Rare association of solitary necrotic nodule of the liver with rheumatoid arthritis and systemic lupus erythematosus.

Solitary necrotic nodule of the liver (SNNL) is a rare benign lesion with uncertain etiology characterized by a "completely necrotic core" and a hyalinized capsule containing elastin fibers (Journal of Clinical Pathology 36:1181-1183, 1983). We report herein a 26-year-old woman with a previous diagnosis of rheumatoid arthritis, systemic lupus erythematosus, and Sjögren's syndrome and no history of malignancy who presented with a complaint of diarrhea of 1-year duration. In the abdominal ultrasound, multiple paraaortic, portocaval, and ileal lymphadenopathies (LAPs) have been found with the largest one being 2 cm in size. The biopsy of the iliac LAP showed reactive nodular hyperplasia. An abdominal CT disclosed an incidental hypoechoic, heterogenous mass sized 27 × 27 mm close to segment VI of the liver. A trucut biopsy of this lesion was made, and clinicopathologic features of the specimen were compatible with a solitary necrotic nodule of the liver. Here, we discuss the diagnosis and the clinical course of this rare entity in light of current literature.

Optimizing the Personalized Care for the Management of Rectal Cancer: A Consensus Statement.

Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acibadem Mehmet Ali Aydinlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.

The reliability and interobserver reproducibility of T2/FLAIR mismatch in the diagnosis of IDH-mutant astrocytomas.

PURPOSE: The reliability and reproducibility of T2-weighted imaging/ fluid-attenuated inversion recovery (T2/FLAIR) mismatch were investigated in the diagnosis of isocitrate dehydrogenase (IDH) mutant astrocytoma between WHO grade II and III diffuse hemispheric gliomas. METHODS: WHO grade II and grade III diffuse hemispheric gliomas (n=133) treated in our institute were included in the study. Pathological findings and molecular markers of the cases were reviewed with the criteria of WHO 2016. The finding of mismatch between T2-weighted and FLAIR images in preoperative magnetic resonance imaging (MRI) of the cases was evaluated by two different radiologists. The readers reviewed MRIs independently, blinded to the histopathologic diagnosis or molecular subset of tumors. The cases were classified as IDH-mutant astrocytoma, oligodendroglioma and IDH-wildtype (IDH-wt) astrocytoma according to molecular and genetic features. RESULTS: T2/FLAIR mismatch positivity was observed in 46 patients (34.6%). T2/FLAIR mismatch positivity was observed in 42 of 75 IDH-mutant astrocytomas (56%) and 4 of 43 oligodendrogliomas (9.30%), while it was not seen among IDH-wt astrocytomas (0/15, 0%). The T2/FLAIR mismatch ratio was significantly different between IDH-mutant astrocytomas (WHO grade II and grade III) and oligodendrogliomas (chi-square, p <0.05). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of T2/FLAIR mismatch in predicting IDH-mutant astrocytomas were 58.7%, 90.7%, 91.7%, 61.4%, and 70.3% respectively. Radiologist 1 diagnosed T2/FLAIR mismatch in 48 of 133 cases (36.1%) and Radiologist 2 in 66 of 133 cases (49.6%). The interrater agreement for the T2/FLAIR mismatch sign was 0.61 (p <0.05), 95% CI (0.55, 0.67). CONCLUSION: T2/FLAIR mismatch appears to be an important MRI finding in distinguishing IDH-mutant astrocytomas from other diffuse hemispheric gliomas. However, it should be kept in mind that T2/FLAIR mismatch sign can be seen in a minority of oligodendrogliomas besides IDH-mutant astrocytomas.

[Sphenoid sinus agenesis]. / Sfenoid sinüs yoklugu.

Agenesis of paranasal sinuses is an uncommon finding mainly seen in the frontal and maxillary sinuses. Agenesis of sphenoid sinuses is an extremely rare condition. In this article, we present an 18-year-old female patient suffering from headache and nasal obstruction without any skeletal or cranial anomalies. Axial, coronal and sagittal computed tomography revealed absent sphenoid sinuses. Surgeons should be aware of sphenoid sinus agenesis, when transsphenoidal hypophysectomy and endoscopic sinus surgery are scheduled, in particular.

Effects of levothyroxine treatment on insulin sensitivity, endothelial function and risk factors of atherosclerosis in hypothyroid women.

OBJECTIVES: Contradictory results are encountered in literature regarding the effects of hypothyroidism on the risk factors of atherosclerosis. We aimed to explore the changes in atherosclerotic risk factors and insulin sensitivity before and after levothyroxine replacement therapy in women with primary hypothyroidism and compare with that of healthy controls. PATIENTS AND METHODS: Twelve patients (mean age of 34±11.7years) without an evident disease except for primary hypothyroidism (TSH≥20mIU/L) and eleven euthyroid, age-matched (33.8±8.4years) female volunteers as controls were included. Baseline thyroid hormones, lipid parameters, homocysteine, fibrinogen levels were measured in both groups. Flow-mediated endothelial-dependent vasodilatation (FMD) method was used to evaluate endothelial dysfunction. Insulin sensitivity was assessed by M values based on euglycemic hyperinsulinemic clamp technique. The same measurements were performed after 6months of levothyroxine treatment and recovery of euthyroid state in hypothyroid patients. RESULTS: Treatment reduced total cholesterol (P<0.005), LDL-cholesterol (P<0.005), lipoprotein(a) (P<0.01), fibrinogen (P<0.0001) and homocysteine (P<0.0005) levels. Treatment significantly improved M values of hypothyroid patients (3.68±1.53mg/kg.min vs 6.02±1.21mg/kg.min, P<0.0001) and FMD (9.1±3.7% vs 16.4±4.4%, hypothyroid vs euthyroid, P<0.0001). Significant correlations were found between M values and TSH (r=-0.6, P<0.005), fibrinogen (r=-0.53, P<0.01) measurements, free T3 (r=0.51, P<0.02) and free T4 (r=0.49, P<0.02) levels. FMD was significantly correlated with fibrinogen levels (r=-0.49, P<0.05). CONCLUSION: Insulin resistance, endothelial dysfunction, atherosclerotic risk markers improves with treatment of hypothyroidism.

Magnetic resonance imaging evaluation of fetal maxillary sinuses.

BACKGROUND AND OBJECTIVE: The growth of maxillary sinus is closely connected to the development of facial structures. However, its definition and reference standards on fetal magnetic resonance imaging (MRI) have not been analyzed so far. In this study, the objectives were to define and evaluate the fetal maxillary sinus (fMS) formation with MRI. METHODS: We reviewed T2-weighted coronal MRI images of 75 fetuses. The MRI features, time of appearance, and boundaries of fMS were defined. Craniocaudal and transverse diameters of both maxillary sinuses and bone biparietal diameters were measured and statistically evaluated. RESULTS: In 150 fMS site analysis, 91 fMSs were identified. The fMSs were visualized as a hyperintense structures on T2-weighted image above the tooth bud. It first appeared at the 22nd gestational week, and in 4% (3/75) of fetuses, there was unilateral development. Mean craniocaudal length was 2.84 mm (1.1-4.8 mm), and mean transverse diameter was 2.67 mm (1.5-4.2 mm). CONCLUSIONS: Magnetic resonance imaging features of fMS that should be sought for the assessment of craniofacial anatomy are identified in this study. Fetal maxillary sinuses can be observed as hyperintense structures on T2-weighted MRI images starting from 22 weeks of gestation. The growth of fMS follows a predictable course throughout gestation; however, the dimensions are larger than the previously reported ex vivo series.

Evaluation of the placenta with relative apparent diffusion coefficient and T2 signal intensity analysis.

PURPOSE: We aimed to test the null hypothesis that relative apparent diffusion coefficient (rADC) and relative signal intensity values (rSI(HASTE)) do not change in the evaluation of placental maturation with advancing gestational age. MATERIALS AND METHODS: Fifty-six fetuses with diffusion-weighted magnetic resonance imaging (DW-MRI) data were enrolled in this retrospective study. Fetuses were analyzed in three different gestational age groups: group 1, 18-23 weeks; group 2, 24-28 weeks; and group 3, 29-38 weeks. The rADC (mean ADC/ADC(globe)) and rSI(HASTE) values (mean SI(HASTE)/SI(globe)) were obtained. Two radiologists experienced in fetal MRI who were blinded to the patient information reviewed MRI images independently. Kruskal-Wallis Test was used to compare the rADC and rSI(HASTE) with gestational age groups. The agreement between the two blinded readers was tested using Krippendorff's alpha ratio. RESULTS: Both placental rADC values and placental rSI(HASTE) values were not significantly different between the gestational age groups (P = 0.688 and P = 0.280, respectively). rADC and rSI(HASTE) measurements were reproducible with a good agreement between the two readers (Krippendorff's alpha ratio was 0.613 and 0.778, respectively). CONCLUSION: The rADC and rSI(HASTE) values do not change with advancing gestational age.

Evaluation of testicular tumour calcification with digital orchiography.

OBJECTIVES: To analyse the calcification of testicular tumours in the orchiectomy specimens detected by digital orchiography obtained in a full-field digital mammography (FFDM) unit. METHODS: Orchiectomy specimens of 37 consecutive patients were imaged by FFDM. Detected foci of calcification were stratified as: type 1, dense microcalcification; type 2, faint microcalcification; type 3, macrocalcification. Histopathology identified the tumour types, the presence of intratubular germ cell neoplasia (IGCN) and associated calcifications. Orchiography results correlated with the histopathology. RESULTS: On orchiography, 32/37of the specimens (86 %) had co-existing foci of calcification. Histopathology results revealed foci of calcification in 23/37 (62 %) of orchiectomy specimens. Of the 20 IGCN cases, 80 % presented with calcifications on orchiography. Fifty-six percent (14/25) of type 1, 70 % (12/17) of type 2, and 30 % (2/6) of type 3 foci of calcification were observed in IGCN-positive cases. CONCLUSION: This study classifies the morphology of testicular tumour calcification in three main groups by digital orchiography. In half of the testicular cancers, histopathologically proven IGCN is also found in addition to the index tumour. Type 2 foci of microcalcification detected by orchiography may be related to IGCN and may prompt further clinical assessment. KEY POINTS: • Orchiography can detect and classify calcification in 86 % of testicular cancers. • Intratubular germ cell neoplasia (IGCN) co-exists in 54 % of testicular cancers. • Type 2 foci of microcalcification detected by orchiography may be related to IGCN. • Orchiography may play a possible future role in the diagnosis of testicular IGCN.