FDG-PET/CT imaging significantly increased the success rate of first-try CT-guided bone biopsies by showing less inconclusive biopsies and misdiagnosis.

Agreement between frozen section and histopathology to detect malignancy in adnexal masses according to size and morphology by ultrasound.

Management of suspect adnexal masses involves surgery to define the best treatment. Diagnostic choices include a two-stage procedure for histopathology examination (HPE) or intraoperative histological analysis - intraoperative frozen section (IFS) and formalin-fixed and paraffin-soaked tissues (FFPE). Preoperative assessment with ultrasound may also be useful to predict malignancy. We aimed at determining the accuracy of IFS to evaluate adnexal masses stratified by size and morphology having HPE as the diagnostic gold standard. A retrospective chart review of 302 patients undergoing IFS of adnexal masses at Hospital de Clínicas de Porto Alegre, between January2005 and September2011 was performed. Data were collected regarding sonographic size (≤10cm or >10cm), characteristics of the lesion, and diagnosis established in IFS and HPE. Eight groups were studied: unilocular lesions; septated/cystic lesions; heterogeneous (solid/cystic) lesions; and solid lesions, divided in two main groups according to the size of lesion, ≤10cm or >10cm. Kappa agreement between IFS and HPE was calculated for each group. Overall agreement between IFS and HPE was 96.1% for benign tumors, 96.1% for malignant tumors, and 73.3% for borderline tumors. Considering the combination of tumor size and morphology, 100% agreement between IFS and HPE was recorded for unilocular and septated tumors ≤10cm and for solid tumors. Stratification of adnexal masses according to size and morphology is a good method for preoperative assessment. We should wait for final HPE for staging decision, regardless of IFS results, in heterogeneous adnexal tumors of any size, solid tumors ≤10cm, and all non-solid tumors >10cm.

Metastatic Lung Adenocarcinomas: Development and Evaluation of Radiomic-Based Methods to Measure Baseline Intra-Patient Inter-Tumor Lesion Heterogeneity.

Radiomics has traditionally focused on individual tumors, often neglecting the integration of metastatic disease, particularly in patients with non-small cell lung cancer. This study sought to examine intra-patient inter-tumor lesion heterogeneity indices using radiomics, exploring their relevance in metastatic lung adenocarcinoma. Consecutive adults newly diagnosed with metastatic lung adenocarcinoma underwent contrast-enhanced CT scans for lesion segmentation and radiomic feature extraction. Three methods were devised to measure distances between tumor lesion profiles within the same patient in radiomic space: centroid to lesion, lesion to lesion, and primitive to lesion, with subsequent calculation of mean, range, and standard deviation of these distances. Associations between HIs, disease control rate, objective response rate to first-line treatment, and overall survival were explored. The study included 167 patients (median age 62.3years) between 2016 and 2019, divided randomly into experimental (N = 117,546 lesions) and validation (N = 50,232 tumor lesions) cohorts. Patients without disease control/objective response and with poorer survival consistently systematically exhibited values of all heterogeneity indices. Multivariable analyses revealed that the range of primitive-to-lesion distances was associated with disease control in both cohorts and with objective response in the validation cohort. This metrics showed univariable associations with overall survival in the experimental. In conclusion, we proposed original methods to estimate the intra-patient inter-tumor lesion heterogeneity using radiomics that demonstrated correlations with patient outcomes, shedding light on the clinical implications of inter-metastases heterogeneity. This underscores the potential of radiomics in understanding and potentially predicting treatment response and prognosis in metastatic lung adenocarcinoma patients.

Features associated with clinically actionable hyperechoic hepatic lesions to determine the need for follow-up.

To evaluate the rate of hyperechoic liver lesions that are clinically actionable and evaluate imaging and clinical factors associated with these to determine the need for follow-up. This retrospective study included 228 hyperechoic hepatic lesions on ultrasound in 228 patients. Reference standards included either dynamic contrast enhanced MRI (n = 130) or CT (n = 46), follow-up ultrasound performed at least 2years from baseline (n = 50), or histopathology (n = 2). Three radiologists independently assessed imaging features including lesion orientation, degree of hyper-echogenicity, lesion heterogeneity, and background liver echotexture. Univariable and multivariable logistic regression was used to determine features associated with an actionable hyperechoic lesion. Of the 228 hyperechoic lesions, 14 (6.1%) lesions were clinically actionable (or requiring follow-up), and 214 (93.9%) were clinically insignificant. Features that differed between patients with clinically insignificant vs. actionable lesions included: age (52.9 ± 15.1 vs. 63.9 ± 15.8 years, p = 0.004), male sex (43.9% vs 71.4%, p = 0.045), history of cirrhosis (6.5% vs 50%, p < 0.001), lesion size (1.9 ± 1.4cm vs. 3.5 ± 2.8cm, p = 0.003), heterogeneous lesion echogenicity (16.4% vs. 50%, p = 0.006), and cirrhotic/coarsened background liver (7.5% vs. 35.7%, p = 0.005). Stepwise logistic regression and multivariable analysis identified age, presence of cirrhosis, and lesion size as features most predictive of an actionable lesion (OR 1.04, 24.3, 1.77 respectively). Reader agreement for imaging features was fair to moderate (k = 0.29-0.53). 100%(168/168) of hyperechoic liver lesions measuring ≤ 3cm in patients without a history of malignancy or underlying liver disease were clinically insignificant. Our study findings support the overall favorable diagnoses of hyperechoic liver lesions ≤ 3cm in patients without underlying risk factors.

Non-keratinizing squamous cell carcinoma – A rare variant of sinonasal tract malignancy invading orbit: A case report and review of literature

This case report presents a rare case of orbital invasion from non-keratinizing squamous cell carcinoma (NKCa) of paranasal sinuses. A male patient presented with painful bleeding from a mass near the left eye, blood-stained discharge from the left nostril, fatigue, and weight loss. There was a heterogenous lesion inferomedial to the left eye, inside the left nostril, and in the oral cavity. Palpable neck lymph nodes, computed tomography scan showing a bone-eroding lesion, histopathology, and immunohistochemistry findings suggested malignancy of the NKCa variant. Immediate chemotherapy showed improvement after the first cycle, and the patient is under regular follow-up.