Satellite Lesions Research Articles

Dynamic risk profiling of HCC recurrence after curative intent liver resection.

Following liver resection (LR) for HCC, the likelihood of survival is dynamic, in that multiple recurrences and/or metastases are possible, each having variable impacts on outcomes. We sought to evaluate the natural progression, pattern, and timing of various disease states after LR for HCC using multistate modeling and to create a practical calculator to provide prognostic information for patients and clinicians. Adult patients undergoing LR for HCC between January 2000 and December 2018 were retrospectively identified at a single center. Multistate analysis modeled post-LR tumor progression by describing transitions between distinct disease states. In this model, the states included surgery, intrahepatic recurrence (first, second, third, fourth, fifth), distant metastasis with or without intrahepatic recurrence, and death. Of the 486 patients included, 169 (34.8%) remained recurrence-free, 205 (42.2%) developed intrahepatic recurrence, 80 (16.5%) developed distant metastasis, and 32 (7%) died. For an average patient having undergone LR, there was a 33.1% chance of remaining disease-free, a 31.0% chance of at least one intrahepatic recurrence, a 16.3% chance of distant metastasis, and a 19.8% chance of death within the first 60 months post-LR. The transition probability from surgery to first intrahepatic recurrence, without a subsequent state transition, increased from 3% (3 months) to 17.4% (30 months) and 17.2% (60 months). Factors that could modify these probabilities included tumor size, satellite lesions, and microvascular invasion. The online multistate model calculator can be found on https://multistatehcc.shinyapps.io/home/. In contrast to standard single time-to-event estimates, multistate modeling provides more realistic prognostication of outcomes after LR for HCC by taking into account many postoperative disease states and transitions between them. Our multistate modeling calculator can provide meaningful data to guide the management of patients undergoing postoperative surveillance and therapy.

AN EXTREMELY RARE CASE OF MALIGNANT TRANSFORMATION OF ECCRINE SPIRADENOMA

Eccrine spiradenoma is a very rare benign dermal tumor. It most commonly presents as a small greyish to pink nodule on upper ventral aspect of the body, mostly solitary. Multiple lesions are rare. This is a case report of a 53 year old female patient who presented with multiple swellings over the posterior aspect of left thigh for the past 5 years, which gradually increased in size and were extending towards calf muscle. On examination multiple soft and tender nodules, largest measuring up-to 2x2 cm surrounded by few satellite lesions were present. Ultrasound was suggestive of enhancing exophytic soft tissue mass with absence of extension into subcutaneous fat. Microscopic appearance on biopsy showed several round well circumscribed nodules of benign spiradenoma in the dermis and the subcutaneous tissue with malignant neoplasm arising from spiradenoma. As surgical excision was the treatment of choice, the lesions were excised and hitopathological examination was done which conrmed the diagnosis. Considering the rarity of this tumour this case was reported, so as to add on to existing literature as it is needed for better understanding and setting up standard therapeutic protocols for this kind of tumour.

Facial Pityriasis Alba, Polymorphous Light Eruption, and Vitiligo in Children: A Dermoscopic Distinction

Background: Hypopigmentary skin disorders are the most worrisome complaints from Indian and Indian subcontinent people. Pityriasis alba (PA), polymorphic light eruption (PLE), and vitiligo are clinically look-alike conditions commonly seen in children. Objectives: We attempted to characterize the dermoscopic features of PA and PLE and differentiate them from vitiligo in the facial region in skin of color. Methods: Dermoscopic evaluation was done using a handheld dermoscope at 10X magnification on facial lesions of a total of 60 patients with PA, PLE, and vitiligo. Dermoscopic features of all three conditions were compared and correlated with histological features. Results: Out of 60 patients, 30 (50%), 20 (33.33%), and 10 (16.66%) patients were diagnosed with PA, PLE, and vitiligo clinically and histologically, respectively. Dermoscopy of PA showed white structureless areas (100%), ill-defined margins (86%), faint brownish pigmentation (70%), and fine scales (70%) (P value = 0.001). Besides, 70% of PLE cases showed white structureless areas and ill-defined margins, and 10% showed faint brownish pigmentation (P value = 0.0001). Coarse scales and clustered dots were the most common findings (75%) in PLE lesions, followed by light brown background (60%), crusts (40%), and yellow clods (30%) (P value = 0.0001). Also, 40% and 35% of the PLE cases showed white and brown course scales, respectively (P value = 0.0001). Moreover, 13.33% of PA cases showed coarse white scales, and 3.33% showed a light brown background. All vitiligo cases showed a white glow appearance (100%), followed by perifollicular pigmentation, leukotrichia, and koebnerization shown by 40% of the cases (P value = 0.0001). Finally, 20% of the cases showed perilesional pigmentation and satellite lesions. Conclusions: PA lesions are dermoscopically characterized by ill-defined white areas with fine branny scales, whereas PLE shows coarse brown scales, ring scales, crusts, and yellow clods along with the above findings. Vitiligo lesions are devoid of scales with various pigment network abnormalities, perilesional and perifollicular pigmentation, and leukotrichia.

A row of nodules on the right side of the face

A row of nodules on the right side of the face

A Computed Tomography Nomogram for Assessing the Malignancy Risk of Focal Liver Lesions in Patients With Cirrhosis: A Preliminary Study.

PurposeThe detection and characterization of focal liver lesions (FLLs) in patients with cirrhosis is challenging. Accurate information about FLLs is key to their management, which can range from conservative methods to surgical excision. We sought to develop a nomogram that incorporates clinical risk factors, blood indicators, and enhanced computed tomography (CT) imaging findings to predict the nature of FLLs in cirrhotic livers.MethodA total of 348 surgically confirmed FLLs were included. CT findings and clinical data were assessed. All factors with P < 0.05 in univariate analysis were included in multivariate analysis. ROC analysis was performed, and a nomogram was constructed based on the multivariate logistic regression analysis results.ResultsThe FLLs were either benign (n = 79) or malignant (n = 269). Logistic regression evaluated independent factors that positively affected malignancy. AFP (OR = 10.547), arterial phase hyperenhancement (APHE) (OR = 740.876), washout (OR = 0.028), satellite lesions (OR = 15.164), ascites (OR = 156.241), and nodule-in-nodule architecture (OR =27.401) were independent predictors of malignancy. The combined predictors had excellent performance in differentiating benign and malignant lesions, with an AUC of 0.959, a sensitivity of 95.24%, and a specificity of 87.5% in the training cohort and AUC of 0.981, sensitivity of 94.74%, and specificity of 93.33% in the test cohort. The C-index was 96.80%, and calibration curves showed good agreement between the nomogram predictions and the actual data.ConclusionsThe nomogram showed excellent discrimination and calibration for malignancy risk prediction, and it may aid in making FLLs treatment decisions.

Role of Diffusion Weighted MRI (DW-MR) in Detection of Satellite Lesions Not Detected with Multiphase CT Scans in Hepatoblastoma and Its Implications for Management.

To evaluate the role of diffusion-weighted magnetic resonance imaging (DW-MR) in hepatoblastoma as compared to multiphase contrast enhanced computed tomography (CECT) scans for detection of satellite lesions. In this prospective study onnew cases of hepatoblastoma, multiphase CECT scans and DW-MR were performed before initiation of chemotherapy. Results of interpretation were compared for detection of satellite lesions. PRETEXT grouping and risk categorization was done according to SIOPEL based on CECT scan. Nine boys and 1 girl with hepatoblastoma, with median age of 11.5 mo were included. All patients were stratified as high-risk group with 2 (20%) in PRETEXT II and 8 (80%) in PRETEXT III. In 2 of 10 (20%) patients, additional satellite lesions were detected on DW-MR, which upgraded their stage. One of the two patients had one satellite lesion identified on CECT, while additional seven satellite lesions were identified on DW-MR imaging. For the other patient, CECT showed no satellite lesion while DW-MRdetected six satellite lesions. MRI has become the gold standard investigation for evaluation of hepatoblastoma. DW-MR, which is a contrast free technique, is a better tool for assessment of satellite lesions which are usually missed on CECT. Thiswould help in proper staging, planning of management and prognostication.

Multiple, Eruptive and Generalised Lobular Capillary HaemangiomasA Rare Morphological Variant

Lobular Capillary Haemangioma or Pyogenic Granuloma (PG) is a common benign, vascular proliferative lesion, usually occurring at sites of preceding trauma. It is known to occur more commonly in children and young females. The most common presentation is a solitary lesion. Multiple, eruptive PG have been reported after antecedent burns, trauma and following retinoid therapy and as satellite lesions after treatment of a primary lesion. A 14-year-old female, without any co-morbidities presented with spontaneous onset of multiple, eruptive and generalised skin coloured papules and nodules over face, neck, upper chest and upper back. The lesions were eruptive in nature, involved the back, face and upper trunk over duration of 4 months. There was intermittent bleeding from the lesions after trivial trauma. Clinical diagnosis of lobular capillary haemangioma was confirmed by histopathology which showed lobules of variably dilated network of blood filled capillaries in the papillary dermis surrounded by typical epithelial collarette. The lesions were removed by Radiofrequency (RF) in subsequent sittings. This case report features an interesting and unusual morphological presentation of generalised eruptive lobular capillary haemangioma, which occurred de novo in a young female without any associated skin or systemic disease.

Methamphetamine enhances caveolar transport of therapeutic agents across the rodent blood-brain barrier

SummaryThe blood-brain barrier (BBB) restricts clinically relevant accumulation of many therapeutics in the CNS. Low-dose methamphetamine (METH) induces fluid-phase transcytosis across BBB endothelial cells in vitro and could be used to enhance CNS drug delivery. Here, we show that low-dose METH induces significant BBB leakage in rodents ex vivo and in vivo. Notably, METH leaves tight junctions intact and induces transient leakage via caveolar transport, which is suppressed at 4°C and in caveolin-1 (CAV1) knockout mice. METH enhances brain penetration of both small therapeutic molecules, such as doxorubicin (DOX), and large proteins. Lastly, METH improves the therapeutic efficacy of DOX in a mouse model of glioblastoma, as measured by a 25% increase in median survival time and a significant reduction in satellite lesions. Collectively, our data indicate that caveolar transport at the adult BBB is agonist inducible and that METH can enhance drug delivery to the CNS.

Dysembryoplastic Neuroepithelial Tumor: A Benign but Complex Tumor of the Cerebral Cortex.

Dysembryoplastic neuroepithelial tumor (DNET) is a distinct type of low-grade glioneuronal tumor. Clinically, DNET is highly associated with intractable epilepsy in young children and adolescents. Therefore, the burden of the tumor comprises oncological concerns (recurrence), seizure control, and quality of life. The pathology of DNET is characterized by glioneuronal elements and floating neurons. Grossly, many DNETs harbor separate nodules on the medial side of the mass. Some of the satellite lesions are bone fide tumor nodules that grow during the follow-up. Therefore, removing all satellite lesions may be important to prevent tumor progression. Seizure control is highly dependent on the complete removal of tumors, and the presence of satellite lesions also exerts a negative impact on seizure outcomes.

SUBCUTANEOUS ZYGOMYCOSIS PRESENTING WITH MULTIPLE SWELLINGS

Subcutaneous mycoses are a heterogenous group of fungal infections of the dermis and subcutis. They affect population in rural communities, often in humid, tropical, or subtropical regions of developing countries. They are directly inoculated into the dermis or subcutaneous tissue through a penetrating injury from vegetative materials.30 year old homemaker presented with two discrete painful hyperpigmented swellings with no surrounding satellite lesions, gradually increasing in size, on right thigh of six months duration. There was a history of penetrating trauma. No comorbidities were present .Histopathology showed septal and lobular panniculitis with foreign body granuloma. Fungal stains showed broad hyphae and Basidiobolus species growth was observed in Sabaroud dextrose agar. A diagnosis of subcutaneous zygomycoses was made and treatment with Itraconazole and potassium iodide was started, to which she responded well within 3 months of therapy. Histopathological examination is reliable and less time consuming. But culture is the gold standard investigation for conrming the diagnosis. The positivity in culture ranges from 40 to 60%, hence histopathology is the main tool for diagnosis. Treatment with itraconazole and potassium iodide has produced excellent results.

A pure nanoICG-based homogeneous lipiodol formulation: toward precise surgical navigation of primary liver cancer after long-term transcatheter arterial embolization

To surmount the critical issues of indocyanine green (ICG), and thus achieving a precise surgical navigation of primary liver cancer after long-term transcatheter arterial embolization. In this study, a facile and green pure-nanomedicine formulation technology is developed to construct carrier-free indocyanine green nanoparticles (nanoICG), and which subsequently dispersed into lipiodol via a super-stable homogeneous lipiodol formulation technology (SHIFT nanoICG) for transcatheter arterial embolization combined near-infrared fluorescence-guided precise hepatectomy. SHIFT nanoICG integrates excellent anti-photobleaching capacity, great optical imaging property, and specific tumoral deposition to recognize tumor regions, featuring entire-process enduring fluorescent-guided precise hepatectomy, especially in resection of the indiscoverable satellite lesions (0.6mm × 0.4mm) in rabbit bearing VX2 orthotopic hepatocellular carcinoma models. Such a simple and effective strategy provides a promising avenue to address the clinical issue of clinical hepatectomy and has excellent potential for a translational pipeline.

Comprehensive radiomics nomogram for predicting survival of patients with combined hepatocellular carcinoma and cholangiocarcinoma.

BACKGROUNDCombined hepatocellular carcinoma (HCC) and cholangiocarcinoma (cHCC-CCA) is defined as a single nodule showing differentiation into HCC and intrahepatic cholangiocarcinoma and has a poor prognosis.AIMTo develop a radiomics nomogram for predicting post-resection survival of patients with cHCC-CCA.METHODSPatients with pathologically diagnosed cHCC-CCA were randomly divided into training and validation sets. Radiomics features were extracted from portal venous phase computed tomography (CT) images using the least absolute shrinkage and selection operator Cox regression and random forest analysis. A nomogram integrating the radiomics score and clinical factors was developed using univariate analysis and multivariate Cox regression. Nomogram performance was assessed in terms of the C-index as well as calibration, decision, and survival curves.RESULTSCT and clinical data of 118 patients were included in the study. The radiomics score, vascular invasion, anatomical resection, total bilirubin level, and satellite lesions were found to be independent predictors of overall survival (OS) and were therefore included in an integrative nomogram. The nomogram was more strongly associated with OS (hazard ratio: 8.155, 95% confidence interval: 4.498-14.785, P < 0.001) than a model based on the radiomics score or only clinical factors. The area under the curve values for 1-year and 3-year OS in the training set were 0.878 and 0.875, respectively. Patients stratified as being at high risk of poor prognosis showed a significantly shorter median OS than those stratified as being at low risk (6.1 vs 81.6 mo, P < 0.001).CONCLUSIONThis nomogram may predict survival of cHCC-CCA patients after hepatectomy and therefore help identify those more likely to benefit from surgery.

Anti-glaucoma agents-induced pseudodendritic keratitis presumed to be herpetic simplex keratitis: a clinical case series

Anti-glaucoma agents-induced corneal toxicity may be misdiagnosed as herpetic simplex keratitis (HSK). In our study, nineteen glaucoma patients were presumed to have HSK before referral. Corneal lesions were classified into (I) linear pseudodendritic lesions formed by elevated opacified cells, (II) linear pseudodendritic lesions formed by grouped superficial punctate keratitis (SPK), (III) satellite full-thickness epithelial defects, (IV) satellite lesions formed by elevated opacified cells, and (V) geographic lesions formed by grouped SPK. We observed thirty-one events, with 15 in the lower and 16 in the central corneas. There were 21 (67.7%) type II, five (16.1%) type V, two (6.5%) of each for types III and IV, and one (3.2%) type I events. Among linear lesions (types I and II), 17 (77.3%) had horizontal and 5 (22.7%) had curvilinear orientations. Exposure duration to the last-added anti-glaucoma agent was three days to 14.5 years. About half of the events (16/31, 51.6%) used prostaglandin analogues, and 30/31 (96.8%) applied benzalkonium chloride (BAK)-containing agents. All lesions resolved within two months after decreasing offending medications or enhancing protection of ocular surface. In conclusion, anti-glaucoma agents-induced pseudodendritic keratitis presents majorly in central-lower cornea as horizontally linear lesions, and BAK-containing agents are observed in the most events.

Prognostic value of baseline imaging and clinical features in patients with advanced hepatocellular carcinoma

SummaryAimsTo investigate the prognostic value of baseline imaging features for overall survival (OS) and liver decompensation (LD) in patients with hepatocellular carcinoma (HCC).DesignPatients with advanced HCC from the SORAMIC trial were evaluated in this post hoc analysis. Several radiological imaging features were collected from baseline computed tomography (CT) and magnetic resonance imaging (MRI) imaging, besides clinical values. The prognostic value of these features for OS and LD (grade 2 bilirubin increase) was quantified with univariate Cox proportional hazard models and multivariate Least Absolute Shrinkage and Selection Operator (LASSO) regression.ResultsThree hundred and seventy-six patients were included in this study. The treatment arm was not correlated with OS. LASSO showed satellite lesions, atypical HCC, peritumoral arterial enhancement, larger tumour size, higher albumin–bilirubin (ALBI) score, liver–spleen ratio <1.5, ascites, pleural effusion and higher bilirubin values were predictors of worse OS, and higher relative liver enhancement, smooth margin and capsule were associated with better OS. LASSO analysis for LD showed satellite lesions, peritumoral hypointensity in hepatobiliary phase, high ALBI score, higher bilirubin values and ascites were predictors of LD, while randomisation to sorafenib arm was associated with lower LD.ConclusionsImaging features showing aggressive tumour biology and poor liver function, in addition to clinical parameters, can serve as imaging biomarkers for OS and LD in patients receiving sorafenib and selective internal radiation therapy for HCC.

O13 A case of chronic recurrent multifocal osteomyelitis

O13 A case of chronic recurrent multifocal osteomyelitis

Selection of surgical strategies for vulvar Paget's disease.

Selection of surgical strategies for vulvar Paget's disease.

Clinical and Computed Tomography (CT) Characteristics of Pulmonary Nodules Caused by Cryptococcal Infection.

PurposeTo investigate the clinical and computed tomography (CT) characteristics of pulmonary nodules caused by cryptococcal infection and gain a greater insight and understanding that will reduce misdiagnosis.Materials and MethodsA total of 47 patients with confirmed pulmonary cryptococcosis (PC) manifested as nodules were retrospectively enrolled from January 2013 to December 2020. The clinical and CT data of patients with single and multiple nodules were analyzed and compared with emphasis on exploring the characteristics of the solitary ones.ResultsAmong the 47 patients, single and multiple nodules were detected in 25 (53.2%) and 22 (46.8%) patients, respectively, with similar clinical characteristics. The diameter of solitary nodules was smaller than that of the largest ones of the multiple nodules (P = 0.000). Compared with multiple nodules, less solitary nodules were located in the subpleural zone (P = 0.031) and had a cavity or vacuole (P = 0.049). Regarding the solitary nodules, 22 (88.0%) and 3 (12.0%) were solid and subsolid, respectively. Eighteen (81.8%) solid solitary nodules exhibited either one of air bronchogram or vacuole, satellite lesions, and halo sign. Twenty-three (92.0%) of 25 patients with solitary nodules had follow-up CT data, and most of them had no changes (12, 52.1%) or increased in size and/or density (8, 34.8%), but only a few (3, 13.0%) decreased with or without anti-inflammatory therapy.ConclusionThe clinical characteristics of patients with solitary and multiple nodules caused by PC are similar. The solitary nodules are smaller, more scattered, but less necrotic than multiple ones. For solitary nodules with air bronchogram or vacuole, satellite lesions, or halo sign, PC should be considered as one of the differential diagnosis.

S3567 No Barrett's, No Way! A Case of De novo Esophageal Adenocarcinoma

Introduction: Instances of esophageal adenocarcinoma have been increasing at a more drastic rate in the United States and Western Europe in recent years. This calls for more aggressive and comprehensive screening processes for patients with chronic reflux and for those found to have Barrett’s esophagus. Barrett’s esophagus is widely accepted as a precursor to adenocarcinoma of the esophagus, but this case provides a caveat to this rule of thumb. Case Description/Methods: This is a case of a 63-year-old woman who initially presented with severe GERD and was complaining of reflux and regurgitation, as well as nocturnal coughing and wheezing. An endoscopy was conducted revealing LA class 3 esophagitis, a large hiatal hernia, and a distal esophageal inflammatory nodule. The patient was treated aggressively with a combination of a daily PPI and a nightly H2RA. A three-month follow-up endoscopy revealed improvement of her esophagitis, which was downgraded to LA class 1. There was no evidence of Barrett’s esophagus, and the esophageal nodule had healed. Despite this treatment plan the patient was still complaining of regurgitation. An upper GI series revealed a 5 cm hiatal hernia with reflux on water siphon test and valsalva maneuver. Subsequently, a laparoscopic partial fundoplication was performed with complete resolution of all symptoms and successful discontinuance of all acid suppression medications. 2 and ½ years later the patient presented with new onset dysphasia. An upper endoscopy was subsequently performed which revealed a large adenocarcinoma of the distal esophagus and 2 satellite lesions above the adenocarcinoma. Discussion: This case highlights an infrequent presentation of de novo adenocarcinoma with no evidence of Barrett’s esophagus in a conservative time interval. In the chance that the endoscopist may have missed a short segment Barrett’s because of sampling error, the standard of care would have been a 3-year interval surveillance endoscopy. A repeat endoscopy was performed in 2.5 years regardless of no evidence of Barrett’s; the standard of care was not sufficient in this case. This patient exhibited LA class 3-4 distal esophagitis and despite healing, still developed an advanced adenocarcinoma. This may indicate that there is an alternative pathway to esophageal adenocarcinoma in patients with such severe reflux. This case should provide support to potentially screen patients more aggressively who present with severe reflux.Figure 1.: Row 1: initial endoscopy Row 2: second endoscopy Row 3: third endoscopy

An Unusual Pigmented Plaque in a Newborn.

An Unusual Pigmented Plaque in a Newborn.

Dermatoscopic assessment of treatment response in patients undergoing autologous non-cultured epidermal cell suspension for the treatment of stable vitiligo: A prospective study.

There is lack of literature on serial dermatoscopic assessment in patients undergoing non-cultured epidermal cell suspension (NCES) for treatment of stable vitiligo. This prospective study was conducted to evaluate the role of serial dermatoscopy in assessing disease stability and predicting repigmentation rates in vitiligo patients undergoing NCES. Dermatoscopic assessment of target lesions were done at baseline and post-NCES at week 4, 8, 12, 16, and 24. Patches obtaining >90% repigmentation at 24 weeks were categorized to have obtained excellent repigmentation. The dermatoscopic features of target lesions that showed clinical signs of disease activity anytime during the follow-up period were compared to those maintaining clinical stability throughout. Twenty-six vitiligo patients with 52 patches, clinically stable for atleast 1year were recruited. At follow-up, six patches showed clinical signs of instability. Five patches in the unstable group developed satellite lesions by week 16, compared to none in the stable group (p <0.05). Excellent repigmentation was achieved in 29 out of 52 patches. Appearance of normal reticular pigment network at 8 weeks was a positive predictor of excellent response (OR=10.5, CI 1.2-89.7), whereas, altered pigment network at 12, 16, and 24 weeks and telangiectasias at 12 and 16 weeks significantly reduced the odds of excellent repigmentation.