A Case Report of Skip Lesions in Perianal Mucinous Adenocarcinoma

Perianal Mucinous Adenocarcinoma (PMA) is a rare gastrointestinal malignancy, known to occur in patients with a long-standing history of recurrent perirectal abscesses or a chronic fistula. In this case report, we present a unique presentation of perianal mucinous adenocarcinoma, which began as a rectal abscess and progressed to a case of perianal mucinous adenocarcinoma, with a skip lesion present all the way up in the mid-rectal region. To the best of our knowledge, this is the first case in which PMA presented with skip lesions as opposed to a continuous lesion, and presented without a long standing history of fistulas and recurrent abscesses, but instead just a 4-day history of perianal burning, itching and tingling. The use of CT imaging, MRI’s and PET scans as diagnostic modalities for PMA are further elucidated in the report, along with a discussion of NCCN guidelines on using radiation therapy followed by an APR with inguinal node dissection for the management and treatment of PMA. Sharing this unique and atypical presentation of PMA with multimodality speciality groups and tumor boards helps in the development of various diagnostic and therapeutic approaches for PMA, as well as enhances our understanding of this rare malignant entity.

Panuveitis in a patient with active Crohn’s disease

A 14-year-old girl presented to the ophthalmology clinic with progressive diminution of vision, redness, pain and photophobia in both eyes for the last 1 month. She had abdominal pain, diarrhoea and weight loss during that period. Ocular examination revealed features of anterior uveitis, vitritis and retinal vasculitis. In view of gastrointestinal symptoms, abdominal imaging was done, which showed multiple enhancing bowel wall thickening with skip lesions in the terminal ileum and ascending colon. Colonoscopy showed ulcers in the ascending colon, caecum and terminal ileum. Histopathology revealed microgranulomas in lamina propria and submucosal granulomas suggestive of Crohn’s disease. The patient was started on topical steroid eye drops and oral budesonide and mesalazine. Her vision improved after 3 weeks and bowel symptoms attained remission after 8 weeks, and at present, she is doing well.

Skip Segment Hirschsprung Disease Managed by Pull-Through of the Right Colon

Hirschsprung disease is the most common neurocristopathy in children, resulting in the congenital loss of enteric ganglia. Rare reports of skip lesions have previously been reported in the literature. We present a case of skip lesions known prior to surgery and managed by pull-through of the right colon that allowed the preservation of the colon.

Magnetic Resonance Imaging Evaluation of Spinal Infections

Background: The advantage of Magnetic resonance imaging include multiplanar capabilities and soft-tissue contrast resolution, which is superior to that of CT. Magnetic resonance (MR) imaging is a powerful diagnostic tool that can be used to help evaluate spinal infection and to help distinguish between an infection and other clinical conditions. Aim of the current study is to evaluate various spectrum and types of spinal infections, and discussing the role of MRI in diagnosing them and their characterization. Subjects & Methods: This Hospital-based prospective study consists 30 patients with clinically suspected spinal infections and chronic non-resolving low backache referred to the department of Radiodiagnosis in a period of 2 years. Investigations include Complete blood count, ESR, sputum analysis for acid-fast bacilli and MRI of the spine. Results: 20 cases involved the lumbar spine, of which 12 were tubercular, seven were pyogenic, and one case was actinomycosis. In total 21 tubercular cases, 12 cases involved lumbar spine (57%), 8 cases affects the thoracic spine (38%), and 1 case involves the cervical spine (P = 0.562). the incidence of spondylodiscitis is common overall in the lumbar spine. 23.8% of tubercular and 12.5 %of pyogenic cases involved more than two vertebrae. T1 hypointensity is seen in 18 cases of tuberculosis (85%), 8 cases of pyogenic (75%), and 1 case of actinomycosis (100%) (P = 0.801). 4 cases showed preservation of disc height, among which three are tubercular (75%), and 1 was actinomycosis (25%). 85 % of tubercular and 100% of pyogenic cases showed disc narrowing. 81 % of tubercular and 100 % of pyogenic cases showed disc hyperintensity. Nine cases of tuberculosis (42.9%) and 3 cases of pyogenic (37.5 %) showed epidural abscess. 26 cases showed para vertebral extension of which 18 were tubercular (69.2 %), 7 were pyogenic (26.9 %) and 1 was actinomycosis (3.8 %). 94% of tubercular and 42 % of pyogenic abscesses showed a well-defined para spinal signal in cases of paraspinal extension. 15 of the 18(83%) tuberculosis, 3 of the 7 (42%)cases of pyogenic, and 1 case of actinomycosis showed subligamentous spread along more than three vertebrae. Heterogenous enhancement was noted in 12 of the 15 (80%) tubercular cases, 1 of the 3 (33%) pyogenic cases, and 1(100%) actinomycosis case. 71% tubercular cases and 2 of 8 (25%) cases showed predominant anterior 2/3rd involvement. Grade III or more (>50%) vertebral destruction was seen in 16 tubercular (76%) and 2 pyogenic cases (25%). Six cases showed skip lesions of which 5were tubercular and 1 was pyogenic. 5 of the 21 (23.8%) tubercular and 1 of the 8 (12.5%) pyogenic cases showed skip lesions. Conclusion: Awareness of atypical MR imaging at early infectious spondylitis is important to avoid diagnostic delay and unnecessary other diagnostic procedures. Several non-infectious conditions may simulate the spinal infections. Hence It is helpful to be aware of these diseases and their MR imaging features. With these points in mind, MR imaging can be very beneficial to patients with spinal infection.

FRI0213 ASSOCIATION BETWEEN SPECIMEN LENGTH AND NUMBER OF SECTIONS AND DIAGNOSTIC YIELD OF TEMPORAL ARTERY BIOPSY: A RETROSPECTIVE, SINGLE CENTER EXPERIENCE OVER A 21 YEARS’ PERIOD

Background:Temporal artery biopsy (TAB) showing inflammation is considered the gold standard for the diagnosis of giant cell arteritis (GCA). However, sampling error may lead to a negative TAB, and a negative TAB does not rule out GCA. The diagnostic sensitivity of TAB can be affected by the discontinuous character of the histopathologic changes (skip lesions) and by the length of specimens. The optimal TAB length and the optimal number of sections that need to be evaluated in order to avoid missing skip lesions are controversial.Objectives:To investigate the association between specimen length and number of section and the diagnostic yield of TAB for GCA.Methods:A pathologist with expertise in vasculitis and blinded to clinical data and final diagnosis reviewed all TABs performed for suspected GCA at our hospital between January 1991 and December 2012. The biopsies were routinely fixed in formalin and completely embedded in paraffin. Sections of 4 microns thickness were cut from paraffin blocks and stained with hematoxylin-eosin. TABs were classified into three categories: inadequate, when the biopsy did not sample the muscular artery; negative when the temporal artery was devoid of inflammation and positive when the temporal artery showed inflammation, arbitrarily defined as at least 1 aggregate of at least 15 inflammatory cells. The blocks of all the inadequate and negative biopsies were recut, and at least three further slides at deeper levels were stained with hematoxylin-eosin.Results:694 TABs were performed in the study period and were reviewed. 32 (4.6%) were classified as inadequate and were excluded from the analysis. Of the remaining 662 TABs [71% female; mean (SD) age, 73.2 (8.8) years], mean (SD) post fixation length was 6.63 (4.42) mm, and median number of sections evaluated was 3 (range 1-33). 382 (58%) TABs were classified as negative and 280 (42%) as positive. Compared with negative TAB, patients with positive TAB were older [mean age (SD) 74 (7.5) years vs 72 (9.6), p=0.009] and there was a trend for female predominance (75% vs 68%, p=0.077). Post fixation length of the specimens was significantly lower in negative compared with positive TAB [mean (SD) 6.37 (4.26) mm vs 6.99 (4.61) respectively, p=0.026]. Piecewise logistic regression identified 5 mm as the TAB length change point for diagnostic sensitivity. Compared with TAB length of <5 mm, age- and sex-adjusted odds ratio for positive TAB in samples ≥5 mm long were 1.536 (95% confidence interval, 1.108 to 2.130).The median (IQR) number of sections evaluated were 2 (1-3) for positive TAB and 4 (2-5) for negative TAB, p<0.0001. In 26/280 (9.3%) positive TABs, the first section was negative, and the inflammation was detected only in deeper sections (the positive section was the second in 14 TABs, the third in 9 and the fourth in 3). In all 26 cases, inflammation detected in deeper section was not transmural, but limited to adventitial or periadventitial small vessels.Conclusion:Our data confirm that a post fixation TAB length of at least 5 mm should be sufficient to make a histological diagnosis of inflamed temporal artery. According to our data, in order to avoid missing skip inflammatory lesions, at least 3 further sections at deeper levels should be cut and evaluated in all negative TABs.Disclosure of Interests:None declared

Malignant Osteoid Matrix Bone Tumors

Chapter 53 discusses malignant osteoid matrix bone tumors and focuses on several types of osteosarcoma, ranging from the most common, conventional osteosarcoma, to secondary osteosarcomas, such as Paget and postradiation sarcomas. Osteosarcoma is the most common primary bone tumor in children and adolescents, and second most frequent primary malignant bone tumor if all age groups are considered. A short discussion on typical radiologic findings with classic examples of various types of osteosarcoma is included. Conventional radiographs show an aggressive lesion with permeative bone destruction, extraosseous soft tissue mass and cortical disruption with periosteal reaction. MRI is useful for assessing tumor extent and skip lesions. Treatment includes surgery and chemotherapy.

FM1-4 Intraneural perineuriomas: radiologically classic, clinically varied

ObjectivesIntraneural perineurioma is a rare, benign neoplasm of peripheral nerve. The histopathological features are well defined.DesignWe describe 5 cases of histologically confirmed perineuriomas and 14 cases diagnosed on clinical and radiological characteristics to highlight the features of this rare entity.MethodsWe identified cases from the imaging and histopathology database and conducted a retrospective case note review.ResultsThe subjects include 7 men and 12 women, with mean (standard deviation) age of 17.64 (13) years at onset of symptoms. 14 of the 15 lower limb cases were located in the sciatic nerve or its divisions. 1 each was identified in ulnar, median and radial nerves and 1 case was in a facial nerve. The MRI features were homogenous between the groups. The nerves biopsied included 1 tibial, 1 ulnar, 1 radial, 1 facial and 1 sciatic all showing classic pathology findings. 2 patients, interestingly, had coincidental intracranial meningioma, given the recent discovery of a potential shared pathogenesis (mutations in TRAF7) with intracranial meningiomas. 2 patients had ‘skip lesions’ within the same nerve and 3 patients had foraminal and extraforaminal involvement of lumbosacral nerve roots.ConclusionsOur unit now favours the clinicoradiological features for diagnosing perineuriomas rather than performing a biopsy on all patients. Also, the potential shared pathogenesis with meningiomas raises the clinical issue of screening in patients with perineuriomas but more clinical evidence is required.