Fwd: contrast media-induced nonrenal adverse drug reactions

Contrast media-induced nonrenal adverse drug reactions
To:

contrast media-induced nonrenal adverse drug reactions over the last three decades: A systematic review p. 131
Maurizio Sessa, Claudia Rossi, Annamaria Mascolo, Antonella Scafuro, Rosanna Ruggiero, Gabriella di Mauro, Salvatore Cappabianca, Roberto Grassi, Liberata Sportiello, Concetta Rafaniello
DOI:10.4103/jpp.JPP_92_18  
The aim of this study was to investigate the scientific contribution of Italian clinical research for contrast media-induced nonrenal adverse drug reactions over the last three decades. Ovid Embase, Ovid MEDLINE, Web of Science, and Cochrane Methodology Register were used as data sources to identify Italian descriptive studies, observational studies, meta-analyses, and clinical trials assessing contrast media-induced nonrenal adverse drug reactions as a safety outcome. The population of interest was men and women exposed to a contrast medium. Between 1990 and 2017, 24 original articles investigating contrast-induced nonrenal adverse drug reactions were identified. The cohort study was the most representative study design (10/24; 41.7%). The 24 studies were conducted mainly as monocenter studies (14/24; 58.3%) and without receiving funding (17/24; 70.8%). Seventeen out of 24 studies provided a level of evidence ranging from III-2 (11/24; 45.8%) to IV (6/24; 25.0%) on a Merlin scale. In total, 14 of 24 (58.3%) studies were published in a scientific journal ranked in the first quartile of their subject area. The 24 original articles mainly focused on adverse drug reactions already observed during clinical trials (i.e., idiosyncratic systemic reactions). In conclusion, during the last three decades and a burst was not observed in the Italian clinical research investigating contrast-induced nonrenal adverse drug reactions. High-quality clinical research is needed especially for procedures to prevent the onset of the aforementioned events, to identify risk factors, to minimize the risk of their occurrence, and to optimize their related prognosis.
http://www.jpharmacol.com/currentissue.asp?sabs=y

Fwd: Gujarati hypertensives

Gujarati hypertensives
To:

: A cross-sectional study p. 153
Jayesh Dalpatbhai Solanki, Hemant B Mehta, Sunil J Panjwani, Hirava B Munshi, Chinmay J Shah
DOI:10.4103/jpp.JPP_59_18  
Objective: To study the effect of different classes and combinations of antihypertensive agents on arterial stiffness and central hemodynamic parameters. Materials and Methods: A cross-sectional study was conducted in 446 treated apparently healthy hypertensives. Oscillometric PWA was performed by Mobil-o-Graph (IEM, Germany) to derive cardiovascular parameters that were further analyzed in groups stratified by antihypertensive used. Study parameters were brachial hemodynamics (blood pressure (BP), heart rate, and rate pressure product); arterial stiffness (augmentation pressure, augmentation index, pulse wave velocity, total arterial stiffness, and pulse pressure amplification); and central hemodynamics (central BP, cardiac output, and stroke work). Statistical significance was kept at P < 0.05. Results: All groups were selected by matching of age, gender, and body mass index. They were comparable with major confounding factors. There was no difference between study parameters in hypertensives taking exclusive angiotensin-converting enzyme inhibitor (ACEI), calcium channel blocker (CCB), or angiotensin II receptor blocker. Multitherapy showed better hemodynamics and monotherapy showed better stiffness parameters. Addition of CCB to ACEI did not make a difference except with diastolic BP. For most comparisons, most of the results lacked statistical significance. Conclusion: Discrete PWA parameters showed no class difference in hypertensives, treated by conventional monotherapy or combination, ACEI appears to be the best drug. This also indicates that early diagnosis and blood pressure control are more important than antihypertensive used.
http://www.jpharmacol.com/currentissue.asp?sabs=y

Fwd: Precontrast T1 signal measurements of normal pituitary and microadenoma

The dynamic contrast enhanced magnetic resonance imaging (DCE MRI),Precontrast T1 signal measurements of normal pituitary and microadenoma
To:

:

 A retrospective analysis through DCE MRI signal time curves p. 380
Ishan Kumar, Tanya Yadav, Ashish Verma, Ram C Shukla, Surya K Singh
DOI:10.4103/ijri.IJRI_104_18  
Background: The dynamic contrast enhanced magnetic resonance imaging (DCE MRI) has currently become the most utilized technique for the detection of pituitary microadenoma. However, owing to differential enhancement of normal pituitary, high rate of false positivity remains a concern in its interpretation. Purpose: Our aim was to assess the utility of precontrast T1 signal intensity ratio (SIR) of the lesions suspected on DCE MRI, in prediction of presence of microadenoma. Materials and Methods: We retrospectively reviewed MRI of 23 patients referred for DCE MRI of pituitary (group 1, 15 patients with diagnosis of pituitary microadenoma; and group 2, patients not clinically labeled as microadenoma). STC were plotted and T1-SIR at t = 0 s was obtained at the suspicious zone of differential enhancement (SIR T) and normal pituitary (SIR P). SIR difference (SIR P − SIR T) and relative SIR difference (SIR P − SIR T/SIR P) were calculated for each patient and was compared between the two groups. Results: Mean T1 SIR is lower in patients with microadenoma than those without (P = 0.065). SIR difference and relative SIR difference was higher in patients with microadenoma (P = 0.003 and 0.005, respectively). Receiver-operated characteristic curve analysis demonstrated that a cut-off of 26 and 0.107 for SIR difference and relative SIR difference, respectively, could diagnose microadenoma with 100% specificity and reasonable sensitivities. Conclusion: The baseline precontrast T1 SIR evaluation of the lesion suspected to be microadenoma on DCE MRI, derived through STC curve, can increase diagnostic confidence in diagnosis of microadenoma.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: 3D SPACE sequence and susceptibility weighted imaging in the evaluation of hydrocephalus and treatment-oriented refined classification of hydrocephalus

The evaluation of hydrocephalus : 3D SPACE sequence and susceptibility weighted imaging in the evaluation of hydrocephalus and treatment-oriented refined classification of hydrocephalus

To:

Role of 3D SPACE sequence and susceptibility weighted imaging in the evaluation of hydrocephalus and treatment-oriented refined classification of hydrocephalus p. 385
Amarnath Chellathurai, Komalavalli Subbiah, Barakath Nisha Abdul Ajis, Suhasini Balasubramaniam, Sathyan Gnanasigamani
DOI:10.4103/ijri.IJRI_161_18  

Objective: The aim of our study was to evaluate the diagnostic utility of three-dimensional sampling perfection with application optimized contrast using different flip angle evolution (3D SPACE) sequence and Susceptibility Weighted Imaging (SWI) in hydrocephalus and to propose a refined definition and classification of hydrocephalus with relevance to the selection of treatment option. Materials and Methods: A prospective study of 109 patients with hydrocephalus was performed with magnetic resonance imaging (MRI) brain using standardized institutional sequences along with additional sequences 3D SPACE and SWI. The images were independently read by two senior neuroradiologists and the etiopathogenesis of hydrocephalus was arrived by consensus. Results: With conventional sequences, 46 out of 109 patients of hydrocephalus were diagnosed as obstructive of which 21 patients showed direct signs of obstruction and 25 showed indirect signs. In the remaining 63 patients of communicating hydrocephalus, cause could not be found out in 41 patients. Whereas with 3D SPACE sequence, 88 patients were diagnosed as obstructive hydrocephalus in which all of them showed direct signs of obstruction and 21 patients were diagnosed as communicating hydrocephalus. By including SWI, we found out hemorrhage causing intraventricular obstruction in three patients and hemorrhage at various sites in 24 other patients. With these findings, we have classified the hydrocephalus into communicating and noncommunicating, with latter divided into intraventricular and extraventricular obstruction, which is very well pertaining to the selection of surgical option. Conclusion: We strongly suggest to include 3D SPACE and SWI sequences in the set of routine MRI sequences, as they are powerful diagnostic tools and offer complementary information regarding the precise evaluation of the etiopathogenesis of hydrocephalus and have an effective impact in selecting the mode of management.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: Olfactory fossa depth: CT analysis

Olfactory fossa depth: CT analysis

To:

Olfactory fossa depth: CT analysis of 1200 patients p. 395
Ashok Chirathalattu Babu, Mattavana Ramakrishna Pillai Balachandran Nair, Aneesh Mangalasseril Kuriakose
DOI:10.4103/ijri.IJRI_119_18  

Background: Olfactory fossa (OF) is a depression in anterior cranial cavity whose floor is formed by cribriform plate of ethmoid. Lateral lamella, which forms its lateral boundary, is a thin plate of bone and is at risk of injury during functional endoscopic sinus surgery, especially when fossa is deep/asymmetric. Aims: To measure the variations in the depth of OF and categorize Kerala population as per Keros classification using computed tomography (CT). Settings and Design: This study was conducted in our institution from January 2016 to August 2017. Patients >16 years of age undergoing CT scan of paranasal sinuses (PNS) were included. Materials and Methods: Coronal PNS CT scan studies of 1200 patients were reviewed. The depth of OF was measured from vertical height of lateral lamella. Statistical Methods: Results were analyzed according to gender and laterality using independent sample t-test and Chi-square test. Results: The mean depth of OF was 5.26 ± 1.69 mm. Statistically significant difference was seen in the mean depth of OF between males and females but not between right and left sides. Keros type I was found on 420 sides (17.5%), type II in 1790 (74.6%), and type III on 190 sides (7.9%). Type III Keros was more on the right (9%) than left (6.8%) side, more in males (9.5%) than females (5.9%), and more among males on the right side (11.4%). Asymmetry in OF depth between two sides was seen in 75% of subjects. Conclusion: Prevalence of the dangerous type III OF, even though low, is significant especially among males and on the right side. Therefore, preoperative assessment of OF depth must be done to reduce iatrogenic complications.
http://www.ijri.org/currentissue.asp?sabs=y

Identifying the aetiology of sudden acute abnormal involuntary movements in a primigravid

A 20-year-old primigravid experienced sudden stiffening of the neck, upper and lower extremities and trunk associated with joint pains. She was generally well before hospital admission with no history of attacks, except for her inflammatory bowel disease that was treated more than a year ago. During physical examination, the patient manifested neck flexion deviated to the right, deviation of the eyes downward and to the right, spooning of the upper extremities, exhibition of milkmaid's grip, extension of both lower extremities and jerky speech. She also showed uncontrollable tremors of the neck and occasional flailing of upper extremities. Her preliminary laboratory tests were within normal range. It was worth noting here that her family's medical history was unremarkable. In this article, the process of arriving at the final diagnosis and treatment would be discussed.

https://ift.tt/2T3pzjN

Extrapulmonary tuberculosis: a debilitating and often neglected public health problem

We report a case of a 33-year-old woman from Nepal who presented to a hospital with paraplegia. She was found to have pulmonary tuberculosis (TB) with lumbar spine involvement, and bilateral psoas abscesses. She had no initial symptoms attributable to pulmonary involvement. Her delayed presentation to the hospital led to complication of TB spine, which compromised the life of this woman working as a labourer. Early diagnosis and treatment of extrapulmonary TB is essential. Awareness regarding symptoms of different forms of extrapulmonary TB and making diagnostic modalities such as CT scan, MRI or biopsy readily available through insurance schemes are some important measures to minimise the problem so that complications like paraplegia as in our patient with spinal TB can potentially be avoided.

https://ift.tt/2T3v2XP

Froins syndrome associated with spinal tuberculosis

https://ift.tt/2CpJxzO

Primary cutaneous 'ulcerative tuberculosis of the scrotum: a rare occurrence

Tuberculosis (TB) is a global disease and if not adequately treated can lead to morbidity and mortality. Though genitourinary TB is common and only next to pulmonary TB, cutaneous 'ulcerative' tuberculosis of the scrotum is not reported so far in the literature. We present a 32-year-old man with a non-healing scrotal ulcer and underwent excision. Histopathology was consistent with TB. Antitubercular therapy was given and at the end of a year's follow-up, there has been no recurrence. TB of the scrotum should be considered in the differential diagnosis of scrotal ulcers. Proper diagnosis and adequate treatment will offer a cure to such patients.

https://ift.tt/2T1YJIJ

Where is the orogastric tube going in this preterm neonate?

https://ift.tt/2CpJyDS

Pseudo-Wellens syndrome in pulmonary embolism

Wellens' syndrome is described as characteristic biphasic or symmetrical T-wave inversion with normal precordial R-wave progression and the absence of Q waves in the right precordial leads. It is seen during chest pain-free interval in a subset of patients with unstable angina. Wellens' syndrome is associated with critical stenosis of proximal left anterior descending (LAD) coronary artery. Similar characteristic ECG changes associated with causes other than LAD stenosis have been described as pseudo-Wellens' syndrome. In this case report, we present a young 22-year-old man who presented with characteristic Wellens' ECG changes in the setting of pulmonary embolism with right ventricular strain. T-wave inversion in right precordial leads is a well-recognised ECG manifestation of right ventricular strain; however, biphasic T waves in the setting of pulmonary embolism are rare. Pulmonary embolism was seen in our patient a week after starting risperidone. There is a reported association between antipsychotic drugs and increased risk of thromboembolism. Risperidone could have potentially contributed to the pulmonary embolism in our patient given the temporal association and absence of risk factors.

https://ift.tt/2T1J7Vp

Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): A Multicenter Patient-blinded Randomized Controlled Trial

Objective: This trial followed a structured nationwide training program in minimally invasive distal pancreatectomy (MIDP), according to the IDEAL framework for surgical innovation, and aimed to compare time to functional recovery after minimally invasive and open distal pancreatectomy (ODP). Background: MIDP is increasingly used and may enhance postoperative recovery as compared with ODP, but randomized studies are lacking. Methods: A multicenter patient-blinded randomized controlled superiority trial was performed in 14 centers between April 2015 and March 2017. Adult patients with left-sided pancreatic tumors confined to the pancreas without vascular involvement were randomly assigned (1:1) to undergo MIDP or ODP. Patients were blinded for type of surgery using a large abdominal dressing. The primary endpoint was time to functional recovery. Analysis was by intention to treat. This trial was registered with the Netherlands Trial Register (NTR5689). Results: Time to functional recovery was 4 days [interquartile range (IQR) 3–6) in 51 patients after MIDP versus 6 days (IQR 5–8) in 57 patients after ODP (P

https://ift.tt/2PIhleN

Fwd: Magnetic resonance imaging of ankle ligaments

Magnetic resonance imaging of ankle ligaments
To:

: A pictorial essay p. 419
Yogini Nilkantha Sawant, Darshana Sanghvi
DOI:10.4103/ijri.IJRI_77_16  
Ankle trauma is commonly encountered and is most often a sprain injury affecting the ligaments. Accurate diagnosis and appropriate treatment rest on knowledge of complex ligamentous anatomy of ankle and the entire spectrum of pathologies. Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnosing ligament pathologies because of its multiplanar capability and high soft tissue contrast. With MRI, it is possible to triage and attribute the cause of post traumatic ankle pain to bone, ligament, or tendon pathologies, which otherwise overlap clinically. In this pictorial essay, emphasis is given to the intricate and unique anatomy and orientation of ankle ligaments. Pathologies of ankle ligaments have been elaborated.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: Pulmonary atresia and ventricular septal defect,Coronary artery as the primary source of pulmonary blood flow

Pulmonary atresia and ventricular septal defect,Coronary artery as the primary source of pulmonary blood flow

To:

Collateral or fistula? Coronary artery as the primary source of pulmonary blood flow in a patient with pulmonary atresia and ventricular septal defect p. 433
Anurag Yadav, Salil Bhargava, T B S Buxi, Krishna Sirvi
DOI:10.4103/ijri.IJRI_489_17  
In patients with pulmonary atresia and ventricular septal defect (PA/VSD), a coronary artery being the primary source of pulmonary blood flow is a rare entity. We describe two cases of PA/VSD with coronary-to-pulmonary artery fistula with emphasis on the role of Computed Tomographic Angiography (CTA) in depicting all the sources of pulmonary blood supply, to predict surgical management and need for unifocalization of Major Aortopulmonary Collateral Arteries (MAPCA's).
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: Evaluation of lung transplant perfusion using iodine maps from novel spectral detector computed tomography

Evaluation of lung transplant perfusion using iodine maps from novel spectral detector computed tomography
To:

p. 436
Nils Große Hokamp, Amit Gupta
DOI:10.4103/ijri.IJRI_35_18  
We report the case of a 51-year-old patient who underwent bilateral lung transplantation and presented with an unstable condition and sepsis 6 days after transplantation. The performed contrast enhanced spectral detector computed tomography (CT) using a dual-layer detector showed absence of perfusion in the left lung on iodine maps, although branches of the pulmonary artery were patent. This prompted retrospective evaluation of CT images and total venous occlusion of the left pulmonary veins was found. Here, iodine maps helped in raising conspicuity of loss of lung perfusion.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: The normal pancreatic dimensions in pediatric age groups

The normal pancreatic dimensions in pediatric age groups
To:

Percentile reference curves for normal pancreatic dimensions in Indian children p. 442
Dhanraj S Raut, Dhananjay V Raje, Vithalrao P Dandge, Dinesh Singh
DOI:10.4103/ijri.IJRI_189_18  
Objectives: This study aims at determining the normal pancreatic dimensions in pediatric age groups considering demographic parameters and thus developing percentile reference curves for normal pancreatic dimensions in Indian children. Setting and Design: It is a cross-sectional study. Materials and Methods: A hospital-based cross-sectional study was planned at a children hospital during July 2016–December 2017, in which the pancreatic dimensions of 1078 normal children in the age range of 1 month to 19 years were obtained through abdominal ultrasonography (USG). The demographic details like age and gender were obtained for each child. Statistical Analysis Used: Percentile reference curves were obtained with reference to age for each gender type independently. Generalized additive models for location, scale, and shape were used to obtain percentile plots for each pancreatic part. Results: The mean age of children was 6.65 ± 4.43 years and the male-to-female ratio was 1.63:1. The head, body, and tail dimensions increased with the age. For head, up to 25th percentile, the curves were similar for both genders, while subsequent curves were higher in males as compared to females. Similar was the observation for body of pancreas. For tail, up to 75th percentile, the curves were similar for both genders. Conclusion: The normal ranges can be supportive in diagnosis of illness related to pancreas. The dimensions within 5–95th percentile along with iso-echogenicity can be regarded as normal, while the dimensions beyond these limits along with change of echogenicity can be suspected for pancreatic disorders.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: Secretory carcinoma (juvenile carcinoma) is one of the very rare breast malignancy reported to be prevalent in pediatric age group

Secretory carcinoma (juvenile carcinoma) is one of the very rare breast malignancy reported to be prevalent in pediatric age group

To:

Clinicoradiologicial aspects of secretory carcinoma breast: A rare pediatric breast malignancy p. 448
Aanchal Bhayana, Ritu N Misra, Sunil K Bajaj, Himani Bankhar
DOI:10.4103/ijri.IJRI_46_18  
Secretory carcinoma (juvenile carcinoma) is one of the very rare breast malignancy reported to be prevalent in pediatric age group. We report imaging and clinicopathological features of secretory carcinoma breast with distant and axillary metastasis, in an 11-year-old girl, who presented with a painful lump in right breast. Ultrasound revealed a well-defined, partially microlobulated hypoechoic mass with skin and pectoralis muscle involvement and a suspicious morphology right axillary lymph node. Color Doppler revealed increased vascularity in both the breast mass and suspicious axillary node. Magnetic resonance imaging helped in better evaluation of pectoralis muscle involvement. Computed tomography (CT) neck, chest, and abdomen revealed multiple fibronodular opacities in bilateral lung fields. 18 Flouro-Deoxy-Glucose Positron Emission Tomography (FDG PET-CT) showed a hypermetabolic retroareolar breast mass with multiple hypermetabolic bilateral lung nodules suggesting lung metastasis. The histopathology confirmed the diagnosis of secretory carcinoma. The patient was offered chemotherapy for 2 years and put on follow-up since then.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: Vertebral or vascular anomalies, anal atresia, cardiac defects, tracheoesophageal – fistula/esophageal atresia, renal defects, and limbs defects

Vertebral or vascular anomalies, anal atresia, cardiac defects, tracheoesophageal – fistula/esophageal atresia, renal defects, and limbs defects

To:

VACTERL association – Ultrasound findings and autopsy correlation p. 452
Naman Kumar Gaur, Sudheer Gokhale
DOI:10.4103/ijri.IJRI_115_18  
VACTERL (vertebral, anal, cardiac, tracheoesophagus, renal, and limbs) is an abbreviation for the congenital group of abnormalities, including vertebral or vascular anomalies, anal atresia, cardiac defects, tracheoesophageal – fistula/esophageal atresia, renal defects, and limbs defects. It is a rare association and not accidental event where several organs are affected by developmental defects during blastogenesis. The exact cause is unknown; however, several environmental and genetic factors are included in literature. Three components out of seven are used to label as VACTERL. The combination is necessary, but the patient may have other congenital malformations as well. We present here an antenatal scan with autopsy correlation of one of the forms of VACTERL association spectrum.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: Preoperative differentiation of benign from malignant thyroid nodules,Diffusion-weighted imaging (DWI) is highly accurate for discrimination between benign and malignant thyroid nodules.

Preoperative differentiation of benign from malignant thyroid nodules,Diffusion-weighted imaging (DWI) is highly accurate for discrimination between benign and malignant thyroid nodules.

To:

Differentiation between benign and malignant thyroid nodules using diffusion-weighted imaging, a 3-T MRI study p. 460
Leila Aghaghazvini, Hashem Sharifian, Nasrin Yazdani, Melina Hosseiny, Saina Kooraki, Pirouz Pirouzi, Afsoon Ghadiri, Madjid Shakiba, Soheil Kooraki
DOI:10.4103/ijri.IJRI_488_17  
Background: Preoperative differentiation of benign from malignant thyroid nodules remains a challenge. Aims: This study assessed the accuracy of diffusion-weighted imaging (DWI) for differentiation between benign and malignant thyroid nodules. Materials and Methods: Preoperative DWI was performed in patients with thyroid nodule by means of a 3-T scanner magnetic resonance imaging (MRI). Images were obtained at b value of 50, 500, and 1000 mm2/s to draw an ADC (apparent diffusion coefficient) map. Findings were compared with postoperative histopathologic results. Receiver operating characteristic curve was used to assess the accuracy of different cutoff points. Results: Forty-one thyroid nodules (26 benign and 15 malignant) were included in this study. None of static MRI parameters such as signal intensity, heterogeneity, and nodule border was useful to discriminate between benign and malignant lesions. Mean ADC value was (1.94 ± 0.54) × 10-3 mm2/s and (0.89 ± 0.29) × 10-3 mm2/s in benign and malignant nodules, respectively (P-value < 0.005). ADC value cutoff of 1 × 10-3 mm2/s yielded an accuracy, sensitivity, and specificity of 93%, 87%, and 96% to discriminate benign and malignant nodules. Conclusion: DWI is highly accurate for discrimination between benign and malignant thyroid nodules.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: Normal adrenal gland thickness on computerized tomography

Normal adrenal gland thickness on computerized tomography

To:

 in an Asian Indian adult population p. 465
Reetu John, Tharani Putta, Betty Simon, Anu Eapen, Felix Jebasingh, Nihal Thomas, Simon Rajaratnam
DOI:10.4103/ijri.IJRI_129_18  

Context: The size and morphology of the adrenal glands are affected by several physiological and pathological conditions. Radiologists need to be aware of the normal thickness of adrenal gland to accurately assess patients with suspected adrenal pathology. However, there is limited data on the normal size of the adrenal glands. Moreover, this has not been studied in our population. Aims: To study the normal thickness of adrenal gland on computerized tomography (CT) in Indian adult population. Settings and Design: Retrospective study in a tertiary care hospital in Southern India. Subjects and Methods: Our study included 586 adults who underwent a CT abdominal angiogram over 15 months, and excluding patients with clinical or imaging evidence of adrenal disease. The measurements made included: the maximum thickness of the body, medial and lateral limbs, measured perpendicular to the long axis. Results: The median age was 51 (range: 18–85) years. The mean maximum thickness of the adrenal body, medial, and lateral limbs were 7.2 ± 1.8, 4.1 ± 1.1, and 4.3 ± 1.1 mm on the right side and 8.8 ± 1.9, 4.7 ± 1.1, and 4.9 ± 1.3 mm on the left. The cumulative thickness of the body and the limbs were 15.6 ± 3.7 mm and 18.4 ± 3.8 mm on the right and left sides, respectively. There was a statistically significant difference in all the measurements between the right and left adrenal glands (all P values = 0.000) and between men and women, being larger in men (P value <0.05). Among our patients 27% had at least one adrenal gland body measuring ≥10 mm in thickness. Conclusions: Our study has defined the normal range of adrenal gland thickness in an Asian Indian adult population, which may be used as a baseline reference for future research and as a reference for radiological reporting.
http://www.ijri.org/currentissue.asp?sabs=y

Fwd: Metastases to the breast from extramammary malignancies

Metastases to the breast from extramammary malignancies
To:

 p. 470
Tanvi Vaidya, Subhash Ramani, Ashita Rastogi
DOI:10.4103/ijri.IJRI_218_18  
Metastases to the breast from extra-mammary malignancies are extremely uncommon. The discovery of a breast mass in a patient with a known primary tumor elsewhere poses a diagnostic challenge to the clinician. An awareness of the various malignancies that can metastasize to the breast and accurate diagnosis of the same is essential to avoid an unnecessary mastectomy and to guide further therapy. In this case series, we describe such clinical scenarios with an emphasis on the imaging features of metastases to the breast, which will enable radiologists to recognize this entity with greater ease.
http://www.ijri.org/currentissue.asp?sabs=y

Metastases to the breast from extra-mammary malignancies are extremely uncommon, with a prevalence ranging from 1.7% to 6.6%.^[1] The most common sources of metastases to the breast are lymphomas/leukemias and melanomas. Rare primary tumors to metastasize to the breast include carcinomas of the lung, ovary, and stomach, and even more uncommonly carcinoid tumors, hypernephromas, carcinomas of the liver, tonsil, pleura, pancreas, cervix, endometrium, and bladder. The dissemination occurs via both hematogenous and lymphatic routes.^[1],[2]

The discovery of a breast mass in a patient with a known primary tumor elsewhere or with a previous history of cancer at another site poses a diagnostic challenge to the clinician. An awareness of the various malignancies that can metastasize to the breast and accurate diagnosis of the same is essential in order to avoid an unnecessary mastectomy and to guide further therapy.

In this article, we present six cases of metastases to the breast, in patients with a primary extramammary malignancy. Metastases in these primary tumors are exceedingly rare, and hence, this case series would serve as a valuable addition to the existing literature. In addition, we present a review on the subject with an emphasis on imaging findings.

Case 1

A 40-year-old lady presented with menorrhagia for about 8 months. She underwent a contrast-enhanced CT scan of the abdomen and pelvis, which revealed a heterogeneously enhancing myometrial mass, with atypical imaging features [Figure 1]A. There was no evidence of distant metastases on cross-sectional imaging. The patient underwent a total hysterectomy with a bilateral salpingo-oophorectomy. Histopathological evaluation of the myometrial mass revealed an intermediate grade leiomyosarcoma (Immunohistochemistry IHC – Mib labeling index of 50%). Thereafter, she presented with a lump in the right breast, progressively increasing in size over a period of 6 months.

Figure 1 (A-D): (A) Coronal sections of contrast-enhanced CT pelvis images showing a heterogeneously enhancing mass involving the myometrium of the uterine fundus (red arrows). (C and D) Right mammogram (extended CC view (C) and MLO view (D)) showing a well-circumscribed isodense mass in the upper outer quadrant of the right breast (red asterisk). (B) Ultrasonography image showing a well-defined, round hypoechoic mass at the 10 o'clock position in the right breast Click here to view

Mammography revealed the presence of a well-circumscribed isodense mass in the upper outer quadrant of the right breast [Figure 1]C and [Figure 1]D. Breast ultrasonography demonstrated a well-defined solid, hypoechoic mass with mild posterior acoustic enhancement, at the site of palpable abnormality [Figure 1]B. A core biopsy of the lesion revealed a spindle cell tumor exhibiting focally moderate to marked nuclear atypia. On IHC, tumor cells were positive for smooth muscle actin, desmin, H-caldesmon and showed a high Mib-1 count. The histopathology report was conclusive for leiomyosarcoma in the clinical context. A contrast-enhanced CT abdomen scan was subsequently done which revealed a metastatic lesion in the liver and a retroperitoneal metastatic nodal mass. Thereafter, the patient received palliative chemotherapy for 2 years but did not survive.

Case 2

A 31-year-old lady, with poorly differentiated adenocarcinoma of the stomach (stage T3N2M0), underwent a radical gastrectomy. She was receiving adjuvant chemo-radiotherapy (CT-RT) during which she developed abdominal distention, along with diffuse pain in the left breast with redness of the overlying skin over a period of 1 month. A contrast-enhanced CT scan of the thorax and abdomen with a mammogram was performed. Contrast-enhanced CT of the thorax and abdomen revealed ill-defined enhancement in the left breast [Figure 2]A.

Figure 2 (A-C): (A) Axial sections of contrast-enhanced CT thorax images showing diffuse ill-defined enhancement in the left breast (red arrows). (B) Bilateral mammograms (CC view) showing a diffuse increase in density in the left breast (red arrows), with thickening of the overlying skin and the nipple–areola complex (red asterisks). (C) Ultrasonography image showing an ill-defined hypoechoic lesion replacing the fibro-glandular parenchyma of the left breast (red asterisk) Click here to view

Mammography revealed a diffuse increase in density involving the left breast, with thickening of the overlying skin and the nipple–areola complex [Figure 2]B. Breast ultrasonography demonstrated an ill-defined hypoechoic lesion replacing the fibro-glandular parenchyma [Figure 2]C. A left breast core biopsy revealed poorly differentiated carcinoma with signet ring cell morphology. Immunohistochemistry revealed positivity for CK 7, ER, CDX2, CK 20, and GCDFP, which was consistent with metastasis from carcinoma stomach. Contrast-enhanced CT abdomen revealed ascites with peritoneal metastases. The patient is being treated with palliative chemotherapy since then, with stable disease.

Case 3

A 37-year-old lady, with carcinoma cervix (stage IIIa) receiving concomitant chemoradiation and brachytherapy for the same, developed a lump in the left breast, gradually increasing over a period of 3 months. A mammogram and a screening ultrasonography of the abdomen were performed.

Mammography revealed a well-circumscribed, isodense mass in the upper central region of the left breast [Figure 3]A and [Figure 3]B. A breast ultrasound revealed a predominantly hypoechoic lesion in the upper central region showing mild internal vascularity [Figure 3]C. Fine-needle aspiration of the lesion revealed clusters of squamous epithelial cells, consistent with metastasis from cervical carcinoma. An ultrasound of the abdomen revealed evidence of liver metastases. The patient was put on palliative chemotherapy, is now being followed up annually.

Figure 3 (A-C): (A and B) Bilateral mammograms (MLO view (A) and CC view (B)) showing a well-circumscribed, isodense mass in the upper central region of the left breast (red arrows). (C) Ultrasonography image showing a well-defined hypoechoic lesion at the 12 o'clock position in the left breast (red asterisk) Click here to view

Case 4

A 16-year-old girl, with Ewing's sarcoma of the left ninth rib being treated with chemotherapy, presented with a slow growing lump in the left breast. About 3 months after commencement of therapy, a contrast-enhanced CT of the thorax was performed for monitoring disease response. The CT revealed a heterogeneously enhancing mass involving the left ninth rib causing bony destruction with intrathoracic extension. In addition, an irregular heterogeneously enhancing mass with central necrosis was also seen incidentally in the left breast. Bilateral pleural effusion was seen [Figure 4]A,[Figure 4]B,[Figure 4]C. A breast ultrasound revealed a predominantly hypoechoic mass with irregular margins in the upper central region [Figure 4]D. A fine-needle aspiration cytology study of the left breast mass revealed cytologic features of PNET (Primitive neuro-ectodermal tumor)/Ewing's sarcoma with positivity for CD99, consistent with metastases from the primary. The patient was treated with systemic chemotherapy and received radiotherapy to the breast. This regimen yielded a good response to therapy with a decrease in disease burden.

Figure 4 (A-D): (A) Axial contrast-enhanced CT image of the thorax showing a heterogeneously enhancing mass with irregular margins in the left breast (yellow arrow). Incidentally seen is bilateral pleural effusion. (B) Sagittal contrast-enhanced CT image of the thorax showing a heterogeneously enhancing soft tissue with erosion of the left ninth rib (red arrow). A heterogeneously enhancing mass with irregular margins is seen in the left breast (yellow arrow). (C) Coronal bone window sections of the thorax showing permeative destruction of the left ninth rib (red arrow). (D) Ultrasonography image showing a heterogeneous mass with irregular margins in the left breast Click here to view

Case 5

A 28-year-old girl, operated for mucinous adenocarcinoma of the rectum, presented with recurrence at the anastomotic site, a year after the surgery. She also presented with a lump in the left breast, increasing in size over a period of 4 months. Mammography revealed high-density masses with partially obscured margins containing coarse calcifications in the upper outer quadrant of the left breast [Figure 5]A, [Figure 5]B. A targeted ultrasound revealed hypoechoic masses with irregular margins and calcifications within, showing posterior acoustic shadowing [Figure 5]C and [Figure 5]D. A core biopsy with IHC revealed features of metastases from mucinous adenocarcinoma, positive for CK20 and negative for CK7. The patient was then treated with palliative chemotherapy but was lost to follow-up.

Figure 5 (A-D): (A and B) Left mammogram ((A) CC view and (B) MLO view) showing high-density masses (red arrows) with partially obscured margins containing coarse calcifications (yellow arrows and yellow asterisk) in the upper outer quadrant of the left breast. (C and D) Ultrasound images showing hypoechoic masses with irregular margins and coarse calcifications within, showing posterior acoustic shadowing (red arrow) at the 2 o'clock position in the left breast Click here to view

Case 6

A 47-year-old lady presented with a history of nasal obstruction, worsening over a period of 6 months associated with mild proptosis of the right eye. A contrast-enhanced CT of the paranasal sinuses revealed an enhancing soft tissue in the right maxillary sinus and nasal cavity causing bony erosion with orbital extension [Figure 6]A. Histopathologic examination of the tissue revealed Non-Hodgkin's lymphoma (NHL) of the diffuse large B-cell type. She received six cycles of chemotherapy for the same. During the course of treatment, she developed painless lumps in bilateral breasts. Mammography revealed multiple well-circumscribed high-density masses involving all quadrants of bilateral breasts [Figure 6]B and [Figure 6]C. Ultrasonography revealed multiple hypoechoic masses with irregular margins showing posterior acoustic shadowing [Figure 6]D. A core biopsy with IHC revealed B-cell type of NHL, positive for CD20, consistent with metastases. The chemotherapy regimen was modified. However, the patient died of fungal pneumonia after 6 months.

Figure 6 (A-D): (A) Contrast-enhanced coronal CT image of the paranasal sinuses showing an enhancing soft tissue (red asterisk) in the right maxillary sinus extending to the ethmoidal sinuses and nasal cavity causing bony erosion with orbital extension. (B and C) Bilateral mammograms ((B) MLO view and (C) CC view) showing multiple well-circumscribed high-density masses involving all quadrants of bilateral breasts (red asterisks). (D) Ultrasonography images showing darkly hypoechoic masses with indistinct margins (yellow asterisks) Click here to view

Discussion

The presence of a breast lesion in any patient with a known primary tumor elsewhere poses a diagnostic challenge to the clinician. The diagnostic approach first involves the differentiation of benign and malignant lesions, and if malignant, it is essential to know whether the lesion is primary or secondary since the treatment and prognosis differ greatly according to the nature of the lesion. Because of the rarity and unusual clinico-pathologic characteristics of breast metastases, it can be difficult to make an adequate diagnosis clinically and histologically.^[1] This is particularly true if the breast abnormality is the first presentation of unknown extramammary primary cancers metastatic to the breast.^[1],[2]

Metastases to the breast may occur years after the diagnosis of a primary cancer.^[2] Clinical differentiation from a primary carcinoma is challenging as majority of metastases present as rapidly growing, painless, palpable, firm breast masses.^[2] Radiology may play a critical role in aiding the diagnosis of metastatic breast disease. On mammography, metastases generally present as one or more well-circumscribed masses,^[3] commonly located in the upper outer quadrants without spiculations, calcifications, and features of desmoplastic reaction that characterizes majority of primary carcinomas.^[3],[4] Exceptions do occur, such as cases of mucinous adenocarcinomas of the rectum, as described in this article or metastatic ovarian carcinomas, in which metastatic lesions to the breast may reveal calcifications.^[5]Diffuseparenchymal involvement mimicking inflammatory carcinoma can be seen rarely, which was seen in the case of metastatic stomach cancer that we encountered. A similar pattern has been described in a previously described case series, in which metastatic stomach cancer presented with diffuse parenchymal infiltration instead of a discrete mass.^[3]

Ultrasonographic appearance of metastases may reveal solitary or multiple lesions, predominantly round or oval, with hypoechoic and solid echo patterns, with usually well-defined posterior margins. Multiple lesions are known to present with similar imaging findings.^[3],[4] On ultrasound, hematogenous metastases tend to have circumscribed margins without spiculations, calcifications, architectural distortion, or posterior acoustic shadowing.^[6] Lymphangitic metastases however manifest as diffuse skin and trabecular thickening because of obstruction of draining lymphatics.^[6] On ultrasonography, metastases to the breast are usually seen in the subcutaneous tissue, as noted in most of our cases or immediately adjacent to the parenchyma.

The primary sources of breast metastases in our case series were leiomyosarcoma, gastric carcinoma, Ewing's sarcoma, cervical carcinoma, colorectal carcinoma, and NHL.

The mammographic features of metastatic leiomyosarcoma to the breast, in our case, were similar to the one reported by Vizcaino et al.^[7] Both cases presented as discrete, well-circumscribed masses, though our patient had a single deposit and Vizcaino et al. reported multiple deposits.^[7]Two other cases of metastases from a primary leiomyosarcoma have been reported in literature;^[8],[9] however, the uterine origin of these deposits has not been documented.

Metastatic gastric adenocarcinoma to the breast has been reported to have variable imaging features. The case reported by Qureshi et al. did not present with suspicious imaging features and was diagnosed purely on histopathology.^[10] In the case reported by Cavazzini et al., the clinical features were similar to the ones reported by us; however, the imaging features differed. They reported an irregular poorly defined mass without calcifications, whereas our patient presented with a diffuse increase in parenchymal density with thickening of the nipple–areola complex.^[11]Kwak et al. reported two cases of metastatic signet ring cell carcinoma with increased parenchymal density on mammography mimicking inflammatory breast carcinoma, similar to our case; however, the organ of origin was not confirmed.^[12]

Vergier et al. reported a case of metastasis to the breast in a patient of epidermoid cervical carcinoma; however, the metastatic deposit in their case was found to have spiculated margins.^[13] Rarely, metastasis from cervical carcinoma may mimic an inflammatory breast cancer as reported by Ward et al.^[14] The imaging features in our case differed from both of these as the deposit in our case was a discrete, well-circumscribed mass.

Mihai et al. reported a case of breast metastasis suspected to be from a primary rectal carcinoma with imaging features not characteristic for malignancy, appearing as a well-defined mass on mammography; however, the organ of origin could not be confirmed.^[15] Li et al. and Zhang et al. reported cases of poorly differentiated adenocarcinoma of the rectum with metastasis to the breast presenting as an indistinctly marginated mass.^[16],[17] Ahmad et al. reported metastases to the breast from well-differentiated colo-rectal adenocarcinoma presenting as a partially well-defined nodule with intermediate type of microcalcifications on mammography, which suggested suspicious morphology favoring primary breast carcinoma; however, it later turned out to be metastatic deposit from a colo-rectal primary.^[18] Our case differed from the above cases as we encountered an extremely rare form of metastasis presenting with coarse calcifications, which differed from all of these.

Very few cases of metastases to the breast from Ewing' sarcoma have been documented. Örgüç et al. have reported a case of breast metastasis from Ewing's sarcoma of the right iliac bone in a 12-year-old girl, with imaging features similar to ours.^[19]

NHL of the breast is an extremely rare occurrence, accounting for about 0.5% of all breast malignancies and 1% of NHL,^[20],[21] and usually manifests as a secondary disease (i.e., in association with extramammary NHL).^[21] Surov et al. studied the imaging features of breast lymphoma in 36 patients. The most common mammographic finding in their study was multiple intramammary masses with circumscribed or microlobulated margins, similar to our case.^[21] The ultrasound features were also identical to ours, with most lesions appearing as hypoechoic, oval, or round masses with circumscribed margins. In the study by Yang et al., most cases of breast lymphoma however presented with a solitary breast mass with indistinct or irregular margins on mammography and ultrasound, which differed from the findings in our study.^[22]

In conclusion, our case series provides an overview of unusual cases of metastases to the breast from various extramammary malignancies. The occurrence of a breast mass in a patient with a known primary must be approached with caution, and the possibility of metastasis must be excluded, as the disease prognosis and course of management can be ascertained only after this distinction is made.