A Case Presenting with Neck Pain and High Sedimentation Rate: Amyloid Goiter.

INTRODUCTION: Amyloid goiter is a rare disease characterized by amyloid deposits that cause sudden growth in the thyroid gland. CASE PRESENTATION: Here we present a case of a 26-year-old woman with euthyroid amyloid goiter who presented with subacute granulomatous thyroiditis clinic. Amyloid goiter was detected as a result of core biopsy from the thyroid parenchyma of the patient with sudden thyroid enlargement. Surgery was not applied to the patient who had no pressure symptoms or signs. In systemic amyloidosis secondary to Familial Mediterranean fever, involvement was found in the heart, kidney, liver, and intestines, except for the thyroid. CONCLUSION: Amyloid accumulation should be considered in addition to anaplastic thyroid cancer and lymphoma in patients with sudden thyroid enlargement. It should not be overlooked that amyloid goiter may mimic subacute thyroiditis clinic. Systemic amyloidosis should be considered in patients with amyloid goiter, and an examination should be made to assess the presence of amyloid accumulations in other organs.

Outcomes of high-risk breast lesions diagnosed using image-guided core needle biopsy: results from a multicenter retrospective study.

PURPOSE: The clinical management of high-risk lesions using image-guided biopsy is challenging. This study aimed to evaluate the rates at which such lesions were upgraded to malignancy and identify possible predictive factors for upgrading high-risk lesions. METHODS: This retrospective multicenter analysis included 1.343 patients diagnosed with high-risk lesions using an image-guided core needle or vacuum-assisted biopsy (VAB). Only patients managed using an excisional biopsy or with at least one year of documented radiological follow-up were included. For each, the Breast Imaging Reporting and Data System (BI-RADS) category, number of samples, needle thickness, and lesion size were correlated with malignancy upgrade rates in different histologic subtypes. Pearson's chi-squared test, the Fisher-Freeman-Halton test, and Fisher's exact test were used for the statistical analyses. RESULTS: The overall upgrade rate was 20.6%, with the highest rates in the subtypes of intraductal papilloma (IP) with atypia (44.7%; 55/123), followed by atypical ductal hyperplasia (ADH) (38.4%; 144/375), lobular neoplasia (LN) (12.7%; 7/55), papilloma without atypia (9.4%; 58/611), flat epithelial atypia (FEA) (8.7%; 10/114), and radial scars (RSs) (4.6%; 3/65). There was a significant relationship between the upgrade rate and BI-RADS category, number of samples, and lesion size Lesion size was the most predictive factor for an upgrade in all subtypes. CONCLUSION: ADH and atypical IP showed considerable upgrade rates to malignancy, requiring surgical excision. The LN, IP without atypia, pure FEA, and RS subtypes showed lower malignancy rates when the BI-RADS category was lower and in smaller lesions that had been adequately sampled using VAB. After being discussed in a multidisciplinary meeting, these cases could be managed with follow-up instead of excision.

DCE-MRI Radiomics Analysis in Differentiating Luminal A and Luminal B Breast Cancer Molecular Subtypes.

RATIONALE AND OBJECTIVES: The aim of the present study was to investigate the association between Luminal A and Luminal B molecular subtypes and radiomic features of dynamic contrast­enhanced magnetic resonance imaging in patients with invasive breast cancer. MATERIALS AND METHODS: Seventy-three patients with histopathologically proven invasive ductal cancer (IDC) were selected. Tumors were classified into molecular subtypes: Luminal A (estrogen receptor (ER)-positive and/or progesterone receptor (PR)-positive, human epidermal growth factor receptor type 2 (HER2) -negative, proliferation marker Ki-67<20) and Luminal B (ER-positive and/or PR-positive, HER2-positive or HER2-negative with high Ki-67 ≥20). A total of 81 tumoral lesions were evaluated on T1-weighted fat-suppressed sagittal post-contrast late-phase MRI images after the required "pre-process" steps and 3D segmentations were made. Forty-three radiomic features including: 1 conventional, 4 shape, 6 histogram, 7 Grey-Level Co-occurrence Matrix (GLCM), 11 Grey-Level Run-Length Matrix (GLRLM), 3 Neighborhood Grey-Level Difference Matrix (NGLDM), 11 Grey-Level Zone-Length Matrix (GLZLM) were extracted by using the software LIFEX. RESULTS: A statistically significant difference was found in radiomic features including; a) Histogram: "skewness", b) Shape: "volume-ml, volume-voxel," c) GLCM: "entropy.log10, entropy.log2, energy", d) GLRLM: "GLNU, RLNU, HGRE," e) NGLDM: "busyness," f) GLZLM: "GLNU, HGZE, ZLNU, SZE" between two different molecular subtypes. The model combining Shape-volume (ml) and GLZLM-HGZE yielded 0.746 area under the curve (AUC), 0.744 sensitivity, 0.643 specificity and 0.694 accuracy. CONCLUSION: Radiomic properties that may distinguish Luminal A and Luminal B molecular subtypes of IDC were identified. The radiomic features were thought to reflect the intratumoral heterogeneity in molecular subtypes. This study demonstrated that the characterization of Luminal A and Luminal B tumors could be made non-invasively by radiomics analysis.

Management of granulomatous lobular mastitis: an international multidisciplinary consensus (2021 edition).

Granulomatous lobular mastitis (GLM) is a rare and chronic benign inflammatory disease of the breast. Difficulties exist in the management of GLM for many front-line surgeons and medical specialists who care for patients with inflammatory disorders of the breast. This consensus is summarized to establish evidence-based recommendations for the management of GLM. Literature was reviewed using PubMed from January 1, 1971 to July 31, 2020. Sixty-six international experienced multidisciplinary experts from 11 countries or regions were invited to review the evidence. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Experts discussed and concluded 30 recommendations on historical definitions, etiology and predisposing factors, diagnosis criteria, treatment, clinical stages, relapse and recurrence of GLM. GLM was recommended as a widely accepted definition. In addition, this consensus introduced a new clinical stages and management algorithm for GLM to provide individual treatment strategies. In conclusion, diagnosis of GLM depends on a combination of history, clinical manifestations, imaging examinations, laboratory examinations and pathology. The approach to treatment of GLM should be applied according to the different clinical stage of GLM. This evidence-based consensus would be valuable to assist front-line surgeons and medical specialists in the optimal management of GLM.

The relationship between apelin and carotid intima media thickness, and the presence of plaque in dialysis patients.

BACKGROUND: Apelin is a peptide that has important effects on the cardiovascular system due to its anti-atherogenic properties and regulating blood pressure. There is not enough research evaluating the effects of apelin levels on the cardiovascular system in hemodialysis (HD) and peritoneal dialysis (PD) patients concurrently. The aim of this study was to determine apelin levels in dialysis, and control groups and to investigate the relationship between apelin and carotid intima media thickness (CIMT). MATERIALS AND METHODS: Thirty three HD patients, 35 PD patients, and 15 healthy individuals were included in the study. All laboratory data, N-terminal pro-B-type natriuretic peptide (NT-proBNP), IL-6, and apelin-13 levels were analyzed. To prevent interobserver errors in CIMT measurement, the analyses were performed by a single radiologist. RESULT: CIMT, presence of plaque, apelin, NT-proBNP, IL-6, and C-reactive protein (CRP) levels were higher in dialysis patients. There was a relationship between apelin and CIMT, and between apelin and high-density lipoprotein (HDL) in PD patients. Age, apelin, HDL, parathormone (PTH), glucose, and smoking were found to affect the presence of plaque in dialysis patients. CONCLUSION: Apelin levels were high in dialysis patients. Especially in PD patients, there was a negative correlation between apelin and CIMT, and between apelin and HDL. Therefore, apelin may play a role in the pathogenesis of cardiovascular diseases in PD patients.

Using the Superb Microvascular Imaging Method in the Distinction of Intraductal Papilloma and Duct Ectasia With Secretion.

OBJECTIVES: To investigate the diagnostic value of a Superb Microvascular Imaging (SMI; Toshiba Medical Systems, Tokyo, Japan) Doppler examination for distinguishing intraductal papilloma (IDP) from duct ectasia with secretion in lesions smaller than 1 cm compared to color Doppler imaging (CDI) and power Doppler imaging (PDI). METHODS: Fifty-nine lesions were evaluated by grayscale ultrasound, CDI, PDI, and SMI. Biopsied tissue samples were analyzed. Ultrasound evaluations and Doppler examinations were performed with a Toshiba Aplio 500 device. The lesions were divided into 2 groups, secretion and IDP, according to the pathologic results. Color Doppler imaging, PDI, and SMI data were compared statistically to investigate their diagnostic values. RESULTS: Of the 59 lesions, 22 were secretion, and 37 were IDP. The mean diameters ± SDs were 4.7 ± 0.6 mm in the secretion group and 4.9 ± 0.8 mm in the IDP group (P = .315). There was no significant difference in grayscale ultrasound features such as shape or margin between the groups (P > .05). No significant difference was found between the groups in CDI or PDI characteristics (P > .999; P = .702, respectively). The color SMI evaluation results showed no vascularity in 18 (81.8%) lesions in the secretion group. Vascularity was detected in 32 patients (86.5%) in the IDP group. In the receiver operating characteristic analysis, the areas under the curve were calculated as 0.842 (95% confidence interval [CI], 0.728-0.925) for SMI, 0.522 (95% CI, 0.388-0.654) for PDI, and 0.518 (95% CI, 0.384-0.650) for CDI. CONCLUSIONS: Superb Microvascular Imaging is more accurate and has more diagnostic ability than CDI or PDI in distinguishing small IDPs from duct ectasia with secretion because of its ability to visualize slow flow speeds of vascular structures.

Can T1 mapping be an alternative of post-contrast magnetic resonance sequences in patients with surgically corrected tetralogy of Fallot?

OBJECTIVE: The objective of this study is to investigate the ability of native T1 mapping in the determination of myocardial fibrosis in patients with surgically corrected tetralogy of Fallot (TOF). METHODS: We included 35 patients with surgically corrected TOF who underwent cardiac magnetic resonance imaging in this study. Additionally, we added pre- and post-contrast T1 mapping sequences at the right ventricular outflow tract (RVOT) and short-axis planes to the routine protocol. We visually evaluated the pre-contrast native T1 mapping images to determine the presence of areas with higher T1 times that indicate focal fibrosis. We compared the findings with the findings of post-contrast images. RESULTS: In 22 of the 35 cases, RVOT enhancement was observed in the delayed enhancement images; however, none of these cases could be distinguished on the native T1 maps. When compared to post-contrast imaging, 28 of the 30 contrast enhancements at right ventricle insertion points and 14 of the 17 contrast enhancements at the remaining left ventricle walls were visually observed on the color-coded native T1 maps. The sensitivity, specificity, positive and negative predictive values of native T1 mapping for the detection of focal fibrosis at the right ventricle insertion points were found to be 93.3%, 100%, 100%, and 71.4%, respectively, whereas these values were found to be 82.4%, 100%, 100%, and 85.8% in the detection of fibrosis in the remaining left ventricle walls. CONCLUSION: Native T1 mapping is valuable in the detection of focal fibrosis at the right ventricle insertion points and the remaining left ventricle walls; however, it was not possible to visually detect RVOT fibrosis by native T1 mapping. Hence, T1 mapping may not replace the contrast-enhanced imaging in patients with surgically corrected TOF.

Do Histopathological Features and Microcalcification Affect the Elasticity of Breast Cancer?

OBJECTIVES: The aim of this study was to evaluate any association between histological grade, molecular subtypes of breast cancer, and strain elastography, and to investigate whether microcalcification affects the stiffness of tumor in breast cancers with the same histological grade. METHODS: Between April 2015 and March 2016, 94 lesions of 94 patients with the diagnosis of invasive ductal carcinoma were included in the study. Strain elastography was performed on all patients before biopsy. Histological grades (Grades 1, 2, and 3), molecular subtypes (luminal A, luminal B, Her-2, and basal-like), and strain ratio (SR) were compared. In the same histological grades, patients were divided into two groups according to the presence of microcalcifications, and the groups were compared with each other. RESULTS: Compared with Grades 1 (20.5) and 2 (23.7), Grade 3 (11.7) showed lower SR values (Grade 3-2, P = .01; Grade 3-1, P = .2). The groups with microcalcification had slightly higher SR in all histological grades, but not of statistical significance. In molecular subtypes, luminal A and B demonstrated higher SR, whereas HER2 and basal-like had lower SR (P > .05 for all group comparisons). CONCLUSIONS: Grade 3 invasive ductal carcinomas are different from other grades with lower SR values. The presence of microcalcifications and molecular subtypes do not affect elasticity like a high histological grade does.

Imaging Findings in Patients with Granulomatous Mastitis.

BACKGROUND: Granulomatous mastitis (GM) is a rare inflammatory breast disease that may mimic the clinical characteristics and radiologic imaging findings of breast carcinoma. Considering the importance of making a correct diagnosis, careful radiologic evaluations and recognition of imaging features are necessary. OBJECTIVES: The aim of this study was to review the radiological findings and diagnostic value of the imaging in GM. PATIENTS AND METHODS: This retrospective study involved a total of 29 patients who were diagnosed with GM between 2009 and 2013 and who underwent mammography (MG) and/or ultrasound (US) examination in addition to magnetic resonance imaging (MRI) before diagnosis. RESULTS: Among 14 patients over 35 years of age who underwent MG imaging, focal asymmetric, ill-defined nodular, or diffusely increased densities were detected in nine (64.3%), two (14.3%), and one (7.1%) subjects, respectively, while there were no pathological findings in two (14.3%) patients. In the overall group of 29 patients, US showed heterogeneous hypoechoic lesions with tubular extensions in 16 (55.2%), well-demarcated heterogeneous hypoechoic lesions in eight (27.6%), parenchymal heterogeneous appearance in three (10.3%), and a heterogeneous hypoechoic lesion with irregular margins in one (3.4%), with another (3.4%) patient having normal US findings. MRI findings included lesions consistent with solitary or multiple separate or confluent abscesses with marked peripheral ring enhancement in 25 (86.2%) patients, accompanied by intensity changes suggesting edematous inflammation in the peripheral parenchyma, as well as non-mass-like heterogeneous segmental and regional contrast enhancement. Four (13.8%) patients had non-mass-like segmental and regional contrast enhancement only. A histopathological diagnosis of GM was established in all patients with biopsy. CONCLUSION: GM presents with a wide range of conventional radiological findings, hampering the diagnosis. In patients with inconclusive conventional findings, MRI may assist in the differential diagnosis and assessment of the extent of disease. However, a definitive diagnosis and relevant treatment require histopathological confirmation.

Effect of a combined oral contraceptive on patency of arterial anastomosis in a female rat model.

BACKGROUND: Oral contraceptives, which may lead to thrombotic events, are widely used drugs by women in reproductive age, some of whom might need emergent or elective microsurgical intervention. This study was planned to investigate the effects of combined oral contraceptives (COC) on arterial anastomosis patency in female rat model. METHODS: A third generation COC (ethinyl estradiol and desogestrel) was used in this study. A total of 50 female Wistar albino rats were included. The rats were divided into two groups. Experimental group received 0.03 mg ethinyl estradiol/0.15 mg desogestrel with gastric catheter for 20 days before the surgery. Afterward, the femoral arteries of all rats were divided and anastomosed. The patency of the anastomoses were assessed surgically (at 15 min, 7th day) and radiologically with Doppler ultrasonography (at 3rd and 7th days). The samples were examined using light microscopy, scanning electron microscopy (SEM), and transmission electron microscopy (TEM). RESULTS: The early patency assessed in the 15th min showed arterial flow in all rats. But at the 7th day 68% of the anastomosis were patent in the COC group while 100% of the anastomosis were patent in the control group as demonstrated surgically and radiologically (P = 0.004). Microscopic examination showed an increase in cytoplasmic organelles and activation of endothelial cells in all rats in the experimental group that received COCs. CONCLUSION: The present study demonstrated the negative effects of the use of COCs on anastomosis patency in rats.

Variants of the popliteal artery terminal branches as detected by multidetector ct angiography.

OBJECTIVE: To evaluate variants of the popliteal artery (PA) terminal branches with 64-multidetector computed tomographic angiography (64-MD CTA). MATERIALS AND METHODS: A total of 495 extremities (251 right, 244 left) of 253 patients undergoing a 64-MD CTA examination were included in the study. Of these, 242 extremities were evaluated bilaterally, whereas 11 were evaluated unilaterally. The terminal branching pattern of the PA was classified according to the classification scheme proposed by Kim; the distance between the medial tibial plateau and the origin of the anterior tibial artery (A) and the length of the tibioperoneal trunk (B) have been measured and recorded. RESULTS: In 459 cases (92.7%) branching of PA occurred distal to the knee joint (Type I); in 18 cases (2.8%) PA branching was superior to the knee joint (Type II); and hypoplasia of the PA branches was found in 27 cases (5.5%) (Type III). Among these types the most frequent branching patterns were Type IA (87.5%), Type IIIA (3.9%), and Type IB (3.8%). The ranges of A and B mean distances were 47.6 mm and 29.6 mm, respectively. CONCLUSION: Variations in popliteal artery terminal branching pattern occurred in 7.4% to 17.6% of patients. Pre-surgical detection of these variations with MD CTA may help to reduce the risk of iatrogenic arterial injury by enabling a better surgical treatment plan.

Magnetic resonance imaging of the breast as a problem-solving method: to be or not to be?

The use of dynamic magnetic resonance imaging (MRI) of the breast as a complementary problem-solving tool was explored in a heterogeneous population sample. A total of 3,076 patients that underwent breast MRI examination between January 2008 and June 2012 in our center were screened retrospectively. Of these, 868 met the following inclusion criteria and were considered eligible for the study: available data on clinical signs, symptoms and on the results of mammography and ultrasound examinations in medical records; at least 1 year of follow-up; and documented pathology findings. Lesions with a stable course over a follow-up period of at least 12 months were considered benign. MRI was suggestive of a suspicious abnormality (BI-RADS 4) or highly suggestive of malignancy (BI-RADS 5) in 129 (15%) of 868 patients, leading to a biopsy examination in these cases. On the other hand, MRI findings were considered normal in 739 (85%) subjects based on normal (BI-RADS 1), benign (BI-RADS 2) or probably benign (BI-RADS 3) findings. Of the 129 patients undergoing a histopathologic examination based on MRI findings, 63 were diagnosed with cancer, and in 66, the biopsy proved to be benign. Forty of the 63 patients (40/63) with a diagnosis of malignancy and 34 of the 66 patients (34/66) with a benign diagnosis had been categorized as BI-RADS 4 with conventional methods. A total of 23 patients with BI-RADS category of 0 to 3 according to conventional methods were diagnosed as having cancer with MRI. In six of these, the family history was positive. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of MRI for the detection of cancer were 100%, 92%, 52%, and 100%, respectively. In cases with inconclusive findings on conventional imaging studies or in patients with clinical/radiological suspicion of malignancy, MRI should be more effectively used as a problem-solving approach owing to its high sensitivity and NPV in this condition. Use of MRI as a problem-solving method in such cases may decrease rather than increase unnecessary biopsy procedures and patient anxiety.

Primary orbital hydatid cyst: computed tomography and magnetic resonance imaging findings.

Orbital hydatid cyst is a rare form of hydatidosis, comprising less than 1% of all hydatid cysts reported. The first choice of treatment for orbital hydatid cyst is surgery. Preoperative diagnosis is important, so as to avoid rupture of the cyst and prevent the spread of the parasitic disease. Herein, we present the computed tomography and magnetic resonance imaging findings of a case of primary orbital hydatid cyst.

Recurrent atretic parietal cephalocele in adult and radiological findings.

Atretic parietal cephaloceles are an extremely rare and occult form of congenital herniations that involve the meninges, remnants of glial cells or central nervous system structures. They are detected as subscalp lesions that are covered by skin. In the literature, atretic parietal cephaloceles have been reported in children in 59 cases and in two cases in adults. We present here a case of a recurrent atretic parietal cephalocele that we recently observed in an adult. This case indicates that an atretic parietal cephalocele should always be considered in the differential diagnosis of subscalp lesions. Radiologic diagnosis is a lifesaving measure that can be undertaken before an operation. Additionally, regular follow-up magnetic resonance imaging is recommended for each case with remnant lesions due to the slow growth of these masses.

Carotid atherosclerosis and cardiovascular risk factors in hemodialysis and peritoneal dialysis patients.

BACKGROUND: Cardiovascular diseases are important factors in mortality and morbidity of dialysis patients. Cardiovascular risk assessment is important in order to arrange the treatment strategies. The aim of the study was to investigate the relationship between carotid atherosclerosis and various CVD risk factors in dialysis patients. METHODS: 22 HD and 54 PD patients were included in the study. Carotid artery intima media thickness (IMT) and plaque score (PS) were obtained by B-mode ultrasonography for each participant. Uric acid, albumin, bilirubin, lipid profile, apolipoprotein A-l (apo A-l), apolipoprotein B (apo B), lipoprotein(a) [Lp(a)], high-sensitivity CRP (hs-CRP), homocysteine (Hcy), vitamin A, vitamin E, sialic acid (SA) and thiobarbituric acid-reactive substances (TBARS) were determined. The differences of the cardiovascular risk factors between the patients according to the treatment modality and the comparison of the risk factors as indicators of IMT and PS were investigated. RESULTS: There was no significant difference in IMT and PS between the two groups. SA, TBARS, hs-CRP, total, HDL- and LDL-cholesterol, white blood cell (WBC) and erythrocyte sedimentation rate (ESR) levels were significantly higher; albumin levels were significantly lower in PD group. In multiple regression analysis, only bilirubin for IMT and SA for PS were independent predictors. CONCLUSIONS: SA can be a superior marker to hs-CRP in PD patients; however, hs-CRP seems to be a more valuable marker than SA in HD patients according to the correlation analysis. This study provides information and opportunity for comparison of relatively new cardiovascular risk markers in hemodialysis and peritoneal dialysis patients using carotid atherosclerosis as an objective assessment criterion.

Doppler ultrasound evaluation of the structural and hemodynamic changes in the brachial artery following two different exercise protocols.

PURPOSE: Examine the effects of incremental and submaximal exercise on structural and hemodynamic changes in the brachial artery flow parameters using Doppler ultrasonography. MATERIALS AND METHODS: Twenty four healthy sedentary males (aged 19.54+/-0.59) performed submaximal (15 minutes heart rate to 75% maximal) and incremental (workload was increased 20W every 3 minutes until exhaustion) exercises by upper extremity ergometer. Before and after exercises the brachial artery diameter, peak systolic maximum velocity (Vmax), end-diastolic minimum velocity (Vmin) and time-averaged mean flow velocity (Vmean), volume blood flow and flow waveform patterns were recorded in a controlled environment. RESULTS: The diameter of the brachial artery, flow velocities, and blood flow increased significantly after each exercise protocol (p < 0.001). The Vmax (p < 0.05), Vmean (p < 0.01), and volume blood flow (p < 0.01) after the incremental exercise were significantly higher than those measured after the submaximal exercise. However, no significant differences were noted between the two exercise protocols when arterial diameters and Vmin were concerned. The flow pattern was monophasic in all subjects after incremental exercise. Nevertheless, the flow pattern remained triphasic in two of the subjects after submaximal exercise. CONCLUSION: Blood flow velocities played important role in hemodynamic mechanism than conduit arterial diameter during arm exercises. Changes in conduit artery diameter did not significantly contribute to blood flow increase during high and moderate intensity exercises. There is minimal variation in waveform shapes of normal individuals after exercise. Doppler ultrasonography proved a practical tool in the studies of the dynamic responses of blood flow and vascular resistance during rest and exercises.