Punctate Calcifications Research Articles

Engineered Hydrogels as Valve Tissue Mimetics That Recapitulate Sexual Dimorphisms Observed in Calcification and Osteopontin Activity

Objective: Recent clinical reports indicate that patients with calcific aortic valve stenosis (AVS) have sexually dimorphic disease phenotypes, where female patients have reduced valve calcification compared to males. Yet, the cellular mechanisms contributing to this dimorphism remain unknown. Our results reveal that diseased valve leaflets from a female tend to have reduced and smaller-scale microcalcifications compared to males. Additionally, osteopontin (OPN) expression, a pro-fibrotic but anti-calcific bone sialoprotein, is elevated in human female valve tissue sections. We hypothesize that OPN may play a role in reducing calcification in female aortic valves. Methods: To this end, we use a hydrogel system with cellularly-degradable crosslinkers and adhesive peptides to culture VICs isolated from male and female pigs in 3D. We further introduced a secondary interpenetrating network of collagen type I and studied differences in the cellular response to osteogenic stimuli. Results: The hydrogel matrix supported VIC survival, matrix remodeling, and recapitulated the mineralization differences that are observed in human diseased valve tissue. Specifically, female valve tissue and female VICs cultured in pro-calcifying hydrogels have more punctate calcification (< 3000 μm2) relative to male samples (> 3000 μm2) (Figure 1). Further, OPN localization shifted from the hydrogel extracellular matrix to the nucleus in female cells in response to exogenously delivered calcification stimuli. Conclusions: OPN localization corresponded to sites of VIC-mediated matrix calcification, suggesting OPN may have a role in suppressing mineralization growth in AVS progression. This 3D hydrogel culture system should prove useful to test additional hypotheses related to sex-specific AVS calcification and potentially guide the development of sex-specific treatments. Figure 1. Von Kossa stained histological sections display reduced calcification of female samples (left) relative to male (right), in both tissue sections of human diseased aortic valve (top) and within in vitro 3D hydrogel valve mimetics (bottom). Scale bar = 100 μm

Metastatic lymph node calcification in rectal cancer: comparison of CT and high-resolution MRI.

Calcification causes mixed signal intensity in the lymph node (LN) on high-resolution magnetic resonance imaging (MRI), which is a strong indicator of regional LN metastasis in rectal cancer. Calcified metastatic LNs in rectal cancer commonly display scattered fine punctate calcifications to varying degrees on computed tomography (CT). On high-resolution MRI, the calcifications manifest a patchy area of signal loss in corresponding calcified area that is larger than on CT. It is necessary to recognize the appearance of metastatic LN calcifications on high-resolution MRI in rectal cancer because it is the primary imaging method for local staging in rectal cancer. This pictorial essay aims to introduce an important imaging finding that can contribute to the diagnosis of LN metastasis by illustrating features and differences between CT and high-resolution MRI of metastatic LN calcifications in rectal cancer.

CTA Evaluation of Basilar Septations: An Entity Better Characterized as Aberrant Basilar Fenestrations.

A basilar artery intraluminal septation is an exceedingly rarely reported, presumed congenital abnormality. In our clinical practice, we have occasionally noticed an intraluminal band within the inferior aspect of the basilar artery on CTA. Furthermore, we have noticed, at times, the presence of a punctate calcification associated with this finding. We hypothesized that what previous studies have called "basilar septations" in fact represent miniature and thus aberrant basilar fenestrations. We retrospectively reviewed CTA studies obtained between January 1, 2017, and August 31, 2019. Identified intraluminal basilar abnormalities were classified as either basilar septations or basilar fenestrations. Association with other posterior circulation abnormalities was documented. A total of 3509 studies were examined. A basilar intraluminal abnormality was evident in 80 patients (2.3%). Of these 80 patients, 59 were classified as having a basilar fenestration (1.7%) and 21 were classified as having basilar septations (0.6%). Associated calcification was evident in 3 of the basilar fenestration cases and 13 of the basilar septation cases. Basilar septations most likely represent and should be referred to as aberrant basilar fenestrations. They should be interpreted as benign congenital incidental findings and should not be misinterpreted as focal dissections or arterial webs. Important variations in the morphology of aberrant basilar fenestrations exist, including areas of thinning, varying thickness, and nodularity. Therefore, when associated with calcification or nodularity, aberrant basilar fenestrations should not be confused with focal intraluminal thrombi or calcified or noncalcified emboli.

Spontaneous remission of primary papillary thyroid carcinoma: case report

Papillary thyroid carcinoma (PTC) is the most common thyroid neoplasm and its spontaneous remission is an extremely exceptional event. In 2010, a 76-year-old male patient was diagnosed in with CPT. Thyroid ultrasonography indicated echographic characteristics of a solid nodule in the distal third of the right lobe, isoechoic, perinodal vascularization, punctate calcification, measuring 10x7.3mm. The cytological report obtained after the Fine Needle Aspiration Biopsy (FNAB) pointed thyroid papillary tumor, indicating total thyroidectomy, surgical proposal refused by the patient. Ten years after the initial diagnosis and clinical follow-up, a cervical Doppler ultrasonography indicated the presence of a solid nodule in the lower third of the right lobe, hypoechoic, regular contours, Chammas II, absent calcification, Ti-RADS 4, measuring 0.7x0.6 cm. In addition, a new cytological report after the FNAB indicated a benign pattern in the sample and spontaneous tumor remission.

Inhibition of extracellular matrix integrity attenuates the early phase of aortic medial calcification in a rodent model

Background and aimsThe mechanism of vascular calcification (VC) resembles that of bone metabolism, and a correlation has frequently been reported between calcification and vascular extracellular matrix (ECM) regulating its integrity; however, the detailed mechanisms remain unclear. In this study, we examined how the vascular ECM, especially collagen metabolism, is involved in the process of VC. MethodsVC was modeled using 5-week-old male Sprague–Dawley rats fed a diet containing warfarin and vitamin K1 (WVK). Additionally, β-aminopropionitrile (BAPN) was administered to inhibit lysyl oxidase (LOX), which is an enzyme that mediates collagen cross-linking. Harvested aortic samples were analyzed by staining with alizarin red (AR), immunohistochemistry (IHC), transmission electron microscopy (TEM), and ex vivo microcomputed tomography (μCT). ResultsRats fed WVK developed increasing numbers of aortic medial calcifications (AMCs) over time. TEM images indicated punctate calcification within collagen fibers in the early phase of AMC. AR staining of translucent samples revealed the distribution and severity of calcification, and these lesions were significantly decreased in the BAPN group. Three-dimensional reconstructed μCT images that allowed the quantification of calcified volumes revealed that BAPN significantly reduced the bulk of calcification. Moreover, IHC showed that both LOX and collagen I were present around the sites of AMC, and thus the IHC-positive area was reduced in the BAPN group compared to the WVK group. ConclusionsThe results indicated that inhibition of LOX by BAPN attenuated AMC, and that collagen metabolism plays a significant role in the early pathogenesis of VC.

The Association of Nasal Septal Deviation with Solitary Sphenoidal Fungus Ball: Retrospective Analysis of 43 Patients

Objective: A Solitary Sphenoid Fungus Ball (SSFB) is an uncommon unilateral collection of non-invasive fungal hyphae in the sphenoid sinus. The association and potential impact of nasal septal deviation (NSD) on the pathogenesis of SSFB has not been fully assessed. The purposes of this study were to investigate whether NSD is associated with SSFB, and to assess the alterations to adjacent structures caused by SSFB. Methods: Forty-three patients with SSFB were enrolled as the study group. Another 43 age and sex matched patients that underwent trans-sphenoidal resection of a pituitary tumor were enrolled as the control group. The incidence of NSD, and alterations to adjacent bony structures were compared between these two groups. Analysis of the relationship between the direction and severity of NSD with the ipsilateral occurrence of fungus ball in the sphenoid sinus was also performed. Results: The incidence of NSD in patients with SSFB (86.05%) was statistically higher than that in control group (39.53%) (p<0.001). Neither the direction of NSD (p=0.861) nor the severity of NSD (p=0.442) would impact the ipsilateral occurrence of the SSFB. An expanded sphenoid ostia, punctate calcifications, and bony wall sclerosis were the main characteristics on CT imaging. Central signal deficiency was a typical characteristic on T2WI MRI. Conclusion: NSD was common in patients with SSFB. However, no statistically significant difference was detected between the direction and severity of NSDon the ipsilateral occurrence of the sphenoidalfungal sinusitis.

Super-Resolution in Digital Breast Tomosynthesis: Limitations of the Conventional System Design and Strategies for Optimization.

Our previous work explored the use of super-resolution as a way to improve the visibility of calcifications in digital breast tomosynthesis. This paper demonstrates that there are anisotropies in super-resolution throughout the reconstruction, and investigates new motion paths for the x-ray tube to suppress these anisotropies. We used a theoretical model of a sinusoidal test object to demonstrate the existence of the anisotropies. In addition, high-frequency test objects were simulated with virtual clinical trial (VCT) software developed for breast imaging. The simulated objects include a lead bar pattern phantom as well as punctate calcifications in a breast-like background. In a conventional acquisition geometry in which the source motion is directed laterally, we found that super-resolution is not achievable if the frequency is oriented in the perpendicular direction (posteroanteriorly). Also, there are positions, corresponding to various slices above the breast support, at which super-resolution is inherently not achievable. The existence of these anisotropies was validated with VCT simulations. At locations predicted by theoretical modeling, the bar pattern phantom showed aliasing, and the spacing between individual calcifications was not properly resolved. To show that super-resolution can be optimized by re-designing the acquisition geometry, we applied our theoretical model to the analysis of new motion paths for the x-ray tube; specifically, motions with more degrees of freedom and with more rapid pulsing (submillimeter spacing) between source positions. These two strategies can be used in combination to suppress the anisotropies in super-resolution.

SAT-LB42 Bilateral Large Calcified Adrenal Leiomyoma Mimicking Adrenal Malignancy: A Rare Case Report With Literature Review

Background: Adrenal leiomyoma is a very rare benign soft tissue tumor, it is even more unusual if presenting bilaterally; 21 cases have been reported in the literature and only six had bilateral involvement; 5 in the pediatric population and only one in an adult patient. Radiological appearance may frequently be confused with malignancy especially if large, calcified and with central necrosis. We report a rare case of bilateral, large, calcified, non-functioning adrenal leiomyoma in a 20-year-old female, who was suspected for a malignancy preoperatively. Clinical Case: A 20 year-old-female presented with chronic abdominal discomfort, fatigue, and inability to gain weight. On examination, she was normotensive, underweight with BMI of 15.6 kg/m2, and there were no stigmata of Cushing’s syndrome, Addison’s disease or pheochromocytoma. A contrast CT scan of the abdomen revealed the presence of bilateral well-defined suprarenal lesions measuring 8.5 x 8.5 x 7.2 cm and 4.7 x 4.2 x 3.5 cm on the right and left side, respectively. The lesions showed large central areas of necrosis with multiple punctate calcifications and heterogenous peripheral enhancement. The radiological differential diagnosis included adrenal cortical carcinoma, adrenal metastasis, infectious etiology, and bilateral pheochromocytoma. Her hormonal assays showed normal free cortisol and catecholamine metabolites in the urine and normal serum androgens. Thus, the tumors were concluded to be non-functioning. Adrenal insufficiency was ruled out after a short Synacthen test. The patient underwent a successful right adrenalectomy. Resected specimen measured 10 x 9.5 x 7.5 cm. Histology revealed a well-circumscribed and pseudo-encapsulated smooth muscle tumor comprised of bland, spindle-shaped cells. The panel of immunohistochemical stains supported the diagnosis of leiomyoma. Postoperatively, the symptoms improved, she gained 4 kg weight over the following 4 months, and short Synacthen test confirmed an intact adrenal function. To avoid lifelong adrenal insufficiency and after discussion with the patient, we agreed to leave the left adrenal mass and follow it by serial imaging. There was only a minimal increase in the size over the following 4 years (5.5 x 4.5 x 3.8 cm). Conclusion: Adrenal leiomyoma is an extremely rare adrenal tumor and can be confused with adrenal malignancy. Therefore, it should be considered in the differential diagnosis of adrenal incidentalomas. In the case of bilateral etiology, permanent adrenal insufficiency and longterm replacement therapy can be avoided in certain population by removing the larger tumor and continuous follow-up for the other side.

Imaging algorithm and multimodality evaluation of spinal osteoblastoma

BackgroundTo analyze the features of CT, MRI and PET/CT and their diagnostic value for spinal osteoblastomas (OBs).MethodsThe radiological and clinical data of 21 patients with histopathologically-confirmed spinal OBs were analyzed retrospectively.ResultsSixteen of the 21 cases were benign and 5 were aggressive OBs. Tumors were located in the lumbar (n = 11), cervical (n = 4), thoracic (n = 5), and sacral (n = 1) spinal regions. Nineteen cases were centered in the posterior elements of the spine, 13 of which extended into the vertebral body. Punctate or nodular calcifications were found in all cases on CT with a complete sclerotic rim (n = 12) or incomplete sclerotic rim (n = 8). The flare phenomenon (indicative of surrounding tissue inflammation) was found in 17/21 cases on CT, thin in 11 cases and thick in 6 cases, and in 19/19 cases on MRI, thin in 1 case and thick in 18 cases. On 18F-FDG PET/CT, all cases (8/8) were metabolically active with the SUVmax of 12.3–16.0; the flare sign was observed in 8 cases, including 7 cases of hypometabolism and 1 case of coexistence of hypermetabolism and hypometabolism. Based on CT, 3, 12, and 6 cases were classified as Enneking stage 1, 2 and 3, respectively. Of 19 cases with MRI, 1 and 18 cases were classified as Enneking stage 2 and 3, respectively.ConclusionsSpinal OB has multiple unique characteristic radiological features. Although a larger sample size is needed, combining CT, MRI and PET may be beneficial to optimize preoperative diagnosis and care of patients with OBs.

Value of High-resolution MRI in Detecting Lymph Node Calcifications in Patients with Rectal Cancer

To analyze CT and high-resolution MRI findings of nodal metastasis calcifications and determine the value of high-resolution MRI in detecting nodal calcifications in rectal cancer patients. In total, 229 rectal cancer patients were included. The CT was reviewed for the presence of nodal calcifications by two radiologists. High-resolution two-dimensional turbo spin-echo T2-weighted imaging (2D-TSE-T2WI) and fat-suppressed gadolinium-enhanced isotropic high-resolution three-dimensional gradient-echo T1-weighted imaging (3D-GRE-T1WI) were independently reviewed for nodal calcifications by the two radiologists at one-month and two-month intervals, respectively. The sensitivities, specificities and accuracies of the two high-resolution MRI in detecting nodal calcifications were calculated using CT results as a reference. Regional calcified metastatic lymph nodes were found in 28 patients. The node-to-node evaluation revealed that 55 (98.2%) of the 56 calcified lymph nodes were metastatic. Fifty-one (92.7%) calcified metastatic lymph nodes displayed scattered fine punctate calcifications to different degrees on CT. In both types of high-resolution MRI, the calcifications demonstrated a patchy area of markedly reduced signal intensity in corresponding areas that were larger than those on CT. The sensitivity and accuracy of fat-suppressed gadolinium-enhanced isotropic high-resolution 3D-GRE-T1WI were significantly higher than those of high-resolution 2D-TSE-T2WI (76.8% vs 58.9%, P = 0.013; 98.3% vs 97.9%, P = 0.007; respectively). Metastatic nodal calcifications are characteristic imaging findings in rectal cancer. Calcifications are indicated by markedly reduced signal on high-resolution MRI, which will alert radiologists to scrutinize CT for nodal calcifications and aid in the accurate diagnosis of metastatic lymph nodes.

Basal ganglia infarction after mild head trauma in pediatric patients with basal ganglia calcification

ObjectivesIncidence rate of basal ganglia infarction (BGI) after mild head trauma was reported higher in children with basal ganglia calcification (BGC). We would like to review patients with BGC showed in head CT scan to see the incidence rate of stroke in these patients and the correlation of variables in these cases. Patients and methodsCT imaging data of cases with diagnosis of mild traumatic brain injury (mTBI) in a large tertiary pediatric center between Mar. 2014 and Mar. 2019 was retrospectively reviewed. Cases with findings of punctate calcification in the region of basal ganglion in CT scan were included. Correlation of variables of these cases (age, side and volume of basal ganglion calcification) with the diagnosis of BGI was the focus of this study. Results37 patients (26 males, 9 females, median age: 3.88±3.54) were included in this study. 17 cases (45.9 %) were diagnosed of BGI and were admitted into the department of neurosurgery. Altogether 63 sides of BGC were categorized into two groups based on whether BGI happened and ROC curve was drawn. ROC curve showed when the cut-off point was 6.55 mm3, the sensitivity was 88.9 % and the specificity was 87.5 %; the area under curve was 0.849 (p<0.01). All the cases were divided into two groups according to whether basal ganglia infarction occurred or not. Mann-Whitney U test showed significant difference between these two groups in age (p=0.01). ROC curve of how age affect BGI after mTBI were drawn. The cut-off point was 3.25 years, and the sensitivity was 65.0 % and the specificity was 88.2 %; the area under curve was 0.746 (p=0.01). All patients received conservative treatment and recovered. ConclusionIncidence rate is higher in children with BGC after mild head injury than that of other children. Larger BGC volume indicates higher risk of developing infarction after minor head injury. Older children with BGC are less-likely getting BGI after mTBI.

Incidental finding of diffuse cavernous rectal haemangiomatosis during bowel cancer screening

BackgroundThis case seeks to highlight to endoscopists a rare benign disorder that may be encountered during endoscopy. Clinicians may be tempted to biopsy, which could lead to a catastrophic gastrointestinal haemorrhage.Case presentationA 66-year-old asymptomatic Caucasian male was referred for colonoscopy with a positive faecal occult blood test as part of the UK national bowel cancer screening programme. Relevant past medical history included atrial fibrillation for which he took Dabigatran. He had a normal haemoglobin, mean cell volume, platelet and clotting function.During colonoscopy, an unusual vascular pattern encompassing the entire rectum extending to the rectosigmoid junction was noted at intubation. The lesion demonstrated confluent circumferential purple discolouration indicating venous blood supply, with heaping up of the mucosa involving the entire rectum and rectosigmoid junction. There was no corresponding history of venothromboembolic disease or liver disease. The patient proceeded to have computed tomography (CT) which revealed a considerably thickened rectosigmoid wall with multiple small rounded punctate calcifications within it, and no other visceral involvement. Subsequent magnetic resonance (MR) scan of the pelvis demonstrated extensive diffuse thickening of the rectum and lower sigmoid with intermediate to high T2 signal, and an internal architecture of multiple ‘grapelike’ lobulations.ConclusionThe findings were consistent with diffuse cavernous haemangiomatosis of the rectum (DCHR), an extremely rare benign submucosal vascular intestinal tumour originating from the dentate line. Misdiagnosis of DCHR is common and the macroscopic appearance of DCHR can mimic varices, haemorrhoids, polyps or proctitis. MR imaging is the gold standard for diagnosis. Common presentation is with haematochezia due to mucosal wall erosion. The treatment of choice for symptomatic DCHR is pull-through transection and colo-anal anastomosis. This case seeks to highlight a rare disorder that can be encountered incidentally during lower GI endoscopy. Injudicious biopsy is potentially catastrophic. In a patient who endoscopically has evidence of a DCHR, we advocate MR pelvis assessment to clarify the nature of the lesion to guide future management if required. The patient discussed remains well, asymptomatic, with no evidence of iron deficiency anaemia.

Application value of inferior vena cava venography in correlation between the subtypes of inferior vena cava obstruction and calcifications at the obstruction in Budd-Chiari syndrome

Objective To investigate the application value of inferior vena cava venography in correlation between the subtypes of inferior vena cava obstruction and calcifications at the obstruction in Budd-Chiari syndrome (BCS). Methods The retrospective cross-sectional study was conducted. The clinical data of 41 patients with BCS who were admitted to the Affiliated Hospital of Xuzhou Medical University between January 2009 and December 2016 were collected. There were 29 males and 12 females, aged (53±10)years, with a range of 34-70 years. Forty-one BCS patients underwent computed tomography (CT), inferior vena cava CT venography and digital subtraction angiography (DSA) within 2 weeks. Balloon dilatation and (or) endovascular stent implantation of inferior vena cava were performed according to calcification morphology and location of the inferior vena cava obstruction detected by DSA. Observation indicators: (1) calcifications of inferior vena cava obstruction; (2) intraoperative situations of interventional therapy; (3) correlation between the subtypes of inferior vena cava obstruction and calcifications at the obstruction; (4)follow-up and survival situations. Follow-up using outpatient examination of inferior vena cava venography was performed at 3, 6, 12, 24, 36, 48 months postoperatively to detect postoperative clinical manifestations, complications and survival situations up to December 2018. Measurement data with normal distribution were represented as Mean±SD. Count data were represented as absolute number and comparison between groups was analyzed using the chi-square test. The likelihood ratio test was used to analyze the correlation between the subtypes of inferior vena cava obstruction and calcifications at the obstruction. The degree of correlation was detected by Cramer′s V contingency coefficient. Results (1) Calcifications of inferior vena cava obstruction: of 41 patients, 17 had no calcification at the inferior vena cava obstruction and 24 had calcifications at the obstruction. Calcification location in 24 patients: there were 17, 4 and 3 patients with proximal, distal, both proximal and distal calcifications at the inferior vena cava obstruction, respectively. Calcification morphology: punctate and irregular calcifications were detected in 20 and 4 patients, respectively. Calcification distribution: 20, 3 and 1 patients had scattered, cluster and diffuse distribution, respectively. (2) Intraoperative situations of interventional therapy: of 41 patients, 21 underwent balloon dilatation and 20 underwent balloon dilatation combined with endovascular stent implantation. Two patients were detected hematoma at the puncture site of right femoral vein and treated using pressure dressing. One patient encountered rupture of balloon due to diffuse calcifications at the inferior vena cava obstruction and was improved after continual replace of balloon for 3 times. One patient had pulmonary embolism caused by detachment of the thrombosis at the distal obstruction during the balloon dilatation and was given anticoagulation therapy combined with thrombolytic therapy using large-dose of urokinase. The other 37 patients underwent successful interventional therapy without exceptional circumstances. (3) Correlation between the subtypes of inferior vena cava obstruction and calcifications at the obstruction: of 24 patients with calcifications at the inferior vena cava obstruction, 13 had membrane obstruction, 7 had segmental obstruction and 4 had fenestrated membrane obstruction. Of 17 patients without calcifications at the inferior vena cava obstruction, 3 had membrane obstruction, 13 had segmental obstruction and 1 had fenestrated membrane obstruction. The likelihood ratio test showed that the subtypes of inferior vena cava obstruction were associated with calcifications at the obstruction (χ2=9.293, P 0.05). (4) Follow-up and survival situations: 41 patients were followed up for 24.0-48.0 months, with a median time of 37.1 months. Postoperative ultrasound showed smooth backflow in the inferior vena cava, different degree of improvements in the lower limb swelling and varicosity in 38 patients. Embolisms in the inferior vena cava obstruction remained existent in 3 patients, 1 of whom showed significant decreasing of embolisms. There were 2 patients found restenosis and undergoing endovascular stent implantation. All the 41 patients survived. Conclusions The subtypes of inferior vena cava obstruction are associated with calcifications at the obstruction in BCS. Inferior vena cava venography evaluating calcifications at the inferior vena cava obstruction in BCS can be helpful for diagnosing the subtypes of inferior vena cava obstruction and guiding its interventional therapy. Key words: Budd-Chiari syndrome; Inferior vena cava; Calcification; Computed tomography, X-ray; Digital subtraction angiography

Diagnosis and surgical management of orbital sparganosis.

Orbital sparganosis represents an extremely rare condition with only a few cases being reported in literature. Here we describe cases of orbital sparganosis, including their etiology, clinical findings, and surgical outcomes. A retrospective review was performed on patients with orbital sparganosis, who were treated at Zhongshan Ophthalmic Center, of Sun Yat-sen University, China between 2000 and 2012. Five patients (three males and two females, one right orbit and four left orbits) were identified. Their mean age was 14.8 years (range = 6-33 years). Four cases were contracted from eating raw snakes and fishes, or placing poultices of frog on open wounds. All cases showed a swelling and/or redness of the eyelid and conjunctiva, and a migrating inflammation was present in one of the cases. High levels of blood eosinophils were observed in three of these cases. Of the two patients examined using computed tomography, one showed a diffuse soft tissue infiltration and a punctate calcification, while one of the three patients examined using magnetic resonance imaging displayed an annular "tunnel sign" within the lesion. All patients underwent an anterior orbitotomy and the entire worm was removed with no surgical complications. Orbital sparganosis should be highly suspected in patients with a history of eating raw snakes and frogs, a migrating orbital inflammation and the presence of eosinophilia. Orbital imaging examinations play an important role in the diagnosis of orbital sparganosis. Surgical removal of the entire worm is required.

Calcified mucinous adenocarcinoma of the stomach metastatic to the iris: a case report

BackgroundGastric cancer has a wide spectrum of clinical features, imaging manifestations, and pathology. Punctate calcifications in gastric cancer are infrequent but are usually found in mucinous adenocarcinoma. However, there have only been a few autopsy case reports describing the correlation between the radiology and pathology findings of calcified mucinous adenocarcinoma of the stomach. We present an autopsy case of mucinous gastric adenocarcinoma with iris metastases as the initial symptom.Case presentationA 74-year-old Japanese woman presented with blurred vision. Her treating ophthalmologist diagnosed acute iritis with secondary glaucoma. The histopathological and immunohistochemical features of a trabeculectomy specimen favored metastatic carcinoma, most likely of gastrointestinal tract origin. Esophagogastroduodenoscopy revealed multiple irregularly shaped ulcerative lesions, multiple erosions, and thickened folds in the corpus of her stomach. Histologic examination of a gastric tissue specimen obtained by endoscopic biopsy revealed poorly differentiated carcinoma with signet ring cell features. Computed tomography revealed a tumor with multiple punctate calcifications in the thickened gastric wall with diffuse low attenuation and multiple lymph node metastases, including the para-aortic lymph nodes, and peritoneal dissemination. She was diagnosed with stage IV gastric cancer (T4N3M1) and underwent seven cycles of 5-weekly TS-1, a novel oral fluoropyrimidine derivative, plus cisplatin therapy. Serial follow-up computed tomography revealed successive increases in the gastric wall calcifications. Her disease stabilized, but she died of aspiration pneumonia 8 months after the first visit. Autopsy tissue specimens had miliary, punctate calcifications present in abundant extracellular mucin pools in the submucosa, corresponding to the thickened low-attenuating middle layer on computed tomography. The final diagnosis was mucinous gastric adenocarcinoma because mucinous adenocarcinoma is diagnosed when more than half of the tumor area contains extracellular mucin pools.ConclusionsWe report the pathology and computed tomography imaging characteristics of a case of calcified mucinous adenocarcinoma of the stomach metastatic to the iris, including findings at autopsy. Metastatic carcinomas in the iris originating in the stomach are exceedingly rare. Multiple punctate calcifications were present in pools of extracellular mucin, a diagnostic clue for mucinous adenocarcinoma. Possible mechanisms underlying scattered punctuate calcifications in gastric mucinous adenocarcinoma warrant further investigation.

Comparison of abdominal ultrasonographic findings with endoscopic ultrasonographic findings of solid pseudopapillary tumor of pancreas

Purpose To compare abdominal ultrasonographic (AU) findings with endoscopic ultrasonographic (EUS) findings of solid pseudopapillary tumor (SPT) of pancreas. Methods Thirteen patients (M:F = 3:10; mean age, 36 years) with surgically proven SPT were included, who underwent both preoperative AU and EUS. Ultrasonographic findings of 2 modalities were compared according tointernal echo texture, calcification, demarcation, internal septum, and main pancreatic duct dilatation. Results Eight cases showed hypoechogenicity on both AU and EUS. Remaining 5 cases showed different echogenicity on both modalities; hypoechogenicity (n = 3) and isoechogenicity (n = 2) on AU, hyperechogenicity (n = 2), unremarkable internal echogenicity due to dense rim calcification (n = 2), isoechogenicity (n = 1) on EUS. In two cases with dense rim calcification, evaluation of the internal content was more difficult on EUS, compared to AU. Additionally, central punctate calcifications of 2 cases were well seen on both AU and EUS, but 1 case of peripheral calcification was only seen on EUS. All cases showed good demarcation without main pancreatic ductal dilatation or internal septum. Conclusions EUS was superior to AU in the evaluation of internal echo texture (solid or cystic) of pancreatic SPT. However, AU was superior to evaluate the larger size tumor and tumors with dense rim calcification.

THE POTENTIALLY PROVOKED PULMONARY EMBOLISM

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Venous thromboembolism (VTE) is a common medical diagnosis, but the cause is not always apparent at presentation. Compared to the general population, patients with unprovoked venous thromboembolisms have a higher incidence of underlying cancer. Despite this, aggressive investigation into an underlying malignancy has been controversial. This case demonstrates the observed relationship between an unprovoked venous thromboembolism and underlying malignancy. CASE PRESENTATION: A 29 year-old man with no significant past medical history presented to the emergency department with a three-day history of intermittent left sided chest pain. His symptoms worsened with coughing and with deep inhalation. He denied any palpitations, fevers, chills, but did complain of an unintentional 17-pound weight loss over the past six months. Social history was pertinent for tobacco smoking of 10 cigarettes per day for the past 10 years. He has no recent surgical procedures, periods of prolonged immobility, or recent travel. Blood work was obtained and showed an elevated D-dimer of 1.5 (normal range 0.19 - 0.91 mg/L). Chest x-ray revealed no abnormalities. A CT with contrast of the chest revealed bilateral pulmonary emboli with lingular consolidation, suspicious for an evolving infarct. He was started on therapeutic enoxaparin twice daily with transition to warfarin anticoagulation. Initial thrombophilia testing was unremarkable, revealed normal Protein C, S, antithrombin, and anti-phospholipid antibody levels. A year later, the patient went to his primary care physician due to a right scrotal mass that he noticed increasing in size two months prior to presentation. Physical examination revealed a palpable 2 - 3 cm nodule on the lower right testicle. Testing for sexually transmitted infections was negative. An ultrasound revealed scattered punctate calcifications within a 3.7 x 3.3 x 1.9 cm mass. MRI of the pelvis with gadolinium showed a lobulated, intratesticular mass measuring 1.8 x 2.5 cm. He underwent a right orchiectomy with pathology revealing two hemorrhagic and encapsulated masses in the lower pole of the testes measuring 2.3 x 2.0 cm and 1.0 x 0.8 cm without local invasion into the tunica albuginea. The tumor was found to be a seminoma with negative margins. Decision was made to continue anticoagulation indefinitely, as cancer relapse could occur, and bleeding risk is low. DISCUSSION: Current observational studies show a significant risk of occult malignancy within six months of initial diagnosis of a VTE, but the incidence tends to decline after that timeframe. Despite this association, there has not been substantial evidence to support aggressive diagnostic testing above basic laboratory testing and a thorough history and physical to investigate for underlying cancer. CONCLUSIONS: Continued attention to this association may help clinicians remain vigilant to malignancy in this higher risk population. Reference #1: Sørensen H. "The Risk of a Diagnosis of Cancer after Primary Deep Venous Thrombosis or Pulmonary Embolism". NEJM 1998 Reference #2: Puurunen MK. "Epidemiology of venous thromboembolism in the Framingham Heart Study” Pubmed Central 2016 Reference #3: Robertson L. "Effect of testing for cancer on cancer- and venous thromboembolism (VTE)-related mortality and morbidity in patients with unprovoked VTE” Cochrane Library 2015 DISCLOSURES: No relevant relationships by Michael Adashek, source=Web Response No relevant relationships by Kellen Mulhern, source=Web Response

ECTOPIC THYROID MASQUERADING AS AN ANTERIOR MEDIASTINAL MASS: A UNIQUE CASE

SESSION TITLE: Lung Cancer 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Ectopic thyroid tissue in the mediastinum is a rare clinical presentation that is sparsely described in the literature. We report a unique case of ectopic thyroid tissue masquerading as an anterior mediastinal mass. CASE PRESENTATION: We present a 60-year-old lady with history of hepatitis C cirrhosis, peptic ulcer disease, chronic obstructive pulmonary disease, and an 80-pack-year smoking history who presented to the hospital with a two month history of abdominal pain. This was associated with thirty pounds of weight loss, productive cough and worsening orthopnea. A computed tomography (CT) scan of the chest was done and revealed a 2.8 x 2.2 centimeter soft tissue mass with punctate calcification located in the superior, anterior mediastinum (Images 1A-D). There was no associated mediastinal, hilar, supraclavicular, or axillary lymphadenopathy. The patient subsequently underwent bronchoscopy with endobronchial ultrasound and transbronchial needle aspiration of the mass (Image 2). Pathologic analysis of the mass revealed normal thyroid tissue without evidence of malignancy or granuloma. This unique presentation is consistent with the diagnosis of ectopic thyroid tissue. DISCUSSION: Ectopic thyroid tissue can occur anywhere along the line of the obliterated thyroglossal duct extending from the tongue to the mediastinum. This rare entity is infrequently described in the literature with a reported prevalence of only one per one hundred thousand to three hundred thousand cases. The most frequent sites of ectopic thyroid tissue are at the base of the tongue and less than 20% of cases are reported to occur in the mediastinum [1-2]. Interestingly, up to 80% of cases occur in females [2]. Endobronchial ultrasound and transbronchial needle aspiration is being increasingly used for substernal biopsies of goiter or thyroid nodules with success. This implies an expanded use for the procedure with regard to mediastinal masses and thyroid biopsy [3]. CONCLUSIONS: This case highlights the importance of considering every possible differential including ectopic thyroid tissue when evaluating mediastinal lesions. Endobronchial ultrasound guided biopsies can be used to further characterize these mediastinal masses. This has implications for expanded use of this procedure when performing thyroid biopsies. Reference #1: Guerra G, Cinelli M, Mesolella M, et al. Morphological, diagnostic and surgical features of ectopic thyroid gland: a review of literature. Int J Surg 2014; 12:S3–S11. Reference #2: Santangelo G, Pellino G, De Falco N, et al. Prevalence, diagnosis andmanagement of ectopic thyroid glands. Int J Surg 2016; 28:S1–S6. Reference #3: Madan K, Mittal S, Hadda V, Jain D, Mohan A, Guleria R. Endobronchial ultrasound-guided transbronchial needle aspiration of thyroid: report of two cases and systematic review of literature. Lung India 2016; 33:682–687. DISCLOSURES: No relevant relationships by Rania Farhat, source=Web Response No relevant relationships by Armin Krvavac, source=Web Response No relevant relationships by Setu Patolia, source=Web Response No relevant relationships by Manasa Reddy, source=Web Response

Facial profile and additional features in fetuses with trisomy 21.

Aneuploidies occur in about 5% of clinically recognized pregnancies. Facial gestalt is a vital tool for the clinical diagnosis of trisomy 21. Facial anomalies are subtle in fetal life and challenging for a clinician not familiar with perinatal dysmorphology. Here, we present the facial profile and additional features in six fetuses with Down syndrome as a visual aid. We present the facial photographs of six fetuses with genetically confirmed trisomy 21. These photographs will serve as a diagnostic aid for trisomy 21 in perinatal dysmorphology. We noted punctate calcifications in two fetuses with trisomy 21.

Comparative study of microvessel density and lymph node metastasis in papillary thyroid carcinoma with different pathological calcifications

Objective To analyze the microvessel density (MVD) and lymph node metastasis in the papillary thyroid carcinoma (PTC) with punctate or sheet calcification. Methods Fifty PTC patients in the Affiliated Hospital of Yangzhou University from May 2015 to October 2017 were retrospectively enrolled in this study. All of the 50 PTC patients were divided into punctate calcification group (38 cases) and sheet calcification group (12 cases) according to the different features of pathological calcification in microscope examination. For the two groups, the central and peripheral zone MVD and the lymph node metastasis of each PTC nodule were compared. Results For PTC nodules of punctate calcification group, the mean central and peripheral zone MVD were (51±7)/HP and (64±8)/HP, respectively. For those of sheet calcification group, which were (35±5)/HP and (49±6)/HP, respectively. The mean MVD in both central and peripheral zone of PTC nodules of punctate calcification group were significantly higher than those of the sheet calcification group (t values were 10.183 and 12.406, both P < 0.05). The neck Ⅵ area lymph node metastasis rates of the punctate and sheet calcification groups were 42.1% (16/38) and 8.3% (1/12), respectively. The lymph node metastasis rate of the punctate calcification group was significantly higher than that of the sheet calcification group (χ2 = 4.635, P < 0.05). Conclusion PTC nodules with different type of pathological calcification may have different invasion and metastasis, and PTC with punctate calcification is more likely to undergo local metastasis than PTC with sheet calcification. Key words: Papillary thyroid carcinoma; Calcification; Microvascular density; Lymph node metastasis