Hyperechoic Lesions Research Articles

Contrast-enhanced ultrasound with microbubbles containing sulfur hexafluoride and perfluorobutane with Kupffer phase for the detection of colorectal liver metastases.

To compare contrast-enhanced ultrasound (CEUS) with microbubbles containing sulfur hexafluoride (SHF) and perfluorobutane (PFB) for the detection of colorectal liver metastasis (CRLM). In this prospective study, conducted from September to November 2021, patients with colorectal cancer were consecutively recruited and underwent same-day ultrasound, SHF-CEUS, and PFB-CEUS. The reference standard was contrast-enhanced MRI and follow-up imaging. The size, depth, echogenicity, and calcification of each focal liver lesion were recorded. The number and conspicuity of CRLMs, based on washout appearance during the late phase (LP) (> 120 s)/Kupffer phase (KP), were evaluated offsite by two blinded readers. Overall, 230 lesions (CRLMs, n= 219; benign lesions, n= 11) in 78 patients were evaluated. Lesion conspicuity (p= 0.344) and accuracy in the detection of CRLM were comparable for SHF- and PFB-CEUS (0.877 for SHF vs. 0.770 for PFB, p= 0.087). More CRLMs ≥ 10 mm were identified by LP contrast washout in SHF-CEUS than in KP PFB-CEUS (p< 0.001). More CRLMs < 10 mm were identified by KP washout in PFB-CEUS than in LP SHF-CEUS (p< 0.001). Conspicuity was better on PFB-CEUS than on SHF-CEUS (p= 0.027). In hyperechoic lesions, lesions located deeper than 80 mm, and calcified lesions, CRLM conspicuity on PFB-CEUS was inferior to that on SHF-CEUS (p< 0.05). The overall accuracy of detection and conspicuity of washout in CRLMs were comparable between SHF and PFB-CEUS. PFB-CEUS has the advantage of identifying washout in small CRLMs. However, larger, hyperechogenic, deep-seated, or calcified lesions were better identified using SHF-CEUS. Accuracy of detection and conspicuity of washout in CRLMs were comparable between SHF- and PFB-CEUS. PFB-CEUS has the advantage in detecting small CRLMs, whereas SHF-CEUS is better for detecting larger, hyperechogenic, deep-seated, or calcified lesions. Contrast-enhanced ultrasound with sulfur hexafluoride in the late phase and perfluorobutane microbubbles in the Kupffer phase were comparable in terms of accuracy in the detection and conspicuity of colorectal liver metastases. Small colorectal liver metastases (< 10 mm) were more often identified in the Kupffer phase contrast-enhanced ultrasound imaging when using perfluorobutane microbubbles. Larger, hyperechogenic, deep-seated, or calcified lesions were better identified in the late phase contrast-enhanced ultrasound imaging (> 120 s) when using sulfur hexafluoride microbubbles.

Spontaneous rupture of a benign renal cyst A rare and misleading cause of Wunderlich syndrome

Wunderlich syndrome (WS) is a rare condition characterized by acute onset of spontaneous renal hemorrhage into the subcapsular and perirenal spaces. Wunderlich syndrome is classically characterized by the Lenk's triad: acute flank pain, flank mass, and hypovolemic shock. In this vignette; we describe our experience with a previously healthy adult female who presented with loin pain for weeks followed by gross hematuria, anemia and hypotension. Ultrasound examination of the abdomen and pelvis revealed; (a) an ill-defined hyperechoic mass-like lesion measuring 4.6X4.1 cm at its upper pole of right kidney which, on doppler study, had minimal internal vascularity, (b) moderate perinephric hematoma, moderate hydroureter and hydronephrosis. Triphasic CT scan and MRI, with contrast, of the abdomen and pelvis disclosed a case of ruptured benign cyst and ruled out renal cancer and vascular etiologies. The patient was treated conservatively and did not require renal embolization or nephrectomy. In conclusion; ruptured renal cysts is a rare cause for WS yet requires prompt management with patient’s stabilization and diagnostic approach. Contrary to the more common etiologies viz. tumors and vasculopathy; it rarely requires more than conservative treatment in stable patients.

PTEN Deficiency: a phenocopy phenomenon

BackgroundActivated PI3K delta syndrome 1 (APDS1) is caused by mutations in PI3KCD. The phosphatidylinositol 3-kinase (PI3K) signaling pathway is essential to cell survival, proliferation, and metabolism. PI3K plays a crucial role in the regulation of function and differentiation of immune cells. Phosphatase and tensin homolog (PTEN) serves to antagonize the PI3K pathway. Overlapping immune features of PTEN deficiency and APDS include high IgM, low IgG, increased transitional B cells, specific antibody deficiencies, autoimmunity, and lymphoproliferation. Because PTEN antagonizes PI3K activity, patients with PTEN loss-of-function mutations exhibit a similar phenotype to those with gain-of-function mutations of PI3K and can respond to mTOR inhibition like APDS patients. Overactivation of PI3K due to PTEN deficiency can lead to generalized immune dysregulation. Here we describe a patient with PTEN deficiency who presents as a phenocopy of APDS1 patients. MethodsRetrospective chart review was performed to obtain data on clinical labs of the PTEN deficient patient and APDS1 patients who presented with a similar clinical phenotype. An Epstein-barr virus (EBV) transformed B cell line (BLCL) was created from the patient PBMCs for functional studies to evaluate the PBK/AIKT/mTOR pathway. Patients were consented on an IRB approved protocol. ResultsThe patient was referred to immunology clinic for autoimmune cytopenias (Evan’s syndrome) and hypogammaglobulinemia. WES revealed De novo heterozygous c.406T>C (p.C136R) pathogenic variant in PTEN. Immune profiling showed elevated transitional B cells, increased naïve B cells and a decreased amount of class-switched memory B cells along with hyper IgM and low IgG. An abdominal ultrasound revealed significant splenomegaly with peri-splenic lymphadenopathy and hyper-echoic lesions in the spleen. Functional studies on BLCLs were reserved for confirmation of dysregulated PI3k/AKT/pS6 signaling. The patient was treated with sirolimus and IgG replacement therapy. After sirolimus therapy, lymphoproliferation and splenic findings resolved. DiscussionPTEN deficiency is a clinical and mechanistic phenocopy of APDS1 due to loss of negative regulation by PTEN to control over-activation of PI3 K. While Evan’s syndrome is reported in APDS1 more readily, it is not as prominent in PTEN. Treatment strategies employed for APDS1 and 2 are viable options for controlling the disease manifestations seen in PTEN deficiency.

Contrast-Enhanced Imaging Features and Clinicopathological Investigation of Steatohepatitic Hepatocellular Carcinoma

Steatohepatitic hepatocellular carcinoma (SH-HCC) is a distinctive histologic variant of HCC for the presence of steatohepatitis. This study intended to evaluate the contrast-enhanced imaging features and clinicopathological characteristics of 26 SH-HCCs in comparison with 26 age-and-sex-matched non-SH-HCCs. The frequency of obesity (34.6%, p = 0.048) and type 2 diabetes mellitus (23.1%, p = 0.042) were significantly higher in SH-HCC patients. As seen via B-mode ultrasound (BMUS), SH-HCCs were predominantly hyperechoic (65.4%, p = 0.002) lesions, while non-SH-HCCs were mainly hypo-echoic. As seen via contrast-enhanced ultrasound (CEUS), 96.2% of SH-HCCs exhibited hyperenhancement in the arterial phase. During the portal venous and late phase, 88.5% of SH-HCCs showed late and mild washout. Consequently, most SH-HCCs and all non-SH-HCCs were categorized as LR-4 or LR-5. As seen via magnetic resonance imaging (MRI), a signal drop in the T1WI opposed-phase was observed in 84.6% of SH-HCCs (p = 0.000). Notably, diffuse fat in mass was detected in 57.7% (15/26) SH-HCCs (p < 0.001). As seen via contrast-enhanced MRI (CEMRI), most of the SH-HCCs and non-SH-HCCs exhibited heterogeneous hyperenhancement in the arterial phase (80.8% versus 69.2%, p = 0.337). During the delayed phase, 76.9% SH-HCCs and 88.5% non-SH-HCCs exhibited hypo-enhancement. Histopathologically, the rate of microvascular invasion (MVI) was significantly lower in SH-HCCs than non-SH-HCCs (42.3% versus 73.1%, p = 0.025). The frequency of hepatic steatosis >5% in non-tumoral liver parenchyma of SH-HCCs was significantly higher than in non-SH-HCCs (88.5% versus 26.9%, p = 0.000). Additionally, the fibrotic stages of S0, S1 and S2 in SH-HCCs were significantly higher than in non-SH-HCCs (p = 0.044). During follow-up, although the PFS of SH-HCC patients was significantly longer than non-SH-HCC patients (p = 0.046), for the overall survival rate of SH-HCC and non-SH-HCC patients there was no significant difference (p = 0.162). In conclusion, the frequency of metabolism-related diseases in SH-HCC patients was significantly higher than in non-SH-HCC patients. The imaging features of SH-HCCs combined the fatty change and typical enhancement performance of standard HCC as seen via CEUS/CEMRI.

“White knight,” “giraffe hide,” and “Swiss cheese” appearance

Sir, Recently, four women, being treated with levothyroxine sodium tablet for primary autoimmune hypothyroidism, were referred to us for further evaluation of “suspicious” features, detected on thyroid ultrasonography (USG). The first woman had one small hyperechoic space-occupying lesion (SOL) [Figure 1a], while the second woman had a larger SOL with similar appearance [Figure 1b and c]. Multiple echogenic nodules were noticed in the third patient [Figure 1d and e], while the fourth patient demonstrated multiple hypoechoic areas scattered throughout the gland [Figure 1f and g]. Thyroid glands were enlarged in all of them with lobular surfaces, and USG-guided fine-needle aspiration cytology (FNAC) was suggestive of chronic lymphocytic thyroiditis (CLT).Figure 1: USG appearances of the patients. (a) (Patient 1): Sagittal view showing hypoechoic gland with a small “white knight” nodule (black arrow). Note the heterogeneous appearance of the gland and the linear hyperechoic lines (represents fibrous bands). (b) (Patient 2): Sagittal view showing large “white knight” nodule (white arrow). (c) (Patient 2): Transverse view showing the same “white knight” nodule (white arrow) in the left lobe. Note the isoechoic nodule in the right lobe (notched white arrow) in the background of hypoechoic gland. (d and e) (Patient 3): Transverse and sagittal views showing focal hypoechoic area (notched white arrow in d) and “giraffe hide” pattern (e). (f and g) (Patient 4): Sagittal view showing the “Swiss cheese” pattern. USG: UltrasonographyCLT, also termed as chronic Hashimoto’s thyroiditis, is the most common etiology of primary hypothyroidism worldwide. The pathological hallmark of CLT is lymphocytic (B-cells and cytotoxic T-cells) infiltration of the thyroid gland; the degree of glandular involvement depends on the stage of the disease. The thyroid gland in CLT typically is diffusely enlarged without any palpable nodule. However, heterogeneous and patchy involvement produces regional parenchymal distortion resulting in a lobular or nodular appearance leading to ultrasonographic evaluation of the thyroid gland. USG in such glands often detects one or more “pseudonodule(s).” Normal thyroid parenchyma appears homogeneously hyperechoic compared to the surrounding strap muscles of the neck. Areas of lymphocytic infiltration appear hypoechoic compared to normal thyroid parenchyma. The thyroid gland in CLT usually has heterogeneous echotexture on USG; regions of lymphocytic infiltration appear hypoechoic, unaffected islands of thyroid parenchyma demonstrate normal echogenicity, and early fibrosis appears as linear echogenic bands. However, the sonological appearance in CLT varies, and the characteristic pattern recognition obviates unnecessary FNAC. A solitary, well-circumscribed, homogenous, markedly hyperechoic nodule of varying size, without internal vascularity, cystic degeneration, or calcifications termed “white knight” nodule [Figure 1a-c], may occasionally be encountered in such patients. Present on a background of a hypoechoic gland, these nodules seem to be regenerative nodules of CLT. Despite its remarkable appearance, such a nodule is considered benign and does not merit further evaluation.[1,2] When multiple echogenic nodules (represents uninvolved areas with normal follicular structure) dispersed across the gland are separated from one another by bands of hypoechogenicity, the ultrasound appearance is called “giraffe hide” (1E), reminiscent of giraffe’s skin. This distinctive pattern is always benign and characteristic of CLT.[1,2] Although the reverse pattern, i.e., multiple hypoechoic areas (represents aggregates of lymphocytes) with ill-defined margins surrounded by echogenic areas of thyroid parenchyma or fibrosis, more closely resembles giraffe skin, which consists of dark areas surrounded by bright lines, the term “giraffe hide” pattern was originally described for the former one. The later pattern, however, is also a characteristic of CLT. More discrete aggregates of lymphocytes appear as discrete focal hypoechoic regions on the background of an echoic gland. Numerous such well-defined hypoechoic areas give the gland a “Swiss cheese” appearance [Figure 1f and g], similar to the holes in Swiss cheese. Once these small hypoechoic areas become almost confluent and there is marked fibrosis with very little parenchyma separating the hypoechoic tissue, the appearance is called “honeycomb” variant. The vascular pattern distinguishes these hypoechoic “pseudonodules” from thyroid nodules. These hypoechoic areas do not demonstrate vascular flow, whereas vascular flow is seen over the isoechoic normal thyroid parenchyma, especially along the areas of fibrosis. The decision for FNAC from a thyroid nodule depends on the size of the nodule and the American College of Radiology (ACR) Thyroid Imaging, Reporting and Data System (TI-RADS) staging.[3] However, the ACR TI-RADS classification does not consider these patterns. Recognition of such characteristic morphologic patterns substantially decreases the number of unnecessary invasive interventions. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Ultrasound findings of subpial hemorrhage in neonates

Subpial hemorrhage (SPH) is a subtype of intracranial hemorrhage characterized by damage to the adjacent brain parenchyma. The aim of this study was to describe the sonographic features of SPH in neonates. The cranial ultrasound (US) findings of neonates with SPH confirmed by brain magnetic resonance imaging (MRI) were analyzed retrospectively. Initial and follow-up US and MRI scans were reviewed by two pediatric radiologists who were blinded to both clinical history and outcomes. The US features were compared with the MRI findings. Sixteen patients were included (median gestational age, 38 weeks; range, 26 to 40 weeks; 69% term). SPH was detected most often in the temporal lobe (63%), and multiple SPHs were found in seven of 16 neonates, based on MRI. Acute SPH with an underlying venous infarct (UVI) was detected on US in 15 of 16 patients: small or large fan-shaped hyperechoic lesions (n=7 and 4, respectively) and gyriform hyperechoic lesions (n=4). The sonographic yin-yang sign was observed in three of the four large fan-shaped SPH cases. The accompanying findings on US were intraventricular hemorrhage (four out of six MRI-confirmed cases), and concurrent periventricular venous infarcts (five out of nine MRI-confirmed cases). In five patients, subpial cysts were observed on follow-up US or MRI (n=4 and n=4, respectively). Acute SPH with UVI can appear as a peripheral fan-shaped or gyriform hyperechoic lesion on cranial US. SPH can be detected and suspected based on the US features of SPH with the accompanying findings.

Evaluation and Classification of Incidentally Detected Splenic Lesions Based on B-Mode and Contrast-Enhanced Ultrasound.

To evaluate B-mode ultrasound (B-US) and contrast-enhanced ultrasound (CEUS) patterns of focal splenic incidentalomas (FSIs), and to correlate ultrasound patterns with benignity and malignancy via histologic examination and/or the clinical course. Between 2004 and 2021, 139 consecutive patients with an FSI detected by B-US were investigated additionally with CEUS. On CEUS, the arterial enhancement (AE) of the FSI (hyperenhancement, isoenhancement, hypoenhancement, and absent enhancement) was analyzed. Subsequently, the malignancy rate according to different B-US echo patterns and CEUS perfusion patterns was determined. The final diagnosis of FSI was malignant in 9/139 (6.5%) and benign in 130/139 (93.5%) cases. The hypoechoic and hyperechoic lesions on B-US with arterial hyperenhancement on CEUS and the echogenic cystic or complex lesions on B-US with predominantly absent enhancement on CEUS were benign in 54/54 (100%) cases. 6/37 (16.2%) hypoechoic lesions on B-US with arterial hypo-/isoenhancement on CEUS and 3/48 (6.3%) of hyperechoic lesions on B-US with an arterial hypo-/isoenhancement on CEUS were malignant. Based on these results, FSIs reveal different malignancy rates depending on the B-US und CEUS patterns, and classification according to these B-US and CEUS patterns may be helpful in further evaluation of an FSI.

ULTRASONOGRAPHIC ASSESSMENT OF LUNG IN DYSPNEIC PATIENTS WITH LUNG INFECTION

Introduction- A wide range of pulmonary illnesses with a signicant clinical prevalence includes infectious lung disease. Numerous studies have examined the clinical value of lung ultrasonography (LUS) in the treatment of patients who present with dyspnea due to an infectious lung illness in the last ten years. We present data on the methodical and standardised use of bedside LUS in the differential diagnosis of patients with acute dyspnea due to infective pulmonary diseases. We conducted a cross-sectional s Materials and Methods- tudy on 120 patients with infectious lung illnesses (mean age, 54.2± 11.5 years; range, 25-85 years; 40 women, 80 men). All individuals underwent a chest X-ray and bedside LUS using a convex probe. A clinically necessary chest CT was done on a subgroup of individuals. By Results- comparing the percentage of pleural effusion and pulmonary consolidation determined by LUS to X-ray, we found a statistically signicant difference (54 vs. 20.8%, respectively, p 0.05; 90 vs. 46.6%, p 0.001). 38.3% of the LUS-detected consolidations had air bronchograms, which were mixed, hypo, and hyperechoic lesions. When conducted, chest CT veried every nding determined by LUS. LUS is a helpful suppl Conclusion- emental technique when used in conjunction with clinical, laboratory, and radiographic workup, as specied by clinical guidelines. When there are chest X-ray visible opacities or when clinical suspicion is high and radiological results are negative, the approach is very helpful in differentiating between pleural effusion and lung consolidation.

Association between biochemical parameters and ultrasonographic measurement for the assessment of hepatic lipidosis in dairy cows

Hepatic lipidosis (HL) is a serious metabolic disorder that affects transient high-producing dairy cows. However, there are many laboratory methods could help in the assessment of HL in dairy cows, the definite diagnosis of the disease under field conditions remains a challenge because of the non-specificity of clinical parameters. The aim of the study was to investigate the utility of serum biomarkers, and ultrasonography (US) measurement to diagnose HL in dairy cows. Forty Holstein dairy cows underwent physical examination and were divided into three groups: non-HL, mild HL, and severe HL groups based on US findings, and the concentrations of beta-hydroxybutyric acid (BHBA) and nonesterified fatty acids (NEFAs). Ultrasound images showed hyperechoic lesions and increased pixel intensity (PI) values of liver echotexture in the HL groups. A significant increase was observed in mild and severe HL groups in the activity of serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), BHBA, NEFAs, malondialdehyde (MDA), and nitric oxide (NO) while the concentrations of triglyceride (TG), glutathione (GSH), and total antioxidant capacity (TAC) were significantly decreased. The classification accuracy was in the interest of NEFAs (cut off 0.62 mmol/L, sensitivity 82.6%, specificity 91.7%, and an AUC of 0.913) and BHBA (cut off 1.35 mmol/L, sensitivity 91.31%, specificity of 86.4%, and an AUC 0.812) as important diagnostic parameters. This study offers new insights into the importance of serum biochemical parameters and oxidative stress biomarkers especially, AST, NEFAs, BHBA, and GSH with the digital values of US images for prompt use of minimally invasive techniques to diagnose HL under farm conditions. HIGHLIGHTS Serum metabolites and oxidative stress indices could diagnose hepatic lipidosis in dairy cows NEFA and BHBA concentrations and ultrasound digital values can use as a non-invasive way to the classification of hepatic lipidosis degrees in cows under farm condition.

Mixed and Purely Hyperechoic Breast Masses: A Radiologic-Pathologic Review.

Breast US is a mainstay of modern-day breast imaging, especially in the diagnostic and interventional realm. The BI-RADS atlas described six echo patterns relative to the subcutaneous mammary fat: anechoic, hypoechoic, complex cystic and solid, isoechoic, heterogeneous, and hyperechoic. Hyperechoic breast masses demonstrate increased echogenicity relative to subcutaneous mammary fat or equal to fibroglandular tissue. Pathologically, the hyperechoic pattern at breast US results from the intermingling of different components: adipose tissue, fibrous tissue or stroma, secretions, blood or vascularity, and calcifications. Most hyperechoic masses are benign, especially homogeneously hyperechoic masses. However, hyperechogenicity does not exclude malignancy. Two echo patterns have been identified in hyperechoic malignant lesions, including those with a hypoechoic center and hyperechoic rim known as the rim pattern and a mass with hyperechoic areas distributed through the mass known as a dispersed pattern. This article aims to illustrate the echogenic patterns of breast lesions and various benign and malignant hyperechoic breast lesions with radiologic-pathologic correlation and to increase awareness of heterogeneously hyperechoic breast lesions as a manifestation of malignancy.

Bilateral Sclerochoroidal Calcifications: A Case Report

Purpose: The aim of this case report is to describe a rare condition of bilateral sclerochoroidal calcification Case Report: A 79 years old asymptomatic Caucasian female was referred to our Ocular Oncology Center of the Ophthalmic Surgery Department of Pisa on November 2021. She was in apparent good health. Funduscopic examination revealed yellowwhite irregular lesions in the supero-temporal quadrant of both eyes. Best-corrected visual acuity was 20/20. B-scan and A-scan ultrasound revealed hyper-echoic solid lesions with acoustic orbital shadowing measuring 1.5 mm in thickness and 4.6 mm in diameter, on average. Enhanced Deep Imaging Optical Coherence Tomography showed a scleral lesion compatible with the presence of deposition of calcium with Table Mountain and rolling pattern. Fluorescein angiography revealed hypofluorescence in the arterial phase and a mild hyper-fluorescence in the venous phase with persistent late staining. Indocyanine green angiography showed hypo-fluorescence at the early, middle, and late phases. Systemic investigation of calcium and phosphate metabolism was performed and the patient didn’t display any underlying systemic disorder. Conclusion: It is important to know and recognize this condition. Although most cases of sclerochoroidal calcifications may be idiopathic, systemic laboratory workup must be performed to exclude calcium-phosphate metabolic disorder that can be associated to these ocular signs. Given the rare possible development of choroidal neovascularization, regular imaging checkup is recommended.

Unusual Breast Malignancies—Going A Step Ahead of Breast Imaging Reporting and Data System

AbstractWith the advent of the Breast Imaging Reporting and Data System (BIRADS), the categorization of the entire gamut of breast lesions has been simplified. However, there are many unusual breast lesions, both benign and malignant, which cannot be categorized accurately using the BIRADS descriptors due to the overlap of features. Carcinomas such as medullary, papillary, and mucinous (colloid) types, may be difficult to recognize as malignant because they may have relatively benign-appearing morphologic features. Well-circumscribed, small, and hyperechoic lesions may not be benign in all cases, and the presence of any microlobulations in margin, vascularity, heterogeneity, round shape, or interval change in size or appearance should raise suspicion of a sinister etiology. Therefore, it is important to be aware of the imaging features of such malignancies so that any mismanagement or undue delay in the diagnosis of any sinister etiology can be avoided.

Mucinous tubular and spindle cell carcinoma of the kidney.

Mucinous tubular and spindle cell carcinoma (MTSCC) is a unique neoplasm attributing to less than 1% of all renal cell carcinoma (RCC). The median age is 6th decade with a significant female preponderance.1 These tumors classically consist of tightly packed, elongated, and anastomosing tubules which merge with bland spindle cells in a myxoid stroma in variable proportions. Tubules with tufting or small papillae and foci of foamy macrophages may occur. The tumor cells are low-grade and may show clear cytoplasm or oncocytic changes with rare mitosis. Immunohistochemically, PAX8, CK7, AMACR, and CD10 are positive in this tumor.1,2 Though it is a morphological diagnosis, it can be challenging to differentiate from a solid variant of papillary RCC, sarcomatoid RCC, or myoid-predominant angiomyolipoma. Immunohistochemistry may be of little help due to overlapping profiles.3 Copy number analyses can help establish a diagnosis in challenging cases or core biopsies since these are associated with multiple chromosomal losses involving chromosomes 1, 4, 6, 8, 9, 13, 14, 15, and 22. Novel biomarkers like VSTM2A overexpression are also emerging, which can be detected by RNA in-situ hybridization. Recurrent Hippo pathway aberrations have been defined as the molecular signature of MTSCC with increased nuclear YAP1 protein expression.4 Adverse features such as necrosis, solid growth, single file infiltration, sarcomatoid transformation, lymphovascular invasion, and increased mitoses are indicators of metastatic disease. Although it has indolent behavior, rare cases with classic morphology have been seen to develop metastases.5-6 We describe gross and histopathological findings of mucinous tubular and spindle cell carcinoma in a 65-year-old male patient. He presented with right abdominal pain for one month. The pain was dull and mild to moderate in intensity. On contrast-enhanced ultrasound, a well-defined, smoothly marginated heterogeneous hyperechoic lesion measuring 5.5x6cm was noted at the upper pole of the right kidney. The lesion was hyper enhancing compared to the rest of the renal parenchyma. Based on the radiological findings, possibilities of chromophobe RCC and oncocytoma were considered. The abdominal computed tomography (CT) revealed a hyperdense lesion in the upper pole of the right kidney with a relatively well-defined margin measuring 63x65x69mm with no evidence of significant post-contrast enhancement in the either arterial, venous or delayed phase. The patient underwent a right radical nephrectomy. On gross examination, a well-encapsulated mass was seen wholly occupying the upper pole of the kidney measuring 6.9x6.5x5.5cm. The cut surface was variegated with grey-white, firm areas admixed with mucinous and hemorrhagic foci (Figure 1A). No capsular breach or perinephric fat extension was noted. The renal pelvis, sinus, and renal vessels were free of tumor. Figure 1 A - gross nephrectomy specimen showing a large, well-demarcated tumor involving the upper pole of the kidney measuring 6.9x6.5x5.5cm. The cut surface is variegated and appears grey-white and firm, along with intervening mucinous and hemorrhagic areas (scale bar = 5 cm); B - microscopically, the tumor is well-circumscribed with sharp demarcation from adjacent normal renal parenchyma (H&E; 40x); C - the dominant epithelial component is seen against the background stroma containing significant extracellular mucin (H&E; 100x); D - higher magnification showing tightly packed anastomosing tubules lined by low-grade cuboidal cells with cytoplasmic vacuoles against mucinous background (H&E; 400x).: Microscopically, the tumor was well-demarcated from the adjacent native renal parenchyma (Figure 1B). It was composed of the dominant epithelial element against the background of extracellular mucinous stroma (Figure 1C). The epithelial component contained tightly packed, elongated, tufted, and anastomosing tubules lined by low-grade cuboidal cells and are seen merging with bland spindle cells (Figure 1D). The nuclei display fine vesicular chromatin, inconspicuous nucleoli, and moderate cytoplasm with vacuolations. Mitotic figures are infrequent (<1/10HPF). No necrosis, lymphovascular invasion, or high-grade transformation was found. However, foamy macrophage collections and lymphoid aggregates are admixed. Cholesterol clefts with focal foreign body giant cell response indicated the long-standing nature of the tumor. Based on the gross and microscopy findings, the diagnosis of mucinous tubular and spindle cell carcinoma [(pT1bpNx; American Joint Committee on Cancer (AJCC) staging manual; 8th edition)] was rendered.

UTERINE SCAR ENDOMETRIOMA: A CASE REPORT

Introduction And Importance: Uterine scar endometriosis is a rare form of endometriosis due to previous surgical scars from obstetrical and gynecological procedures. Its challenging diagnosis to make. A 34- Case presentation: year-old multiparous female presented with intermittent lower abdominal pain and inter-menstrual bleeding for the past 4 months .Ultrasound revealed a heterogenous, predominantly hyperechoic lesion measuring 40x51x54mm in the myometrium of anterior lower uterine segment extending to cervical stroma. MRI revealed a lobulated mass lesion in the anterior wall of lower uterine segment, extending along the scar niche. The lesion showed heterogenous hyperintense signal on T2WI with hyperintense signal on T1WI (sub-acute blood). No significant post contrast enhancement was seen. Impression of a scar site endometriosis was made. Subsequently the patient underwent diagnostic laparoscopy, which revealed a lobulated cystic mass in the lower uterine segment, with oozing of chocolate brown material on compression. As the mass was deep-seated in the lower uterine segment, a laparotomy was decided upon and total abdominal hysterectomy with varian conservation was performed. Histopathology confirmed the diagnosis of endometriosis. Conclusion: In any women of reproductive age with lower abdominal pain and solid appearing mass lesion at the uterine scar from previous obstetric or gynaecologic surgery, uterine scar endometriosis should be considered.

Acute epiploic appendagitis - a rare differential diagnosis of acute abdomen.

Acute epiploic appendagitis is a rare differential diagnosis of unclear or acute abdomen. To describe - by means of a scientific case report - the extraordinary diagnosis of acute epiploic appendagitis along with contained diverticulitis and incarcerated herniation of the greater omentum into the hernial sac of a former trocar site (medical history, significant for laparoscopic ovarian cyst removal) in a 29-year-old female based on experiences obtained in the successful clinical case management, and on selective references from medical scientific literature. Medical history: A 29-year-old female was admitted with abdominal pain in the lower left quadrant. She reported a laparoscopic ovarian cyst removal 3 years prior. Physical examination of the abdomen revealed tenderness in the lower left quadrant without a palpable mass.Leading diagnoses were found using transabdominal ultrasound and confirmed by an abdominal CT scan; namely, incarcerated trocar hernia, diverticulitis of sigmoid colon, and acute epiploic appendagitis. Therapeutic approach was comprised of an explorative laparoscopy (because of the incarcerated hernia), adhesiolysis, removal of a tip of the greater omentum out of the hernial sac, closure of the hernial orifice, and removal of an unclear, inflamed, and bloody fatty tissue from the wall of the descending colon (histopathological investigation confirmed acute epiploic appendagitis). This was flanked by conservative treatment of diverticulitis of the sigmoid colon.Further clinical course was uneventful, with discharge on the 3rd postoperative day with favorable long-term outcome, characterized by no further complaints for 15 months. Acute epiploic appendagitis is an inflammatory, usually self-limiting condition of the epiploic appendages of the colon. It typically manifests with abdominal pain in the lower left quadrant. Imaging is an important diagnostic tool to determine whether the patient has, in fact, acute epiploic appendagitis, so recognizing the characteristic oval lesions with the surrounding inflammation and central fat attenuation on CT, as well as the hyperechoic oval lesions with a hypoechoic peripheral band on ultrasound images is crucial. Nevertheless, it is often overlooked in patients and confused with other differential diagnoses, such as appendicitis or diverticulitis. Although the condition appears infrequently, it is essential to be proficient in the diagnostic evaluation, as a misdiagnosis may lead to unnecessary treatment and even surgical intervention. , the patient was initially diagnosed with an incarcerated abdominal hernia, and therefore subsequently underwent surgery. The inflamed epiploic appendage was discovered in laparoscopic exploration, removed, and confirmed through the histopathology report. This is an approach to be performed with great caution so as not to 1. : misinterpret an inflamed diverticula or covered perforation of it as well as not 2. : overlooking a peritoneal tumor lesion.

Choroidal haemangioma and its multimodal diagnosis: A case report

AbstractPurpose: To describe the clinical manifestations and diagnosis of choroidal haemangioma with the aid of different multimodal images, as well as its usefulness for making a differential diagnosis.Methods: A case of a patient who comes due to blurred vision is described, who underwent different complementary tests of multimodal images: optical coherence tomography (OCT), fluorescein angiography (FA), indocyanine green angiography (ICGA), autofluorescence (AF), ultrasound eye exam and retinography to achieve the accurate diagnosis.Results: We present the case of a 50‐year‐old patient who debuted with recently‐onset blurred vision in the left eye (LE). In the eye fundus of LE, a yellow‐orange temporal‐inferior lesion of 3 disc diameter (DD) with neurosensory detachment of 4 DD that affects the fovea is observed. An OCT is performed that shows a choroidal mass associated with subretinal and intraretinal fluid with hyperrefringent points, the B‐scan ultrasound shows a hyperechoic lesion in the posterior pole, and both ICGA and FA reveal a hyperfluorescent pattern in all its phases, being the choroidal vessels of better visualization in the latter phase (without double vascularization pattern). AF shows hyperautofluorescence. After the definitive diagnosis of choroidal haemangioma, he was referred for treatment with Argon laser with favourable results.Conclusions: Choroidal haemangioma is a rare benign vascular tumour that occurs in middle‐aged adults and can be circumscribed (CCH) or diffuse depending on its extension. For the diagnosis of intraocular tumours it is very important to make a good differential diagnosis with the help of multimodal images: OCT, FA, ICGA, AF, Ultrasound and retinography; in order to differentiate it from similar posterior pole lesions with worse prognosis. CCH itself is benign and asymptomatic, and its treatment consists of observation; but it can present inflammatory signs with subretinal fluid and affect the macular area and therefore a more invasive treatment is indicated.References.1. Singh AD, Kaiser PK, Sears JE. Choroidal hemangioma. Ophthalmol Clin North Am. 2005;18(1):151–61, ix.2. Berry M, Lucas LJH. Circumscribed choroidal hemangioma: A case report and literature review. J Optom. 2017;10(2):79–83.

Rare site and age of presentation: Prostatic sarcoma of the Ewing family in an adolescent

Ewing sarcoma/primitive neuroectodermal tumor (PNET) is the second most primary malignant bone tumor in children and adolescents between 10 and 25 years. The extraosseous sarcomas are rare and often cause diagnostic confusion for clinicians. The cell of origin is unclear, but exhibits rapid growth and recurrence, leading to a poor survival rate of 10% only. This imposes an increased risk of chronic health conditions, financial burden, and impaired quality of life. We report the uncommon presentation in age and site of the tumor in the peri-prostatic tissue of a 14-year-old boy and discuss our treatment approach. An exploratory observational case study was conducted. The ultrasound of an enlarged pelvis mass showed a large heterogeneously hyperechoic lesion with central necrosis and increased vascularity in the mass. The magnetic resonance imaging scan and histopathology of the transrectal ultrasound-guided biopsy specimen confirmed the prostate tumor. The transrectal biopsy proved to be a feasible and effective diagnostic tool for such an unclear pelvic mass. The extraskeletal manifestation of Ewing’s sarcoma imposes diagnostic confusion, but the case fulfilled the extraosseous Ewing sarcoma’s diagnostic characteristic. The Ewing’s sarcoma/PNET of the prostate being rare and posing a poor prognosis needs vigilant differential diagnosis and a multidisciplinary treatment approach for optimal and cost-effective treatments.

S1786 Pancreatic Metastasis Secondary to the Masters of Costumes, Renal Cell Carcinoma

Introduction: Renal cell carcinoma (RCC) has been one of the most studied cancers, and its metastatic capabilities are well documented in literature. RCC accounts for 80%-85% of primary renal neoplasm. Approximately 25% of individuals have distant metastases at the time of diagnosis. Its metastatic capabilities continue to be one of the most challenging aspects of the disease. Metastasis to the pancreas has been described in about 2%-5% of all malignant pancreatic tumors. Case Description/Methods: Case of an 80-year-old man with medical history of Stage IV RCC, treated with immunotherapy. Treatment was discontinued due to adverse effects. Patient presents to the ER with a complaint of intractable pruritus. On laboratory values, found with elevated liver enzymes and total bilirubin, with a mixed hepatocellular and cholestatic pattern, reason why gastroenterology service was consulted. Physical examination showed generalized jaundice. Abdominal CT scan showed multiple intrabdominal lesions, including in the pancreas, causing intra and extrahepatic ductal dilation. MRCP showed multiple intrabdominal masses encasing the common bile duct, causing intra and extrahepatic biliary tree and distal pancreatic duct dilation. Concern of a primary pancreaticobiliary malignancy arose. On EGD, multiple gastric and duodenal clean base ulcers and 2 large pedunculated polyps in the second portion of the duodenum removed using hot snare polypectomy technique, and random biopsies on gastric and duodenal ulcers taken. On EUS, a large hyperechoic vascular lesion was observed in the pancreatic head, infiltrating the intrapancreatic bile duct. Another large 3.3 cm x 3.0 cm vascular mass at the gastro-hepatic ligament was observed. Biopsies from duodenal ulcer, duodenal polyp, and pancreatic mass were consistent with metastatic clear cell neoplasm as seen in RCC. ERCP was made to place a fully covered metallic stent at CBD stricture caused by extrinsic compression. Discussion: RCC is the most common renal tumor. Up to 25% of cases present with advanced disease at diagnosis. Our patient presents with multiple intrabdominal masses causing biliary tree and pancreatic duct obstruction. Advanced endoscopic techniques and cross-sectional images play an essential role in the diagnosis and management of pancreaticobiliary pathologies. Other etiologies such as metastatic RCC may mimic primary pancreaticobiliary malignancies. In this case, advanced endoscopic modalities were used for tissue diagnosis and management of metastatic disease.

S1994 Cecal Lymphangioma During Routine Colonoscopy

Introduction: Abdominal lymphangioma is a rare finding. Most of them arise from the mesentery or omentum, and those arising from the GI tract is extremely rare. Lymphangioma involving the colon is usually asymptomatic and can be encountered during screening colonoscopy. It is characterized by a soft, cystic appearing lesion that contains dilated lymphatic channels. Cecal lesions should be differentiated from appendiceal neoplasms including mucocele and carcinoid tumors. Case Description/Methods: A 61-year-old male underwent a screening colonoscopy which revealed a soft cystic lesion in the cecum measuring about 20 mm wide, with a positive cushion sign. Appendiceal orifice and the ileocecal valve appeared normal. CT of the abdomen showed a low-density cystic lesion arising from the wall of the cecum and separate from the appendix. Endoscopic ultrasound (EUS) exam using a mini ultrasound probe revealed a cystic anechoic subepithelial lesion measuring (18 x 17 mm) with septations arising from the submucosa (Figure). Discussion: Lymphangioma of the colon is a rare asymptomatic finding often encountered during screening colonoscopy. It is characterized by a soft, cystic appearing lesion that contains dilated lymphatic channels. It is often solitary and is usually benign in nature. Cecal lesions, especially if in proximity to the appendiceal orifice should be differentiated from appendiceal neoplasms including mucocele and carcinoid tumors. Lymphangioma may be difficult to be differentiated from a lipoma on endoscopic appearance. Signal characteristics on CT imaging differ between the 2; Lipomas have characteristics similar to subcutaneous fat and usually have Hounsfield unit measurements between -65 and -120; Lymphangiomas on the other hand are cystic appearing with Hounsefield units corresponding to the fluid density and the average Hounsefield unit of the lesion in our patient was 17. Similarly, endosonographic features vary between the 2. Lipomas are hyperechoic lesions arising from the submucosa, whereas lymphangiomas are anechoic. Endoscopic appearance of a cystic lesion often with a bluish hue and a positive cushion/ pillow sign and ultrasonographic features (anechoic subepithelial lesion often with septations and without solid component) aid towards the diagnosis of lymphangioma without the need for invasive tissue diagnosis. Rare cases of intussusception from large cecal lymphangioma have been reported. Given the benignity, surgical intervention is not needed in asymptomatic patients.Figure 1.: positive cushion sign.

Polycystic ovarian syndrome with endometrial hyperplasia and uterine fibroids treated with homoeopathy: A case report

Introduction: Any circumstance that alters the balance of oestrogen and progesterone leads to excessive, prolonged estrogenic stimulation, or preventing the counteracting effects of progesterone causing various pathological conditions in the reproductive system, as a result. Women with polycystic ovarian syndrome (PCOS) have mostly anovulatory cycles and low serum progesterone levels. Endometrial hyperplasia is most often due to excess oestrogen without progesterone. The clinical significance of chronic oestrogen secretion is an increased risk of endometrial hyperplasia. A striking feature of uterine fibroids (UFs) is their dependency on the ovarian oestrogen and progesterone. Existing treatments are mostly directed at the symptoms but not at the syndrome itself. Case Summary: A patient suffering from PCOS, with Endometrial Hyperplasia and multiple UFs, was successfully treated with the homoeopathic medicine Pulsatilla nigricans. Repeat ultrasonography showed normal endometrial thickness, no hyperechoic or hypoechoic lesions in uterus and no ovarian PCOS morphology after treatment. Thus, the usefulness of homeopathic medicines for the treatment of multi-morbid pathologies related to reproductive system of women is demonstrated.