Nonspecific Imaging Findings Research Articles

Tuberculosis testicular: presentación de un caso y revisión de la literatura

Descripción del caso clínico: Presentamos el caso de un paciente masculino de 33 años con historia familiar de tuberculosis pulmonar, quien acude a consulta por presentar fiebre de predominio nocturno y percepción de masa testicular derecha no dolorosa, sin otro síntoma asociado, marcadores tumorales en rangos normales.
 Relevancia: De acuerdo con cifras de la OMS (Organización Mundial de la Salud), la infección por Mycobacterium tuberculosis es considerada la infección oportunista más frecuente en el mundo.
 Conclusión: La presentación clínica característica de la tuberculosis testicular (TbT) es una masa testicular no dolorosa, difícil de diferenciar de una tumoración maligna. Los hallazgos inespecíficos en los exámenes de laboratorio e imagen acompañados de baja sospecha diagnóstica llevan a un alto porcentaje de diagnósticos tardíos. Hoy en día una cantidad considerable de pacientes se detectan por hallazgos de patología en la pieza quirúrgica. Si bien el pronóstico a corto y mediano plazo suele ser favorable, una de las complicaciones a largo plazo de la TbT es la infertilidad secundaria a la destrucción del parénquima testicular y/o la obstrucción del trayecto de salida de los espermatozoides.

Pearls and Pitfalls in the Imaging of Soft-Tissue Masses in Children

There is a broad spectrum of soft-tissue masses in children that can be challenging to diagnose clinically and on imaging. This article reviews the typical clinical and imaging findings of the most common and relevant benign, intermediate and malignant pediatric soft-tissue tumors in the following categories of the 2013 World Health Organization (WHO) classification: adipocytic tumors (lipoma, lipoblastoma, and liposarcoma), fibroblastic/myofibroblastic tumors (nodular fasciitis, myositis ossificans, fibrous hamartoma of infancy, fibromatosis colli, desmoid-type fibromatosis, lipofibromatosis, and infantile fibrosarcoma), pericytic tumors (myofibroma/myofibromatosis), skeletal muscle tumor (rhabdomyosarcoma), nerve sheath tumors (neurofibroma, malignant peripheral nerve sheath tumor), and uncertain differentiation (synovial sarcoma). In general, ultrasound and magnetic resonance imaging are used as first- and second-line imaging modalities, with limited roles for plain radiographs, computed tomography, and fluorodeoxyglucose-positron emission tomography. Many of these tumors have nonspecific imaging findings although there are some key imaging clues that in conjunction with the clinical information allow a specific diagnosis or a narrow differential diagnosis. However, in many instances, histology is required for final diagnosis.

Imaging features of disseminated xanthogranulomatous inflammation in eclectus parrots (Eclectus roratus).

Xanthogranulomatous disease is a rare condition, which can be caused by infection, inflammation, hemorrhage, immunologic disease, or inherited lysosomal disorders. It is characterized by non-intracellular lipid and cholesterol deposits among an inflammatory infiltrate of vacuolated macrophages and giant cells. The diagnosis of xanthogranulomatous disease is challenging, with nonspecific imaging findings often misinterpreted as aggressive neoplastic processes in humans. In this retrospective case series study, we describe the diagnostic imaging characteristics of a disseminated xanthogranulomatous condition identified in five eclectus parrots (Eclectus roratus). Decreased serosal detail and celomic distension were present in all three birds radiographed, with multifocal variably sized celomic mineralization (3/3 birds), and extracelomic mineralized masses (1/3 birds). Celomic effusion with foci of celomic mineralization and hepatomegaly were identified in all birds (3/3) imaged with ultrasound. Finally, a mineralized mural ventricular mass was present in one of three patients imaged with CT, multifocal celomic mineralization with moderate to severe celomic effusion in two of three patients, diffuse severe proventricular and intestinal dilation in all three patients, and atherosclerosis of the major arterial trunks in all three patients. Veterinary radiologists should be aware of this inflammatory condition in birds, especially in eclectus parrots, and should be able to recognize the imaging features of xanthogranulomatous inflammation.

MICROBIOLOGICALLY PROVEN CASE OF PRIMARY BREAST TUBERCULOSIS

Tuberculosis (TB) of the breast is an uncommon presentation of extrapulmonary TB, it is uncommon even in countries where the incidence of pulmonary and extrapulmonary TB is high and its diagnosis is challenging due to non-specific clinical and imaging findings and often misdiagnosed as abscess or carcinoma. It is mainly diagnosed on the basis of histopathological examination. We have reported a case of primary TB of breast diagnosed by microbiological investigations. A 19-year-old female presented with a painful lump in the breast for the past 3 months. Primary breast TB was diagnosed by sample collect by fine-needle aspiration cytology, wherein Ziehl–Neelsen stain for acid-fast bacilli and cartridge-based nucleic acid amplification test were positive. The patient received antitubercular drugs and at 4 months follow-up, the swelling had resolved and the patient was asymptomatic.

Non-thrombotic pulmonary embolism in emergency CT.

Non-thrombotic pulmonary embolism (NTPE) results from the embolization of non-thrombotic materials. It can often be a challenging diagnosis due to non-specific (similar to thrombotic pulmonary embolism) or uncommon clinical and imaging findings. Patients with NTPE often present to the emergency department with acute respiratory distress, and contrast-enhanced computed tomography (CT) of the chest and CT pulmonary angiography are the imaging modalities of choice for respiratory distress. Since the treatment of NTPE is entirely different from thromboembolism, its distinction is essential. Moreover, early diagnosis of NTPE is necessary. Radiologists must be familiar with the diagnostic findings of NTPE, and this article aims to review the imaging features of various causes of NTPE.

Ultrasound guided interventions in the diagnosis and management of hepatic lesions

Background:Space occupying lesions of the liver are frequently reported during imaging of the abdomen. Patients with these lesions may be symptomatic or asymptomatic. Most of these lesions have nonspecific imaging findings. Hepatic lesions can be inflammatory like abscesses, benign lesions like hemangiomas or malignant lesions like hepatocellular carcinoma. Guided interventions in the liver may be for diagnostic purposes like fine needle aspiration cytology or biopsy for focal lesions or for therapeutic purposes like fine needle aspiration cytology (FNAC) or catheter drainage for abscesses and collections. Aims and objectives: The aims of this study were 1) to conduct US guided biopsy in hepatic lesions and to evaluate the safety of procedures as well as quality and adequacy of specimens obtained. 2. To conduct US guided aspiration or catheter drainage of hepatic abscesses and to evaluate the clinical outcome. 3. The utility of these ultrasound guided interventions to laboratory procedures. Methods:The study is a hospital based observational study of ultrasound guided interventional procedures in patients with liver lesions (benign or malignant) for. The study includes patients both sexes with age ranging from 4 years to 80 years. The study period was for duration of 18 months from October 2018 to May 2019. The study includes two groups of patients, one with liver abscesses for drainage and other with focal or diffuse hepatic lesions for diagnostic biopsy or cytology under sonographic guidance referred from various departments Results:This study describes the safety of ultrasound guided interventions in patients with varying hepatic lesions, the quality and adequacy of specimens obtained in diagnostic biopsy and FNACs and the clinical out come in patients with hepatic abscess treated by percutaneous abscess aspiration. Ultrasound guided intervention was performed in 55 patients with varying hepatic lesions. 25 patients with clinical and imaging diagnosis of hepatic abscess were treated with needle aspiration (21) or by pig tail catheter drainage (4). The patients were followed up until were discharged with complete clinical cure. Out of 25 patients only one patient was not cured and he had multiple complications due to liver abscess per se. Rest of 24 patients were completely cured with hospital stay ranging between 3 to 7 days after the procedure. Diagnostic biopsy (18) and FNAC (11) were performed in 29 patients with clinical and imaging diagnosis of malignant hepatic lesions. Out of 11 ultrasound guided FNACs one was suboptimal due to inadequate sample. Repeat trucut needle biopsy in that patient yielded adequate sample with histopathological diagnosis of hepatocellular carcinoma. The diagnostic yield of ultrasound guided FNAC was 91%. Conclusions:Ultrasonography is choice of image guidance as it provides real time visualization of needle (and catheter) position and movement, cost effective and free of ionizing radiation. Sonographically guided liver biopsy with 18-20-gauge automated gun biopsy needles is a safe procedure in expert hands with low morbidity. Ultrasound guided diagnostic biopsy or cytology providesrequisite and decent quality specimen for histopathological examination

A case of primary hepatic lymphoma and a review of the literature

Introduction. Primary hepatic lymphoma (PHL) is a rare disease and represents lymphoproliferative disorder confined to the liver parenchyma. This condition is difficult to distinguish from other liver diseases. Histopathology is essential and confirms the diagnosis. Treatment options for PHL include surgery, chemotherapy, radiation, or combinations of these modalities. The objective of this this report is to present a case of PHL and to discuss disease features and treatment options in order to facilitate diagnostics and therapy. Case outline. A 72-year-old female was presented with abdominal pain, nausea, weight loss, and fatigue. Computed tomography (CT) revealed hypoattenuating solitary lesion in liver segment VIII. The detected liver lesion showed elevated 2-[fluorine 18] fluoro-2-deoxy-D-glucose uptake on positron emission tomography/CT examination. Extrahepatic disease was not detected. The tumor board opted for surgery, and atypical resection of liver segments VII and VIII was performed. Pathohistological examination of the resected tumor demonstrated liver infiltration with non-Hodgkin?s lymphoma, diffuse large B-cell type. Postoperative recovery was complicated by fluid collections in the right subphrenic space, successfully managed by percutaneous drainage. Subsequently, the patient was treated with chemotherapy and attained a complete remission documented by negative CT findings. Conclusion. PHL can easily be misdiagnosed as another more frequent primary liver tumor due to its non-specific clinical manifestations, laboratory and imaging findings, and therefore should be considered in the differential diagnosis of a hepatic lesion.

Brain MRI in Epstein-Barr Virus Meningoencephalitis in Children.

Background and Purpose:Epstein–Barr virus (EBV) meningoencephalitis can have variable and nonspecific brain magnetic resonance imaging (MRI) findings in children. This study was done with the purpose of describing brain MRI findings in children with EBV meningoencephalitis.Materials and Methods:The study included 45 pediatric patients that presented with variable neurological symptoms and were found to have EBV meningoencephalitis based on positive EBV deoxyribonucleic acid (DNA) in the cerebrospinal fluid. All these patients had undergone brain MRI. Clinical and radiological features were evaluated.Results:Fever was a presenting feature in all cases. Signs of meningitis and raised intracranial pressure (ICP) were seen in 24 (53.3%) cases, encephalopathy in 15 (33.3%), and seizures were present in 33 (73.3%). MRI was abnormal in 29 (64.4%) patients. The cortical/subcortical pattern was diagnosed in 9 (20%) cases, white matter involvement in 7 (15.5%), basal ganglia in 5 (11.1%), thalamic involvement in 4 (8.8%), brain stem involvement in 2 (6.2%), substantia nigra involvement in 2 (4.4%), and cerebellar involvement in 2 (4.4%). Diffusion restriction was present in 11 (24.4%) cases and susceptibility changes in 7 (15.5%). Meningeal enhancement was present in 10 (22.2%) cases. In addition, brain abscess and subdural effusion/empyema were present in 1 (2.2%) case each.Conclusion:Pediatric EBV meningoencephalitis has varied clinicoradiological spectrum and there is no specific MRI pattern to characterize the meningoencephalitis on imaging. Common MRI findings include cortical-subcortical involvement, white matter changes, basal ganglia, and thalamic involvement.

Clinicopathologic risk factors of radioactive iodine therapy based on response assessment in patients with differentiated thyroid cancer: a multicenter retrospective cohort study.

We investigated whether predictive clinicopathologic factors can be affected by different response criteria and how the clinical usefulness of radioactive iodine (RAI) therapy should be evaluated considering variable factors in patients with differentiated thyroid carcinoma (DTC). A total of 1563 patients with DTC who underwent first RAI therapy after total or near total thyroidectomy were retrospectively enrolled from 25 hospitals. Response to therapy was evaluated with two different protocols based on combination of biochemical and imaging studies: (1) serum thyroglobulin (Tg) and neck ultrasonography (US) and (2) serum Tg, neck US, and radioiodine scan. The responses to therapy were classified into excellent and non-excellent or acceptable and non-acceptable to minimize the effect of non-specific imaging findings. We investigated which factors were associated with response to therapy depending on the follow-up protocols as well as response classifications. Multivariate logistic regression analysis was performed to identify factors significantly predicting response to therapy. The proportion of patients in the excellent response group significantly decreased from 76.5 to 59.6% when radioiodine scan was added to the follow-up protocol (P < 0.001). Preparation method (recombinant human TSH vs. thyroid hormone withdrawal) was a significant factor for excellent response prediction evaluated with radioiodine scan (OR 2.129; 95% CI 1.687-2.685; P < 0.001) but was not for other types of response classifications. Administered RAI activity, which was classified as low (1.11GBq) or high (3.7GBq or higher), significantly predicted both excellent and acceptable responses regardless of the follow-up protocol. The clinical impact of factors related to response prediction differed depending on the follow-up protocol or classification of response criteria. A high administered activity of RAI was a significant factor predicting a favorable response to therapy regardless of the follow-up protocol or classification of response criteria.

Extrapulmonary Tuberculosis: Pathophysiology and Imaging Findings.

Extrapulmonary tuberculosis (TB) represents approximately 15% of all TB infections. It is difficult to diagnose on the basis of imaging characteristics and clinical symptoms, and biopsy is required in many cases. Radiologists must be aware of the imaging findings of extrapulmonary TB to identify the condition in high-risk patients, even in the absence of active pulmonary infection. In extrapulmonary TB, the lymphatic system is most frequently affected. The presence of necrotic lymph nodes and other organ-specific imaging features increases the diagnostic probability of extrapulmonary TB. Disseminated infection and central nervous system involvement are the most frequent manifestations in immunosuppressed patients. Renal disease can occur in immunocompetent patients with very long latency periods between the primary pulmonary infection and genitourinary involvement. In several cases, gastrointestinal, solid-organ, and peritoneal TB show nonspecific imaging findings. Tuberculous spondylitis is the most frequent musculoskeletal manifestation. It is usually diagnosed late and affects multiple vertebral segments with extensive paraspinal abscess. Articular disease is the second most frequent musculoskeletal manifestation, and synovitis is its predominant imaging finding.©RSNA, 2019.

Laparoscopic Excision of Obturator Nerve Schwannoma

Video Objective Obturator nerve schwannomas are extremely rare with only 11 cases being reported in the English-language literature. The pre-operative diagnosis is difficult due to non-specific symptoms and atypical imaging findings. The excision of an obturator nerve schwannoma is a challenging task because of the narrow obturator fossa which is surrounded by vital structures and it is important to preserve the nerve to prevent any post-operative neurological disorders Setting A 42 year old married lady presented to us with complaints of pain in the left leg for the past 4 years. The examination was unremarkable and MRI pelvis revealed a 6.1 × 6.3cm encapsulated retroperitoneal mass on left side with septations and cystic changes and it was displacing the internal iliac vessels medially. Interventions With the help of laparoscopy, we could achieve a magnified view of the pelvic anatomy and meticulous dissection could be done to enucleate the tumor and preserve the integrity of obturator nerve. The operative time was 40 minutes and there was no blood loss. The post-operative course was uneventful and the patient was discharged after 4 days. On follow-up, the patient did not have any neurological deficits and no bowel, bladder complaints. Conclusion Thus, laparoscopic surgery can be done with basic knowledge of surgical anatomy of pelvis and it helps in preserving the nerve function and faster recovery.

CT and MRI features of scalp lesions.

Scalp lesions can be classified as congenital, traumatic, inflammatory, or neoplastic in origin. Although patients presenting with scalp masses are frequently seen in daily practice, differentiation of scalp lesions is often challenging for radiologists who are not familiar with the imaging of cutaneous lesions. The majority of scalp lesions are fortunately benign, with cystic lesions accounting for over 50% of all benign scalp lesions. Such lesions include trichilemmal cysts (pilar cysts), sebaceoma, epidermoid cysts, dermoid cysts, and teratoid cysts. Radiologists may also occasionally encounter benign neoplasms of the scalp, including melanocytic nevi, keratoacanthoma, pilomatricoma, neurofibroma, and lipoma. Malignant scalp tumors are uncommon; however, they carry a potential risk of delayed detection, resulting in poorer outcomes. Most scalp lesions show nonspecific imaging findings, although some possess characteristic features on CT and MRI. Radiologists must be familiar with the appearances of common scalp lesions to reach an accurate diagnosis. Hence, the aim of this article is to describe the clinical and imaging features of scalp lesions.

Analysis of the risk of ovarian torsion in 49 consecutive pediatric patients treated at a single institution

PurposeAn early diagnosis of ovarian torsion is sometimes difficult due to variable clinical symptoms and non-specific imaging findings. We retrospectively reviewed patients with pediatric ovarian masses manifesting torsion.MethodsFifty-eight ovarian masses...

Primary tuberculosis of the breast: a diagnostic dilemma

Primary tuberculosis of the breast is a rare disease, despite the high prevalence of pulmonary and extra-pulmonary tuberculosis in disease endemic countries. The diagnosis of primary breast tuberculosis is challenging due to it’s non-specific clinical and imaging findings. Lesions of tuberculosis such as nodular mastitis, disseminated mastitis, and sclerosing lesions clinically mimic fibroadenoma, carcinoma, and fibrocystic changes, depending on the mode of presentation. We report a case of primary tuberculosis of breast, she presented with breast lump. The diagnosis was confirmed on histopathology after wide excision of the lump. The patient recovered uneventfully and was discharged on antitubercular therapy for 9 months with follow-up protocol. The primary tuberculosis of the breast presents with a diagnostic dilemma for the surgeons. A high index of suspicion for tuberculosis is needed in diseases endemic countries, especially in the Indian subcontinent.

Individualized Follow-Up Strategy for Patients with an Indeterminate Response to Initial Therapy for Papillary Thyroid Carcinoma.

The concept of a dynamic risk-stratification scheme has been suggested for individualized management of patients with papillary thyroid carcinoma (PTC). However, there is no specified follow-up strategy for patients with an indeterminate response. This study evaluated 403 PTC patients who had an indeterminate response during the first 12-24 months after initial therapy. All patients underwent total thyroidectomy with radioactive iodine remnant ablation. Patients were further classified into three groups based on risk of structural persistence/recurrence: a Tg+ group (detectable thyroglobulin [Tg], regardless of antithyroglobulin antibody [TgAb] or imaging findings; 196 patients), a TgAb+ group (positive results for TgAb with undetectable Tg, regardless of imaging findings; 46 patients), and an Image+ group (nonspecific findings on neck ultrasonography or faint uptake in the thyroid bed on whole-body scan, with undetectable Tg and negative results for TgAb; 161 patients). With a median of 9.6 years (interquartile range 7.7-11.2 years) of follow-up, 56 (14%) PTC patients had structural persistent/recurrent disease: 50 (89%) at locoregional sites and six (11%) at distant sites. The recurrence rate in Tg+, TgAb+, and Image + groups were 26.5%, 8.7%, and 0%, respectively. The median time to detection of structural persistent/recurrent disease from the initial thyroid surgery was 3.7 years (interquartile range 2.5-6.3 years). The optimal cutoff stimulated Tg level to predict structural persistent/recurrent disease was 3.1 ng/mL in the Tg+ group. This classification system revealed higher predictability of structural persistent/recurrent disease than the tumor-node-metastasis staging system and American Thyroid Association risk stratification (proportion of variation explained: 15.7% vs. 2.4% and 0.9%, respectively). Six (3%) patients with distant metastatic disease were all classified in the Tg+ group, and all had lung metastasis. The findings suggest a more individualized follow-up strategy for patients with an indeterminate response. More careful evaluation, including early evaluation of distant metastasis, is necessary in patients with elevated Tg levels. However, for patients testing positive for TgAb or those with only nonspecific imaging findings, regular follow-ups of Tg and TgAb levels and neck ultrasonography are sufficient.

Radiologic Findings in Polyarticular Amyloid Arthropathy and Myopathy in Multiple Myeloma: A Case Report

Patient: Male, 56Final Diagnosis: Amyloid arthropathy and myopathySymptoms: PolyarthralgiaMedication: —Clinical Procedure: —Specialty: RadiologyObjective:Rare diseaseBackground:Amyloid arthropathy and myopathy are complications of amyloidosis that can be associated with non-specific imaging findings, which may be challenging to interpret. The report is of a case of polyarticular amyloid arthropathy and myopathy in a 56-year-old man with multiple myeloma and includes a description of the radiographic, computed tomography (CT), and magnetic resonance imaging (MRI) findings.Case Report:A 56-year-old man with multiple myeloma presented with chronic polyarticular pain and swelling. Soft tissue thickening of the wrist and knee were found on MRI to be of intermediate T1 weighted imaging (T1WI) and low to intermediate T2 weighted imaging (T2WI) signal intensity. Denervation muscle edema seen in the thenar muscles on the MRI of the right wrist were associated with carpal tunnel syndrome secondary to amyloid deposition. Soft tissue lesions in the periarticular regions of both hip joints were contiguous with subchondral bone lesions. Diffusely scattered myeloma lesions were shown as hyperintense on short tau inversion recovery (STIR) MRI imaging throughout the appendicular and axial skeleton, with vertebral compression fractures. Bilateral iliopsoas involvement with hypertrophy and abnormal surrounding fat reticulated signal intensity was consistent with amyloid myopathy. The patient had a pathological fracture of the right femoral neck and underwent surgical fixation. Histology of the right femoral head confirmed amyloid deposits.Conclusions:Because the clinical presentation and imaging findings of musculoskeletal amyloidosis can be nonspecific, they can result in delay in diagnosis and treatment. Early radiologic identification of polyarticular amyloid arthropathy and myopathy should prompt confirmatory biopsy to confirm the diagnosis.

Pyogenic Liver Abscess Secondary to Bowel Perforation by Ingested Fish Bone

Accidental ingestion of foreign bodies is a common clinical occurrence in medical practice, but hepatic abscess caused by said ingested foreign bodies is rather uncommon. Pre-operative diagnosis is difficult due to lack of patient awareness of the foreign body as well as non-specific symptoms and imaging findings. We hereby report a rare case of a 68-year-old African male who was admitted with fever and abdominal pain. Further investigation revealed a pyogenic liver abscess caused by an ingested fish bone penetrating the second part of the duodenum, without resolution despite initial antibiotic therapy. Final diagnosis and treatment included a combined endoscopic and surgical approach to remove the fish bone and repair the duodenal perforation along with CT-guided drainage of the abscess by interventional radiology.

Solitary Fibrous Tumor of the Male Breast: A Case Report with Imaging Findings

: Solitary fibrous tumor (SFT) is an uncommon neoplasm of mesenchymal origin, and it most often occurs in the pleura. Mammary gland involvement is extremely rare in this disease. Herein, we report a case of SFT that presented as a slowly growing large mass in the breast of a 64-year-old man. On ultrasonographic examination, the mass was oval and circumscribed with heterogeneous echogenicity and increased intralesional blood flow. Moreover, the mass showed hard elasticity as revealed by shear-wave elastography (SWE), which has not been reported in English literature so far. We also briefly review the literature on the radiologic findings. Because of the nonspecific imaging findings and difficulty in its differentiation from other soft tissue tumors, complete excision with detailed immunohistochemistry is essential.

99mTc-Sulfur Colloid Bone Marrow Scintigraphy in Diagnosis of Diffuse Pulmonary Extramedullary Hematopoiesis Secondary to Myelofibrosis.

Our objective was to define the role of combined 99mTc-sulfur colloid bone marrow (SC BM) scintigraphy, SPECT or SPECT/CT, and chest CT in diagnosing diffuse pulmonary extramedullary hematopoiesis (PEMH) in patients with myelofibrosis. Methods: We retrospectively reviewed 99mTc-SC BM scintigraphy scans performed at our institution for the diagnosis of diffuse PEMH, as well as accompanying chest CT and SPECT/CT imaging findings. Relevant clinical information, including respiratory manifestations, pulmonary hypertension, and subjective response to whole-lung radiation therapy, was also summarized. Results: Twenty-two myelofibrosis patients with 27 99mTc-SC BM scintigraphy scans were diagnosed with diffuse PEMH. In 21 patients (95%) with accompanying chest CT and SPECT/CT scans, the most common CT findings were ground-glass opacity, interstitial infiltration, and pleural effusion. Of 20 patients (91%) who underwent 2-dimensional echocardiography studies, 12 (55%) were diagnosed with pulmonary hypertension. All 12 patients exhibited the aforementioned nonspecific CT imaging findings, with 8 (66%) of them presenting with respiratory symptoms, including dyspnea, shortness of breath, and cough. In the remaining 8 patients, without pulmonary hypertension, half had similar respiratory symptoms. Fourteen patients (64%) of this cohort received whole-lung radiation therapy, of whom 7 (50%) experienced symptom relief after therapy. Conclusion: Nonspecific respiratory symptoms should raise concern about pulmonary hypertension and diffuse PEMH in patients with advanced-stage myelofibrosis. Combined 99mTc-SC BM scintigraphy and SPECT/CT is a promising noninvasive imaging tool to diagnose this rare clinical entity.Key Words: hematology; respiratory; SPECT/CT; pulmonary hematopoiesis; Tc-99m sulfur colloid scintigraphy; myelofibrosis.

Primary Skull Base Lymphoma: Manifestations and Clinical Outcomes of a Great Imitator.

Objectives Primary skull base lymphoma (PSBL) represents a rare manifestation of extranodal lymphoma. Presenting with nonspecific symptomatology and imaging findings, PSBL often masquerades as more common cranial base pathology and thus can present a diagnostic challenge. The objectives of this study were to characterize the manifestations and clinical outcomes of PSBL. Study Design Case series and chart review. Setting Tertiary referral center. Subjects and Methods Review of 48 patients with PSBL treated between 1994 and 2016. Results The median age at diagnosis was 60 years. Diffuse large B-cell lymphoma comprised the most common subtype (56%). Presenting symptoms included diplopia (52%), trigeminal hypesthesia (38%), headache (29%), facial nerve weakness (25%), B-symptoms (fevers, night sweats, and/or weight loss) (25%), and hearing loss (21%). Discrete lesions commonly mimicked meningioma, schwannoma, and nasopharyngeal carcinoma. Diffuse lesions imitated neurosarcoidosis, granulomatosis with polyangiitis, and carcinomatosis meningitis. Only 26% of all initial clinical evaluations suspected lymphoma. The combination of restricted diffusion on diffusion-weighted imaging, an absence of flow voids or surrounding hyperostosis, bony erosion and/or marrow signal replacement, and heterogeneous contrast enhancement facilitated delineation between PSBL and common skull base pathology. Cerebrospinal fluid (CSF) analysis was diagnostic of lymphoma in 24% of cases. Lymphoma within CSF portended significantly worse overall survival (85% vs 18% at 3-years; P < .001). Conclusion A history significant for multiple cranial nerve palsies, B-symptoms, and imaging findings inconsistent with common skull base pathology should raise suspicion for PSBL. CSF analysis in the setting of PSBL can provide diagnostic and prognostic value for patients.