Nodular Image Research Articles

Utility of using Indocyanine green to locate parathyroid adenoma and predict hypocalcemia

Introduction: Secondary hypocalcemia due to hypoparathyroidism is a frequent complication of parathyroidectomy, which has certain difficulties in terms of intraoperative localization of the gland, since the surgeon uses his sight, touch and experience, to reach the task of the surgical act. Clinical case: 62-year-old woman, who started her current condition 8 months ago when she was diagnosed with osteoporosis, with hypercalcemia and significant elevation of parathyroid hormone. Cervical ultrasound and 99mTc-MIBI scintigraphy were requested, showing a nodular image compatible with parathyroid adenoma in the left lower thyroid lobe. The patient underwent left inferior parathyroidectomy with the use of indocyanine green. Conclusion: The identification of a parathyroid adenoma intraoperatively with the aid of fluorescence appears to be a reproducible, safe and easy way to use when treating this type of endocrine pathology.

Nodular image in the appendix observed on ultrasound: endometriosis or neuroendocrine neoplasia?

To evaluate the association between clinical and imaging with surgical and pathological findings in patients with suspected neuroendocrine tumor of appendix and/or appendix endometriosis. Retrospective descriptive study conducted at the Teaching and Research Institute of Hospital Israelita Albert Einstein, in which medical records and databases of patients with suspected neuroendocrine tumor of appendix and/or endometriosis of appendix were analyzed by imaging. Twenty-eight patients were included, all of which had some type of appendix alteration on the ultrasound examination. The pathological outcome of the appendix found 25 (89.3%) lesions compatible with endometriosis and three (10.7%) neuroendocrine tumors. The clinical findings of imaging and surgery were compared with the result of pathological anatomy by means of relative frequency. It was possible to observe a higher prevalence of appendix endometriosis when the patient presented more intense pain symptoms. The image observed on ultrasound obtained a high positive predictive value for appendicular endometriosis.

Retropubic Leiomyoma Causing Urinary Retention: A Case Report

<h3>Study Objective</h3> To present a rare case and the surgical treatment of a retropubic leiomyoma. <h3>Design</h3> Case report illustrated with video. <h3>Setting</h3> We used the da Vinci Si platform in a side docking fashion, with four robotic arms and a laparoscopic 11mm trocar. Uterine manipulator and foley catheter were placed. <h3>Patients or Participants</h3> We present the case of a 39-year-old woman complaining of voiding difficulty, recurrent urinary tract infections and dyspareunia. At the pelvic examination, she had a 4 cm nodule in the anterior vaginal wall, occupying the retropubic space. The complementary investigation with pelvic MRI evidenced an infravesical solid nodular image with lobulated and well-defined contours, located anteriorly to the urethra, with a plane of contact with its anterior wall. It is manifested by intermediate signal on T1 and T2, absence of restriction to the water molecules diffusion and enhancement by contrast medium similar to the myometrium, measuring 3.0 × 3.6 × 3.1 cm. The patient was seen by a urologist which suggested a transvaginal biopsy to exclude malignancy. The biopsy result was leiomyoma. <h3>Interventions</h3> Patient was eligible for a robotic-assisted laparoscopic excision of a retropubic (FIGO 8) leiomyoma. The access to retropubic space was made through the urachus until the pubic bone. The fibroid was easily identified behind the pubic symphysis. Lateral dissection was carried out to identify landmarks and the fibroid was excised using gentle movements. There was no urethral or vesical lesion. The defect was closed with a double layer suture. <h3>Measurements and Main Results</h3> The foley catheter was removed in the first postoperative day and the patient had complete remission of symptoms. The final histopathological report confirmed leiomyoma. <h3>Conclusion</h3> Although being extremely rare, leiomyomas in the Retzius space should be considered in the differential diagnosis of voiding dysfunctions.

Graves' Disease Caused by SARS-CoV-2 Infection.

Graves’ disease is an autoimmune disorder that results in hyperthyroidism, caused by autoantibodies to the thyrotropin receptor (TRAbs) stimulating thyroid hormone synthesis, giving rise to a variety of systemic manifestations such as goitre, dermatopathy and orbitopathy.The authors present the case of a 28-year-old man admitted to hospital for a 3-week history of fatigue, shortness of breath, palpitations and diffuse goitre, after recent mild SARS-CoV-2 infection. Laboratory investigation revealed hyperthyroidism with TRAbs elevation. Thyroid ultrasound confirmed a diffusely heterogeneous and irregular thyroid gland and a nodular image below the sternal notch. Thyroid scintigraphy excluded the nodule and confirmed a Graves’ disease pattern. Following the initiation of methimazole, the patient had complete resolution of symptoms and normalization of thyroid values.The results suggest a possible association between Graves’ disease and SARS-CoV-2 infection acting as a trigger. Graves’ disease is an important differential diagnosis to keep in mind when patients present with hyperthyroidism after COVID-19 disease.LEARNING POINTSGraves’ disease may be induced after SARS-CoV-2 infection by a possible autoimmune pathway.Graves’ disease induced by SARS-CoV-2 infection responds well to antithyroid medication.

SAT-388 Dry Cough as Only Sign of a Parathyroid Adenoma Producer of PTH

BACKGROUND: The parathyroid adenoma producing an excess of PTH is characterized by hypercalcemia, asthenia, physical weakness and renal lithiasis. This clinical case is presented only with a dry (non-productive) cough sign of long duration.CASE: 51-year-old female born in Padre Las Casas, D.R. presenting with chief complain of dry cough for about four years. Clinical findings: (03/13/2019) Height 62”, Weight 142 lbs, Temperature 36.2 Celsius, BP 90/60 mmHg, RR 16 rpm, HR 60 bpm, on her neck no adenopathies or thyroid changes. Occasional coughing. A sonographic evaluation of the neck (04/09/2019) reveals a solid, heterogeneous nodular image of 0.7 cm x 0.5 cm in the left lobe of the Thyroid (Fig. 1) which by FNAB (04/10/2019) showed a benign adenomatoid node with cystic changes (Bethesda II) (Fig. 2). TEST: (03/20/2019) anti-TG 0.10 IU/mL (NV -115), anti-TPO 9.00 IU/mL (NV -34), TG 9.41 (NV -78 ng/mL), TSH 0.34 μIU/mL (VN 0.27-4.20), free T3 2.05 pg/mL (NV 2.04-4.40), total T3 0.74 ng/mL (NV 0.83-2.00), total T4 8.46 μg/dL (NV 5.1-14.1), free T4 1.61 ng/dL (NV 0.93-1.71) Calcium 10.4 mg/dL (NV 8.1-10.4), Phosphorus 2.6 mg/dL (NV 2.5-4.5), PTH-Intact 157 pg/mL (NV 14.5-87.1) Thyroid-Parathyroid scintigraphy (Sestamibi-Technetium 99mTc04: 15 mCi) (04/23/2019) shows lower left Parathyroid Adenoma (Fig. 3). She undergoes surgery (05/23/2019) removing the left thyroid lobe and left inferior parathyroid gland whose pathology shows chronic nodular colloid goiter, with areas of hemorrhage. Parathyroid adenoma of main cells (Fig. 4-5). Post-surgical TEST (06/24/2019) PTH-intact 69.0 pg/mL (NV 14.5-87.1), Calcium 8.6 mg/dL (NV 8.1-10.4), Phosphorus 2.7 mg/dL (NV 2.5-4.5), anti-TG 10.0 IU/mL (NV <115), anti-TPO 9.00 IU/mL (NV <34), TG 8.92 ng/mL (NV <78), total T3 0.68 ng/mL (NV 0.83-2.00), free T3 1.95 pg/mL (NV 2.04-4.40), total T4 6.40 μg/dL (NV 5.1-14.1), free T4 1.02 ng/dL (NV 0.93-1.71). Post-surgical clinical evaluation (06/21/2019) Weight 142 lbs, Temperature 36.5 Celsius, BP 110/70 mmHg, RR 16 rpm, HR 60 bpm. Patient has not shown signs of coughing. Last TESTS (10/20/2019) Calcium 9.40 mg/dL, Phosphorus 3.10 mg/dL, PTH-intact 24.40 pg/mL, TG 11.90 ng/mL, total T4 6.80 μg/dL, free T4 1.23 ng/dL, total T3 0.88 ng/mL, free T3 2.66 pg/mL, anti-TPO 11.14 IU/mL, anti-TG 10 IU/mL. CONCLUSIONS: Lower left (benign) parathyroid adenoma whose clinical manifestations are not common. Dry (non-productive) cough is not known as a manifestation of elevated PTH-intact. Calcium and Phosphorus levels in normal values. In addition, histological alterations of the left thyroid lobe of benign character with few manifestations of hormonal alterations and normal antibodies. It is of crucial clinical importance to observe and document more cases with similar presentation in order to identify the possible causes of cough with an elevated PTH manifestation.

SAT-259 Acromegaly by Pituitary Adenoma Associated with ACTH-Independent Cushing Syndrome by Adrenal Carcinoma: Case Report

Introduction: The coexistence of acromegaly and Cushing’s syndrome is quite rare. Case reports with this association have been described in the literature, including both ACTH-dependent and ACTH-independent Cushing’s syndrome. In these cases, when considering ACTH-independent hypercortisolism, the main etiology reported is adrenal adenoma. We will describe the case of an acromegalic patient with ACTH-independent cushing syndrome due to adrenal cortical carcinoma. Clinical Case: A 62-year-old male patient with acromegaly diagnosed by headache investigation. He had a previous medical history of T2DM for 20 years, grade III obesity (BMI 40.3), hypertension, obstructive sleep apnea and depression. Initial investigation showed IGF-1 levels of 818 ng/mL (81–225), GH: 3.39 ng/mL (<0.97), prolactin diluted: 2.578 ng/mL (2.1–17, 7), LH: <0.07 mIU/mL (1.5–9.3), FSH: 0.6 mIU/mL (1.4–18.1), total Testosterone: 51 ng/dL (241- 827) Cortisol at 8 AM: 15 µg/dL, TSH: 1.54 µg/dL (0.55–4.78), free T4: 1.0 ng/dL (0.89–1.76) and brain MRI with a large expansive sella turcica process, invading the right cavernous sinus, with growth to the sphenoid sinus and suprasellar compressing the optic chiasm, suggestive of pituitary macroadenoma. He underwent transsphenoidal resection with histology confirming a prolactin and GH co-secretory pituitary adenoma with Ki-67: 5%. He started treatment with octreotide LAR (30 mg/month) and cabergoline (3.5 mg/week) and underwent 25 radiotherapy sessions. Three years after the diagnosis of acromegaly, the patient underwent CT scan of the abdomen, which identified a 3.8 cm left adrenal nodular lesion that evolved in the 12-month control exam to nodular image with lobulated contours (5.0 x 3.4 cm) and non-contrast phase density > 25 HU. At that time, he had two 24-hour cortisoluria samples: 640.9 and 637 µg/24hs (54–403) and ACTH <5.0 pg/mL (<46).The patient underwent videolaparoscopic adrenalectomy confirming the pathology of the lesion compatible with adrenal cortical carcinoma with invasion of the capsule and peri-adrenal adipose tissue and Ki-67: 20%. Even after primary resection of the adrenal lesion, the patient evolves with local and metastatic progression of the disease, dying a few months later, due to infectious complications of a new surgical approach. Conclusions: To the best of our knowledge, this is the first case of ACTH-independent Cushing’s syndrome caused by adrenocortical carcinoma in an acromegalic patient.

P691 New onset severe mitral regurgitation in oncological patient: when the disease progresses

Abstract Nonbacterial thrombotic endocarditis is frequently diagnosed in postmortem autopsies. However, in some patients with systemic diseases it is diagnosed in the context of multiple embolic events, so a high degree of clinical suspicion must be maintained to offer the best treatment to these patients. We report a case of a 59-year-old woman with diagnosis of stage IV lung adenocarcinoma in the context of first episode of cardiac tamponade requiring urgent pericardiocentesis. She was admitted to the emergency department for an acute ischemic stroke, so antiplatelet therapy was started and chemotherapy discontinued. After few weeks, she required new admission due to progression of the oncological disease and bilateral pulmonary thromboembolism secondary to deep vein thrombosis of the lower extremities. Given the progression of the disease, it was decided not to return to chemotherapy and to start anticoagulant therapy with low molecular weight heparin. A transthoracic echocardiogram (TTE) was requested, which highlighted a thickened mitral valve with severe mitral regurgitation, not present in the TTE performed one year before. She was asymptomatic, without fever, with repeatedly negative blood cultures and absence of infectious markers. A new TTE was repeated 4 weeks later, beeing under antiplatelet and anticoagulant treatment, observing a greater thickening of both mitral leaflets with nodular image on the anterior mitral leaflet, persisting a severe mitral regurgitation. Given the low probability of infective endocarditis, these findings were attributed to a nonbacterial thrombotic endocarditis in the context of a progressive malignant disease. Nonbacterial thrombotic endocarditis is characterized by the presence of sterile vegetations formed by the accumulation of platelets and fibrin. It is associated with neoplastic processes (specially with mucinous adenocarcinomas) as well as with autoimmune, rheumatologic and infectious processes. These vegetations tend to produce multiple systemic embolizations, which usually manifests as the first symptom. Patients do not usually present murmurs in the physical examination, nor fever, and blood cultures are negative. It is necessary to complete the study with a TTE, where the left valves tend to be affected more frequently (mitral valve in 2/3 of the cases). In case of doubt, the study should be completed with a TEE, although neither of these techniques differentiates infectious vegetations from thrombotic ones. Treatment consists of treating the underlying cause and starting anticoagulation with heparin to prevent new embolisms. In some isolated cases the surgical treatment of this entity has been proposed. Conclusion presence of nonbacterial thrombotic endocarditis should be suspected in all patients with multiple embolisms and concomitant systemic disease. Study must be completed with a TTE/TEE and anticoagulant treatment should be started. Abstract P691 Figure. A: Mitral valve 1 year before. B: now

P236 Pinball game over

Abstract Introduction Transthoracic echocardiogram (TTE) is recommended for the diagnosis of acute pulmonary embolism (PTE) only in unstable patients, as it lacks specificity and sensitivity in stable ones. However, the rare documentation of intracavitary thrombus confirms the diagnosis and is associated with right ventricular dysfunction and high mortality, up to 42%. We report a 69year-old female patient with history of hypertension and obesity, presenting at the emergency department with hypothermia (35º C), cyanosis, tiredness and breathless to minimal efforts. At examination she had no measurable blood pressure, low peripheral perfusion, tachycardia, tachypneia and no other abnormalities. Arterial blood gases on 10L/min facemask showed an uncompensated metabolic acidosis with pCO2 27mmHg, HCO3 12mmol/L, hyperlactacidemia and hypoxemia (pO2 57mmHg). Lab results had leucocytosis and neutrophilia, CRP 30mg/L, serum creatinine 2.53mg/dL, K+ 5.1mmol/L and high sensitivity troponin I 305pg/ml. Chest X-ray showed enlargement of the right chambers with a nodular image next to the right hila. Although sepsis complicating acute pneumonia was firstly assumed and intravenous antibiotics and fluids were rapidly started; persistent hypoxemia with hypocapnia and tachycardia lead to the suspicion of acute PTE and workup proceeded in that direction. A TTE was primarily done because of the renal injury, showing a dilated right ventricle with flattening of the interventricular septum and a large, long, mobile mass in the right atria, protruding to the right ventricle, consistent with a thrombus. As the patient was no more hemodynamic unstable, prompt anticoagulation with low molecular weight heparin (LMWH) was initiated. Lately performed thoracic angio-CT with no contrast showed mild dilation of pulmonary artery and scintigraphy confirmed extensive perfusion defects of the left lung, preserving only posterobasal segment, with normal ventilation. Additional study revealed a deep venous thrombosis of left popliteal and right gemelar veins and a heterozygosity for two polymorphisms of methyltethahdrofolate reductase enzyme C677T and A1298C, clinically relevant in the context of patient’s hyperhomocysteinemia. The patient recovered initially, with compression stockings and anticoagulation. A follow-up TTE showed no remaining intracavitary mass and no signs of right side overload. In the day after, the patient evolved with sudden refractory hypotension and signs of hypoperfusion with cardiorespiratory collapse and death. Conclusion The incidence of intracardiac thrombus in the right chambers in a patient with PTE is low (3-23%) and probably underestimated by the absence of early echocardiography in all patients. This case highlights the lability of the clinical evolution of these patients, even tough disappearance of the right atrium thrombus, which is in line with their high early mortality. Abstract P236 Figure. Imaging study

P232 A cardiac thrombus... or maybe not

Abstract A 61 years old female with history of rheumatic arthritis and Sjogren Syndrom resorted to the emergency room in December of 2017 for pleuritic chest pain and dyspnea. An angioCT showed a luminal filling defect at the left inferior pulmonary artery with extension to the segmentar vessels. A pulmonary embolism (PE) was diagnosed and the patient was admitted. The study performed, including transthoracic echocardiogram (TTE) was unremarkable. Patient was discharged after 15 days treated with a direct oral anticoagulant. Six months later she returned to the emergency room with the same complaints. A new angioCT showed reduction of the previous luminal filling defects, but a focal defect in the filling of the right atrium (RA) was visualized. A TTE showed a mass (17 mm) at the RA with apparent origin at the superior vena cava. A presumptive diagnostic of atrial thrombus was done and patient started therapy with vitamin K antagonist. Three months later, TTE was repeated and the mass was still present (19 mm). Five months later, the mass was still visualized at TTE (17 mm). A transesophagic echocardiogram confirmed the presence of a RA mass with 30x22 mm of major dimensions, with close relation with the interatrial septum suggestive of a tumor. A cardiac magnetic resonance revealed a RA mass without vascularization. A cardiac gated CT showed at the RA a low density nodular image of 26x22 mm at the axial plan, with an extension of 28 mm, adjacent to the posterior wall of the RA. After contrast administration, some areas did not had significant captation while some did, aspects compatible with a "pseudoenhancement" aspect. A positron tomography showed mild to moderate FDG captation at the RA. Meanwhile, patient was under anticoagulation for 2 years with no regression of the mass. For this reason, patient was oriented to cardiac surgery. The mass was resected and the histology revealed a RA myxoma. Cardiac masses can be due to tumour, thrombus or vegetation. In this case, the mass was highly considered to be a thrombus due to the presence of multiple risk factors: prothrombotic disease and pulmonary embolism. However, the fact that the mass did not reduce with therapy raised suspicion of other diagnosis. Although rare, myxomas can be found in the RA, and should be included in the differential diagnosis of right-sided intracardiac masses. Although myxomas are histologically benign, potential for embolization and sudden death make surgical resection a priority. Its diagnosis has now increased with the use of echocardiogradiography, and has made it the main modality for the evaluation of myxomas. PE is the most dreaded and devastating complication of right-sided myxoma. In cases of RA myxomas, clinically evident PE events are uncommon. Nevertheless, there have been reports of embolization of thrombi or tumor fragments into the pulmonary vessels in cases of right in approximately 3.2% of myxoma patients.

Caso Clínico: Metástasis Tumoral a Tumor. Un Raro Fenómeno.

Introducción: La metástasis tumor a tumor es muy rara con menos de 50 casos descritos en la literatura. Este artículo informa de un caso de metástasis de cáncer de mama en un tumor renal de células claras.&#x0D; Caso clínico: El caso corresponde a una mujer de 61 años de edad con antecedente de cáncer de mama, libre de enfermedad por 23 años. Por control, se solicita Tomografía computarizada (TC) simple y contrastada observándose a nivel de pelvis renal izquierda imagen nodular hipercaptante heterogénea de 2.4 cm, de bordes definidos, no infiltrante a tejidos adyacentes, por localización de lesión es sometida a nefrectomía radical izquierda. El examen patológico demostró un carcinoma de mama metastásico de 3 mm, mal definido, dentro de un carcinoma de células renales claras de 2,5x2x2cm. Este caso pone de relieve la importancia de los antecedentes previos de neoplasia maligna de un paciente, así como del muestreo adecuado de las neoplasias renales.

Tiroides Lingual Ectópica en Paciente Adulta Hipotiroidea. Diagnóstico Casual por Tomografía Computarizada

Introducción: Los casos de tiroides ectópica localizados en la base de la lengua son anormalidades congénitas raras y difíciles de diagnosticar. Razón de presentación del caso.&#x0D; Caso Clínico: El caso corresponde a una mujer de 41 años con tiroides en base de la lengua diagnosticada incidentalmente con tomografía computarizada (TC), con antecedentes de hipotiroidismo y cáncer de mama derecha. Al examen físico de cuello no se palpa glándula tiroidea ni se observa masa o protuberancia en cavidad bucal. Por control del cáncer de mama, se solicita tomografía por emisión de positrones (PET) y ecografía de cuello, reportándose captación del radiofármaco en la región cervical anterior y superior de cuello, y ausencia de tejido glandular tiroideo a nivel habitual, respectivamente. Por cuanto, se realiza TC simple y contrastada observándose a nivel de la raíz de la lengua una imagen nodular hipercaptante que mide 23x20x20 mm, bien definida, contornos regulares, no infiltra tejidos adyacentes, impronta luz de la orofaringe, sin individualizar la glándula tiroides a nivel habitual, corroborando así el diagnóstico de tiroides ectópica lingual.&#x0D; Conclusión: El diagnóstico de tiroides ectópica en paciente adulto hipotiroideo es raro, por lo que debe considerarse la realización de TC si al examen físico y ecográfico no es palpable ni observable.

Náuseas no Natal: o papel do médico de família no diagnóstico de doença grave

Introduction: The family physician (FP) is often the patient’s first contact with health system, dealing with diseases in early stages when symptoms are still nonspecific. With this case report, we intend to promote the reflection about the role of FP in the several stages of the process of diagnosis, and about the characteristics intrinsic to general and family medicine specialty that facilitate it. Case report: We present the case of a 48-years-old female, integrating a reconstructed family of medium socioeconomic status, with history of depressive syndrome (medicated with fluoxetine), in climacteric. She presented with nausea, bloating, and generalized pruritus for the last 10-days and a single vomit on Christmas Eve. The physical examination revealed mild abdominal pain in the epigastrium. She was prescribed according her symptoms and ordered blood tests and an abdominal ultrasound. The patient returned 3 days later with scleral icterus and acholic stools, maintaining nausea. No choluria or fever were present. Complementary diagnostic tests showed conjugated hyperbilirubinemia; ultrasound revealed pronounced dilation of the common bile duct, a nodular image in the pancreatic body/tail and multiple adenopatic conglomerates. The patient had no evident consumptive symptoms. Abdominal computed tomography revealed an adenopatic conglomerate implicating the pancreatic head, most likely to be associated with a lymphoproliferative disorder. Patient was urgently referred to the Hematology-Oncology consultation where the final diagnosis was established: non- Hodgkin’s diffuse large B cell lymphoma. She completed 8 sessions of chemotherapy and is currently under remission. Comment: Although the FP’s decision-making process is mainly based on the community epidemiology of diseases and patient’s sociocultural context, the diversity of diagnostic hypothesis that may result from the natural course of disease can’t be forgotten nor underestimated. The FP should rely on the advantages of health care continuity and accessibility, thus enhancing his diagnostic role.

Imaging of Human Neurolisteriosis: A Prospective Study of 71 Cases.

Neurolisteriosis ranks among the most severe neurological infections. Its radiological features have not been thoroughly studied. We describe here the neuroradiological features of neurolisteriosis and assess their prognostic value. Patients with microbiologically proven neurolisteriosis were enrolled from November 2009 to October 2013 in MONALISA study. Magnetic resonance and computed tomography images were studied by 2 independent neuroradiologists. Predictors of 3-month mortality were determined using logistic regression. Seventy-one patients were included; 42 were men (59%). Mean age was 64 years. Sixty patients (85%) reported signs of encephalitis, with clinical brainstem involvement in 16 (23%). Images were abnormal in 87% of cases (62/71). Main neuroradiological images were meningeal enhancement (25/71, 35%), abscess(es), or nodular image(s) evocative of abscess (10/71, 14%), hemorrhages (11/71, 15%), contrast-enhancing ventricles, or hydrocephalus (7/71, 10%). White-matter images (42/71, 59%), dilated Virchow-Robin spaces (22/71, 31%), and cerebral atrophy were also reported (34/71, 48%). Brainstem involvement (meningeal enhancement, abscess) was reported in only 7/71 cases (10%). Three-month survival was lower in patients with hydrocephalus or contrast-enhancing ventricles (1/7 [14%] than without [47/64, 73%], P = .005) and in patients with parenchymal images (abscess[es], nodule[s]\, or white matter images; 25/46 [54%] vs 23/25 without [92%], P = .004). Parenchymal images were associated with lower 3-month survival in the multivariable model (odds ratio 5.60, 95% confidence interval [1.42-29.6], P = .02). Neurolisteriosis presents as a combination of neuroradiological images, none being specific. Radiological signs of rhombencephalitis are uncommon, whereas, unexpectedly, hemorrhagic images are frequent. The negative prognostic value of parenchymal neuroradiological images was evidenced. NCT01520597.

Learning Lung Nodule Malignancy Likelihood from Radiologist Annotations or Diagnosis Data

Lung cancer is the world’s most lethal type of cancer, being crucial that an early diagnosis is made in order to achieve successful treatments. Computer-aided diagnosis can play an important role in lung nodule detection and on establishing the nodule malignancy likelihood. This paper is a contribution in the design of a learning approach, using computed tomography images. Our methodology involves the measurement of a set of features in the nodular image region, and train classifiers, as K-nearest neighbor or support vector machine (SVM), to compute the malignancy likelihood of lung nodules. For this purpose, the Lung Image Database Consortium and image database resource initiative database is used due to its size and nodule variability, as well as for being publicly available. For training we used both radiologist’s labels and annotations and diagnosis data, as biopsy, surgery and follow-up results. We obtained promising results, as an Area Under the Receiver operating characteristic curve value of 0.962 ± 0.005 and 0.905 ± 0.04 was achieved for the Radiologists’ data and for the Diagnosis data, respectively, using an SVM with an exponential kernel combined with a correlation-based feature selection method.

An Unusual Clinical Presentation of Solitary Fibrous Tumor in the Oral Cavity

Solitary fibrous tumor is a rare neoplasm of mesenchymal origin that usually affects the pleura. This rarity becomes more relevant in the oral cavity since the clinical features are nonspecific. A 66-year-old female patient presented with a 3-month history of a swelling in the floor of the mouth, measuring 2 cm in greatest diameter, and pain symptomatology. Occlusal and panoramic radiographs showed no bone involvement. Ultrasonography of the submandibular and parotid salivary glands revealed normal morphology, dimensions, and echogenicity. During this exam, a nodular image of low echogenicity measuring about 2.7 × 1.8 cm was detected. An excisional biopsy was performed and histopathological analysis revealed a well-defined tumor-like lesion with alternation between hypercellular areas without a defined pattern and hypocellular areas. On immunohistochemistry, the tumor was positive for CD34 and CD99 and negative for α-SMA, S-100, and bcl-2. Combining the histopathological and immunohistochemical features, the diagnosis was solitary fibrous tumor. The patient is under periodical clinical follow-up and shows no signs of recurrence 7 months after surgical excision of the tumor. The combination of clinical-pathological and immunohistochemical features is necessary for the diagnosis.

123I-MIBG, 18F-DOPA y 18F-FDG en una paciente con síndrome de neoplasia endocrina múltiple tipo 2 y recidiva de feocromocitoma

Pheochromocytoma is a rare tumor located in the medulla of the adrenal gland that is characterized by high catecholamine synthesis. Surgery is the treatment of choice and is usually curative if appropriately diagnosed and excised. Imaging methods, both morphological and functional, are of great importance in presurgical evaluation. We report the case of a female patient with multiple endocrine neoplasia syndrome type 2, with bilateral adrenalectomy due to two pheochromocytomas and progressive elevation of urinary metanephrine. Magnetic resonance imaging showed a nodular image in the right adrenal fossa. The patient was referred to our unit in order to confirm suspicion of recurrence. Due to the absence of pathological findings in the (123)I-MIBG scintigraphy and high suspicion of recurrence, PET/CT imaging with (18)F-DOPA and (18)F-FDG were performed, and the diagnosis was confirmed.

Dermatomiosite como primeira manifestação de uma neoplasia pulmonar

Dermatomyositis (DM) is a rare disease characterised by proximal muscle weakness and a typical cutaneous rash. The muscle biopsy shows inflammatory lesions consistent with myositis, being related to an increased risk of cancer, often considered as a paraneoplastic syndrome. The authors present a case of a 63-year-old man, with progressive proximal muscle weakness and cutaneous rash, appearing in two months. The muscle and skin biopsies were consistent with DM. Chest tomography showed a nodular image in the lingular region and bronchy biopsy confirmed the diagnosis of small cell lung carcinoma (SCLC). This clinical case intends to enhance the importance of a thorough diagnostic study in patients with DM, as it is often a paraneoplastic syndrome.

Hamartoma Associated to Pseudoangiomatous Stromal Hyperplasia (Pash) of the Breast and Chondroid Metaplasia

INTRODUCTION: Hamartoma of the breast is rare benign lesion, generally detected through the screening mammographic. PURPOSE: Case report of two rare histopathological alterations in the breast: PASH and Chondroid metaplasia associated to the hamartoma. For the attention of us, in this case was the compound of “chondroid metaplasia” (unusual in benign lesion) associated PASH that is histologically benign myofibroblastic proliferation of mammary stroma, and complex network of anastomosing slit-like spaces within a dense collagenous stroma. REPORT: RCM, female, 47 years old, history of the left breast nodule painless, for 5 years ago, detected by mammographic screening. Physical exam: right breast without palpable tumour. Left breast: size nodule 5. 0mm in inferomedial quadrant (IMQ), elastic, mobile, free skin and deep plans surface localized in junction medial quadrants (JMQ), Axillary lymph nodes uninvolved. MMG: ovale hyperdense nodule, margins partially defined, associated with calcifications, measuring 45mm in IMQ left breast BIRADS zero. USG: Heterogeneous nodular image, irregular with calcifications measuring 59 per 33 per 44 mm, localized at 9 o’clock position left breast. Core biopsy: PASH and cartilagenous differentiation. It was suggested total resection of lesion. Freezing exam: its didn’t conclude. Surgical pathological report: left breast quadrant, mammary hamartoma, chondroid metaplasia, and PASH with tubular microcystic adenosis and fat. Immunohistochemical: positive P63 and Calponin in the myo-epithelial cells. Immunohistochemical profile together morphological findings consistent to mammary hamartoma. DISCUSSION: Hamartoma has been incidence of 0. 1-0. 7%, average 45 years old, in the mammographic shows circumscribed lesion lobular pseudocapsular and heterogenous density. The classical mammography appearance is circumscribed area consisting of both soft tissue and lipomatous elements, surrounded by a thin radiolucent zone. Despite the pathogenic of the lesion is not clear, it’s thought to result from a mesenchymal dysgenesis rather than a true tumoral process. Histologically, the most characteristic is appearance otherwise normal breast and fat tissue distributed in a nodular fashion within a fibrous stroma. Some cases have been reported to a genetic defect named Cowden’s disease. The current management of hamartoma is surgical removal. CONCLUSION: The aim of this report was the presents rare hamartoma benign breast lesion associated to chondroid metaplasia, uncommon lesions that leads us to do a differential diagnostic with fibroadenoma and benign phyllodes tumours, as well PASH areas although benign lesion that histologically need the differential diagnosis with low grade mammary angiosarcoma. The patient is very well and she is in follow up uneventful.

Case Report: Preventive Aprochment in Pregnant Women

INTRODUCTION: The approach in young women, the decision when should be the initiation of radiological routine, according to the Brazilian Society of Mastology and the Brazilian College of Radiology, at age 35 would be a baseline mammogram. However, in relation to a young woman with the desire to become pregnant, there is no consensus. There are those who suggest a routine mammogram before pregnancy. REPORT: C. M. F. L. , female, 24 years, menarche at 13 years, child I. Use of oral contraceptives for three consecutive years. Deny hypertension, diabetes mellitus or family history of breast cancer. Complained of painless, nodule palpable in the union of the lower quadrants of the left breast for about 12 months with rapidly growing breast during pregnancy. Physical examination of the breast describes asymmetrical breasts, volumetric increase of the left breast, palpable nodule occupying almost the entire body left gland, mobile, regular skin and armpit. Radiological examinations (mammography and ultrasound) in combination showed a nodular image rounded, no microcalcifications, circumscribed, hypoechoic, heterogeneous areas without liquid, lymph node without abnormalities. DISCUSSION: mammography could be suggested in the pre-pregnancy tests, involving the breast ultrasound, thus avoiding disturbances during pregnancy in the case of suspicious findings.

Spontaneous chronic epidural hematoma of the lumbar spine mimicking an extradural spine tumour

Spontaneous chronic epidural hematomas are extremely rare and can be extremely challenging to diagnose and differentiate. The clinical findings, computed tomographic scan and magnetic resonance imaging does not always enough to complete differentiate this condition. Our purpose is to report a case of a spontaneous chronic epidural hematoma presenting as an extradural mass leading to compressive radicular symptoms with images of bony scalloping which are sparsely reported in the literature. We describe a 61-year-old woman who was evaluated after 18-month history of pain, disestesias and mild weakness in both lower extremities with significant radicular symptoms on the right side associated to neurogenic claudication. CT scans revealed a nodular image of soft tissue density located in the right anterolateral epidural space at the L4-L5 level demonstrating resorption of the bony margins. MRI studies revealed a round mass in the vertebral canal displacing the dural sac and scalloping the posterior wall of the L4 vertebral body. Diagnosis was established between a degenerative cyst versus an atypical neurinoma. Surgical findings demonstrated an isolated well-formed chronic hematoma. Spontaneous chronic epidural hematomas are rare, even more when they produce scalloping of bony structures becoming a diagnostic challenge. Therefore they should be always considered as a differential diagnosis in patients with extradural chronic compressions taking into account that also chronic epidural hematomas can cause bone involvement.