Occult Lesions Research Articles

Myeloid derived suppressor cells and the release of micro-metastases from dormancy.

Metastasis is the primary cause of cancer mortality and an improved understanding of its pathology is critical to the development of novel therapeutic approaches. Mechanism-based therapeutic strategies require insight into the timing of tumor cell dissemination, seeding of distant organs, formation of occult lesions and critically, their release from dormancy. Due to imaging limitations, primary tumors can only be detected when they reach a relatively large size (e.g. > 1 cm3), which, based on our understanding of tumor evolution, occurs approximately 10years and about 30 doubling times following tumor initiation. Genomic profiling of paired primary tumors and metastases has suggested that tumor seeding at secondary sites occurs early during tumor progression and frequently, years prior to clinical diagnosis. Following seeding, tumor cells may enter into and remain in a dormant state, and if they survive and are released from dormancy, they can proliferate into an overt lesion. The timeline of tumor initiation and metastatic dormancy is regulated by tumor interactions with its microenvironment, angiogenesis, and tumor-specific cytotoxic T-lymphocyte (CTL) responses. Therefore, a better understanding of the cellular interactions responsible for immune evasion and/or tumor cell release from dormancy would facilitate the development of therapeutics targeted against this critical part of tumor progression. The immunosuppressive mechanisms mediated by myeloid-derived suppressor cells (MDSCs) contribute to tumor progression and, we posit, promote tumor cell escape from CTL-associated dormancy. Thus, while clinical and translational research has demonstrated a role for MDSCs in facilitating tumor progression and metastasis through tumor escape from adoptive and innate immune responses (T-, natural killer and B-cell responses), few studies have considered the role of MDSCs in tumor release from dormancy. In this review, we discuss MDSC expansion, driven by tumor burden associated growth factor secretion and their role in tumor cell escape from dormancy, resulting in manifest metastases. Thus, the therapeutic strategies to inhibit MDSC expansion and function may provide an approach to delay metastatic relapse and prolong the survival of patients with advanced malignancies.

PSMA-PET/CT Registry for Recurrent Prostate Cancer (PREP): Initial findings from a single center.

5064 Background: Several lesion-targeted therapies exist for locally recurrent or limited stage metastatic prostate cancer (PCa) post-radiotherapy (RT) and radical prostatectomy (RP). However, detection of disease sites is limited using conventional imaging (CI) including computed tomography (CT) and bone scan. Prostate specific membrane antigen (PSMA) targeting PET radiopharmaceuticals like [18F]DCFPyL may help detect disease not seen on CI. Our objective was to assess the ability of PSMA targeted PET/CT to detect sites of disease recurrence and impact on patient management. Methods: This multi-center prospective registry study included six Ontario centers. Eligible patients in 1 of 7 clinical cohorts (Table) were identified and approved by Cancer Care Ontario (CCO) to have restaging with PSMA targeted PET/CT. Referring physicians were asked to complete a form indicating whether a change in management strategy would occur based on the PET/CT results. At 6 months post-PET/CT, actual patient management will be confirmed via provincial registries. These interim results are from a single center. Results: 253 patients were enrolled and had a PSMA targeted PET/CT. At baseline, median age was 71 years (range 50-102 years) and median PSA was 2.7 ng/mL (range 0.04-134.0 ng/mL). The majority of patients (n=59; 23.3%) were in cohort 2 (biochemical failure post-RP). In patients with negative CI, PSMA targeted PET/CT detected disease sites in 68.5% (170/248), resulting in a change in management for 67.8% (137/202) overall and 72.1% and 64.3% post-RT and post-RP, respectively. Conclusions: PSMA targeted PET/CT detected occult lesions on CI in the majority of patients enrolled, leading to a high rate of change in management. Our institutional results are in keeping with preliminary results reported for the provincial cohort. Clinical trial information: NCT03718260. [Table: see text]

Extracutaneous involvement of subcutaneous panniculitis-like T-cell lymphoma associated with hemophagocytic lymphohistiocytosis and refractory to intensive chemotherapy

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is an uncommon primary cutaneous lymphoma characterized by subcutaneous infiltration of mature cytotoxic T-cells with rearranged alpha/beta T-cell receptor phenotype. SPTCL is typically a disease of young adults with 36 years old being the median age. Patients commonly present with B-symptoms and multiple painless skin nodules in the extremities and trunk. Extracutaneous involvement is rare. Here, we present a case of SPTCL in a 32-year-old woman with diffuse but clinically occult skin lesions detected on imaging through multiple modalities and pathology-proven extracutaneous involvement in the mesentery. Retrospective chart review, review of patient specimens, and literature review for similar cases were performed. Histologic examination revealed SPTCL in the skin and omentum. Our patient’s clinical course was associated with hemophagocytic lymphohistiocytosis (HLH), a known poor prognostic indicator, and refractoriness to intensive chemotherapy. Due to the rarity of this disease, treatment is not yet standardized. However, for our patient, an allogeneic stem-cell transplant resulted in positron emission tomography/computed tomography-negative remission 11 months post-transplant or 20 months post-initial presentation. We report an unusual case of subcutaneous panniculitis-like T-cell lymphoma (SPTCL) with clinically occult subcutaneous lesions and prominent biopsy-proven extracutaneous mesenteric involvement. Further investigation is required to better understand the mechanism of disease, prognosis, and optimal treatment approach for SPTCL patients presenting with extracutaneous involvement and HLH.

Association Between the Degree of Inclusion of Components Identified on Fluorescein or Indocyanine Green Angiography in Target Spots and Relapse of Exudate in Eyes with Polypoidal Choroidal Vasculopathy and Typical Age-Related Macular Degeneration After Photodynamic Therapy.

PurposeTo investigate the association between the inclusion of components identified on images in target spots of photodynamic therapy (PDT) and exudate relapse in eyes with age-related macular degeneration (AMD).MethodsForty-one eyes (39 patients) with polypoidal choroidal vasculopathy (PCV) and 32 eyes (31 patients) with typical AMD (tAMD) who underwent PDT were retrospectively investigated. Each component identified on fluorescein (FA) or indocyanine angiography (IA), optical coherence tomography (OCT), or color photography was graded as not depicted, covered with a margin ≥500 µm or <500 µm, and protruding. Associations between these grades and the dry rate (proportion of subjects with continuous absence of exudate over following 12-month period) and the relapse index (2 × number of injections administered + accumulation of exudate for 12 months post-PDT) were investigated.ResultsIn PCV, the association between worse coverage and decreasing dry rates for feeder vessels and polyps approached statistical significance. With coverage margins ≥500 µm, dry rate tended to be greater than with coverage margins <500 µm for feeder vessels, classic lesions, and occult lesions on FA. In the tAMD group, coverage with margins ≥500 µm tended to yield a higher dry rate than coverage with margins <500 µm for CNV on IA. Coverage with margins ≥500 µm for occult and classic lesions on FA yielded no dry subjects, and all subjects with classic lesions or staining had recurrence (P = 0.009 and 0.050). Worse coverage and worse dry rate in PCV and worse relapse index in tAMD were related to pigment epithelial detachment on OCT (P = 0.040 and 0.006).ConclusionPolyps in PCV and pigment epithelial detachment (PED) in tAMD were verified as appropriate targets, corresponding to the existing guidelines, and feeder vessels, classic lesion, occult lesion, and PED in PCV and CNV on IA in tAMD were suggested as further targets. OCT was superior to FA for evaluating PED.

P046. Radiofrequency seeds compared with wire-guided localisation for occult breast lesions: Initial experience

P046. Radiofrequency seeds compared with wire-guided localisation for occult breast lesions: Initial experience

P179. Comparing roll and magseed in management of impalpable breast lesions a single unit experience

Background: Screening and the use of Neoadjuvant therapy has increased the number of breast lesions requiring localisation. The search for the ideal technique is still on. ROLL (Radioisotope guided Occult Lesion Localisation) is a reliable technique though not widely available, Magnetic Seed, is a new alternative. These two techniques have never been compared.

Cosmetic outcomes following wide local excision of impalpable breast cancer: is radioguided occult lesion localization using iodine-125 seeds better than hookwire localization?

Hookwire localization (HWL) is the gold standard for localizing impalpable tumours for breast conserving surgery. An alternative technique, radioguided occult lesion localization using iodine-125 seeds (ROLLIS), has been associated with lower re-excision rates. This paper investigates if cosmetic outcomes differ in women undergoing breast conserving surgery with HWL or ROLLIS. Women who had ROLLIS or HWL guided excision for impalpable breast cancer within a multicentre randomized controlled trial (RCT) (ANZCTR 12613000655741) were recruited. Exclusions were level 2 oncoplasty and mastectomy. Cosmetic outcome was calculated using BCCT.core, the Hopwood Body Image Scale and estimated percentage breast volume excised. Chi-squared analysis was used to determine the difference between the intervention groups. Analysis was performed for 123 participants (66 ROLLIS and 57 HWL). The cosmetic outcome determined by BCCT.core for all participants was good with no significant difference between the ROLLIS and HWL groups. When reviewing the number of patients who experienced either a good or excellent result, there was a significantly higher number of patients in the ROLLIS group (n=53, 82%) compared to the HWL group (n=42, 74%, P=0.02. There were no differences in Hopwood Body Image Scale or estimated percentage breast volume excised between groups. There was a reduction in the frequency of re-excision in the ROLLIS group (n=3, 4.5%) versus HWL group (n=8, 14%); however, this was not significant (P=0.06). Pre-operative localization of impalpable breast lesions using either ROLLIS or HWL resulted in a good cosmetic outcome with no significant difference between localization techniques.

Identification of a localization wire tip in an occult breast lesion using a handheld magnetometer.

The Sentimag hand-held probe detects the magnetic response from iron oxide particles trapped in a sentinel node. To investigate if an electromagnetic probe can be helpful in the identification of a hook wire tip located in an occult breast lesion. Forty-two patients undergoing lumpectomy without axillary procedure were enrolled. In all cases, suspicious non-palpable microcalcifications without mass were found, and a vacuum-assisted stereotactic biopsy was performed. On the day of surgery, a traditional localization wire (LW) was placed under imaging guidance. The Sentimag magnetometer was used to precisely detect the wire tip through the skin. Then, the skin incision was made and Sentimag was used again to guide the surgeon to the lumpectomy bed. The accuracy of excision was assessed with intra-operative specimen 3D tomosynthesis. Median lesion size was 16 mm (range: 4-38 mm) and median depth was 33 mm (range: 14-78 mm). In all cases, the wire tip was successfully identified. Neither wire displacement nor transection occurred. Intraoperative radiography demonstrated doubtful margin requiring selective cavity shaving in 6 patients (14%). The need for cavity shaving was significantly influenced by the lesion size and histology: median size 30 mm (range: 24-38 mm) compared to 15 mm (range: 4-28 mm) and histology of ductal carcinoma in situ (DCIS) compared to atypical ductal hyperplasia (ADH) and lobular neoplasia (LN). Tumors requiring cavity shaving tended to be deeper - they had a median depth of 43 mm (range: 17-78 mm) compared to 32 mm (range: 14-76 mm) in patients who did not need cavity shaving, but this parameter was statistically significant. Intraoperative identification of the wire tip using Sentimag is a simple technique facilitating targeted excision without excessive removal of breast tissue. Since it is not associated with additional costs, it may be worth considering, particularly in developing countries.

En Bloc Tumor Resection, Optical Molecular Imaging, and the Potential Synergy of the Combination of the Two Techniques in Bladder Cancer.

Although transurethral resection of bladder tumor is the golden standard for the treatment of non-muscle invasive bladder cancer, this surgical procedure still has some serious drawbacks. For example, piecemeal resection of tumor tissue results in exfoliated tumor cells dissemination and implantation, and fragmented tumor specimens make it difficult for pathologists to accurately assess the pathological stage and histologic grade. En bloc tumor resection follows the basic principle of oncological surgery and provides an intact tumor specimen containing detrusor muscle for pathologists to make accurate histopathological assessment. However, there is no robust clinical evidence that en bloc tumor resection is superior to conventional resection in terms of oncological outcomes. Considering the high recurrence rate, small or occult tumor lesions may be overlooked and incomplete tumor resection may occur during white light cystoscopy-assisted transurethral resection. Molecular fluorescent tracers have the ability to bind tumor cells with high sensitivity and specificity. Optical molecular imaging mediated by it can detect small or occult malignant lesions while minimizing the occurrence of false-positive results. Meanwhile, optical molecular imaging can provide dynamic and real-time image guidance in the surgical procedure, which helps urologists to accurately determine the boundary and depth of tumor invasion, so as to perform complete and high-quality transurethral tumor resection. Integrating the advantages of these two technologies, optical molecular imaging-assisted en bloc tumor resection shows the potential to improve the positive detection rate of small or occult tumor lesions and the quality of transurethral resection, resulting in high recurrence-free and progression-free survival rates.

Characterizing New-Onset Exudation in the Randomized Phase 2 FILLY Trial of Complement Inhibitor Pegcetacoplan for Geographic Atrophy

To evaluate clinical characteristics of eyes in which investigator-determined new-onset exudative age-related macular degeneration (eAMD) developed during the FILLY trial. Post hoc analysis of the phase 2 study of intravitreal pegcetacoplan in geographic atrophy (GA). Patients with GA secondary to age-related macular degeneration (AMD), n = 246. Either 15 mg intravitreal pegcetacoplan or sham given monthly or every other month for 12 months followed by a 6-month off-treatment period. Time of new eAMD onset in the study eye, history of eAMD in the fellow eye, presence of double-layer sign (DLS) on structural OCT in the study eye, changes in retinal anatomic features by structural OCT and fluorescein angiography (FA), and changes in visual acuity. Exudation was reported in 26 study eyes across treatment groups over 18 months. Mean time to eAMD diagnosis was 256 days (range, 31-555 days). Overall, a higher proportion of patients with a baseline history of eAMD in the fellow eye (P= 0.016) and a DLS in the study eye (P= 0.0001) demonstrated eAMD. Among study eyes in which eAMD developed, 18 of 26 (69%) had history of fellow-eye eAMD and 19 of 26 (73.1%) had DLS at baseline, compared with 76 of 217 study eyes (35%; P= 0.0007) and 70 of 215 study eyes (32.5%; P < 0.0001), respectively, in which eAMD did not develop. All 21 patients with structural OCT imaging at the time of eAMD diagnosis demonstrated subretinal fluid, intraretinal cysts, or both consistent with exudation. Among 17 patients who underwent FA at eAMD diagnosis, 10 showed detectable macular neovascularization (MNV), all occult lesions. Development of eAMD did not have an appreciable impact on visual acuity, and all patients responded to anti-vascular endothelial growth factor (VEGF) therapy. Intravitreal pegcetacoplan slowed the rate of GA growth and was associated with an unexpected dose-dependent increased incidence of eAMD with no temporal clustering of onset. Exudative AMD seemed to be associated with baseline eAMD in the contralateral eye and a DLS, suggestive of nonexudative MNV, in the study eye. The safety profile of pegcetacoplan was acceptable to proceed to phase 3 studies without adjustments to enrollment criteria.

Techniques for overcoming a missing clip during pre-operative needle localization for lumpectomy: case report

: Breast conservation therapy (BCT) has become the standard of care for treating low-stage breast lesions. The principle of this therapy is to conserve as much normal breast tissue as allowable while still achieving a proper oncologic resection. These breast-sparing dissections would be difficult if not impossible without any intra-operative guidance. For this reason a wire is typically placed near the lesion pre-operatively to serve in directing the surgeon. To accurately place a wire, a lesion must be identifiable on imaging. This creates a potential dilemma as candidates for breast-conserving therapy typically have low-stage lesions which can be illusive at times. Thus, fiduciary markers such as clips have become integral in the treatment of low-stage breast lesions as they can serve as a reference point for identifying non-palpable breast lesions. In fact, cases in which a clip serves as the only identifiable landmark for an occult breast lesion are not uncommon. While undoubtedly useful, the heavy reliance we place on these markers creates a potential for significant dilemma when they cannot be visualized. We present a case that demonstrates one of the potential pitfalls that can occur when relying on a fiduciary marker, specifically, the inability to perform pre-operative wire-guided localization (WGL) for lumpectomy due to a lack of clip visualization. We discuss the potential causes for lost markers such as clip migration as well as several techniques available for attempting a “blind” lumpectomy with particular focus on intra-operative fluoroscopy. By utilizing this technique we were able to successfully complete an unexpected blind lumpectomy without any sacrifice in regards to oncologic margins or cosmesis.

Cost-effectiveness of radioguided occult lesion localization using 125I seeds versus hookwire localization before breast-conserving surgery for non-palpable breast cancer.

The aim was to determine the cost-effectiveness of radioguided occult lesion localization using 125I-labelled seeds (125I seeds) versus hookwire localization in terms of incremental cost per reoperation avoided for women with non-palpable breast cancer undergoing breast-conserving surgery. This study was based on a multicentre RCT with eight study sites comprising seven public hospitals and one private hospital. An Australian public health system perspective was taken. The primary effectiveness outcome for this study was reoperations avoided. Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were used to explore uncertainty. The willingness to pay (additional cost of localization using 125I seeds justified by reoperation cost avoided) was set at the weighted, top-down cost of reoperation. Costs were in 2019 Australian dollars ($1 was equivalent to €0.62). The reoperation rate was 13.9 (95 per cent confidence interval 10.7 to 18.0) per cent for the 125I seed group and 18.9 (14.8 to 23.8) per cent for the hookwire localization group. The ICER for 125I seed versus hookwire localization was $4474 per reoperation averted. The results were most sensitive to uncertainty around the probability of reoperation. Accounting for transition probability and cost uncertainty for 125I seed localization, there was a 77 per cent probability that using 125I seeds would be cost-effective, with a willingness to pay of $7693 per reoperation averted. Radioguided occult lesion localization using 125I seeds is likely to be cost-effective, because the marginal (additional) cost compared with hookwire localization is less than the cost of reoperations avoided.

PELVIC FLOOR MUSCLE TRAINING USING BIOFEEDBACK THERAPY VERSUS BILATERAL POSTERIOR TIBIAL NERVE STIMULATION FOR TREATMENT OF OBSTRUCTED DEFECATION A RANDOMISED CONTROLLED TRIAL

Obstructed defecation syndrome (ODS) is a type of constipation characterized by two or more of the following symptoms in more than 25 percent of defecation trials: straining, lumpy or hard stools, urgency, sense of incomplete evacuation, pelvic heaviness and manual maneuvers to promote defecation.obstructed defecation is of two basic types: functional and mechanical. The functional type involves idiopathic megarectum, anismus (pelvic floor dys-synergy), and descending perineal syndrome, while the mechanical type includes rectocele, enterocele, internal rectal intussusception and overt rectal prolapse.An excessive straining is likely to be the “primummovens”, causing tissue weakness and organ descent, and often is due to longterm anxiety, muscle tension and resulting in non-relaxing puborectalis muscle. The increased straining causes pudendal nerve stretch which may lead to a pudendal neuropathy which affects the rectal sensations.ODS has been also defined as an “iceberg syndrome”, as the two most frequent lesions, i.e., rectocele and rectal internal mucosal prolapse, present in more than 90% of patients with ODS, are easily detectable and may be considered “emerging rocks”, whereas the “surgical ship” is likely to “sink” due to the “underwater rocks”, i.e., the occult lesions.

Diagnostic accuracy of tomosynthesis-guided vacuum assisted breast biopsy of ultrasound occult lesions

This study aims to evaluate the diagnostic accuracy of digital breast tomosynthesis-guided vacuum assisted breast biopsy (DBT-VABB) of screening detected suspicious mammographic abnormalities comprising of calcifications, asymmetric densities, architectural distortions and spiculated masses. In this institutionally approved study, a total of 170 (n = 170) DBT-VABB were performed, 153 (90%) were for calcifications, 8 (4.7%) for spiculated mass, 5 (2.9%) for asymmetric density and 4 (2.4%) for architectural distortion. All these lesions were not detected on the corresponding ultrasound. Histopathology results revealed 140 (82.4%) benign, 9 (5.3%) borderline and 21 (12.4%) malignant lesions. The total upgrade rate at surgery was 40% for atypical ductal hyperplasia and 5.9% for ductal carcinoma in-situ. 3.6% discordant benign lesions showed no upgrade. DBT-VABB showed 100% specificity, 91.3% sensitivity and 100% positive predictive value (PPV) for detecting malignant lesions. The negative predictive value (NPV) was 80%. 2 (1.2%) patients had mild complications and 1 (0.6%) had severe pain. Our study showed that DBT-VABB was a safe and reliable method, with high sensitivity, specificity, PPV and NPV in the diagnosis of non-palpable benign and malignant breast lesions. Our data also confirmed the accuracy of DBT-VABB in detecting malignant lesions and we suggest further surgical excision in borderline lesions for a more accurate diagnostic evaluation.

Prevalence and Functional Implication of Silent Coronary Artery Disease in Marathon Runners Over 40 Years of Age: The MATCH-40 Study

BackgroundMarathon participation is becoming increasingly popular among individuals ≥40 years of age. Little is known about the prevalence of subclinical coronary artery disease (CAD) and corresponding ischemia in this patient population. The study objectives are: (1) to characterize the prevalence of silent CAD in marathoners ≥ 40 years old using cardiac computed tomography angiography (CCT); and (2) if subclinical CAD was detected, to determine the functional significance of occult lesions by stress echocardiography (SE). MethodsMarathoners aged ≥ 40 years who completed a full marathon between 2018 and 2019 were recruited to undergo a prospective CCT. Coronary artery stenosis was graded as zero, mild (1%-49%), moderate (50%-69%), or severe (> 70%). All study participants diagnosed with mild-to-severe atherosclerotic CAD on CCT further underwent functional imaging with exercise treadmill SE. ResultsA total of 65 individuals (53 ± 7 years, 65% males, 24 ± 3 kg/m2) underwent a prospective CCT within 12 months of marathon completion. Of the total study population, 13 participants (20%) were diagnosed with CAD, of whom 10 (77%) had mild disease, 1 (8%) had moderate disease, and 2 (15%) had severe disease by CCT. Despite the identification of subclinical CAD on CCT, none of the 13 patients had any evidence of inducible ischemia on SE. ConclusionsThis is the first study to incorporate both CCT and SE in the evaluation of subclinical CAD in marathoners ≥40 years old. Although the overall prevalence of anatomic CAD was 20%, there was no evidence of functional ischemia in this highly competitive cohort.

Role of myeloid-derived suppressor cells in metastasis.

The spread of primary tumor cells to distant organs, termed metastasis, is the principal cause of cancer mortality and is a critical therapeutic target in oncology. Thus, a better understanding of metastatic progression is critical for improved therapeutic approaches requiring insight into the timing of tumor cell dissemination and seeding of distant organs, which can lead to the formation of occult lesions. However, due to limitations in imaging techniques, primary tumors can only be detected when they reach a relatively large size (e.g., > 1 cm3), which, based on our understanding of tumor evolution, is 10 to 20years (30 doubling times) following tumor initiation. Recent insights into the timing of metastasis are based on the genomic profiling of paired primary tumors and metastases, suggesting that tumor cell seeding of secondary sites occurs early during tumor progression and years prior to diagnosis. Following seeding, tumor cells may remain in a dormant state as single cells or micrometastases before emerging as overt lesions. This timeline and the role of metastatic dormancy are regulated by interactions between the tumor, its microenvironment, and tumor-specific T cell responses. An improved understanding of the mechanisms and interactions responsible for immune evasion and tumor cell release from dormancy would support the development of novel targeted therapeutics. We posit herein that the immunosuppressive mechanisms mediated by myeloid-derived suppressor cells (MDSCs) are a major contributor to tumor progression, and that these mechanisms promote tumor cell escape from dormancy. Thus, while extensive studies have demonstrated a role for MDSCs in the escape from adoptive and innate immune responses (T-, natural killer (NK)-, and B cell responses), facilitating tumor progression and metastasis, few studies have considered their role in dormancy. In this review, we discuss the role of MDSC expansion, driven by tumor burden, and its role in escape from dormancy, resulting in occult metastases, and the potential for MDSC inhibition as an approach to prolong the survival of patients with advanced malignancies.

Management of Sub-ungual Glomus Tumor of the Finger Tips

Background: Glomus tumors present as painful lesions especially in colder weather, most commonly at finger tips. Glomus tumors are hamartomas that account for 1% to 5% of all soft tissue tumors of the hand. These tumors are usually benign. High-resolution magnetingresonence imaging (HR-MRI) is useful in the diagnosis of patients with subungualglomus tumor, excellent diagnostic informationin detecting the occult lesion. Objective: present study was aimed at delineatingcommon presentation and long term treatment outcome. Materials & methods: This prospective study was done from January 2004 to july 2019. We found 30patients diagnosed as having sub-ungualglomus tumorsin finger tips and thumbover 15 yearsperiod and which were operated in hand unit in the Department of orthopaedic surgery, Bangabandhu Sheikh Mujib Medical university (BSMMU) Dhaka, Bangladesh. The data were collected included demographics, presenting symptoms, duration, physical examination, treatment and recurrence. Results: The mean duration of symptoms before presentation was 3.2 years (range 6 months to 15 yrs) Mean age at presentation was 33.7 years (range 20 to 65 yrs.) andfemale to male ratio 20:10. Thirteen (13) patientshad left hand involvement among them ring finger were 06, index finger were 04, middle finger were 02, and thumb 1 and 17 patients had right hand involvement amongthem ring finger were 06, index finger were 05, middle finger were 03 and little finger were 03. Clinical and radiological assessment were made preoperatively. All the lesionsinvolvedthe sub- ungual region. The mean size of the lesion was 3.5 mm (range 2.5 to 10mm). All the patients confirmed by histopathological examination. No recurrence in this study and nail change were 03. Transungual approachto be simple procedure which can reduce the chances of recurrence by allowing examination of entiresub ungual region. Nail deformities are minimal if adequate care is taken during surgery. Conclusion: The diagnosis of glomus tumor is largely clinical butHR-MRI is also helpful in diagnosis of patient with sub- ungualglomus tumor. Complete surgical excision offers the only prospect of complete cure. Early diagnosis of glomus tumor is important to avoid lengthy treatment delays.

Recurrent Parathyroid Adenoma at the Same Site Importance of ROLL

Background: Recurrent hyperparathyroidism is defined by the re-appearance of parathyroid hormone (PTH) and high blood calcium levels more than 6 months after successful initial surgery for primary hyperparathyroidism. Many causes are associated with recurrent hyperparathyroidism and one of the main reasons is the presence of parathyroid adenoma. Radio-guided occult lesion localization (ROLL) has emergent role in per-operative localization of pathological lesions. ROLL has established role in breast cancer, axillary and thyroid surgery. ROLL is a valuable addition in parathyroid exploration especially in small sized parathyroid adenomas. ROLL is safe and efficient techniques helping in more accurate lesion centricity. Case presentation A 35 years old female was referred to our Nuclear Medicine department due to recurrently raised Calcium and PTH levels. She had complaints of generalized aches and pains with no visible neck nodule. Her Ultrasound neck showed no abnormal lesion while 99m Tc MIBIscan showed an area of increased radiotracer uptake in the right side of neck. Focused surgical neck exploration was done and a parathyroid adenoma was removed. Conclusions Parathyroid adenoma is a most common cause of primary hyperparathyroidism and usually presents symptomatically with high calcium and parathyroid hormone levels. Parathyroid adenoma is diagnosed by imaging and laboratory studies. One stop management is the surgical removal of 3 and a half removal of parathyroid gland and only sparing half of the gland.

Ductal Carcinoma In Situ. Interventional Diagnosis.

Most ductal carcinomas in situ are clinically occult; therefore, proper techniques must be used for adequate diagnosis. Current guidelines recommend minimally invasive tissue sampling before surgical excisions of all breast malignancies. Regardless of the technique used, correctly performed biopsies that are geographically, dimensional and numerical representative are essential, and post-interventional markers can be placed at the site. Whenever possible, vacuum-assisted guided by mammography should be the first choice of biopsy for all nonpalpable lesions of the breast, especially for microcalcifications. Surgical excision is expected in most ductal carcinomas in situ; therefore, appropriate imaging-guided localization techniques must be deployed in the hope of aiding the surgeon to perform a free-margin cosmetically adequate procedure. No significant performance differences have been noticed by comparing wire localization to radio guided occult lesion localization or radioactive seed technique, while the choice of imaging guidance should consider the best visibility of the lesion or marker. In the current paper we review the main interventional procedures used for diagnosis in ductal carcinoma in situ, illustrated with images from the database of the Cluj-Napoca Institute of Oncology and Fundeni Clinical Institute.

Role of EUS in detection of liver metastasis not seen by computed tomography or magnetic resonance imaging during staging of pancreatic, gastrointestinal, and thoracic malignancies.

Background and Objectives:Liver metastases might not be detected by computed tomography (CT) and magnetic resonance imaging (MRI) due to their small size, but they can be detected by EUS. Furthermore, EUS-FNA has a significant impact on improving the diagnostic accuracy of EUS. The purpose of this study was to assess the feasibility of EUS in detection of occult small hepatic focal lesions at the time of primary tumor staging, not seen by CT or MRI.Methods:This prospective study included 730 patients who underwent EUS for staging or sampling of gastrointestinal, pancreatic, or thoracic malignancy. The liver was examined thoroughly for detection of occult lesions. CT or MRI was done within 1 week of EUS examination.Results:EUS examination of the liver detected focal lesions in 150 patients (20.5%) and metastases in 118 patients (16.2%); meanwhile, CT and MRI detected focal lesions in 99 patients (13.6%) and metastases in 82 patients (11.2%). EUS missed focal lesions in 7 patients, 6 of which were liver metastases (1.0% and 0.8%, respectively), while CT and MRI missed focal lesions in 58 patients, 42 of which were metastases (7.9% and 5.8%, respectively), which were detected by EUS.Conclusion:Thorough dedicated EUS examination of the liver is a feasible useful tool for detection of small hepatic lesions missed by CT and MRI. It is not considered an extra financial burden to the patient or health-care system because those patients are indicated for EUS examination for evaluation of their original lesion in the first place. Furthermore, EUS-FNA can add another advantage in diagnosing the etiology of such lesions.