Surgical excision of giant vulvar angiofibroma: A case report and a review of literature.

RATIONALE: Cellular angiofibroma (CA) is a rare tumor of the soft tissue classified as a benign fibroblastic/myofibroblastic tumor. Considering this, the literature regarding CA mainly, but not exclusively, comprises single case reports and case series. Here, we report a case of giant CA of the vulva with comprehensive literature review. PATIENT CONCERNS: We present a case of a massive vulvar CA arising in 53-year-old woman with no notable medical or surgical history. The mass has grown considerably over time, causing pain and difficult urination, defecation, and movement. The patient had normal regular menstrual cycle with no previous contraception use. Vaginal examination exposed a right-sided large tender vulvar mass with normal-looking vagina. DIAGNOSES: Pelvic magnetic resonance imaging with contrast revealed a large right vulvar heterogeneously enhancing soft tissue mass measuring 13.1 × 10.9 × 10.7 cm expending the left vulva, with internal and peripheral voids resembling feeding vessels. The mass was surgically removed, and subsequent histopathology showed skin-covered dermal-based lesion composed of fibroblast-like bland and spindle cell proliferation with thin-walled blood vessels of various sizes. Immunohistostaining of CD34 and smooth muscle antigen were both positive, while desmin was found to be negative. A diagnosis of vulvar angiofibroma was made based on the clinical scenario, imaging, and histopathology. INTERVENTIONS: Mass vulvectomy was performed starting with a circumferential incision at the base of the mass and structural dissection to separate the mass from the vulvar wall. The incision was successfully closed, and subcuticular stitches were applied to the skin. OUTCOMES: The patient's complaints were significantly relieved with no postoperative complications and the patient is being followed regularly in an outpatient setting. LESSONS: Due to its extremely benign nature of CA, and the implausible ability of its recurrence, it was decided to surgically excise it. Despite its rarity, it can be readily identified at its earlier stages preventing the vexing and exasperating symptoms accompanied with increased size as mentioned.

A Striking Case of Perfusion-Metabolism "Flip-Flop" in a Patient With Left Anterior Descending Artery Total Occlusion.

ABSTRACT: A 57-year-old man diagnosed with left anterior descending artery chronic total occlusion underwent rest gated 99mTc-MIBI scan showing moderately to markedly decreased perfusion with abnormal wall motion in the apex, anterior, anteroseptal, and apical anterolateral walls. 18F-FDG PET showed a "flip-flop" phenomenon with markedly increased FDG uptake in the hypoperfused regions and absent/markedly decreased uptake in the normally perfused, normokinetic myocardium, presumably due to the predominant use of free fatty acids under normoxic conditions. After coronary artery bypass grafting, left ventricular motion normalized except for surgery-related paradoxical septal motion and the left ventricular ejection fraction improved from 52% to 68%.

Back Pain in Children and Diagnostic Value of (99m)Tc MDP Bone Scintigraphy.

AIM: The aim of our study is to assess the diagnostic value of Technituim-(99m)-Methyle diphosphonate ((99m)Tc-MDP) Bone scintigraphy in the assessment of children with back pain. METHODS: Included in this retrospective study were 68 child referred to us complaining of back pain (mean age of 13+ 2). There were 45 boys and 23 girls. All children have been investigated with conventional x-ray which revealed normal or inconclusive result. All underwent bone scintigraphy after the injection of (99m)Tc-MDP with calculated doses according to there body weights. RESULTS: Bone scintigraphy revealed 17 (25%) abnormal scans in 11 boys and 6 girls. Scans findings were suggestive of spondylolysis (n=4); malignancy including primary tumors and metastases (n=3); infection including osteomyelitis and discitis (n=3); sacroiliitis (n=2); benign tumors (n=2); pseudo fractures in ribs (n=1); necrosis in femoral head epiphysis(n=1) and nonskeletal-renal retention due to hydronephrosis (n=1). Sensitivity, specificity and accuracy of bone scan in detecting gross skeletal abnormality as a cause for back pain were 94% and 100% and 99% respectively. CONCLUSION: Bone isotope scan is a sensitive imaging modality in the assessment of pediatric patients with back pain. It is a reliable modality to detect and role out most benign and aggressive serious etiologies.

The value of F-18 FDG PET in patients with primary sclerosing cholangitis and cholangiocarcinoma using visual and semiquantitative analysis.

AIM: The aim of this study was to assess the value of 18F-fluorodeoxyglucose positron emission tomography (F-18 FDG PET) in patients with suspected cholangiocarcinoma (CC). METHODS: Sixty-five patients with suspected CC were included in this retrospective study. All patients had whole-body FDG PET/CT imaging at a mean time of 100 minutes after administration of FDG injection. PET studies were analyzed using visual analysis and semiquantitative analysis. Semiquantitative analysis was performed using maximum standardized uptake value (SUVmax) and tumor-to-normal liver (T/N) ratio. Malignancy was defined using the following criteria: (1) Visual analysis; (2) SUVmax >3.9; (3) T/N >1.6. Analysis of variance test and receiver operating characteristic analysis were used in statistical analysis. P < 0.05 was considered significant. RESULTS: Follow-up revealed 47 patients with CC. The average SUVmax in CC tumors was 8 ± 2.9 versus 3 ± 1 in benign lesions (P < 0.0001). The average T/N in malignant lesions was 3.5 ± 1.8 versus 1.3 ± 0.4 in benign lesions (P < 0.0001). Sensitivity, specificity, and accuracy for the 3 criteria were as follows: (1) 96%, 67%, and 88%; (2) 94%, 83%, and 91%; (3) 89%, 78%, and 86%. CONCLUSION: F-18 FDG PET semiquantitative analysis using SUVmax >3.9 as criterion for malignancy could improve the diagnostic accuracy in differentiating malignant from benign lesions in patients with suspected CC.

Impact of dual-time-point F-18 FDG PET/CT in the assessment of pleural effusion in patients with non-small-cell lung cancer.

AIM: The aim of this study was to assess the utility of dual-time-point F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) in differentiating benign from malignant pleural disease, in patients with non-small-cell lung cancer. METHODS: A total of 61 patients with non-small-cell lung cancer and pleural effusion were included in this retrospective study. All patients had whole-body FDG PET/CT imaging at 60 ± 10 minutes post-FDG injection, whereas 31 patients had second-time delayed imaging repeated at 90 ± 10 minutes for the chest. Maximum standardized uptake values (SUV(max)) and the average percent change in SUV(max) (%SUV) between time point 1 and time point 2 were calculated. Malignancy was defined using the following criteria: (1) visual assessment using 3-points grading scale; (2) SUV(max) ≥2.4; (3) %SUV ≥ +9; and (4) SUV(max) ≥2.4 and/or %SUV ≥ +9. Analysis of variance test and receiver operating characteristic analysis were used in statistical analysis. P < 0.05 was considered significant. RESULTS: Follow-up revealed 29 patient with malignant pleural disease and 31 patients with benign pleural effusion. The average SUV(max) in malignant effusions was 6.5 ± 4 versus 2.2 ± 0.9 in benign effusions (P < 0.0001). The average %SUV in malignant effusions was +13 ± 10 versus -8 ± 11 in benign effusions (P < 0.0004). Sensitivity, specificity, and accuracy for the 5 criteria were as follows: (1) 86%, 72%, and 79%; (2) 93%, 72%, and 82%; (3) 67%, 94%, and 81%; (4) 100%, 94%, and 97%. CONCLUSIONS: Dual-time-point F-18 FDG PET can improve the diagnostic accuracy in differentiating benign from malignant pleural disease, with high sensitivity and good specificity.

Quantitative assessment of the hepatic metabolic volume product in patients with diffuse hepatic steatosis and normal controls through use of FDG-PET and MR imaging: a novel concept.

AIMS AND OBJECTIVES: The aim of this study was to compare hepatic standardized uptake values (SUVs) and hepatic metabolic volumetric products (HMVP) between patients of diffuse hepatic steatosis and control subjects with normal livers. MATERIALS AND METHODS: Twenty-seven subjects were included in the study (13 men and 14 women; age range, 34-72 years). All had 18F-2-fluoro-2-D-deoxyglucose-positron emission tomography (FDG-PET) and magnetic resonance imaging (MRI) scans with an interscan interval of 0-5 months. Twelve of 27 subjects had diffuse hepatic steatosis on MRI. The remaining 15 were selected as age-matched controls based on normal liver parenchyma on MRI. Mean and maximum hepatic SUVs were calculated for both patient groups on FDG-PET images. Hepatic volumes were measured from MRI. HMVP in each subject was subsequently calculated by multiplication of hepatic volume by mean hepatic SUV. HMVPs as well as mean and maximum hepatic SUVs were compared between the two study groups. RESULTS: HMVPs, mean hepatic SUVs, and maximum hepatic SUVs were greater (statistically significant, p < 0.05) in subjects with diffuse hepatic steatosis compared to those in the control group. CONCLUSION: The increase in HMVP is the result of increased hepatic metabolic activity likely related to the diffuse hepatic steatosis. The active inflammatory process related to the diffuse hepatic steatosis is the probable explanation for the increase in hepatic metabolic activity on FDG-PET study.

Quantitative assessment of FDG uptake in brown fat using standardized uptake value and dual-time-point scanning.

OBJECTIVES: Brown fat is a potential source of false-positive findings on FDG PET. The purpose of this study was to show the variability in body distribution of brown fat, the degree of FDG uptake, the changes on dual-time-point scanning, and determine if dual-time-point scanning can help in differentiating brown fat from malignant lesions. METHODS: Thirty-two patients were included in this retrospective study (14 male, 18 female, age range: 8-72 years). All patients had hypermetabolic brown fat activity on FDG PET imaging confirmed by computed tomography (CT) scanning. All patients underwent 2 sequential FDG PET scanning (dual-time-point imaging). The average percent change in maximum standardized uptake value (SUVmax) for 120 brown fat spots between time point 1 and time point 2 was calculated. RESULTS: Body distribution of hypermetabolic brown fat in the 32 patients included supraclavicular area (n = 7); cervical and supraclavicular (n = 5); cervical, supraclavicular, and axillae (n = 5); cervical area, supraclavicular, axillae, and paravertebral (n = 8); supraclavicular, cervical, axillae, paravertebral, and mediastinum (n = 4); supraclavicular, cervical, axillae, paravertebral, and upper abdomen (n = 2); and supraclavicular, cervical, axillae, paravertebral, mediastinum, and intercostals (n = 1). SUVmax for brown fat spots ranged from 0.8 to 12.4 and mean SUV was 4.6 + 1.6. On dual-time-point imaging, 91 (76%) of the brown fat spots demonstrated an increase in SUVmax that ranged from 12% to 192% and mean value of 42%, whereas 16 (13%) brown fat spots did not show any change and 11 (11%) spots underwent a drop in SUVmax by 4% to 12%. There was an increase in the number of active brown fat spots in 3 patients on the second time images. CONCLUSIONS: Brown fat is a potential source of false positives, which has wide variability in distribution and degree of FDG uptake. On dual-time-point scanning, there is a progressive increase in FDG uptake within most of the hypermetabolic brown fat areas that mimic malignant lesions.

Impact of dual-time-point (18)F-FDG PET imaging and partial volume correction in the assessment of solitary pulmonary nodules.

PURPOSE: Our aim was to assess the diagnostic potential of (18)F-FDG PET using partial volume correction and dual-time-point imaging in the assessment of solitary pulmonary nodules. METHODS: We included 265 patients in this retrospective study (171 men; 94 women; age range, 41-92 years). All had pulmonary nodules on CT, and diagnosis was confirmed by biopsy or follow-up CT. All underwent whole body FDG PET, 60 min after FDG injection. Of the 265 patients, 255 underwent second FDG PET for chest 100 min after injection. Maximum SUVs for nodules were calculated from both scans. Partial volume correction for first time SUVs was applied, using coefficient factor. Malignancy was defined using the following criteria: (1) Visual assessment; (2) First time SUV > or = 2.5; (3) Partial volume corrected first time SUV > or = 2.5; (4) second time SUV > or = 2.5; (5) Increase in SUV over time; (6) Increase or no change in SUV; (7) First time SUV > or = 2.5 and/or increase or no change in SUV. RESULTS: Biopsy and follow-up revealed 72 malignant lung nodules and 193 benign nodules. Sensitivity, specificity and accuracy for the five criteria were as follows: (1) 97, 58 and 68%; (2) 65, 92 and 85%; (3) 84, 91 and 89%; (4) 90, 80 and 83%; (5) 84, 95 and 92%; (6) 92, 92, and 92%; (7) 95, 90 and 91%, respectively. CONCLUSION: Dual-time-point (18)F-FDG PET has potential impact on improving the diagnostic accuracy for malignant lung nodules. Dual-time-point (18)F-FDG PET imaging should be included in the clinical work-up of patients with pulmonary nodule.

Determination of age-related changes in structure and function of skin, adipose tissue, and skeletal muscle with computed tomography, magnetic resonance imaging, and positron emission tomography.

In this article, we report quantitative preliminary data obtained from retrospective analysis of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) and combined PET-computed tomography (PET/CT) examinations in subjects ages 3 to 84 years pertaining to changes in the metabolism of skin, subcutaneous adipose tissue, visceral adipose tissue, and skeletal muscle with age, as well as age-related changes in skeletal muscle attenuation. We also propose a new method for identifying hypermetabolic brown fat on FDG-PET. Finally, we present a review of the literature regarding reported age-related structural and functional changes that occur in skin, fat, and skeletal muscle. Using FDG-PET, We evaluated 213 subjects for changes in the metabolism of skin, adipose tissue, and skeletal muscle with aging. Thirty-two separate subjects were chosen to measure maximum standardized uptake value (SUV) of hypermetabolic brown fat on dual-time point PET imaging. Finally, 15 subjects evaluated by PET/CT were selected to measure changes in metabolism and attenuation of skeletal muscle, and changes in metabolism of adipose tissue with aging. We found that skin, fat, and skeletal muscle all demonstrate significant (P < 0.05) increases in SUV with increasing age on PET imaging. Dual-time point PET imaging demonstrates increasing FDG uptake of hypermetabolic brown fat in various regions studied. Finally, our PET/CT studies revealed statistically insignificant (P > 0.05) decreases in SUV of adipose tissue with aging and the opposite trend in skeletal muscles (P > 0.05). Skeletal muscle attenuation in the various regions studied was found to significantly decrease with age (P < 0.05). Our study shows notable trends in metabolism and attenuation of skeletal muscle and metabolism of skin and adipose tissue that occur with normal aging. We hope that the methodologies and data we present here will serve as a useful starting point for those interested in conducting future prospective research on age-related changes in these structures.

Quantitative assessment of the atherosclerotic burden of the aorta by combined FDG-PET and CT image analysis: a new concept.

INTRODUCTION: Our objective was to develop a technique for quantifying the extent of atherosclerosis in the aorta by combining standard uptake values (SUVs) in the aortic wall with volumetric data provided by computed tomography (CT). METHODS: Eighteen patients who had both 18-fluorodeoxyglucose (FDG)-positron emission tomography (PET) and contrast-enhanced CT of the chest and abdomen were selected. All had homogeneous diffuse FDG wall uptake in four segments of the aorta. We divided the patients into three groups according to their age and measured FDG uptake in all four segments of the aorta by calculating the mean SUV for each segment. On each axial CT image, region-of-interest tracings along the inner and outer wall contours of the aorta were generated. The inner surface area was subtracted from the outer surface area. The net area values for each segment were subsequently multiplied by slice thickness to calculate arterial wall volume. By multiplying SUV with wall volume, we were able to calculate the atherosclerotic burden (AB) for each segment of the aorta. We compared the aortic wall volumes, SUVs and AB values in each arterial segment for each age group. RESULTS: In each aortic wall segment, AB values, SUVs and wall volumes increased with age (P<.05). CONCLUSION: AB can be used as an indicator of the extent of the atherosclerotic process in the aorta through the use of both metabolic and morphologic data provided by FDG-PET and CT, respectively. This may allow for the optimal screening, diagnosis and management of patients with this common and potentially lethal disorder.