Diagnostic performance of multishot echo-planar imaging (RESOLVE) and non-echo-planar imaging (HASTE) diffusion-weighted imaging in cholesteatoma with an emphasis on signal intensity ratio measurement.

PURPOSE: To evaluate the diagnostic efficacy of multishot echo-planar imaging (EPI) [RESOLVE (RS)] and non-EPI (HASTE) diffusion-weighted imaging (DWI) in detecting cholesteatoma (CHO), and to explore the role of signal intensity (SI) ratio measurements in addressing diagnostic challenges. METHODS: We analyzed RS-EPI and non-EPI DWI images from 154 patients who had undergone microscopic middle ear surgery, with pathological confirmation of their diagnoses. Two radiologists, referred to as Reader A and Reader B, independently reviewed the images without prior knowledge of the outcomes. Their evaluation focused on lesion location, T1-weighted (T1W) signal characteristics, and contrast enhancement in temporal bone magnetic resonance imaging. Key parameters included lesion hyperintensity, size, SI, SI ratio, and susceptibility artifact scores across both imaging modalities. RESULTS: Of the patients, 62.3% (96/154) were diagnosed with CHO, whereas 37.7% (58/154) were found to have non-CHO conditions. In RS-EPI DWI, Reader A achieved 89.6% sensitivity, 79.3% specificity, 87.8% positive predictive value (PPV), and 82.1% negative predictive value (NPV). Non-EPI DWI presented similar results with sensitivities of 89.6%, specificities of 86.2%, PPVs of 91.5%, and NPVs of 83.3%. Reader B's results for RS-EPI DWI were 82.3% sensitivity, 84.5% specificity, 89.8% PPV, and 74.2% NPV, whereas, for non-EPI DWI, they were 86.5% sensitivity, 89.7% specificity, 93.3% PPV, and 80% NPV. The interobserver agreement was excellent (RS-EPI, κ: 0.84; non-EPI, κ: 0.91). The SI ratio measurements were consistently higher in non-EPI DWI (Reader A: 2.51, Reader B: 2.46) for the CHO group compared with RS-EPI. The SI ratio cut-off (>1.98) effectively differentiated hyperintense lesions between CHO and non-CHO groups, demonstrating 82.9% sensitivity and 100% specificity, with an area under the curve of 0.901 (95% confidence interval: 0.815-0.956; P < 0.001). Susceptibility artifact scores averaged 1.18 ± 0.7 (Reader A) and 1.04 ± 0.41 (Reader B) in RS-EPI, with non-EPI DWI recording a mean score of 0. CONCLUSION: Both RS-EPI and non-EPI DWI exhibited high diagnostic accuracy for CHO. While RS-EPI DWI cannot replace non-EPI DWI, their combined use improves sensitivity. SI ratio measurement in non-EPI DWI was particularly beneficial in complex diagnostic scenarios. CLINICAL SIGNIFICANCE: This study refines CHO diagnostic protocols by showcasing the diagnostic capabilities of both RS-EPI and non-EPI DWI and highlighting the utility of SI measurements as a diagnostic tool. These findings may reduce false positives and aid in more accurate treatment planning, offering substantial insights for clinicians in managing CHO.

Case Presentation of Duodenal Obstruction Caused by Complete Annular Pancreas.

Teaching Point: A complete annular pancreas, a rare congenital anomaly, can lead to duodenal obstruction, causing recurrent symptoms like vomiting and often requiring surgical intervention for relief.

Diagnostic Efficacy of Ultrasonography, Doppler Ultrasonography and Elastography in the Evaluation of Suspected Malignant Lymph Nodes.

Aim: In this prospective study, the efficiency of imaging findings was investigated by comparing the histopathological results of lymph nodes with Doppler and ultrasound features and elasticity scores. Material and method: A total of 100 cervical or axillary lymph nodes with a suspected malignancy or whose size did not decrease after treatment were examined. In addition to the demographic data of the patients, B-mode ultrasound, Doppler ultrasound, and elastography features of the lymph nodes were evaluated prospectively. The irregular shape, increased size, pronounced hypoechogenicity, presence of micro/macro calcification, short axis/long axis ratio >2, increased size of the short axis, increased cortex thickness, obliterated hilus or increased cortex thickness >3.5 mm were evaluated on ultrasound. Resistivity index, pulsatility index, acceleration rate and time were evaluated for intranodal arterial structures on color. Doppler ultrasound, strain ratio value and elasticity score were recorded on ultrasound elastography. After sonographic examination, patients underwent ultrasound-guided fine needle aspiration cytology or tru-cutting needle biopsy. Histopathological examination results of the patients were compared with the B-mode ultrasound, Doppler ultrasound, and ultrasound elastography. Results: When the individual and combined effects of the ultrasound, Doppler ultrasound, and ultrasound elastography were evaluated, the combination of all three imaging methods was found to have the highest sensitivity and the highest overall accuracy (90.4% and 73.9%). As an individual method Doppler ultrasound had the highest specificity (77.8%). B-mode ultrasound was found to have the lowest accuracy (56.7%) both in individual and combined evaluations. Conclusion: Addition of ultrasound elastography to the combination of B-mode and Doppler ultrasound findings increases diagnostic sensitivity and accuracy in the differentiation of benign and malignant lymph nodes.

Does the Thymus Index Predict COVID-19 Severity?

BACKGROUND: The COVID-19 (coronavirus disease 2019) pandemic is a global health emergency that is straining health care resources. Identifying patients likely to experience severe illness would allow more targeted use of resources. This study aimed to investigate the association between the thymus index (TI) on thorax computed tomography (CT) and prognosis in patients with COVID-19. METHODS: A multicenter, cross-sectional, retrospective study was conducted between March 17 and June 30, 2020, in patients with confirmed COVID-19. The patients' clinical history and laboratory data were collected after receiving a signed consent form. Four experienced radiologists who were blinded to each other and patient data performed image evaluation. The appearance of the thymus was assessed in each patient using 2 published systems, including the TI and thymic morphology. Exclusion criteria were lack of initial diagnostic thoracic CT, previous sternotomy, pregnancy, and inappropriate images for thymic evaluation. A total of 2588 patients with confirmed COVID-19 and 1231 of these with appropriate thoracic CT imaging were included. Multivariable analysis was performed to predict the risk of severe disease and mortality. RESULTS: The median age was 45 (interquartile range, 33-58) years; 52.2% were male. Two hundred forty-nine (20.2%) patients had severe disease, and 60 (4.9%) patients died. Thymus index was significantly associated with mortality and severe disease (odds ratios, 0.289 [95% confidence interval, 0.141-0.588; P = 0.001]; and 0.266 [95% confidence interval, 0.075-0.932; P = 0.038]), respectively. Perithymic lymphadenopathy on CT imaging had a significantly strong association with grades of TI in patients with severe disease and death ( V = 0.413 P = 0.017; and V = 0.261 P = 0.002, respectively). A morphologically assessable thymus increased the probability of survival by 17-fold and the absence of severe disease by 12-fold. CONCLUSION: Assessment of the thymus in patients with COVID-19 may provide useful prognostic data for both disease severity and mortality.

The Oncologic Safety of Sentinel Lymph Node Biopsy in Patients with Node-Positive Breast Cancer with Complete Response to Neoadjuvant Chemotherapy: A Single-Center Experience.

Objective: To evaluate the efficiency and safety of sentinel lymph node biopsy (SLNB) in patients with breast cancer with complete response to neoadjuvant chemotherapy (NAC). Methods: Ninety-two consecutive (T1-4 and N1-2) patients with breast cancer who had pathologic and/or clinical and radiologic axillary lymph node involvement were included. All patients received NAC. Patients with a clinical and radiologic complete response in the axilla after NAC underwent SLNB. Pathologic complete response (ypCR) was defined as the absence of residual invasive and in situ cancer, and near-complete response (ypNCR) represented in situ and/or ≤ 1 mm residual tumor in the breast and/or presence of malignant cell clusters (≤0.2 mm) and/or micrometastases (≤2.0 mm) in the axillary lymph nodes (ALN) (ypTis/T1mi, ypN0i+/pN1mi). Results: The mean age of the 92 patients was 49.6 ± 10.3 years and the mean follow-up was 34.0 ± 17.8 months. With respect to breast tumors, 23 (25.0%) patients had complete and 14 (15.2%) had a near-complete response to NAC. Complete response in ALN was obtained in 39 (42.4%) patients and near-complete in six (6.5%) patients. The overall survival of the 33 patients who achieved ypCR and ypNCR was 100% and the remaining 59 patients with partial or no response to NAC was 83.1% at a mean follow-up of 34 months (p=0.063). Conclusions: In this study, no event developed in cases with ypCR and ypNCR in the breast and axilla. The persistence of the same results in long-termfollow-ups may enable the use of ypNCR as a positive prognostic marker in addition to ypCR.

Cerebrospinal Fluid Gusher in Cochlear Implantation and Its Association with Inner-Ear Malformations.

BACKGROUND: It is aimed to investigate the incidence of cerebrospinal fluid gusher in cochlear implantation and the association between cerebrospinal fluid gusher and inner-ear malformations in adult and pediatric patients. METHODS: A retrospective case review of 1025 primary cochlear implantation procedures was performed. Patients with inner-ear malformation or cerebrospinal fluid gusher during primary cochlear implantation were included and divided into 2 groups according to age: pediatric and adult groups. RESULTS: The incidence of inner-ear malformation was 4.19% (17/405) and 7.6% (47/620) in the adult and pediatric groups, respectively. There was a significant difference in the incidence of inner-ear malformation in the pediatric group. The incidence of cerebrospinal fluid gusher was 0.9% (4/405) and 4.1% (26/620) in the adult and pediatric groups, respectively. There was a significant difference in the incidence of gusher between the adult and pediatric groups. CONCLUSION: The incidence of a cerebrospinal fluid gusher is higher in the pediatric group, compared to adults due to a higher rate of inner-ear malformation. Inner-ear malformation poses a risk factor for cerebrospinal fluid gusher.

The Importance of the Pathological Perspective in the Management of the Invasive Lobular Carcinoma.

Background: Invasive lobular carcinomas (ILC) account for 10-15% of all breast cancers and are the second most common histological form of breast cancer. They usually show a discohesive pattern of single cell infiltration, tend to be multifocal, and the tumor may not be accompanied by a stromal reaction. Because of these histological features, which are not common in other breast tumors, radiological detection of the tumor may be difficult, and its pathological evaluation in terms of size and spread is often problematic. The SSO-ASTRO guideline defines the negative surgical margin in breast-conserving surgeries as the absence of tumor detection on the ink. However, surgical margin assessment in invasive lobular carcinomas has not been much discussed from the pathological perspective. Methods: The study included 79 cases diagnosed with invasive lobular carcinoma by a Tru-cut biopsy where operated in our center between 2014 and 2021. Clinicopathological characteristics of the cases, results of an intraoperative frozen evaluation in cases that underwent conservative surgery, the necessity of re-excision and complementary mastectomy, and consistency in radiological and pathological response evaluation in cases receiving neoadjuvant treatment were questioned. Results: The tumor was multifocal in 37 (46.8%) cases and single tumor focus in 42 (53.2%) cases. When the entire patient population was evaluated, regardless of focality, mastectomy was performed in 27 patients (34.2%) and breast-conserving surgery (BCS) was performed in 52 patients (65.8%). Of the 52 patients who underwent BCS, 26 (50%) required an additional surgical procedure (cavity revision or completion mastectomy). There is a statistical relationship between tumor size and additional surgical intervention (p < 0.05). BCS was performed in 7 of 12 patients who were operated on after neoadjuvant treatment, but all of them were reoperated with the same or a second session and turned to mastectomy. Neoadjuvant treatment and the need for reoperation were statistically significant (p < 0.05). Additional surgical procedures were performed in 20 (44.4%) of 45 patients in BCS cases who did not receive neoadjuvant therapy. Conclusions: Diagnostic difficulties in the intraoperative frozen evaluation of invasive lobular carcinoma are due to the different histopathological patterns of the ILC. In our study, it was determined that large tumor size and neoadjuvant therapy increased the need for additional surgical procedures. It is thought that the pathological perspective is the determining factor in order to minimize the negative effects such as unsuccessful cosmesis, an additional surgical burden on the patient, and cost increase that may occur with additional surgical procedures; for this reason, new approaches should be discussed in the treatment planning of invasive lobular carcinoma cases.

How did radiologists' diagnostic performance has changed in COVID-19 pneumonia: A single-centre retrospective study.

AIMS: Delay and false positivity in PCR test results have necessitated accurate chest CT reporting for the management of patients with COVID-19-suspected symptoms. Pandemic related workload and level of experience on covid-dedicated chest CT scans might have affected the diagnostic performance of on-call radiologists. The aim of this study was to reveal the interpretation errors (IEs) in chest CT reports of COVID-19-suspected patients admitted to the Emergency Room (ER). METHODS: Chest CT scans between March and June 2020 were re-evaluated and compared with the former reports and PCR test results. CT scan results were classified into four groups. Parenchymal involvement ratios, radiology departments' workload, COVID-19-related educational activities have been examined. RESULTS: Out of 5721 Chest CT scans, 783 CTs belonging to 664 patients (340 female, 324 male) were included in this study. PCR test was positive in 398; negative in 385 cases. PCR positivity was found to be highest in "normal" and "typical for covid" groups whereas lowest in "atypical for covid" and "not covid" groups. 5%-25% parenchymal involvement ratio was found in 84.2% of the cases. Regarding the number of chest CT scans performed, radiologists' workload has found to be increased six-folds. With the re-evaluation, a total of 145 IEs (18.5%) have been found. IEs were mostly precipitated in the first two months (88.3%) and mostly in the "not covid" class (60%) regardless of PCR positivity. COVID-19 and radiology entitled educational activities along with the ER admission rates within the first two months of the pandemic have seemed to be related to the decline of IEs within time. CONCLUSION: COVID-19 pandemic made a great impact on radiology departments with an inevitable burden of daily chest CT reporting. This workload and concomitant factors have effects on diagnostic challenges in COVID-19 pneumonia.

Impact of magnetic resonance on the decision of conservative surgery in advanced larynx cancer.

OBJECTIVE: To evaluate the utility of magnetic resonance images (MRI) in the selection of treatment procedures for intermediate-advanced laryngeal cancers. MATERIAL AND METHOD: This study included patients with histologically proven laryngeal squamous cell carcinoma defined as cT3 and T4a at our tertiary academic care hospital. All scans were evaluated by two radiologists experienced in head and neck cross-sectional studies. Signal patterns in MRI sections of laryngeal compartment subsites were delineated as T1w, T2w hyperintensity, and T2w intermediate signals, and were compared with the postoperative pathological results. Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) were calculated. RESULTS: The study included 51 patients with a mean age of 62.55 ± 9.14 (range, 45-80) years. Tumor was glottic in 12 (23.5%) patients, supraglottic in 19 (31.4%) patients, glottic-supraglottic in 11 (21.6%) patients, transglottic in 9 (27%) patients. The posterior paraglottic space had the strongest specificity of MRI according to tumor infiltration in the histologic analysis (specificity 96.9% and sensitivity 78.6%). The specificity of MRI was poor for tumor infiltration in thyroid cartilage (specificity 70.0%). Spearman's test demonstrated that there was a statistically significant correlation between the MRI-based prediction scores of all subunites and the findings of histopathologic analyses (mean±SD: 4.96±4.46-5.53±4.38, respectively, R2: 0.711, p<0.001). CONCLUSION: The high specificity values of the predictions, which were MRI-based in all subsites, indicated that MRI could provide an important contribution for defining tumor infiltration and the presurgical assessment of patients with tumors of the larynx.

Clinicopathologic features of single bone metastasis in breast cancer.

ABSTRACT: The most common site for metastasis in patients with breast cancer is the bone. In this case series, we investigated patients whose surgical and medical treatment for primary breast cancer was conducted at our center and first disease recurrence was limited to only 1 bone.We analyzed 910 breast cancer patients, 863 had no metastasis and 47 cases had a single bone metastasis ≥ 6 months after their first diagnosis. Demographic, epidemiological, histopathological and intrinsic tumor subtype differences between the non-metastatic group and the group with solitary bone metastases and their statistical significance were examined. Among established breast cancer risk factors, we studied twenty-nine variables.Three variables (Type of tumor surgery, TNM Stage III tumors and mixed type (invasive ductalcarsinoma + invasive lobular carcinoma) histology) were significant in multivariate logistic regression analysis. Accordingly, the risk of developing single bone metastasis was approximately 15 times higher in patients who underwent mastectomy and 4.8 and 2.8 times higher in those with TNM Stage III tumors and with mixed type (invasive ductal carcinoma + invasive lobular carcinoma) histology, respectively.In conclusion, the risk of developing single bone metastasis is likely in non-metastatic patients with Stage III tumors and possibly in mixed type tumors. Knowing this risk, especially in patients with mixed type tumors, may be instrumental in taking measures with different adjuvant therapies in future studies. Among these, treatment modalities such as prolonged hormone therapy and addition of bisphosphonates to the adjuvant treatments of stage III and mixed breast cancer patients may be considered.

Neuroendocrine Differentiated Breast Cancer Cases: A Retrospective Analysis and Literature Review.

Objectives: Neuroendocrine breast carcinoma (NEBC) is a rare subgroup of breast cancer, which makes up 2-5% of all invasive breast cancers. The aim of this retrospective analysis is to present and analyze our own data of primary NEBCs. Methods: We retrospectively analyzed clinical, pathological, and radiological characteristics of 36 patients diagnosed with neuroendocrine differentiated breast cancer between 2008 and 2019 compared to that of 925 patients with invasive ductal carcinoma (IDC/NOS) along with a literature review. Results: In this study, 36 patients with neuroendocrine differentiated breast carcinoma and 961 patients with (IDC/NOS), as the comparison group, were identified between 2008 and 2019. In NEBC patients, seven were premenopausal and 29 postmenopausal. Patients whose ultrasound (USG), magnetic resonance, and mammographic (MMG) images available in our hospital, high-density masses were detected in the MMG with irregular (77%), microlobulated (80%) and spiculated margins (63%), unaccompanied by asymmetry and structural distortion. Calcifications were less common than invasive breast cancer, present only in four patients (17%). When NEBC were compared to ductal carcinomas (n=925), NEBC were more often human epidermal growth factor receptor 2 negative (p=0.039), estrogen receptor positive (p=0.05), progesterone receptor positive (0.03), and the NEBC patients were older (p=0.02). Age, grade, metastatic status, lymph node number, and molecular type were identified as prognostic factors that significantly affect survival in both groups (p<0.05). Conclusion: NEBC is a subtype that is both histopathologically and radiologically distinct from other breast cancer subtypes, and neuroendocrine differentiation may be an important predictive marker in the future.

Predictive Value of Additional Clinical and Radiological Parameters for Discrimination of Malignancy in Bosniak 3 Cysts.

INTRODUCTION: Almost half of the cystic renal lesions are still overdiagnosed and overtreated. New clinical and radiological parameters are needed to distinguish the malignant Bosniak 3 lesions from the benign ones. We aimed to evaluate the clinical and radiological parameters that may be related to malignancy risk for Bosniak category 3 renal cysts. MATERIALS AND METHODS: Patients who underwent surgical resection of a histopathologically confirmed Bosniak 3 renal cyst between March 2007 and September 2019 were evaluated. Two experienced uro-radiologists have reevaluated the last preoperative computed tomography and/or MRI images of the patients and reclassified the lesions according to the Bosniak classification. They also reported cystic features such as nodularity, septation, focal thickening, enhancement, and calcification. Clinical, pathological, and oncological outcomes were recorded. Then patients were divided into 2 groups as Group 1 (benign pathology) and Group 2 (malignant pathology) according to final histopathological report. RESULTS: A total of 79 patients were included in this study. Mean follow-up time was 47 ± 34 months. There were 30 patients in Group 1 and 49 patients in Group 2. Hypertension (p = 0.001) and smoking history (p = 0.008) were more common in malignant group. Among the radiological findings, lower tumor diameter (p = 0.024), presence of cyst wall enhancement (p = 0.025), presence of nodularity (p = 0.002), and presence of focal thickening (p = 0.031) were found to be statistically significant for malignancy. Most of the tumors were at pathological T1 stage and Fuhrmann Grade 1-2. Only nodularity was found to be independent predictive factor for malignancy in multivariate analysis. CONCLUSION: Clinical factors including hypertension and smoking, radiological factors including lower lesion size, cyst wall enhancement, nodularity, and focal thickening were predictors for malignancy of Bosniak 3 cysts.

Comparison of diagnostic accuracy of ACR-TIRADS, American Thyroid Association (ATA), and EU-TIRADS guidelines in detecting thyroid malignancy.

PURPOSE: This study aims to compare three guidelines according to their diagnostic accuracy in the management of thyroid nodules. METHODS: A total of 540 patients with 597 thyroid nodules were enrolled in this study. Sonographic images were classified and scored with the American Thyroid Association (ATA-2015), American College of Radiology (ACR), and European Thyroid Association (EU) Thyroid Imaging, Reporting, and Data Systems (ACR-TIRADS and EU-TIRADS) guidelines. Fine-needle aspiration biopsy (FNAB) was performed, and cytopathological results were reported with the Bethesda system. Outcomes of these three classification systems were then correlated with Bethesda results. RESULTS: FNAB procedures revealed a total of 447 benign and 45 malignant nodules. With guideline dedicated FNAB criteria; 38 malignant nodules could have been diagnosed with ATA-2015, which is followed by 34 nodules with ACR-TIRADS, and 31 nodules with EU-TIRADS. Nonetheless, 301 benign nodules would have been biopsied with ATA-2015, 143 benign nodules with ACR-TIRADS, 222 benign nodules with EU-TIRADS. The accuracy rate was found to be highest with ACR-TIRADS (59.93 %); while 55.20 % with ATA-2015 and 51.25 % with EU-TIRADS. The sensitivity and specificity ratios of these guidelines were as follows; ATA-2015 (82.22, 53.47), ACR-TIRADS (48.89, 60.63), and EU-TIRADS (86.67, 48.99). A total of 23 nodules (3.8 %) could not be classified with ATA-2015. CONCLUSION: Diagnostic strengths, unnecessary recommended FNAB rates, and categorization capabilities differ among various guidelines. Clinicians and interventional radiologists should keep in mind these features in the management of thyroid nodules.

Surgical considerations and audiological results of cochlear implantation in patients with otosclerosis

Background/aim: To emphasize the role of cochlear implantation (CI) in the auditory rehabilitation of patients with otosclerosis (OS) and share our surgical experiences on this rare group of patients. Materials and methods: Retrospective analysis of the patients who have a diagnosis of otosclerosis and implanted between January 1998­May 2019 was performed. Preoperative and postoperative clinical, radiological, audiological and surgical findings are presented. Results: Among 2195 patients who have been implanted in our institution, 12 (0.54%) met the diagnostic criteria of OS according to their preoperative (clinical, radiological, audiological) and peroperative (surgical) findings. Electrode insertion was performed via "round window membrane and cochleostomy" in 8 and 4 patients, respectively. No major complications occured. All patients showed satisfactory performances by means of audiometric scores postoperatively. Nonauditory stimulation (NAS) which manifested as "facial twitching" was a challenging problem in one patient during the surgery and subsided after the operation. Conclusion: Our experience on CI in patients with OS revealed that the implantation was a relatively safe procedure and had satisfactory impact on audiological performances.

The Histopathologic Correlation of Bosniak 3 Cyst Subclassification.

OBJECTIVE: To evaluate the histopathologic correlation of recently described subclassification of Bosniak category 3 cysts (3s and 3n). MATERIALS AND METHODS: A total of 106 patients who underwent partial/radical nephrectomy due to a complex renal cyst (≥Bosniak 3) were retrospectively reviewed. All the scans of the patients were reevaluated by 2 experienced uroradiologists. Bosniak 3 cysts were reclassified as 3n (nodularity on the cyst wall/septae) and 3s (septated cysts without nodularity) as described in a recently published paper. Group 1 consisted of patients with Bosniak 3s, Group 2 consisted of patients with Bosniak 3n, and Group 3 consisted of patients with Bosniak 4 cysts. Three groups were compared according to patients' characteristics, radiological findings, histopathologic results, and survival outcomes. RESULTS: There were 52 patients in Bosniak 3 group and 54 patients in Bosniak 4 group. Mean follow-up was 35.3 months. Among Bosniak 3 cysts, 37 lesions were classified in 3s and 15 were classified in 3n. Malignancy was higher in 3n group than 3s (86.7% vs 54.1%, P= .026). Lesion size was significantly lower for malignant cysts compared to benign ones in the patients with Bosniak 3 lesions (44.2 ± 27.5 vs 80 ± 55.9 P= .005). In the subgroups, malignant lesions were significantly smaller than benign lesions in 3s group similar to general Bosniak 3 group. Most of the Bosniak 3 lesions were organ confined and low grade. CONCLUSION: The subclassification of Bosniak 3 cysts as 3s and 3n can help to differentiate highly suspicious malignant lesions from the relatively less suspicious ones.

Axillary metastasis in clinically node-negative breast cancer.

AIM OF WORK: This study investigates the factors related to metastasis detection in a sentinel lymph node biopsy (SLN) in patients without clinical axillary involvement. PATIENTS AND METHODS: The medical records of patients who underwent an SLN biopsy after diagnosis with early-stage breast cancer were evaluated retrospectively. The study sample included 64 patients divided into two groups according to the histopathological examination of the SLN biopsy: Group I (positive for axillary metastasis) and Group II (negative for axillary metastasis). RESULTS: The frequency of lymphovascular invasion was significantly higher in Group I (57%) than in Group II (13%) (p = 0.003). The progesterone receptor status (p = 0.036), tumor T-stage(p = 0,047), and Ki-67 index differed significantly (p = 0.045) between the two groups. While in univariate analysis, lymphovascular invasion, T-stage and KI-67 index were significant, in multivariate analysis only lymphovascular invasion was found to be significant. No significant differences were found in terms of estrogen receptor and HER2 considering tumor invasion type, histologic grade, vascular invasion, neural invasion, multifocality or bilaterality, hormone receptor status, menopause status, total number of lymph nodes, presence of non-sentinel lymph nodes and the number of SLNs in the groups (p > 0.05). CONCLUSIONS: The results of this study indicate that lymphovascular invasion is associated with axillary metastasis, based on an SLN biopsy.

An adult case of atypical hemolytic uremic syndrome presented with posterior reversible encephalopathy syndrome: Successful response to late-onset eculizumab treatment.

Atypical hemolytic uremic syndrome is a rare and progressive disease caused by uncontrolled alternative complement activation. Dysregulation of the complement activation results in thrombotic microangiopathy and multiorgan damage. A 29-yearold woman who was admitted with complaints of vomiting and headache was detected to have acute renal failure with microangiopathic hemolytic anemia (MAHA). After the diagnosis of atypical hemolytic uremic syndrome (aHUS), she was treated with plasma exchange (PE) and hemodialysis (HD). She has experienced hypertensionrelated posterior reversible encephalopathy syndrome (PRES) at the second plasma exchange. She was initiated on eculizumab therapy because of no response to PE on the 34th days. Her renal functions progressively improved with eculizumab treatment. Dependence on dialysis was over by the 4th month. Dialysis free-serum Creatinine level was 2.2 mg/dL [glomerular filtration rate (e-GFR): 30 mL/min/1.73 m2] after 24 months. Neurological involvement (PRES, etc.) is the most common extrarenal complication and a major cause of mortality and morbidity from aHUS. More importantly, we showed that renal recovery may be obtained following late-onset eculizumab treatment in patient with aHUS after a long dependence on hemodialysis.

The accuracy of bedside USG in the diagnosis of nasal fractures.

A comparison of the sensitivity and specificity of bedside ultrasonography with conventional radiography for the evaluation of nasal fractures. INTRODUCTION - PURPOSE: There is increasing use of ultrasonography in the Emergency Dept (ED) and other areas. The purpose of the present study was to evaluate the sensitivity and specificity of bedside ultrasonography with conventional radiographs in the evaluation of nasal fractures in the ED. METHOD: Patients admitted to ED with maxillofacial trauma were evaluated in this prospective study. Ultrasonography scans of the patients were taken by the emergency physician at the bedside. The images were obtained from both laterals and parallel to the nasal dorsum. The nasal radiography scans were evaluated by an experienced radiologist blinded to the study. The ultrasonography and radiography results were compared statistically. RESULTS: The study included 103 patients. In showing the presence of nasal fracture, the sensitivity of ultrasonography was determined to be 84.8% (95% CI 71.13%-93.66%), specificity was 93.0% (95% CI 83.00%-98.05%), positive predictive value (PPV) was 90.7% (95% CI 77.86%-97.41%), negative predictive value (NPV) was 88.3% (95% CI 77.43%-95.18%). CONCLUSION: Ultrasonography can be used in ED as an alternative method to conventional radiography with high rates of sensitivity and specificity in the evaluation of nasal fractures.

Effects of cigarette smoking on cortical thickness in major depressive disorder.

Findings of surface-based morphometry studies in major depressive disorder (MDD) are still inconsistent. Given that cigarette smoking is highly prevalent in MDD and has documented negative effects on the brain, it is possible that some of the inconsistencies may be partly explained by cigarette use. The aim of the current study was to examine the influence of cigarette smoking on brain structure in MDD. 50 MDD patients (25 smokers and 25 non-smokers) and 22 age, education, gender and BMI matched non-smoker healthy controls underwent structural magnetic resonance imaging. Thickness and area of the cortex were measured using surface-based morphometry implemented with Freesurfer (v5.3.0). The non-smoker MDD patients had significantly increased cortical thickness, including in the left temporal cortex (p < 0.001), right insular cortex (p = 0.033) and left pre- and postcentral gyrus (p = 0.045), compared to healthy controls. We also found decreased cortical thickness in MDD patients who smoked compared to non-smoking patients in regions that overlapped with the regions found to be increased in non-smoking patients in comparison to controls. Non-smoker MDD patients had increased surface area in the right lateral occipital cortex (p = 0.009). We did not find any region where cortical thickness or surface area significantly differed between controls and either smoker MDD patients or all MDD patients. The findings of the current study suggest that cigarette smoking is associated with cortical thinning in regions found to be increased in patients with MDD. However, these results should be considered preliminary due to methodological limitations.

The new classification system for inner ear malformations: the INCAV system.

CONCLUSIONS: The proposed INCAV system standardizes reporting of inner ear malformations; gives adequate information about the structures of inner ear; defines the ears which could not be classified before; and helps in the selection of the ear as the cochlear implant candidate. Also it is easy-to-use for radiologists, and useful to the referring otolaryngologists. OBJECTIVE: This study was conducted to explore a more specific, definitive classification system which was based on radiological criteria for inner ear malformations. METHOD: This study found 43 patients who had inner ear malformations, magnetic resonance (MR), and computed tomography (CT) imaging, together with the retrospective evaluation of the medical records between August 2010 and February 2015. It analyzed inner ear structures by dividing five sub-groups and each sub-group was given a letter: internal acoustic canal (I), cochlear nerve (N), cochlea (C), vestibular aqueduct (A) and vestibule (V). Based on their malformations, these anatomical structures have been assigned grades and have been classified by using increasing numbers which were dependent to increasing order of severity of the malformation. RESULTS: Among these 43 patients, there were six normal (I0N0C0A0V0) and 80 inner ear malformations. All of the ears were defined successfully by the INCAV system.