Inhomogeneous Enhancement Research Articles

High-grade astrocytoma with piloid features (HGAP): the Charit\xe9 experience with a new central nervous system tumor entity

PurposeHigh-grade astrocytoma with piloid features (HGAP) is a recently described brain tumor entity defined by a specific DNA methylation profile. HGAP has been proposed to be integrated in the upcoming World Health Organization classification of central nervous system tumors expected in 2021. In this series, we present the first single-center experience with this new entity.MethodsDuring 2017 and 2020, six HGAP were identified. Clinical course, surgical procedure, histopathology, genome-wide DNA methylation analysis, imaging, and adjuvant therapy were collected.ResultsTumors were localized in the brain stem (n = 1), cerebellar peduncle (n = 1), diencephalon (n = 1), mesencephalon (n = 1), cerebrum (n = 1) and the thoracic spinal cord (n = 2). The lesions typically presented as T1w hypo- to isointense and T2w hyperintense with inhomogeneous contrast enhancement on MRI. All patients underwent initial surgical intervention. Three patients received adjuvant radiochemotherapy, and one patient adjuvant radiotherapy alone. Four patients died of disease, with an overall survival of 1.8, 9.1, 14.8 and 18.1 months. One patient was alive at the time of last follow-up, 14.6 months after surgery, and one patient was lost to follow-up. Apart from one tumor, the lesions did not present with high grade histology, however patients showed poor clinical outcomes.ConclusionsHere, we provide detailed clinical, neuroradiological, histological, and molecular pathological information which might aid in clinical decision making until larger case series are published. With the exception of one case, the tumors did not present with high-grade histology but patients still showed short intervals between diagnosis and tumor progression or death even after extensive multimodal therapy.

Magnetic investigations on irradiation-induced nanoscale precipitation in reactor pressure vessel steels: A first-order reversal curve study

We have investigated magnetic properties for reactor pressure vessel model alloys with variable Cu contents, subjected to neutron irradiation up to a fluence of 9 × 10 19 n cm − 2 . Unlike a monotonic increase of microhardness with neutron fluence, the major-loop coercivity decreases at a higher fluence and the decrease becomes larger for the alloy containing a higher amount of Cu. The measurements of first-order reversal curves (FORCs) for the high-Cu alloy show that the position of the FORC distribution peak shifts toward a lower coercivity just after neutron irradiation, followed by a slight increase, associated with the broadening along both the coercivity and interaction field axes. The results can be explained by the enhancement of magnetic inhomogeneity in a matrix due to Cu precipitation and an increasing magnetostatic interaction between local magnetic regions with different coercivity. The magnetic method using FORCs can be a possible technique which provides in-depth information on microstructural changes due to neutron irradiation, which is not obtained by measurements of a conventional major hysteresis loop.

Contrast-Enhanced Ultrasound in Locating Axillary Sentinel Lymph Nodes in Patients with Breast Cancer: A Prospective Study

The objective was to explore the clinical value of contrast-enhanced ultrasound (CEUS) in locating the sentinel lymph node (SLN) in patients with early breast cancer. We screened 143 consecutive patients with breast cancer between July 2017 and August 2019. The number of SLNs identified by CEUS and dual labeling (blue dye and radiolabeled colloid) were recorded. The accuracy of CEUS plus fine-needle aspiration cytology (FNAC) was assessed. The rate of identification of SLNs with CEUS was 84.0% (121/144), and that of dual labeling was 97.92% (141/144). There was no significant association between non-enhancement (p = 0.060) or inhomogeneous enhancement (p = 0.468) and lymph node metastasis. The sensitivity and specificity of CEUS-SLNs plus FNAC was 78.38% and 100%, respectively. The technique of CEUS is a promising method for locating the axillary SLN. But it is hard to identify lymph node metastasis with CEUS alone. CEUS-SLNs plus FNAC is a sound technique for diagnosis of the metastasis of SLN.

Cardiac Myeloid Sarcoma: Multimodal Imaging and Histopathologic Findings.

Supplemental material is available for this article.

Perfusion Patterns of Peripheral Pulmonary Lesions in COVID-19 Patients Using Contrast-Enhanced Ultrasound (CEUS): A Case Series.

PurposeTo describe perfusion patterns of peripheral pulmonary lesions (PPLs) in COVID‐19 patients using contrast‐enhanced ultrasound (CEUS).Patients and methodsFrom April 2020 until July 2020, 11 consecutive patients with RT‐PCR‐confirmed COVID‐19 and PPLs sized over 5 mm were investigated by B‐mode ultrasound (B‐US) and CEUS. The homogeneity of enhancement (homogeneous and inhomogeneous) was examined retrospectively using CEUS. An inhomogeneous enhancement was defined as a perfused lesion with coexisting non‐perfused areas (NPA).ResultsOn B‐US, all 11 patients showed an interstitial syndrome (B‐lines) with PPLs between 0.5 and 6 cm. On CEUS, all cases showed peripheral NPA during the complete CEUS examination. One patient underwent a partial lung resection with subsequent histopathological examination. The histological examination showed vasculitis, microthrombus in the alveolar capillary, and small obliterated vessels.ConclusionIn our case series, PPLs in patients with RT‐PCR‐confirmed COVID‐19 infection presented a CEUS pattern with NPA during the complete CEUS examination. Our findings suggest a peripheral pulmonary perfusion disturbance in patients with COVID‐19 infection. In 1 case, the histopathological correlation with the perfusion disturbance in the PPL was proven.

Clinical and Radiologic Characteristics, Surgical Outcomes, and Its Possible Origins of Chondroma of the Dural Convexity

Chondroma of the dural convexity (CDC) is a benign and extremely rare type of intracranial chondroma. In this study, we reported five CDCs in a single center and reviewed the available literature to determine the clinical characteristics and surgical outcomes and possible origins of the disease. The clinical data of five patients (4 females) who confirmed to be CDC between 2000 and 2019 in our single center was collected together with 22 cases from literatures. The clinical characteristics and surgical outcomes were reviewed and analyzed. Among all the available CDC cases, the mean age was 31 ± 13.7 years; the mean tumor volume was 42.3 ± 40.9 cm3, showing a female predominance (63% vs. 37%). The tumors showed calcification in 88.2% cases (15/17) on CT scans and hypointense on T1WI (15/19, 78.9%), mixed intense on T2WI (10/18, 55.6%), and inhomogeneous enhancement without dural tail sign after administration of gadolinium (20/21, 95.2%). Almost all the tumors were misdiagnosed as meningiomas preoperatively. In addition, almost all image available CDC lesions (24/25, 96%) located across the cranial sutures indicating that the tumor originated from ectopic chondrocytes from adjacent skull sutures. No tumors recurred after total resection in follow-up. CDCs are characterized with female predominance and may originate from ectopic chondrocytes from adjacent skull sutures. The lesion with inhomogeneous contrast enhancement without dural tail sign and avascular in cerebral angiography are key points to be differentiated from meningioma. The most effective treatment is total resection.

Rapidly progressive respiratory failure with multiple halo signs on computed tomography in a patient with primary cardiac angiosarcoma derived from the right atrium: a case report

BackgroundPrimary cardiac neoplasms are extremely rare, with an autopsy incidence of 0.0001–0.003%. Primary cardiac sarcoma is usually derived from the right atrium and it manifests as chest pain, arrhythmia, hemoptysis, dyspnea, and fatigue. The most common target organ for metastasis of primary angiosarcoma is the lungs, but the radiological-pathological correlation has been rarely reported.Case presentationA 38-year-old healthy Japanese man was admitted to our hospital with persistent hemoptysis, exaggerated dyspnea, and two episodes of loss of consciousness in the past 3 months. Non-enhanced thoracic computed tomography (CT) revealed multiple scattered nodules with halo signs. Contrast-enhanced thoracic CT revealed a filling defect in the right atrium, which corresponded to the inhomogeneously enhancing tumor in the right atrium on enhanced electrocardiogram-gated cardiac CT. On day 2, acute respiratory failure occurred, and the patient was placed on mechanical ventilation. The patient was diagnosed with primary cardiac angiosarcoma based on the urgent transcatheter biopsied specimen of the right atrium mass and was treated with intravenous administration of doxorubicin. However, his respiratory status rapidly deteriorated, and he died on day 20. Postmortem biopsy showed that the multiple lung nodules with the halo signs corresponded to the intratumoral hemorrhagic necrosis and peripheral parenchymal hemorrhage in their background, suggesting the fragility of the lung tissue where the tumor had invaded, which caused hemoptysis. Furthermore, two episodes of loss of consciousness occurred probably due to a decreased cardiac output because of a massive tumor occupying the right atrium, recognized as an inhomogeneous centripetal enhancement on enhanced electrocardiogram-gated cardiac CT.ConclusionsThis case clearly demonstrated that primary cardiac angiosarcoma could expand in the right atrial cavity, which led to a decreased cardiac output resulting in repeated syncope, together with the fragility of lung tissue by tumor invasion, thereby generating a halo sign on thoracic CT.

Clinical value of high-resolution dynamic contrast-enhanced (DCE) MRI in diagnosis of cutaneous squamous cell carcinoma.

While uncomplicated cases of skin squamous cell carcinoma (cSCC) can be treated with surgery topical therapy alone, more objective and non-invasive examination methods are needed to guide clinicians to make more detailed biopsy and surgical plans for lesions with atypical or subcutaneous growth. High-resolution magnetic resonance imaging (HR-MRI) is a novel skin imaging method. Prospective collection of 19 patients with clinically suspected cSCC. All patients underwent high-resolution DCE-MRI using a 70-mm microscopy coil before operation. The imaging features and results of surgical pathology were recorded. Ktrans , Kep , Ve values, and the time-signal curve (TIC) types were determined using DCE images. 16 cases of cSCC, 3 cases of acanthoma. The subcutaneous invasion of all lesions was clearly displayed, of which 8 lesions invaded the subcutaneous fat layer, 5 invaded the muscle layer, 1 invaded the periosteum, 2 invaded the cap fascia, and the layer of all lesions invasion judged by HR-MR imaging was consistent with the postoperative pathology. The main manifestations of cSCC were ill-defined margin, obvious inhomogeneous enhancement, higher perfusion parameters value and type-III TIC, while acanthoma showed well-defined and type-I TIC. Some imaging findings (such as boundary, enhancement) and DCE perfusion parameters of the two groups overlap. High-resolution DCE-MRI can fully and directly display the subcutaneous invasion of cSCC, and more work needs to be done to prove its value. Next, we will expand the sample size, and further explore its value in the differential diagnosis and prognosis evaluation of cSCC from acanthoma or other skin tumors.

Value of contrast-enhanced malignancy imaging features in secondary grade diagnosis of BI-RADS-US type 4 breast lesions.

To explore the value of contrast-enhanced malignancy imaging features in secondary grade diagnosis of Breast Imaging Reporting and Data System for Ultrasonography (BI-RADS-US) type 4 breast lesions. After initial diagnosis by ultrasound, 124 BI-RADS-US type 4 patients with 130 lesions were examined by contrast-enhanced ultrasound (CEUS) and were classified again before surgery according to five contrast-enhanced malignancy imaging features: inhomogeneous enhancement, peripheral ring-like enhancement, expansive enhancement, internal filling defects, and surrounding radioactive convergence. Lesions with no contrast-enhanced features of malignancy were categorized as type 3; lesions with one, two, or three features of malignancy were categorized as type 4A, 4B, or 4C, respectively; and lesions with four or more indices of malignancy were categorized as type 5. The value of contrasted imaging features of malignancy in diagnosing BI-RADS-US type 4 breast lesions was analyzed. The accuracy of CEUS diagnosis for type 3 lesions was 93.8% (46/49), 76.9% (10/13) for type 4A, 71.4% (5/7) for type 4B, 75.0% (9/12) for type 4C, and 93.8% (46/49) for type 5 lesions. The sensitivity of CEUS in diagnosing malignant lesions was 90.4%, specificity was 83.6%, and accuracy was 86.9%. CEUS decreased the benign lesion biopsy ratio to 68.5% (46/67) and increased the diagnosis ratio of malignant lesions to 73.0% (46/63). CEUS can further optimize the classification of BI-RADS-US type 4 breast lesions and may provide a better reference basis for clinical diagnosis and treatment of those breast lesions.

Airway obstruction as the primary manifestation of infantile thyroid hemangioma

BackgroundThyroid hemangioma mostly occurs in adults and is extremely rare in infants. So far, only four pediatric cases of thyroid hemangioma have been reported, one of which has only been clinically diagnosed. Most of the reported cases are of cavernous hemangiomas; capillary hemangioma cases are very rare. To date, there are no reports on capillary thyroid hemangioma in an infant. Therefore, here we present the case of an infant with a primary capillary hemangioma of the thyroid gland, and discuss its treatment and follow-up.Case presentationA2-month-old infant with normal thyroid function presented with airway obstruction as the primary manifestation of thyroid hemangioma. The main symptoms were laryngeal wheezing and dyspnea. Ultrasonography revealed hypoechoic lesions at the lower pole of the bilateral thyroid. Computed tomography revealed enlargement of the thyroid gland, inhomogeneous parenchyma enhancement, and multiple thyroid nodules. However, these imaging modalities were unable to provide an exact diagnosis and the nature of the mass remained unknown prior to an operation. Therefore, a postoperative histopathological examination was undertaken, which revealed capillary thyroid hemangioma. The symptoms significantly improved by a combined treatment involving surgery and oral propranolol.ConclusionWhen a well-defined capsulate mass is detected on the medical image, the possibility of primary thyroid hemangioma must be considered.

Computed tomography imaging and clinical features of congenital hepatoblastoma

Congenital hepatoblastoma (CHB) is the most common hepatic malignant tumor of fetus or neonates, but few studies focusing on the radiological characteristics of CHB have been reported to date.To investigate the characteristic clinical and computed tomography (CT) findings of CHB to facilitate recognition and noninvasive diagnosis.Medical records of 7 patients with CHB were retrospectively reviewed. The demographic, clinical, and laboratory data were extracted from the electronic medical records. Two pediatric radiologists evaluated the abdominal CT examinations for the hepatic tumor location, size, enhancement characteristics, vascular invasion, and intra-/extra-hepatic metastasis.Among the included 7 patients (3 males and 4 females), only 1 had an elevated serum alpha-fetoprotein level. All patients had solitary intrahepatic mass with a mean size of 4.7 cm (range: 2.9–10.2 cm), of which liver SV-VII were most involved. 4/7 tumors were round while 3/7 irregular or lobulated. 6/7 tumors were well-defined. Microhemorrhage, cystic necrosis, and coarse calcification were present in 5/7, 4/7, and 1/7 tumors, respectively. All lesions showed inhomogeneously significant enhancement, with multiple nodular or striped appearance in the center and periphery of the tumors on the arterial phase, and then the enhancement area showed progressive expansion and fusion filling over time but the attenuation gradually declined on the portal and delayed phases, and finally the majority (6/7) of tumors presented multiple band- or island-like characteristics with prominently peripheral enhancement on the delayed phase while the remaining 1 relatively small tumor showed nearly complete but inhomogenous enhancement. In addition, only 1/7 tumor had hilar hepatic bile duct and portal vein invasion and secondary intra-hepatic bile duct dilation. No metastatic lesions were identified in all patients at diagnosis. The abdominal aorta distal to the coeliac trunk was significantly narrowed in 3/7 patients. Pathological examinations suggested that 6/7 tumors showed fetal histology with only 1 containing mesenchymal elements.The relationship between serum alpha-fetoprotein and CHB could be more complicated and yet to be determined. Dynamic contrast-enhanced CT can facilitate recognition and noninvasive diagnosis of CHB, presenting a pattern of progressive expansion and fusion filling but inhomogeneously significant enhancement.

MRI and the pathology of breast invasive micropapillary carcinoma.

Diagnosis of breast invasive micropapillary carcinoma (IMPC) before surgery is of great value for determining the optimal treatment strategy. The aim of the present study was to investigate the magnetic resonance imaging (MRI) and pathological features of IMPC. MRI features of IMPC were characterized in relation to the patients' clinicopathological features. Clinical manifestations, mammography results and/or MRI findings of patients with IMPC were retrospectively analyzed. Parameters included morphology, plain T2-weighted imaging (T2WI) signal intensity, the apparent diffusion coefficient (ADC), the internal enhancement mode, early enhancement rates and time-intensity curve (TIC) types during dynamic enhanced scanning. A total of 10 lesions were detected by MRI in eight patients, with one case having three lesions with the mean diameter of 34.44 mm. In plain T2WI scanning, the lesions appeared inhomogeneous with a moderate or high signal intensity. When the b value was 800 sec/mm2, the average ADC value was 0.823±0.12×10−3 mm2/sec. A total of four cases exhibited mass-like enhancement, including an oval rim in one case (three lesions), irregular inhomogeneous enhancement in two cases and irregular uniform enhancement in one case. The margins were clear in one case (three lesions), irregular in two cases and spiculate in one case. Among the four cases with non-mass enhancement, the distribution was focal in two cases, linear in one case and regional in one case, and the internal enhancement mode was cluster-like in one case, heterogeneous in one case and uniform in two cases. The average early enhancement rate was 116.96±45.26%. TICs of type III were observed in all cases. In conclusion, MRI of IMPC demonstrated typical features of malignant tumors and lymphatic vessel infiltration, suggesting that MRI may exhibit guiding significance for the diagnosis and treatment planning of IMPC.

Adult pancreatic hemangioma: a rare case report and literature review

BackgroundAdult pancreatic hemangioma is an extremely rare type of benign vascular tumor. To date, about 20 cases have been reported in the English literature. Adult patients with pancreatic hemangiomas usually have no specific symptoms, particularly in early stages. Therefore, it is difficult to detect and diagnose these lesions, which usually are identified during cross sectional imaging for an apparently unrelated causes or when biliary obstruction occurs because of compression by a tumor.Case presentationThis study presents the case of a 52-year-old female with a chief complaint of epigastric pain. Contrast-enhanced computed tomography revealed a well-defined mass with mildly inhomogeneous enhancement in the body of the pancreas. Endoscopic ultrasonography showed calcifications in the lesion, and a few small vessels were detected by Doppler imaging. The patient received a central pancreatectomy, and pathological examination confirmed the diagnosis of pancreatic hemangioma.ConclusionIn this report, we reviewed the clinical manifestations, radiologic features, preoperative diagnosis, pathologic characteristics, and surgical treatment of adult pancreatic hemangioma.

Magnetic resonance imaging features for predicting axillary lymph node metastasis in patients with breast cancer

PurposeThe purpose of this study was to assess the clinical value of conventional magnetic resonance imaging (MRI) and intravoxel incoherent motion (IVIM) features for predicting the risk of axillary lymph node (ALN) metastasis in patients with breast cancer. MethodsThis retrospective study involved 265 patients with breast cancer who underwent 3.0 T breast magnetic resonance imaging examinations prior to surgery and other treatment. Of these, 119 underwent IVIM examination. The features of MRI and IVIM and postoperative pathologic results were collected. The association of MRI features of breast cancer with ALN metastasis were determined by univariate and multivariate analyses. Comparison of IVIM parameters between breast cancer patients with and without ALN metastasis was performed using the Mann–Whitney U test. ResultsAmong the 265 patients, 144 (54.3%) had ALN metastasis, and 121 (45.7%) did not. The size and shape of the tumours, T2WI signal, inhomogeneous enhancement, washout intensity–time curves and the values of slow ADC, fast ADC and fraction of fast ADC parameters were significantly associated with ALN metastasis. The AUC of conventional MRI for diagnosing axillary lymph node metastasis was 0.722. The AUC of MRI combined with slow ADC, fast ADC and fraction of fast ADC parameters that were used to diagnose breast cancer with ALN metastasis were 0.814, 0.803 and 0.900, respectively. ConclusionsThe features of IVIM parameters and conventional MRI can be used to predict the ALN metastasis in patients with breast cancer. MRI combined with fraction of fast ADC showed higher diagnostic efficiency for ALN metastasis in breast cancer than MRI did.

Desmoid Type Fibromatosis of the Breast: Ten-Year Institutional Results of Imaging, Histopathology, and Surgery

Background: Desmoid type fibromatoses has proven to be a diagnostic and therapeutic challenge, as they often appear primarily as a carcinoma of the breast with a high recurrence risk. Patients: A digital archive search was performed for the period from 2009 to the end of 2018. Inclusion criteria consisted of histological examination of at least the surgical specimen in the reference pathology department and at least a second opinion diagnosis in the reference radiology department. Results: A total of 14 women and 1 man underwent surgery on desmoid type fibromatosisof the breast. The average patient age was 49 years (range: 22–72 years). The mean tumor size was 2.2 cm (range: 0.8–4.2 cm). The tumor was detectable in mammography in 12 out of 13 patients and in all 15 patients in sonography. MRI was performed preoperatively in 6 patients; in all of the patients, the tumor was visualized with inhomogeneous contrast enhancement. In the imaging procedures, all desmoid type fibromatoses were classified as suspicious. Performing the core biopsy, preoperative histology confirmed desmoid fibromatosis in 12 out of 15 patients. Nuclear stain for ß-catenin was positive in 7 out of 10 patients.Negative staining was found for AE1/A3 in 10 out of 10 and CD34 in 12 out of 12 patients. In all of the patients, a single-stage operation without the detection of border-forming tumor margins was performed. The follow-up interval ranged from 16 to 96 months (mean: 44.86 months, median: 43 months). In this follow-up period, no patient was diagnosed with desmoid tumor recurrence. Conclusion: In imaging, desmoid type fibromatosis of the breast has typical malignancy-related criteria. Extensive preoperative diagnostics enable the planning of complete primary excision of the lesion and reduce the recurrence risk.

SAT-LB23 Paraneoplastic Hypercalcemia in a PTH Producing Adrenocortical Carcinoma - a Rare and Deadly Condition

Background: Hypercalcemia is a commonly encountered paraneoplastic manifestation of certain cancers with or without endocrine differentiation. However, the association between adrenocortical carcinoma (ACC) with paraneoplastic hypercalcemia is very rare, and therefore little is known about the cause and its relevance in the disease. Clinical Case: A 40-year-old woman presented in the hospital with a 5-month history of progressive flank pain with unintentional weight loss of 6 kg. MRI revealed a mass of 9x8.1x4.8 cm of the right adrenal gland with inhomogeneous contrast enhancement. Biochemical investigations provided evidence of endogenous hypercortisolism (24-hour urinary cortisol excretion [490 µg, n<236 µg/l], 1mg dexamethasone suppression test [199 nmol/l, n<50 nmol/l], ACTH [28 ng/l, n<61 ng/l]) although the patient did not show any specific clinical sign of overt hypercortisolism. In addition, laboratory testing revealed an exceptionally high plasma level of calcium [max 3.67 mmol/l (albumin-corrected)] and low phosphate [min 0.26 mmol/l] in the setting of low PTH [6.4 ng/l, n>15 ng/l] and PTHrP levels [<0.50 pmol/l]. However, subsequent dilution unmasked a highly elevated PTH concentration of 2171.5 ng/l with persistent low PTHrP levels, indicating false low values due to a hook effect in the initial measurement. Levels of 1,25-dihydroxy vitamin D and 25-hydroxy vitamin D were in the normal range. A PET-CT provided no indications of metabolically active (osseous) metastases. After correction of the serum calcium towards tolerable values, the tumor was removed by open en bloc adrenalectomy. Histologic evaluation confirmed an ACC (TNM pT4 pN1 (2/3), L1, V1, high grade) despite missing immunohistochemically expression of classical adrenal markers (diagnosis of exclusion). Supplemental quantitative RT-PCR studies support the diagnosis of ACC by detecting significant SF-1 and CYP11B2 expression in the tumor cells. Further analyses provided evidence that the mRNA expression of PTH, but not PTHrP, was moderately increased in the ACC sample compared to NCI H295R cells. Upon tumor resection, serum calcium levels swiftly normalized indicating the tumor as the sole source of PTH secretion. Despite initiation of adjuvant mitotane- and salvage chemo-therapy, the patient died 3 months later upon of a massive tumor relapse with a recurrence of severe hypercalcemia. Conclusion: This case demonstrates paraneoplastic hypercalcemia in a PTH producing ACC. PTH may induce hypercalcemia, impair adrenal steroid synthesis and act as an autocrine growth factor in ACC, as described in few individual cases for PTHrp producing ACC [1]. This suggests a poor prognosis for this rare entity.1. Rizk-Rabin, M., et al., Differential Expression of Parathyroid Hormone-Related Protein in Adrenocortical Tumors: Autocrine/Paracrine Effects on the Growth and Signaling Pathways in H295R Cells. 2008.

SUN-288 Atypical Teratoid Rhabdoid Tumor of the Sellar Region: An Unusual Cause of Hypopituitarism

Background: Atypical teratoid/rhabdoid (AT/RT) tumor of the sellar region is an extremely rare malignant tumor in adults. To date, there are no definitive guidelines for optimal treatment and the prognosis of this tumor is poor. The pituitary insufficiency was rarely mentioned in previous literature and might be overlooked. Clinical case: A 43 years old female presented to our clinic with severe periorbital pain. The magnetic resonance imaging of the brain revealed a 1.5x1.5x 3 cm sellar mass which showed inhomogeneous enhancement after gadolinium administration. Hormonal work up showed 8AM cortisol of 1.86 mcg/dL, free T4 1.0 (0.8–1.8 ng/dL), TSH 0.05 (0.3 - 4.1 uIU/ml), FSH 6.0 (1.6–9.3 IU/L), LH 1.8 (2.4–9.3 IU/L), estradiol <18.35 (80–790 pmole/L), IGF-1 96.6 (50.6–263.7 ng/ml), prolactin 56.6 ng/ml.She underwent transsphenoidal surgery with tumor removal. The pathological result showed a mixture of pleomorphic spindle cell, oval shape tumor and poorly differentiated cell. The tumor was negative for INI1 (SMARCB1) compatible with AT/RT WHO grade IV. She developed pan hypopituitarism after surgery. She received 6 courses of 5950 cGy/25 fractions cranial irradiation and 6 courses of ifosfamide, cisplatin and etoposide. She completed the treatment regimen without significant toxicity. She continued hormonal replacement for panhypopituitarism and is still being followed at our clinic for 4 years without tumor progression or other complications.In previously reported cases, all of the sellar AT/RT were female with a median age of 45 years old (range 20–61). The clinical presentations are rapidly enlarged sellar mass with compressive symptoms to the adjacent structures. The radiological findings of sellar AT/RT are non-specific. The diagnosis is based on histopathological findings. Presence of rhabdoid cells on histopathology and polyphenotypic immunopositivity for epithelial, mesenchymal, and neuroectodermal markers along with loss of expression of SMARCB1/INI1 help in establishing a diagnosis of AT/RT.Currently, there are no definitive guidelines for optimal treatment. Multimodality treatment consisted of surgery, radiation and chemotherapy are the mainstays of treatment of the AT/RT. Of the 16 adults reported in the literature, 9 patients survived more than 12 months resulted in 47% of one-year survival rate. To our knowledge, this case is the sellar AT/RT with the longest survival to date. Conclusion: AT/RT is one of the most aggressive tumors in the sellar area. Due to its aggressiveness, hypopituitarism is anticipated. Our patient had postoperative secondary adrenal insufficiency, secondary hypothyroid and hypogonadotropic hypogonadism. Apart from multimodality treatment required for tumor control, pituitary hormones should be evaluated preoperatively to prevent perioperative mortality and long-term improvement in the quality of life.

The Value of CEUS in Distinguishing Cancerous Lymph Nodes From the Primary Lymphoma of the Head and Neck.

Aim: The purpose of this study was to assess the ability of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of cancerous lymph nodes.Methods: Contrast-enhanced ultrasonography was performed in the cervical nodules of included patients, and the diagnoses were confirmed by pathological examination. Contrast-enhanced ultrasonography images and parameters of head and neck lymphomas were compared with those of cancerous lymph nodes. Besides, receiver operating characteristic curve was operated to access the diagnostic value of CEUS.Results: Finally, a total of 63 head and neck lymphomas and 80 cervical cancerous lymph nodes were enrolled in this study. Results showed that the CEUS images of lymphoma were mainly characterized by homogeneous enhancement (71.43%), and approximately half of them were centripetal perfusion (58.73%), whereas most CEUS images of cancerous lymph nodes were inhomogeneous enhancement (82.50%) and centripetal perfusion (92.50%). Quantitative analysis of CEUS parameters indicated that PI (derived peak intensity) and AUC (area under the curve) of lymphomas were both lower than those of cancerous lymph nodes (PI: 8.78 vs. 10.51, AUC: 652.62 vs. 784.09, respectively) (P < 0.05). Receiver operating characteristic analysis showed that the sensitivity of CEUS parameters in the differential diagnosis was significant (80.00%), although the specificity was not high (47.62%). When parameters were combined with the image features, the accuracy of diagnosis was greatly improved (from 0.655 to 0.899).Conclusion: Contrast-enhanced ultrasonography could be a promising tool for the differential diagnosis of head and neck lymphomas and cancerous lymph nodes.

Primary hepatic perivascular epithelioid cell neoplasm (PEComa) with fever in a 53-year-old man

A 53-year-old male patient, presenting merely with fever for a week, was admitted to the hospital. Contrast-enhanced CT showed a round inhomogeneous enhancement lesion on the early arterial phase and...

P1342 Secondary cardiac tumour -a metastasis from renal cell carcinoma via transvenous extension

Abstract Secondary cardiac tumour is 20-40 times more common than primary cardiac tumour. Most common tumour that metastasize to the heart are lung cancer, breast cancer and hematologic malignancy. Melanoma and pleural mesothelioma has high inclination to metastasize. Other cancer with high rate of cardiac metastasis include gastric, ovarian, renal and pancreatic cancer. The presentation of cardiac metastasis is usually non-specific and sometimes mimic other cardiac condition. We would like to present one such case where we used multimodality approach for proper evaluation. A 57 year old lady presented with intermittent chest discomfort for one month which worsen on day of admission. Otherwise she had good effort tolerance. Electrocardiogram had no acute ischemic changes and Troponin T was not elevated. Bedside echocardiography revealed a large cardiac mass in right atrium around 66mm x 29mm, protruding to right ventricle. Apart from that noted aneurysm of interatrial septum towards LA. MRI cardiac showed an inhomogenous mass extending from the right renal vein and inferior vena cava(IVC) into the right atrium(RA). The tumour mass in the right atrium a highly mobile and flops across the tricuspid valve into the right ventricle during ventricular diastole causing right ventricular outflow tract obstruction. The mass was hyperintense on T2- and isointense on T1-weighted images. There was vascularity within the mass with inhomogenous gadolinium enhancement. There was also 2 masses in right kidney , a larger inhomogenous encapsulated mass at the right lower pole and smaller at lower pole. The findings were suggestive of a primary renal cell carcinoma with tumour mass extension into right renal vein, inferior vena cava and into the right atrium. A staging CT scan thorax , abdomen and pelvis did not show any other possible primary source of cancer and reconfirm the extracardiac finding of the MRI. No evidence of tumour extension into hepatic veins and left renal vein. There was however small nodular opacities in both right and left lung suggesting lung metastasis. A combined operation was done with our cardiothoracic surgeon and urologist from nearby tertiery hospital. Nephrectomy and removal of tumour thrombus from IVC and RA was done with 18 degree Celcius circulatory arrest with cardiopulmonary bypass. Section of renal mass showed a poorly circumscribed lobulated tumour with areas of hemorrhage and necrosis. The tumour was close to capsule but has not breached it. The tumour was mainly clear cell carcinoma variant, nuclear grade III. Section from IVC that extend to RA appeared elongated sausage-like measuring 150mm in length and 30mm in diameter had tumour embolus. Pulmonary artery and perirenal blood vessel also had tumour emboli. The hilar nodes however were free from tumour. Patient recovered well and was discharged home day 9 post operation. Follow-up echocardiogram 3weeks post-op showed no recurrence of the mass and good LV function. Abstract P1342 Figure. Echo, CTscan, MRI and Pathology images