Trabecular Pattern Research Articles

"Vascular tuft sign" in neuroendocrine tumors of the pancreas.

The often well-developed microvasculature in pancreatic neuroendocrine tumors (PanNETs) has been studied from different perspectives. However, some detailed structural findings have received less attention. Our objective is to study an overlooked event in PanNETs: "enclosed vascular tufts" (EVTs). For this purpose, 39 cases of PanNETs were examined with conventional (including serial sections) and immunochemistry procedures. In typical EVTs, the results show: 1) an insulated terminal vascular area, with a globular (glomeruloid) aspect, formed by a cluster of coiled microvessels, presenting CD31-, CD34-positive endothelial cells, αSMA-positive pericytes, and perivascular CD34-positive stromal cells/telocytes, separated by a pseudoglandular space from the surrounding trabeculae of tumor neuroendocrine cells; and 2) a pedicle joining the insulated terminal vascular area, with connective tissue tracts around the enclosing tumor trabeculae. EVTs predominate in the trabecular and nested gyriform pattern of PanNETs, with tumor trabeculae that follow a ribbon coil (winding ribbon pattern) around small vessels, which acquire a tufted image. In EVTs, secondary modifications may occur (fibrosis, hyalinization, myxoid changes, and calcification), coinciding or not with those of the connective tracts. In conclusion, the typical characteristics of unnoticed EVTs allow them to be considered as a morphological sign of PanNETs (a vascular tuft sign). Further in-depth studies are required, mainly to assess the molecular pathways that participate in vascular tuft formation and its pathophysiological implications.

Use of Albumin In Situ Hybridization to Diagnose Cutaneous Metastatic Hepatocellular Carcinoma With Poorly Differentiated Features: A Case Report and Review of the Literature.

Hepatocellular carcinoma (HCC) rarely metastasizes to the skin. When it occurs, it is often poorly differentiated making the diagnosis challenging. There exists a male predominance, and clinical presentation usually includes papules or nodules resembling pyogenic granulomas or dermal deposits. Histopathology shows malignant dermal cells. Hepatoid features including nests or cords of cells arranged in a trabecular or pseudoglandular pattern, sinusoidal formation, or the presence of bile exist in less than 50% of cases. Limitations exist with immunohistochemical staining, particularly in poorly differentiated neoplasms. Albumin in situ hybridization is more sensitive for detecting poorly differentiated HCC. Immunostaining in conjugation with albumin in situ hybridization enhances the detection of metastatic hepatocellular carcinoma. We report the case of a 74-year-old man with a history of HCC and a stable lung metastasis who presented with painful, growing bumps on his nose for 2 months. Examination revealed multiple, pink to white, shiny dermal-based papules with telangiectasias involving the right nasal tip and naris. Alpha-fetoprotein level was markedly elevated. Computed tomography showed expanding right lower lobe lung nodules. Histopathology of the cutaneous biopsy revealed features of a poorly differentiated basaloid carcinoma. Immunohistochemical staining was diffusely positive for glypican-3, focally positive for arginase-1, and negative for hepatocyte paraffin 1. Albumin in situ hybridization was diffusely positive, clinching the diagnosis of HCC. Metastatic HCC is a rare encounter for dermatopathologists. We aim to increase awareness of its occurrence in patients with advanced HCC and highlight the importance of clinical correlation when faced with poorly differentiated or unusual-looking basaloid neoplasms.

Uncommon Presentation of Pulmonary Adenoid Cystic Carcinoma: A Case of Brain Metastasis in a Young Smoker

Abstract Introduction/Objective Pulmonary adenoid cystic carcinoma (PACC) is a rare entity, accounting for only 0.04-0.2% lung cancers, and mainly originating from the small salivary glands in the tracheobronchial tree. Due to slow-growing pattern and unspecific symptoms, the diagnosis is often delayed. While metastasis in PACC is uncommon, reports of brain metastasis are exceedingly rare. We present a case of PACC with metastasis to the brain in a young smoker. Methods/Case Report A 29-year-old female with history of smoking presented with headache, hypersomnia, episodes of vomiting and falling. Physical examination revealed multiple palpable nodes on the mid head, left temporal and right parietal area, left shoulder area were found. CT scan demonstrated complex cystic mass with a mural nodule within the left cerebellar hemisphere, with displacement of the cerebellar tonsils, as well as a 7.4 cm left infrahilar mass with heterogenous enhancement. Patient underwent craniotomy with tumor resection and left lower lobe endobronchial biopsy. Touch smear of the brain lesion showed clusters of hyperchromatic cells with myxoid like and hyalinized stroma. H&E stain showed cords of neoplastic cells embedded in a basophilic/myxoid stroma. Lung biopsy showed similar histological patterns. IHC stain showed the tumor cells were positive for epithelial and myoepithelial cells markers(CAM5.2, CK7, p63, Sox 10), retained INI1/BAF47 and BRG1 expression, negative for NUT and BCOR. Salivary Gland NGS Fusion Panel was performed and detected a MYBL1::NFIB [t(8;9)(8q13.1;9p23)] fusion alteration, which confirmed the diagnosis of adenoid cystic carcinoma. Considering no lesion was found in the patient’s head and neck, diagnosis of PACC was made. Results (if a Case Study enter NA) NA Conclusion PACC manifests three histologic subtypes: cribriform (most common), trabecular, and solid. In this case, brain and lung lesions exhibited similar patterns - nests of small, monomorphic cells within a myxoid-like and basophilic stroma background, consistent with trabecular pattern. Cytologically, densely packed cellular clusters were embedded in a myxoid like matrix. Distinguishing PACC from other salivary gland tumors is challenging. Immunostains for epithelial and myoepithelial cells, along with morphology, aid in diagnosis. The MYB::NFIB fusion helps differentiate from other lung salivary gland malignancies, but is found in a lower percentage of PACC cases (~40%) compared to other primary adnoid cystic carcinoma (~85%).

The umblicus says it all

Abstract Introduction/Objective Umbilical nodules can be divided into benign and malignant. Malignant lesions of the umbilicus are very rare. They can arise from primary tumors or secondary to abdominal and pelvic malignancies. Literature review suggests that these umbilical lesions can present as primary tumor in 38% of the cases, endometriosis in 32%, and metastatic lesions in 30%. Umbilical metastasis is one of the main characteristic signs of extensive neoplastic disease and is known as Sister Mary Joseph’s nodule (SMJN). It is a very rare finding and the incidence of SMJN is 1- 3% in people diagnosed with intra-abdominal or pelvic malignancies. Methods/Case Report A 31-year-old male with no past medical history presented to the emergency room with 3 months history of umbilical nodule and 60 pounds weight loss. He experienced early satiety, abdominal pain, nausea and generalized fatigue. CT abdomen showed hepatomegaly with numerous hypoattenuating lesions throughout the liver with peripheral enhancement, and hypoattenuating mass within the pancreatic tail and body measuring approximately 2.1 x 5.8 cm that appears contiguous with hilar splenic lesion. CT chest showed multiple pulmonary metastases with prominent precarinal and subcarinal lymph nodes. Serologic tests revealed elevated Alpha fetoprotein, ALP, ALT, and CA19-9. Patient underwent umbilical nodule core biopsy and right liver core biopsy. Microscopic evaluation of the specimens revealed pancreatic acinic cell carcinoma with two different morphological variants. Umbilical nodule with glandular pattern and liver lesion with trabecular pattern. Immunohistochemical stains were performed with tumor cells positive for CK 7, Trypsin and BCL-10 and negative for Glypican 3, CK 20, AFP and CD56. The prognosis is poor, with an average survival time of about 19 months. After the diagnosis patient underwent chemotherapy. Results (if a Case Study enter NA) NA Conclusion Umbilical nodules can be diagnosed with careful clinical and histopathological evaluation. The prognosis of patients presenting with SMJN is generally poor as it is a sign of advanced malignancy. Sometimes it may be the first and only sign of an internal neoplasm. Therefore, this is an important differential diagnosis to consider.

Conclusive evidence for the origin of the carcinoid component in strumal carcinoids and a new morphological pattern

Abstract Introduction/Objective There has been debate whether strumal carcinoids are carcinoids with areas resembling thyroid or arise from bonafide thyroid tissue in struma. While the thyroid nature has been proven by demonstrating positive TTF-1 in the struma component, evidence for the origin of the carcinoid component is sparse. Herein, we describe a case of strumal carcinoid and use a panel of markers to show definitive morphological and immunohistochemical evidence of the evolution of the neoplasm from struma ovarii to struma carcinoid, within the same lesion. We also report a unique component of a more sinister single cell pattern of invasion apart from the usual insular, trabecular, and mucinous patterns. Methods/Case Report A 40-year-old woman with an adnexal mass underwent bilateral salpingo- oophorectomy/hysterectomy. Microscopic analysis identified thyroid tissue consistent with struma ovarii, juxtaposed with a neuroendocrine neoplasm. The interface between the two showed strong PAX-8 and uniform TTF-1 staining in the struma but gradual loss of TTF-1 with retained/weak PAX-8 staining, moving away from the struma component and into the carcinoid. Additionally, a pattern of single cell invasion was identified, away from the main tumor and at the ovarian surface. These cells closely resemble luteinized ovarian stromal cells but are stained like the carcinoid tumor. Two months postoperatively, the patient had no evidence of recurrence or metastasis. Results (if a Case Study enter NA) NA Conclusion We have provided conclusive morphological and immunohistochemical evidence that strumal carcinoid develops from native neuroendocrine cells of thyroid tissue in struma ovarii. Specifically, retained/weak PAX-8 with interspersed TTF-1 in an adnexal carcinoid provides valuable insight when dealing with tumors of unknown etiology, strongly favoring an ovarian primary (specifically, from struma ovarii) and not metastasis from the gastrointestinal tract or other Mullerian tissue. Lastly, the single cell pattern of invasion that we elucidate here is something to be aware of in the context of metastases or frozen sections.

Type-H endothelial cell protein Clec14a orchestrates osteoblast activity during trabecular bone formation and patterning

Type-H capillary endothelial cells control bone formation during embryogenesis and postnatal growth but few signalling mechanisms underpinning this influence have been characterised. Here, we identify a highly expressed type-H endothelial cell protein, Clec14a, and explore its role in coordinating osteoblast activity. Expression of Clec14a and its ligand, Mmrn2 are high in murine type-H endothelial cells but absent from osteoblasts. Clec14a−/− mice have premature condensation of the type-H vasculature and expanded distribution of osteoblasts and bone matrix, increased long-bone length and bone density indicative of accelerated skeletal development, and enhanced osteoblast maturation. Antibody-mediated blockade of the Clec14a-Mmrn2 interaction recapitulates the Clec14a−/− phenotype. Endothelial cell expression of Clec14a regulates osteoblast maturation and mineralisation activity during postnatal bone development in mice. This finding underscores the importance of type-H capillary control of osteoblast activity in bone formation and identifies a novel mechanism that mediates this vital cellular crosstalk.

7191 When Pain Is Misdiagnosed: A Case of Parathyroid Carcinoma Masked as Fibromyalgia

Abstract Disclosure: H. Pham: None. P.V. Kumar: None. S. Taylor: None. Parathyroid carcinoma is a rare and aggressive cause of hyperparathyroidism, typically associated with <1% of primary hyperparathyroidism cases. Incidence occurs mainly in the 5th decade of life, with less than 4% of all cases presenting in patients under age 30. Here, we highlight a case involving a 28-year-old woman with fibromyalgia who presented for worsening right shoulder pain in the setting of progressive, poorly characterized pain for the past year. Her initial physical exam was unremarkable aside from a non-tender left sided neck enlargement. However, her laboratory results were significant for corrected serum calcium of 15 mg/dL, serum phosphorus of 2.3 mg/dL, parathyroid hormone (PTH) >2500 pg/mL, and alkaline phosphatase 1604 units/L. X-ray of her right shoulder demonstrated mottled bone concerning for degenerative disease. Thyroid ultrasound revealed a complex cystic lesion posterior to the left thyroid lobe measuring 5.3 x 3.9 x 2.9 cm, worrisome for giant parathyroid adenoma. CT abdomen/pelvis showed diffuse osteosclerosis and innumerable lytic lesions, consistent with osteitis fibrosa cystica, as well as bilateral nephrolithiasis, likely medullary nephrocalcinosis. Her hypercalcemia was treated with aggressive hydration with normal saline and IV pamidronate. She underwent surgical resection of her parathyroid adenoma, which was unfortunately complicated by symptomatic hypocalcemia requiring prolonged care in the ICU. Her calcium levels did improve within a few days, and she was subsequently discharged with close outpatient follow-up. Final pathology report showed predominant thickened trabecular growth pattern with focal vascular invasion consistent with parathyroid carcinoma. Our patient’s case represents a rare presentation of parathyroid carcinoma in a young patient without any additional risk factors. Although atypical, her severe symptomatic hypercalcemia, nephrolithiasis, presence of large neck mass, and diffuse skeletal disease warranted immediate concern for malignant hyperparathyroidism instead of benign adenoma. Delayed diagnosis in our patient led to prolonged bone disease and severe complications. While hungry bone syndrome typically manifests post-parathyroidectomy in patients with end-stage renal disease, our patient experienced this complication in the setting of advanced, untreated hyperparathyroidism. We should consider hypercalcemia and hyperparathyroidism in our differential diagnosis for chronic pain, especially if pain remains uncontrolled with conservative measures. The most appropriate initial test for evaluation of hypercalcemia is a PTH level to distinguish between PTH-dependent and PTH-independent etiologies. Parathyroid carcinoma, even in young patients, should be considered when PTH is >3x upper limit of normal, serum calcium is >14, or skeletal and renal involvement is present. Presentation: 6/3/2024

Automated Screening of Hip X-rays for Osteoporosis by Singh's Index Using Machine Learning Algorithms.

Osteoporosis is a significant and growing global public health problem, projected to increase in the next decade. The Singh Index (SI) is a simple, semi-quantitative evaluation tool for diagnosing osteoporosis with plain hip radiographs based on the visibility of the trabecular pattern in the proximal femur. This work aims to develop an automated tool to diagnose osteoporosis using SI of hip radiograph images with the help of machine learning algorithms. We used 830 hip X-ray images collected from Indian men and women aged between 20 and 70 which were annotated and labeled for appropriate SI. We employed three state-of-the-art machine learning algorithms-Vision Transformer (ViT), MobileNet-V3, and a Stacked Convolutional Neural Network (CNN)-for image pre-processing, feature extraction, and automation. Each algorithm was evaluated and compared for accuracy, precision, recall, and generalization capabilities to diagnose osteoporosis. The ViT model achieved an overall accuracy of 62.6% with macro-averages of 0.672, 0.597, and 0.622 for precision, recall, and F1 score, respectively. MobileNet-V3 presented a more encouraging accuracy of 69.6% with macro-averages for precision, recall, and F1 score of 0.845, 0.636, and 0.652, respectively. The stacked CNN model demonstrated the strongest performance, achieving an accuracy of 93.6% with well-balanced precision, recall, and F1-score metrics. The superior accuracy, precision-recall balance, and high F1-scores of the stacked CNN model make it the most reliable tool for screening radiographs and diagnosing osteoporosis using the SI.

Fractal Dimension and Lacunarity Analysis in the Dentulous and Edentulous Mandibular Posterior Region Using Cone-beam Computed Tomography: A Cross-sectional Retrospective Study.

This cross-sectional retrospective study was conducted to assess the differences in the microarchitecture of the trabecular bone of the posterior mandibular region at dentulous and edentulous sites with the help of fractal dimension (FD) and lacunarity using cone-beam computed tomography (CBCT). Ninety CBCT scans were analyzed for the purpose of the present study. Inclusion criteria included subjects with unilaterally missing mandibular molars or premolars and an with intact contralateral opposing tooth. The coronal view of the dentulous and edentulous sites was used, and the region of interest (ROI) was selected 2.6 mm below the apex of the tooth present. These images were then transferred to ImageJ Software, and fractal analysis was done using the box-counting method of the FracLac plug-in. A paired samples t-test was performed to compare the means of FD and lacunarity, and a Kendall correlation was performed to check correlations. A p-value less than 0.05 was considered to indicate statistical significance. Statistical analysis revealed that the mean FD of the edentulous side was significantly greater than that of the dentulous side (p-value = 0.011). Additionally, the mean lacunarity of the edentulous side was marginally significantly greater than that of the dentulous side (p-value = 0.089). A significant negative correlation was detected between the FD and lacunarity of the edentulous region (p-value = 0.017), and a marginally significant negative correlation was detected between edentulous lacunarity and dentulous lacunarity (p-value = 0.081). The differences in occlusal forces exerted in dentulous and edentulous regions can lead to a change in the trabecular pattern of the bone in these regions. This change in the microarchitecture of bones can be detected by FD and lacunarity, which can further help us assess changes pre- and post-implant. The advanced technology, the assessment of microarchitecture of the bone has been made easy, using FD and lacunarity, as done in the present study. This analysis can further aid us in both pre- and post-implant analysis to prevent failure of the implant. How to cite this article: Bhoraskar M, Denny C, Srikant N, et al. Fractal Dimension and Lacunarity Analysis in the Dentulous and Edentulous Mandibular Posterior Region Using Cone-beam Computed Tomography: A Cross-sectional Retrospective Study. J Contemp Dent Pract 2024;25(6):581-587.

Mixed hepatocellular carcinoma and high-grade neuroendocrine neoplasm with ambiguous histopathological features: a case report.

Well-differentiated neuroendocrine tumor (NET) and poorly differentiated neuroendocrine carcinoma (NEC) are distinct entities with different biological behavior. However, difficult cases showing equivocal morphology have been reported in some organs. Herein, we report a case of primary hepatic neuroendocrine neoplasm (NEN) with ambiguous histopathological features admixed with conventional hepatocellular carcinoma (HCC). A 70-year-old man with untreated chronic hepatitis B underwent left medial sectionectomy because of two incidental liver masses. On pathological examination, one of the resected tumors had intermingling NEN and HCC components. The NEN component consisted of relatively uniform tumor cells proliferating in trabecular, cord-like, or solid patterns with peripheral nuclear palisading. The tumor cells were immunopositive for synaptophysin, chromogranin A, cluster of differentiation 56 (CD56), and focally hepatocyte paraffin 1. p53 showed wild-type expression. The Ki-67 labeling index was 27% at the hot spot. Eleven months after the surgery, he died of a cerebral hemorrhage without evidence of recurrent liver cancer. The intermediate degree of differentiation and the modest proliferative activity can challenge the distinction between NEC and NET G3. While the coexisting HCC indicates NEC rather than NET in a pathogenetic viewpoint, such ambiguous tumor may not be as aggressive as typical NECs.

Efficacy of Follicular Cell Pattern Analysis in Thyroid Fine-needle Aspiration Cytology Evaluation.

Fine-needle aspiration cytology (FNAC) is widely utilized for thyroid lesion diagnosis but faces challenges such as sample inadequacy and overlapping cytological features. This study examines how accurately these patterns correlate with histopathological diagnoses, shedding light on FNAC's limitations and diagnostic potential. To study the application of the architectural pattern of follicular cells in the interpretation of thyroid lesions and to demonstrate the diagnostic accuracy (DA) of FNAC. Cross-sectional study carried over 1 year. A total of 110 cases were reviewed by the cytopathologists. The prominent follicular cell architecture, namely macrofollicular, microfollicular, papillary, trabecular, three-dimensional clusters, and dispersed cells, was described in each case. In addition to these patterns, cellular morphology and background features were also noted, and a final cytological diagnosis was established. The cytology diagnosis was correlated with the histopathological diagnosis. Sensitivity, specificity, positive predictive value, negative predictive value, DA of FNAC in diagnosing nonneoplastic and neoplastic lesions. Macrofollicular pattern was seen in 80.26% of colloid goiter cases. Microfollicular pattern was observed in 72.2% of follicular neoplasm. About 62.5% of papillary thyroid carcinomas showed a papillary pattern. The trabecular pattern was seen in 42.86% of chronic lymphocytic thyroiditis and 16.67% of follicular neoplasms. The sensitivity and specificity of FNAC in diagnosing neoplastic lesions was 92.59% and 97.59%, respectively. FNAC is a simple, rapid, definite, and cost-effective primary diagnostic tool for thyroid evaluation. Cell architecture pattern is a simple and appropriate approach that complements cell morphology and background details in arriving at the final cytological diagnosis of thyroid lesions.

Mandibular analysis of Beta thalassemia patients from hematological institutes of Karachi Pakistan.

Objective: To study the mandibular changes in the β-thalassemia major patient. Study Design: Cross sectional study. Setting: Husaini Blood Bank and Institute of Hematological Diseases Karachi, Department of Oral and Maxillofacial Surgery, and Department of Orthodontics, Baqai Dental College Baqai Medical University, Karachi. Period: January 2023-December 2023. Methods: 50 Orthopanthogram (OPG) radiographs of beta-thalassemia major patient were taken, analyzed and compared to check any variation from normal. Fifty diagnosed β-thalassemia major patients were voluntarily selected through convenience sampling. The study was carried out in collaboration of Husaini Institute of Blood Diseases Karachi, National institute of Oral Diseases Karachi Pakistan and, Department of Oral and Maxillofacial Surgery and department of orthodontics Baqai Dental College Baqai Medical University. Results: 18 (36%) patient’s alteration of trabecular pattern are present and in 32 (64%) patient alteration of trabecular pattern absent. Similarly, in 16 (32%) patients have short spiky roots are present and 34 (68%) patients short spiky roots absent. Conclusion: Effect of anemia is not so profound in mandible of thalassemia patients from population of Karachi.

Losartan alters osteoblast differentiation and increases bone mass through inhibition of TGFB signalling in vitro and in an OIM mouse model

Excessive production of Transforming Growth Factor β (TGFβ) is commonly associated with dominant and recessive forms of OI. Previous reports have indicated that administration of TGFβ-targeted antibodies maybe of potential therapeutic benefit to OI patients. However, direct targeting of TGFβ is likely to cause multiple adverse effects including simulation of autoimmunity. In the current study we use patient-derived normal and OI fibroblasts, osteoblasts and OIM mouse models to determine the effects of Losartan, an angiotensin II receptor type 1 (AT1) antagonist, on TGFβ signalling and bone morphology in OI. In OIM mice bred on a mixed background administration of 0.6 g/L losartan for 4 weeks was associated with a significant reduction in TGFβ from 79.2 g/L in the control to 60.0 ng/ml following losartan (p < 0.05), reduced osteoclast activity as measured by CTX from 275.9 ng/ml in the control to 157.2 ng/ml following 0.6 g/L of losartan (p < 0.05) and increased cortical bone thickness (P < 0.001). Furthermore in OIM mice bred on a C57BL/6 background 0.6 g/L losartan increased trabecular bone volume in the tibiae (P < 0.05) and the vertebrae (P < 0.01), increased cortical bone thickness (P < 0.001) reduced the trabecular pattern factor (P < 0.01 and P < 0.001 for the tibiae and vertebrae respectively), reduced osteoclast (P < 0.05) and osteoblast (P < 0.01) numbers as well as reducing the area of bone covered by these cell types. Interestingly, losartan did not affect immune cells infiltrating into bone, nor did this drug alter TGFβ signalling in normal or OI fibroblasts. Instead, losartan reduced SMAD2 phosphorylation in osteoblasts, inhibiting their ability to differentiate. Our data suggest that losartan may be an effective treatment for the bone-associated dysmorphia displayed in OI whilst minimising potential adverse immune cell-related effects.

Porocarcinomas with PAK1/2/3 fusions: a series of 12 cases.

Porocarcinoma is a malignant sweat gland tumour differentiated toward the upper part of the sweat duct and may arise from the transformation of a preexisting benign poroma. In 2019, Sekine etal. demonstrated the presence of YAP1::MAML2 and YAP1::NUTM1 fusions in most poromas and porocarcinomas. Recently, our group identified PAK2-fusions in a subset of benign poromas. Herein we report a series of 12 porocarcinoma cases harbouring PAK1/2/3 fusions. Five patients were male and the median age was 79 years (ranges: 59-95). Tumours were located on the trunk (n = 7), on the thigh (n = 3), neck (n = 1), or groin area (n = 1). Four patients developed distant metastases. Microscopically, seven cases harboured a benign poroma component and a malignant invasive part. Ductal formations were observed in all, while infundibular/horn cysts and cells with vacuolated cytoplasm were detected in seven and six tumours, respectively. In three cases, the invasive component consisted of a proliferation of elongated cells, some of which formed pseudovascular spaces, whereas the others harboured a predominant solid or trabecular growth pattern. Immunohistochemical staining for CEA and EMA confirmed the presence of ducts. Focal androgen receptor expression was detected in three specimens. Whole RNA sequencing evidenced LAMTOR1::PAK1 (n = 2), ZDHHC5::PAK1 (n = 2), DLG1::PAK2, CTDSP1::PAK1, CTNND1::PAK1, SSR1::PAK3, CTNNA1::PAK2, RNF13::PAK2, ROBO1::PAK2, and CD47::PAK2. Activating mutation of HRAS (G13V, n = 3, G13R, n = 1, Q61L, n = 2) was present in six cases. Our study suggests that PAK1/2/3 fusions is the oncogenic driver of a subset of porocarcinomas lacking YAP1 rearrangement.

Pathophysiology and treatment of bone edema: focus on the knee

Bone edema is a frequent condition that can involve several joints, especially the hip and knee. The radiological signal patterns for knee bone marrow edema are typically nonspecific. In recent literature, the general term “bone edema” has been replaced with the expressions “bone edema syndrome” or “bone edema lesions”. The causes of this condition can be traumatic, metabolic, inflammatory or micro-vascular, and may determine blood stasis, increased intra-bone pressure and, consequently, bone ischemia. The outcome of bone edema syndrome is variable, ranging from complete healing to osteonecrosis (ON), depending on the repair response. Pain is the main symptom; the most important differential diagnoses in bone edema syndrome are traumatic injuries, bone tumors or neurosensory changes. At the level of the knee, lesions can be distinguished into traumatic versus atraumatic, reversible versus irreversible, and subchondral versus joint-extended. Traumatic cases are the consequence of impact with bony surfaces impact and the most frequent mechanisms are pivot-shift, hyper-extension or varus-valgus stress; patellar luxation may contribute too. In contrast, atraumatic lesions are divided into reversible (regional migratory osteoporosis or algo-dystrophic syndrome) or irreversible such as avascular necrosis or spontaneous osteonecrosis of the knee (SONK). In recent literature, a spontaneous trabecular bone insufficiency fracture pattern (spontaneous insufficiency fracture of the knee, SIFK) has also been identified. This can self-limit and resolve spontaneously or degenerate into more severe forms of necrosis. Conservative treatment is considered in small lesions (&lt; 3.5 cm2) or early cases of SONK and SIFK. It consists of partial load bearing, physical therapy, painkillers and treatment with bisphosphonate/prostacyclin. Surgical treatment, on the other hand, is reserved for patients with persistent pain after conservative treatment, meniscal extrusions or clear signs of marked ON. We here aim to provide a review of the current literature on bone edema injuries of the knee, focusing on the different clinical features and most recent effective treatments. KEY WORDS: Bone marrow edema, Knee, SONK, SIFK, AVN.

Application of Fractal Analysis in Detecting Trabecular Bone Characteristics Around Mandibular Impacted Third Molars on Dental Panoramic Radiographs

Purpose: Surgical extraction of third molars can be difficult for many reasons, including increased bone density, which causes bone structures to lose their elastic properties. The aim of this study is to compare the trabecular structure around the impacted mandibular third molar(M3M) and the normal alveolar trabecular pattern using the fractal analysis method. Materials and Methods: Panoramic images of 47 patients were included in the study. ROI1 is the area between the distal root of the second molar and the mesial of the third molar tooth. On the other hand, ROI2 was selected between the distal root of the first molar tooth and the mesial root of the second molar tooth. Fractal Dimension (FD) and Bone Marrow Dimension analyzes were applied to the selected ROIs using the ImageJ software. Results: The mean FD values of 47 patients were found to be 1.135 for ROI1 and 1.105 for ROI2, respectively (p=0,078).The mean Bone Marrow Dimension values were found to be 1.591 for ROI1 and 1.587 for ROI2(p=0.731). There was no significant difference in FD and Bone Marrow Dimension analysis when ROI1 and ROI2 were compared. It is very important to know the pattern of trabecular structure before surgical procedure on M3M. The bone density around the impacted M3M may be higher than the healthy alveolar bone, however, the fact that males have denser bone than females should not be ignored during the operation. Conclusion: The method of FD analysis can be useful for evaluating the trabecular structure of impacted M3M. Key words: fractal dimension; bone structure; panoramic imaging; impacted tooth; third molars

Degenerative Temporomandibular Disorders: An Assessment of Bone Trabecular Structure Using Fractal Analysis in Digital Panoramic Radiographs.

Introduction Fractal analysis has proved to be a salient tool to quantitatively assess the qualitative changes in the bone trabeculae of patients with hyperparathyroidism, osteoporosis, and various temporomandibular disorders, including osteoarthritis (OA) and rheumatoid arthritis of temporomandibular joint (TMJ), in several previous studies. The purpose of this study was to use fractal analysis to assess alterations in the trabecular pattern of the mandibular condyle in patients with degenerative temporomandibular disorders. Materials and methods This study comprised 98 subjects with 49 subjects in the study group and 49 subjects in the control group, aged 18-50 years. Age and sex in the control group were matched to those in the case group. The subjects were assessed clinically with the Diagnostic Criteria for Temporomandibular Disorders. Digital panoramic X-ray equipment with set parameters of 70 kvp, 8 mA, and 16-second exposure duration was used to take panoramic radiographs. Fractal analysis was done and the calculated fractal dimension value was obtained usingImageJ version 1.48 software (National Institutes of Health, Bethesda, MD). The same observer used Muir and Goss's method to rate the total degenerative changes in the condylar surfaces, which were substantiated by the calculated fractal dimension value. The data were statistically analyzed. Results The results revealed a significant difference (p-value = 0.041) between the mean fractal valuein the case group's (1.35) and the control group's (1.38) left sides whereas the differences in the mean fractal values between the case and control groups on the right side was not significant (p-value = 0.49). Conclusion It is recommended to use the fractal dimension value and the total degenerative severity score together to quantify degenerative changes in the TMJ OA rather than exclusively relying on fractal value.

Strut and radio-morphometric analysis of mandibular trabecular structure in pre-and post-menopausal women to aid in the diagnosis of osteoporosis

PurposeThe purpose of the study is to evaluate the mandibular trabecular pattern in pre- and postmenopausal age women. By analysing the strut, fractal, grey level co-occurrence matrix, and radio-morphometric indices in the panoramic radiograph. MethodPanoramic radiographs from 2019 to 2022 were used to assess pre- and postmenopausal women's bone mineral density. A total of 272 panoramic radiographs, which exhibited clear visibility of the mental foramen on both sides without any blurring, motion artefacts, surgical errors, overlapping hyoid bone, or inferior mandibular cortex, were divided into two groups. Group A (136 premenopausal women) and Group B (136 postmenopausal women). It is a retrospective study that is non-interventional/observational in design. Strut features, fractal dimensions, a grey-level co-occurrence matrix, and radio morphometric indices were used to investigate bone texture in an image processing program. The mean difference between group variables was calculated using an independent sample t-test/unpaired t-test. ResultsPre-menopausal women had a mean age of 38.83 ± 6.01 years, while postmenopausal women had a mean age of 68.26 ± 8.31 In the postmenopausal group Four regions of interest exhibited fractal dimensions with a P value of less than 0.01 and GLCM features including contrast (0.812), correlation (0.230), energy (0.215), and homogeneity (0.322). Strut features of the four regions showed that 15 of 19 characteristics were significantly different. ConclusionOrthopantomogram is useful in screening for osteoporosis. Strut, radio-morphometric indices, and fractal analysis can assess bone texture and quality. Future research incorporating artificial intelligence can revolutionize image analysis and support clinical decision-making.

Perivascular Epithelioid Cell Tumor with Uncertain Malignant Potential Arising in the Round Ligament.

A 12-year-old adolescent was diagnosed with a right-sided solid mass in the round ligament of the uterus. The chief complaints were abdominal pain and pelvic discomfort. She underwent laparoscopic tumor resection. Histological examination demonstrated a trabecular growth pattern of epithelioid cells with mitotic activity (3 per 50 HPF), which expressed melanocytic and myoid markers. Due to aforementioned findings, a final diagnosis of perivascular epithelioid cell tumor (PEComa) with uncertain malignant potential was made. To the best of our knowledge, this localization of PEComa is considered to be infrequent with only occasionally reported cases.

Prognostic value of micrometric substaging in pT1 bladder cancer patients treated with en-bloc transurethral resection.

We aimed to assess the oncological impact of micrometric extent of invasion in patients with pT1 bladder cancer (BCa) who underwent en-bloc resection for bladder tumour (ERBT). We retrospectively analysed the records and specimens of 106 pT1 high-grade BCa patients who underwent ERBT. The extent of invasion, such as depth from basal membrane, number of invasive foci, maximum width of invasive focus, muscularis mucosae invasion and infiltration pattern (pattern A: solid sheet-like, nodular or nested growth, pattern B: trabecular, small cluster or single-cell pattern) were evaluated by a single genitourinary pathologist. The end-points were recurrence-free (RFS) and progression-free survival (PFS). Within a median follow-up of 23 months, overall, 36 patients experienced recurrence and 13 patients experienced disease progression. The 2-year PFS differed significantly depending on depth from basal membrane (< 1.3 mm: 94.8% versus ≧ 1.3 mm: 65.2%, P = 0.005), maximum width of invasive focus (< 4 mm: 91.7% versus ≧ 4 mm: 62.3%, P < 0.001), muscularis mucosae (MM) invasion (above MM = 96.1% versus into or beyond MM = 64.8%, P = 0.002) and infiltration pattern (pattern A: 100% versus pattern B: 83.3%, P = 0.037). In a multivariable analysis, MM invasion [hazard ratio (HR) = 4.54, 95% confidence interval (CI) = 1.25-16.5] and maximum width of invasive focus ≧ 4 mm (HR = 4.79, 95% CI = 1.25-16.5) were independent prognostic factors of progression. En-bloc resection facilitates the evaluation of pathologic variables that might be useful in predicting disease recurrence and progression. In particular, not only the MM invasion but also the maximum width of invasion focus, reflecting the invasive volume, appear to be reliable prognosticators for disease progression.