Invasion Of Adjacent Structures Research Articles

A Rare Presentation of Lymphangioma in a Patient With Hematochezia

Lymphangiomas are rare benign cysts caused by congenital malformation of the lymphatic system. The incidence of lymphangiomas is between 1.2:1,000 to 4:10,000 births per year. Amongst lymphangiomas 80-90% originate from the head and neck. Intra-abdominal lymphangiomas make up about 5% of lymphangiomas. There is no specific data on the incidence of colonic lesions. We present a case of a 38 year old female with no significant past medical history presenting with bright red blood per rectum. The patient had been having issues with chronic hematochezia since her teenage years, which had been attributed to hemorrhoids. The patient denied any early satiety, nausea, vomiting, unintentional weight loss, or black stools. Physical exam was unremarkable, except for a palpable mass on rectal exam. Laboratory evaluation revealed a microcytic anemia, but otherwise was within normal limits. She had never before undergone endoscopic evaluation. The patient subsequently underwent a full colonoscopy that revealed an extensive network of cyst like structures from just proximal to her dentate line to 15 cm. These lesions were examined radiographically, endoscopically, and via endoscopic ultrasound (EUS). EUS and MRI investigations demonstrated extent of disease down into the perirectal fat region, but with no invasion of adjacent structures. Biopsies of the lesion revealed multiple areas of dilated lymph vessels extending into the muscularis mucosae lined with endothelial cells, diagnostic of lymphangioma. The approach to treatment of lymphangiomas is varied, from conservative expectant course to sclerosant injections and aspiration, to surgical resection. There are reported cases of spontaneous regression, up to 15-20%. Recurrence rates of 50% are reported with surgery. Although very rare, there is a potential risk for malignant transformation. The patient ultimately elected for the expectant course. This case demonstrates a rare cause for hematochezia, which emphasizes the importance of a broad differential diagnosis, and the need to not discount patient's symptoms regardless of prior evaluations.Figure 1Figure 2

Progress in the Diagnosis and Classification of Pituitary Adenomas.

Pituitary adenomas are common neoplasms. Their classification is based upon size, invasion of adjacent structures, sporadic or familial cases, biochemical activity, clinical manifestations, morphological characteristics, response to treatment and recurrence. Although they are considered benign tumors, some of them are difficult to treat due to their tendency to recur despite standardized treatment. Functional tumors present other challenges for normalizing their biochemical activity. Novel approaches for early diagnosis, as well as different perspectives on classification, may help to identify subgroups of patients with similar characteristics, creating opportunities to match each patient with the best personalized treatment option. In this paper, we present the progress in the diagnosis and classification of different subgroups of patients with pituitary tumors that may be managed with specific considerations according to their tumor subtype.

CT and MRI findings of radiation-induced external auditory canal carcinoma in patients with nasopharyngeal carcinoma after radiotherapy.

To summarize the radiological and clinical features of radiation-induced external auditory canal carcinomas (RIEACCs) in patients with nasopharyngeal carcinomas (NPCs) after radiation therapy. CT, MRI and clinical features in 16 patients with histologically proven RIEACCs were retrospectively reviewed. There were 2 females and 14 males, with a median age of 52.5 years at the time of diagnosis of RIEACC. Imaging parameters including lesion extent, size, margin, shape, bone destruction, adjacent structure invasion, density/signal intensity, and pattern and degree of enhancement were assessed. Clinical features including clinical staging, histological type, treatment and radiation dose (RD) of primary NPC as well as the histological type, staging of radiation-induced tumour and the latent period between NPC and RIT were recorded. All patients had a single RIEACC. The lesions had a size of 3.5 ± 1.4 cm and were localized (n = 7) or extensive (n = 9). Most of the lesions were partially or ill defined with an irregular shape and had an intermediate density/signal pattern and moderate homogeneous enhancement. The latent period of RIEACCs ranged from 10 to 20 years in nine patients with a RD of 68-70 Gy; from 2 to 10 years in five patients with a RD of 68-74 Gy; and more than 20 years in two patients with a RD of 70 or 72 Gy. An external auditory canal (EAC) mass with homogeneous, intermediate CT density or signal intensity in patients with NPC after radiotherapy is highly suggestive of RIEACC, which should be included in the routine surveillance for patients with NPC after radiotherapy. RIEACCs could occur as short as 2 years after radiotherapy in patients with NPC and have distinct features from otitis media and sarcomas. This EAC malignancy should be included in routine surveillance for patients with NPC after radiotherapy.

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Invited Commentary

Anterior mediastinal masses in the Framingham Heart Study: Prevalence and CT image characteristics

PurposeTo investigate the prevalence and CT image characteristics of anterior mediastinal masses in a population-based cohort and their association with the demographics of the participants. Materials and methodsChest CT scans of 2571 Framingham Heart Study participants (mean age 58.9 years, 51% female) were evaluated by two board-certified radiologists with expertise in thoracic imaging for the presence of anterior mediastinal masses, their shape, contour, location, invasion of adjacent structures, fat content, and calcification. For participants with anterior mediastinal masses, a previous cardiac CT scan was reviewed for interval size change of the masses, when available. The demographics of the participants were studied for any association with the presence of anterior mediastinal masses. ResultsOf 2571, 23 participants (0.9%, 95% CI: 0.6–1.3) had anterior mediastinal masses on CT. The most common CT characteristics were oval shape, lobular contour, and midline location, showing soft tissue density (median 32.1HU). Fat content was detected in a few cases (9%, 2/23). Six out of eight masses with available prior cardiac CT scans demonstrated an interval growth over a median period of 6.5 years. No risk factors for anterior mediastinal masses were detected among participants’ demographics, including age, sex, BMI, and cigarette smoking. ConclusionsThe prevalence of anterior mediastinal masses is 0.9% in the Framingham Heart Study. Those masses may increase in size when observed over 5–7 years. Investigation of clinical significance in incidentally found anterior mediastinal masses with a longer period of follow-up would be necessary.

Chondroblastoma of the Temporal Bone: A Case Report and Review of the Literature

Introduction: Chondroblastomas occurs in 1% of primary benign bone tumors and those involving the temporal bone is extremely rare. Most of the cases occur in the petrous apex, affecting individuals, especially in the age range between 30 and 40 years. It may also show a malignant behavior with invasion of adjacent structures.

MRI of placental adhesive disorder.

Placental adhesive disorder (PAD) is a serious pregnancy complication that occurs when the chorionic villi invade the myometrium. Placenta praevia and prior caesarean section are the two important risk factors. PAD is classified on the basis of the depth of myometrial invasion (placenta accreta, placenta increta and placenta percreta). MRI is the preferred image modality for pre-natal diagnosis of PAD and as complementary technique when ultrasonography is inconclusive. Imaging findings that are helpful for the diagnosis include dark intraplacental bands, direct invasion of adjacent structures by placental tissue, interruption of normal trilayered myometrium and uterine bulging. Clinicians should be aware of imaging features of PAD to facilitate optimal patient management.

Congenital Primary Penile Teratoma in a Child

Teratomas rarely present as a pediatric congenital primary penile mass. We describe a 14-month-old boy with a blister-like mass on his distal left penis. The subcutaneous mass measured 1.5 cm (length)×1.0 cm (width)×1.2 cm (height) on ultrasonography. There were clear margins between these structures and the lesion. At the age of 5 years, he received an extirpation surgery. Histologic analysis revealed that it was a mature teratoma. In our view, surgical resection should be the treatment of choice for a pediatric penile mass with the alertness of teratomas because of the possibility of malignant alteration and invasion of adjacent structures till unresectable.

Review article: the biology, diagnosis and management of gastrointestinal stromal tumours.

Gastrointestinal stromal tumours (GIST) are the most common mesenchymal tumours of the gastrointestinal tract with an increasing incidence. To review the biology, diagnosis and treatment of gastrointestinal stromal tumours. A PubMed search using the phrases 'Gastrointestinal stromal tumor', 'imatinib', 'c-kit'. The diagnosis of GIST is established by histology supplemented by the immunohistochemical marker CD117, which is positive in 95% of cases. The most common site of the tumour is the stomach. Most GIST are benign with 20-30% malignant. Five-year survival for malignant GIST ranges between 35% and 65% and depends primarily on tumour size, mitotic index and location. The malignant behaviour of GIST is best assessed by invasion of adjacent structures and distant metastases. The gold standard for treatment is surgical resection. Imatinib, a tyrosine kinase inhibitor, is the primary therapy for unresectable, recurrent or metastatic disease. Gastrointestinal stromal tumours are rare tumours of the gastrointestinal tract and they vary in presentation. When surgical resection is not achievable, imatinib is the treatment of choice.

4D CT and lung cancer surgical resectability: A technical innovation

A 74-year-old man presents with a left upper lobe lung adenocarcinoma, which demonstrated a wide base intimately with the aortic arch. We utilised 4D CT technique with a wide field of view CT unit to preoperatively determine likely surgical resectability. We propose that 4D CT may be of use in further investigating lung cancer with likely invasion of adjacent structures.

Utilidad de la PET/TC en el manejo del cáncer de vulva

To describe the clinical impact of PET/CT in the management of patients with vulvar cancer.Retrospective analysis of 13 PET/CT studies with (18)F-FDG (6 staging and 7 suspected recurrence) corresponding to 10 patients diagnosed with vulvar cancer by biopsy, with a mean age of 64.5 years. The preoperative PET/CT study was analyzed qualitatively according to the lesion region. Surgical excision was carried out, covering all the suspected areas according to the PET/CT study. This was compared with the histopathologic analysis.Abnormal vulvar PET/CT uptake was found in 9 out of the 13 studies and invasion of adjacent structures in 5 of them (urethra, perineal, vagina). The inguinal-femoral lymph nodes were considered as affected in 3 studies and one pelvic lymph node was also affected. Four of the studies had extralymphatic involvement: 3 in lung and 1 in ischiorectal fossa. The PET/CT showed a 100% sensitivity for the detection of the vulvar lesion in squamous cell carcinomas and 60% in non-squamous cell ones. There was a false positive result for local invasion due to urine contamination. One of the studies with lung metastases was related to a synchronous breast tumor. All the pathological lymph node levels detected in the PET/CT study were confirmed in the histopathology study. No new lesions were identified by surgery. PET/CT changed the therapeutic management in 8/13 studies (61.5%).PET/CT is postulated as a useful imaging test for the management of vulvar cancer, mainly in the identification of nodal metastases. It may affect both surgical planning and clinical management. Larger series are needed to confirm our findings.

Utility of the PET/CT in vulvar cancer management

ObjectiveTo describe the clinical impact of PET/CT in the management of patients with vulvar cancer. Material and methodsRetrospective analysis of 13 PET/CT studies with 18F-FDG (6 staging and 7 suspected recurrence) corresponding to 10 patients diagnosed with vulvar cancer by biopsy, with a mean age of 64.5 years. The preoperative PET/CT study was analyzed qualitatively according to the lesion region. Surgical excision was carried out, covering all the suspected areas according to the PET/CT study. This was compared with the histopathologic analysis. ResultsAbnormal vulvar PET/CT uptake was found in 9 out of the 13 studies and invasion of adjacent structures in 5 of them (urethra, perianal, vagina). The inguinal–femoral lymph nodes were considered as affected in 3 studies and one pelvic lymph node was also affected. Four of the studies had extralymphatic involvement: 3 in lung and 1 in ischiorectal fossa. The PET/CT showed a 100% sensitivity for the detection of the vulvar lesion in squamous cell carcinomas and 60% in non-squamous cell ones. There was a false positive result for local invasion due to urine contamination. One of the studies with lung metastases was related to a synchronous breast tumor. All the pathological lymph node levels detected in the PET/CT study were confirmed in the histopathology study. No new lesions were identified by surgery. PET/CT changed the therapeutic management in 8/13 studies (61.5%). ConclusionsPET/CT is postulated as a useful imaging test for the management of vulvar cancer, mainly in the identification of nodal metastases. It may affect both surgical planning and clinical management. Larger series are needed to confirm our findings.

Ruptured Mature Cystic Teratoma in the Posterior Mediastinum: A Case Report

Mature teratomas are the most common mediastinal germ cell tumors. Most mature teratomas are located in the anterior mediastinum, and only 3–8% of mature teratomas occur in the posterior mediastinum (1). Mature teratomas may rarely rupture into adjacent structures (2). Based on a review of the literature, ruptured mature teratomas in the posterior mediastinum have not been reported previously. Ruptured teratomas with invasion of adjacent structures, such as the pleural space, pericardium, or lung parenchyma, have rarely been reported, but all reported mediastinal mature teratomas have been located in the anterior mediastinum (2). In this case report, we noted an unusual tumor location and imaging findings of ruptured mature teratomas in the mediastinum. We present a case of ruptured mature cystic teratoma located in the posterior mediastinum with fistula formation of the adjacent lung and esophagus.

The Role of Three Dimensional Echocardiography in the Detection of Cardiac Metastasis from Melanoma

Melanocarcinoma, considered the most malignant of skin tumors, with enormous potential for systemic metastasis mainly through the blood, usually occurs from 30 to 60 years of age. Its incidence increases progressively, affecting 4% to 8% of the white population2. Until recently, cardiac involvement was rarely diagnosed3. The limitations of imaging methods associated with nonspecific clinical symptoms made this diagnosis a challenge. Positron emission tomography (PET scan), together with the 3D TTE, plays an important role in palliative surgical planning, when recommended, as it provides detailed information of the tumor, such as size and invasion of adjacent structures. This case report describes the use of three-dimensional echocardiography for diagnosing cardiac neoplastic involvement due to melanoma, confirmed by PETscan, in a female patient with nonspecific symptoms.

Accuracy of Computed Tomography for Predicting Pathologic Nodal Extracapsular Extension in Patients With Head-and-Neck Cancer Undergoing Initial Surgical Resection

Nodal extracapsular extension (ECE) in patients with head-and-neck cancer increases the loco-regional failure risk and is an indication for adjuvant chemoradiation therapy (CRT). To reduce the risk of requiring trimodality therapy, patients with head-and-neck cancer who are surgical candidates are often treated with definitive CRT when preoperative computed tomographic imaging suggests radiographic ECE. The purpose of this study was to assess the accuracy of preoperative CT imaging for predicting pathologic nodal ECE (pECE). The study population consisted of 432 consecutive patients with oral cavity or locally advanced/nonfunctional laryngeal cancer who underwent preoperative CT imaging before initial surgical resection and neck dissection. Specimens with pECE had the extent of ECE graded on a scale from 1 to4. Radiographic ECE was documented in 46 patients (10.6%), and pECE was observed in 87 (20.1%). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 43.7%, 97.7%, 82.6%, and 87.3%, respectively. The sensitivity of radiographic ECE increased from 18.8% for grade 1 to 2 ECE, to 52.9% for grade 3, and 72.2% for grade 4. Radiographic ECE criteria of adjacent structure invasion was a better predictor than irregular borders/fat stranding for pECE. Radiographic ECE has poor sensitivity, but excellent specificity for pECE in patients who undergo initial surgical resection. PPV and NPV are reasonable for clinical decision making. The performance of preoperative CT imaging increased as pECE grade increased. Patients with resectable head-and-neck cancer with radiographic ECE based on adjacent structure invasion are at high risk for high-grade pECE requiring adjuvant CRT when treated with initial surgery; definitive CRT as an alternative should be considered where appropriate.

Intrathoracic malignant peripheral nerve sheath tumors: imaging features and implications for management

BackgroundThe aim of the study was to analyze the clinical and imaging characteristics of primary intrathoracic malignant peripheral nerve sheath tumors (MPNSTs).Patients and methods.In this institutional review board (IRB)-approved retrospective study, clinical and imaging features of 15 patients (eight men; mean age 50 years [range 18–83)] with pathologically proven malignant peripheral nerve sheath tumors seen from January 1999 to December 2011 were analyzed. Imaging features (CT in 15, MRI in 5 and PET/CT in 4) of primary tumors were evaluated by three radiologists and correlated with clinical management.ResultsOf the 15 tumors, six were located in the mediastinum (two each in anterior, middle and posterior mediastinum), four in chest wall, two were paraspinal, and three in the lung. Four patients had neurofibromatosis-1 (NF1); four tumors had heterologous rhabdomyoblastic differentiation (malignant triton tumor). Masses typically were elongated along the direction of nerves, with mean size of 11 cm. The masses were hypo- or isodense to muscles on CT, isointense on T1-weighted images, hyperintense on T2-weighted images and intensely fluorodeoxyglucose (FDG) avid (mean standardized uptake value [SUV]max of 10.5 [range 4.4–23.6]). Necrosis and calcification was seen in four tumors each. Finding of invasion of adjacent structures on imaging led to change in management in seven patients; patients with invasion received chemoradiation.ConclusionsIntrathoracic MPNSTs appear as large elongated masses involving mediastinum, lung or chest wall. Radiological identification of invasion of adjacent structures is crucial and alters therapy, with patients with invasion receiving neoadjuvant or adjuvant chemoradiation.

Targeting Cancer-Related Inflammation: Chinese Herbal Medicine Inhibits Epithelial-to-Mesenchymal Transition in Pancreatic Cancer

Pancreatic cancer is an almost universally fatal disease resulting from early invasion of adjacent structures and metastasis and the lack of an effective treatment modality. Our previous studies have shown that Qingyihuaji Formula (QYHJ), a seven-herb Chinese medicine formula, had significant anti-cancer effects in pancreatic cancer. Here, we examined the effects of QYHJ on pancreatic cancer cell invasion and metastasis and the potential associated mechanism(s). We found that QYHJ inhibited both tumor growth and metastasis in nude mice with human pancreatic cancer cell xenografts. Further study indicated that QYHJ inhibited epithelial-to-mesenchymal transition (EMT), which is characterized by increased E-cadherin expression and decreased vimentin, N-cadherin and Slug expression. Interleukin 6 (IL-6), a pro-inflammatory cytokine produced mainly by macrophages, could promote cancer cell EMT and invasion. In contrast, treatment with QYHJ inhibited cancer-related inflammation in tumors by decreasing infiltration of tumor-associated macrophages and IL-6 production, thus preventing cell invasion and metastasis. These results suggested that the Chinese herbal medicine QYHJ could inhibit pancreatic cancer cell invasion and metastasis in part by reversing tumor-supporting inflammation.

Comparison of Standard Radiography and Computed Tomography in 21 Dogs with Maxillary Masses

Imaging of patients with oral cancer is required to determine tumor extension in order to assist in prognosis and surgical planning. Conventional screen-film radiography (SFR) used to be the most common method for oral assessment, but computed tomography (CT) has become more available and is being used for obtaining complementary information. CT examinations eliminate superimposition by acquiring cross-sectional images of the region of interest. The objective of this study was to determine the diagnostic value of SFR compared with CT examinations for evaluation of oral masses in dogs. Twenty-one dogs received head and thorax SFR, and pre- and post-contrast head CT. Bony changes were observed in 80.9% and 95.2% of the cases in SFR and CT studies, respectively. Invasion of adjacent structures (i.e. nasal cavity, frontal and sphenoidal sinuses, orbit, maxillary recess, nasopharynx) was observed in only 30% of cases with SFR while CT showed 90.4% involvement. CT is an important preoperative examination modality and is more effective in identifying bone changes and tumor invasion of adjacent structures compared with SFR.

Radiographic parameters in predicting outcome of patients with nonsquamous non-small cell lung cancer (NSCLC) treated with bevacizumab.

e19009 Background: Bevacizumab has increased survival in NSCLC patients (pts) when added to standard chemotherapy. However, whether radiographic features at baseline and/or post-treatment can predict benefit from addition of anti-angiogenic therapy to standard chemotherapy remains unknown. In addition, the impact of VEGF-targeted therapy on CT parameters is not fully characterized. Methods: A retrospective review was performed using CT scans of pts enrolled into a prospective phase II clinical trial of pemetrexed, gemcitabine and bevacizumab in stage IV chemo-naïve, non-squamous, NSCLC pts (Wozniak A, et al. IASLC2011). Treatments were repeated every 2 wks (1 cycle). CT scans were obtained at baseline and at the end of every 4 cycles. The radiographic CT features of the primary tumors were retrospectively reviewed at baseline and after first 4 cycles. RECIST 1.1 and Morphology, Attenuation, Size, and Structure (MASS) criteria were used to assess tumor radiographic response. Results: Twenty-four pts (43% males; median age, 62 y [range: 41-82]), were evaluable for this analysis. On baseline CT, median tumor size was 2.9 cm (range: 1.6. to 6.3 cm), median attenuation was 56 HU (range: 31 to 87 HU), 81% of tumors had heterogeneous enhancement, and 50% of tumors demonstrated invasion of adjacent structures. Well-defined margins were noted in 43% of tumors and 81% had < 30% necrosis. On post-4 cycle CT, 63% of tumors had decreased long diameter (median 15% decrease), 81% had decreased attenuation (median 21% HU reduction) and 50% had increased necrosis. RECIST-defined PR was seen in 37%, SD in 56%; and PD in 1 (4%) based on size despite > 75% necrosis. MASS criteria response was favorable in 25% and non-favorable in 75% of tumors. Pts with tumors that demonstrated FR response by MASS after 4 cycles were more likely to have prolonged progression free survival (HR 2.94; p= 0.175). Conclusions: In tumors treated with anti-angiogenic therapy, imaging response criteria that include changes in tumor morphology, attenuation, and size may capture anti-tumor effect more accurately than size-based RECIST criteria alone. These results support the need for prospective investigation of the efficacy of MASS criteria.

Risk of concomitant malignancy in hyperfunctioning adrenal incidentalomas

BackgroundAdrenal masses are common incidental findings on radiologic imaging. The association between malignancy and hormonal hyperactivity found in incidentally discovered adrenal tumors, however, remains unclear. MethodsA retrospective analysis of prospectively collected data from patients who underwent adrenalectomy for incidentally discovered adrenal tumors at a single institution. Outcomes and operative data were compared by univariate analysis. Area under the curve was used to analyze the effect of tumor size in predicting malignancy. ResultsThere were 49 patients who initially presented with adrenal incidentalomas that underwent adrenalectomy. Most patients were Caucasian women with an average age of 51 ± 14 years. Of this group, 24 patients underwent resection for hyperfunctioning adrenal glands. There were no significant differences in malignancy rates between hyperfunctional and nonfunctional tumors (4.1% vs. 12.0%, P = 0.32). On final histopathology, there were four patients with adrenal malignancies: two adrenocortical carcinomas and two metastatic from renal carcinoma. Only one patient with a hyperfunctioning adrenal tumor had underlying malignancy. Overall, invasion of adjacent structures (P < 0.001), presence of lymphadenopathy (P = 0.02), metastasis (P = 0.03), irregular tumor margins (P = 0.01), heterogeneity (P = 0.05), and tumor size >6 cm (P = 0.04) on radiologic imaging were strongly associated with malignancy in adrenal incidentalomas. ConclusionsThe risk of concomitant malignancy and hormonal hyperactivity in adrenal incidentalomas is very low. Tumor size (>6 cm) and radiographic features remain the most important predictors of adrenal malignancy, regardless of tumor function.