Prognosis of Single Early-Stage Hepatocellular Carcinoma (HCC) with CEUS Inconclusive Imaging (LI-RADS LR-3 and LR-4) Is No Better than Typical HCC (LR-5)

The American College of Radiology (ACR) released the Liver Imaging Report and Data System (LI-RADS) scheme, which categorizes hepatic nodules in risk classes from LR-1 to LR-5 (according to the degree of risk to be HCC) and LR-M (probable malignancy not specific for HCC). The aim of this study was to test whether HCC with different LR patterns on CEUS have different overall survival (OS) and recurrence-free survival (RFS). We retrospectively enrolled 167 patients with the first definitive diagnosis of single HCC (by using CT/MRI or histological techniques if CT/MRI were inconclusive) for whom CEUS examination was available. The median size of HCC lesions was 2.2 cm (range 1.0–7.2 cm). According to CEUS LI-RADS classification, 28 patients were in LR-3, 48 in LR-4, 83 in LR-5, and 8 in LR-M. Patient liver function and nodule characteristics were not statistically different between CEUS LI-RADS classes. Using univariate analysis, CEUS LI-RADS class was not found to be a predictor of survival (p = 0.347). In conclusion, HCC showing the CEUS LI-RADS classes LR-3 and LR-4 have no better clinical outcome than typical HCC. Such data support the EASL policy, aimed at conclusive diagnostic investigations of indeterminate nodules up to obtaining histological proof to avoid leaving aggressive HCC not timely treated.

Painful catamenial vulvar lesions misleading gynecologist

Endometriosis usually presents as cyclical pain in the pelvis but may also present as painful cutaneous lesions. Many diseases may mimic hidradenitis suppurativa (HS) since HS, a chronic inflammatory painful skin disease, is a clinical diagnosis. A 32-year-old woman presented with painful lumps on her vulva and groin accompanied with bloody discharge during menstruation. She was followed up with preliminary diagnosis of endometriosis. Previous excision without definitive diagnosis resulted in temporary relief. She was prescribed oral contraceptive pills that alleviated her symptoms but quitted due to headache. Surgical excision was performed for definitive diagnosis and therapeutic relief. Pathology report revealed HS. She was prescribed oral doxycycline. She responded well to the therapy and has symptom-free for the last 2 years. She delivered one healthy girl via cesarian section 2 years after the treatment. Endometriosis and HS should be included in the differential diagnosis when women present with menstrual painful lesions around external genitalia for diagnosis and treatment.

Purposeful use of multimodality imaging in the diagnosis of caseous mitral annular calcification: a case series report

Background Caseous mitral annular calcification (CMAC) is a rare liquefactive variant of mitral annular calcification (MAC) and superficially mimics a cardiac vegetation or abscess. CMAC is viewed as a benign condition of MAC, while MAC has clinical implications for patients’ lives. Correctly diagnosing CMAC is essential in order to avoid unnecessary interventions, cardiac surgery or even psychological suffering for the patient. Case presentation We report on 6 patients with suspected intra-cardiac masses of the mitral annulus that were referred to our institution for further clarification. A definitive diagnosis of CMAC was achieved by combining echocardiography (Echo), cardiac magnetic resonance imaging (MRI) and cardiac computed tomography (CT) for these patients. Echo assessed the mass itself and possible interactions with the mitral valve. MRI was useful in differentiating the tissue from other benign or malign neoplasms. CT revealed the typical structure of CMAC with a “soft” liquefied centre and an outer capsule with calcification. Conclusion CMAC is a rare condition, and most clinicians and even radiologists are not familiar with it. CMAC can be mistaken for an intra-cardiac tumour, thombus, vegetation, or abscess. Non-invasive multimodality imaging (i.e. Echo, MRI, and CT) helps to establish a definitive diagnosis of CMAC and avoid unnecessary interventions especially in uncertain cases.

Nasal Transmissible Venereal Tumor (TVT) in Dogs

Background: Transmissible venereal tumors (TVT) are naturally occurring neoplasms that can be transmitted through copulation or cell transplantation. It is a disease that affects canines, has no preference for sex or breed, and generally noticed in the external genital apparatus. Extragenital occurrence may eventually be seen; however, nasal involvement has been described in only a few reports of studies conducted in Brazil. Therefore, the objective of this study is to report 3 cases of nasal TVT in dogs who were treated in 2 municipalities in the mountainous region of Santa Catarina, Brazil.Cases: This case report includes 3 male mixed-breed canines of age 3-13. Only 1 of the animals was castrated. As per the medical history, some points, such as an enlarged nasal region, sneezing, nasal discharge, and hoarseness, reported by the dogs’ respective owners were similar among all the dogs. Likewise, nosebleed was observed on physical examination in all the cases. The result of cytological examination was inconclusive only in 1 case. Rhinoscopy, incisional biopsy, and histopathological examination were then performed for achieving a definitive diagnosis. In the 2 cases wherein cytology gave conclusive results, the cytological smears showed changes suggestive of TVT, such as cells with eccentric nuclei and little cytoplasm, which had vacuoles inside them. In 2 cases, radiographic examinations of the skull were also performed. The images showed changes in bone radiopacity, conformation of trabeculae with areas of bone lysis and cell proliferation, and irregularity in the contour of the nasal bone. After TVT diagnosis was confirmed, chemotherapy was initiated using vincristine at a dose of 0.75 mg/m2 for 2 cases and 0.025 mg/kg for the remaining case. The number of chemotherapy sessions and duration of treatment until the resolution of lesions and clinical signs varied as per the differences in the patients’ blood counts performed prior to each session.Discussion: TVT occurs between 1 and 7 years of life. It occurs more frequently in sexually active animals and has no preference for breed. Of the 3 cases reported herein, only one of the patients was elderly. All the patients were male mixed-breed dogs, and only 1 of them was castrated. The implantation of neoplastic cells through natural mounts, licks, scratches, or bites of affected areas are the most widely accepted reasons for the transmission of this neoplasm. With regard to the nasal presentation described in the present report, it is hypothesized that the smelling or licking of the neoplastic areas by the animal may favor cell implantation, leading to the subsequent development of a tumor. Nasal TVT should be considered as a differential diagnosis for dogs with chronic symptoms of the upper respiratory tract, such as increased local volume, nasal discharge, nosebleed, and sneezing. These signs are consistent with those described in this report. Radiographic evaluation was performed in 2 cases and both showed changes in bone radiopacity and trabeculae conformation, in addition to areas of bone lysis and cell proliferation, which are common in neoplastic processes. A presumptive diagnosis can be achieved from the medical history, clinical signs, and physical examination. Cytological and histopathological examination are the confirmatory methods; however, it is used less frequently and especially when cytological evaluation does not provide a definitive diagnosis. Antineoplastic chemotherapy with vincristine is the first-choice treatment protocol, which also proved to be effective for the patients in this report. Although TVT commonly affects the external genitalia of dogs, in the cases reported herein, it was located exclusively in the nasal region. Keywords: TVT, dog, nasal, vincristine.Título: Tumor venéreo transmissível (TVT) nasal em cãesDescritores: TVT, cão, nasal, vincristine.

Abdominal cyst of unclear aetiology: gastrointestinal stromal tumour or reactivation of abdominal tuberculosis

Differential diagnosis of a new abdominal mass is broad and includes infection, malignancy and other inflammatory processes. Definitive diagnosis may be challenging without invasive biopsy, as history, physical exam and imaging may be non-specific. A 69-year-old man with a history of abdominal tuberculosis presented with a new painful abdominal cyst consistent with reactivation of tuberculosis versus new malignancy. Investigations revealed 4+ acid-fast bacilli from the aspirate suggestive of tuberculosis, but no improvement was noted on antituberculous therapy. Core needle biopsy noted c-KIT-positive spindle cells, diagnostic for a gastrointestinal stromal tumour, while cultures grew non-tuberculous mycobacteria.

THE ROLE OF DIAGNOSTIC OESOPHAGO-GASTRODUODENOSCOPY (OGD) AND COLONOSCOPY IN CANCER OF UNKNOWN PRIMARY

Objective: To study the role of gastrointestinal procedures, namely oesophago-gastroduodenoscopy (OGD) and colonoscopy, in helping to establish a definitive primary tumour site in cancer of unknown primary. Study Design: Prospective observational study. Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore Pakistan, from Jan 2018 to Jan 2019. Methodology: A total of 115 patients included in the study were those, who underwent OGD and a colonoscopy for the diagnosis of a cancer of unknown primary. Data collected included demographics, baseline clinical characteristics, definitive diagnosis, tissue diagnosis and immune-histochemical stains. Primary outcome was the attainment of a definitive diagnosis via OGD and/or colonoscopy. Results: A total of 115 patients underwent a diagnostic gastrointestinal procedure. Of these 70 (61%) were males. Mean age was 63 ± 12.6 years (range 22-88 years). Abdominal pain comprised the most common presenting complaint, found in 61 (53%). The most common tissue diagnosis of the metastatic sites was adenocarcinoma 81 (70.45%). Tumour markers including carcinoembryonic antigen, alpha-fetoprotein and carbohydrate antigen 19-9 were checked in 90 (78.2%), 46 (40%) and 69 (60%) patients respectively. No patient reached a definitive diagnosis by means of OGD and/or colonoscopy. Conclusion: OGD and colonoscopy when done collectively as diagnostic procedures to look for a primary tumour, have no value in the evaluation of patients with cancer of unknown primary.

Evaluation of Clinical Follow-Up of The Patients Monitored at Home Due To COVID-19 Pandemic

Aim: The most valuable approach to prevent the spread of the novel COVID-19, which is a pandemic today, is to detect, isolate, and treat patients. The majority of patients are mild or asymptomatic cases. These cases are followed up and isolated at home in many countries. With a governmental decision issued in Turkey, it has been deemed appropriate to follow up the suspected, contact or definitive diagnosis patients who do not indicate inpatient treatment, have a mild clinical course, or do not have a risk factor that may lead to a severe course of COVID-19, at home by the family practice units. In this study, we aimed to investigate the characteristics of the patients with COVID-19 who were being monitored at home. Methods: The study was designed as a retrospective cross-sectional observational study. In this study, 321 people who were registered at the Education and Family Health Centers of our hospital and followed up as COVID-19 suspects, contacts, or definitive cases were identified. Home follow-up data of these patients between April 1-30 were obtained retrospectively from the records of family health centers. Data, such as the presence and course of symptoms of people followed at home, their isolation status, medicine usage status, and test results were recorded electronically for further analysis. Results: In this study, 321 patients, 163 (50.28%) males, and 158 (49.22%) females were included. Among 321 patients, 287 (89.41%) were contact patients, 54 (16.82%) were suspected patients, and 28 (8.72%) had a definitive diagnosis. The mean age of the patients was 40.00±20.68. Among the patients included in this study, 27 (8.41%) were hospitalized, symptoms worsened in 8 (2.49%), 5 (1.56%) were re-applied to the hospital, 5 (1.56%) were re-hospitalized, and 28 people (8.72%) were administered medication. Conclusion: The mean age of patients who complied with the measures of isolation was higher than patients who did not. The mean age of hospitalized patients was higher than in non-hospitalized patients. The frequency of observed symptoms was consistent with the previous studies in the literature. Keywords: cough, fever, pandemics, quarantine, SARS-CoV-2

Experience Professional dermatomycosis of the face, neck and upper part of chest caused by T. mentagrophytes

A 43-year-old female zoologist has an occupational dermatomycosis of the face, neck and upper part of chest caused by T. mentagrophytes. It was mistakenly diagnosed and treated as "Rosacea, papulopustular subtype, ocular rosacea" for 1.5 years. Symmetrical, atypical clinical manifestations with recurrent blepharoconjunctivitis developed as a result of self-treatment using a topical steroid. The detection of cicatrizing folliculitis in the eyebrow area and an arcual peripheral edge in fresh foci on the chest helped to suspect dermatomycosis. The definitive diagnosis was made after the detection of abundant coarse septate mycelium during microscopic investigation of skin scales from foci on the face and chest with 30% KOH and an abundant growth of Trichophyton mentagrophytes during a cultural research study of skin scales, eyebrow hair and eyelashes from lesions. The use of terbinafine for 4 weeks led to the recovery of the patient.

Clinicopathologic Appearance of Advanced Ketoacidosis With Basal Vacuolation in Renal Tubules

Context.— Basal vacuolization (BV) in renal tubules is a histopathologic hallmark of advanced ketoacidosis that enables us to retrospectively diagnose these cases. Objective.— To clarify the pathologic background and serologic findings of ketoacidosis with BV, and to reveal the pathologic findings by each pathologic background. Design.— We examined 664 serial autopsy cases. A systemic histopathologic examination and measurement of serum β-hydroxybutyrate concentration were performed for the cases with BV. The extent of steatosis and fibrosis in the organs and the degree of coronary artery stenosis were semiquantitatively investigated. Immunohistochemistry for adipophilin was also performed to analyze its usefulness for the pathologic diagnosis. Results.— Basal vacuolization was found in 16 cases, all of which showed a pathologic serum β-hydroxybutyrate concentration. The main background of ketoacidosis was considered as alcohol abuse in 6 cases, diabetes in 5, malnutrition in 3, and hypothermia and infection in 1 case each. Severe hepatic fibrosis was observed only in the alcohol-abuser group. Moreover, cardiac steatosis was more severe in patients with possible alcohol abuse than in those with other causes. Immunohistochemistry for adipophilin showed immunoreactivity consistent with BV in 13 of 16 cases. There was no correlation between β-hydroxybutyrate concentration and either the postmortem or storage interval. Conclusions.— Basal vacuolization may be a useful finding for detecting ketoacidosis cases in a postmortem investigation. Serum β-hydroxybutyrate was a stable and reliable compound for the definitive diagnosis of ketoacidosis in such cases. The present study showed that pathologic changes in some organs may vary by each pathologic background of ketoacidosis with BV.

Fibrous dysplasia of maxilla – A rare case report

Fibrous dysplasia (FD) is a skeletal developmental anomaly, which is non-hereditary in origin and idiopathic in nature. It is a benign fibro-osseous disease that affects one or more bones. It usually affects unilaterally and is seen in the posterior region. Approximately 0.5% of untreated cases show the malignant transformation. We report the case of a 35-year-old female patient with FD involving the maxilla. The clinical diagnostic approach, different imaging modalities, and histological examination methods for definitive diagnosis have been elaborated.