Sarcoidosis of the pineal gland: an unusual presentation of neurosarcoidosis

Introduction Sarcoidosis is an inflammatory disease characterized by noncaseating granulomas that is rarely found as primary CNS pathology. We report an unusual case of sarcoidosis involving the pineal gland with radiographic, histopathology, and clinical data. Case report A 45-year-old man without evidence of systemic sarcoidosis presented with a history of gradual onset of blurry vision and diplopia that progressed over 3 months. MR imaging demonstrated an enhancing mass in the pineal region. A suboccipital craniotomy was performed with resection of the mass through a supra-cerebellar infratentorial approach. Histopathologic analysis did not reveal a pineoblastoma but instead revealed noncaseating granulomas within the pineal gland. Extensive hematologic laboratory examinations, cerebral spinal fluid studies, and cultures for infection were all negative. This mass lesion was diagnosed as solitary neurosarcoidosis of the pineal gland, without dissemination. The patient was treated with steroids and at 4-year follow-up is asymptomatic with an unremarkable MRI scan. Conclusion This is an unusual case of pineal sarcoidosis mimicking a tumor with associated MRI, CT and histopathologic findings reported together. Although rare, sarcoidosis of the pineal gland should not be excluded from a comprehensive differential diagnosis of an enhancing pineal region mass.     

Morphology of Penicillium marneffei under oxidative stress in vitro

Penicillium marneffei is an intracellular pathogen; the mechanism allowing it to survive under oxidative stress remains unclear. For a better understanding of the response of P. marneffei to oxidative stress, the change in ultrastructure of this fungus before and after treatment with hydrogen peroxide was examined. A bamboo rat isolate and human isolate of P. marneffei were cultured on PDA at 25 °C and on BHI agar at 37 °C for 7 days respectively, with and without hydrogen peroxide; the morphology of strains was examined by optical microscopy and transmission electron microscopy. While comparing the human isolate with the bamboo rat isolate cultured without hydrogen peroxide, it showed no significant difference in ultrastructure. Microbodies were seen under transmission electron microscope in the yeast form, but could not be seen in mould form. After the strains were cultured with hydrogen peroxide, the mould form produced more rose red pigment; organelles of the fungal cells had been involved at different levels. Furthermore, the mould form of the human isolate with decreased conidia production and the yeast form with apoptosis could be observed. These results indicated that different strains of P. marneffei may have different levels of power to survive under oxidative stress.     

Outcome and management of invasive candidiasis following oesophageal perforation

The regular colonisation of the oesophagus with a Candida species can, after oesophageal perforation, result in a contamination of the mediastinum and the pleura with a Candida species. A patient cohort of 80 patients with oesophageal perforation between 1986 and 2010 was analysed retrospectively. The most common sources with positive results for Candida were mediastinal biopsies and broncho‐alveolar secretions. Candida species were detected in 30% of the patients. The mortality rate was 41% in patients with positive microbiology results for Candida, whereas it was 23% in the remaining patient cohort. This difference did not reach statistical significance (P = 0.124). Mortality associated with oesophageal perforation was attributed mainly to septic complications, such as mediastinitis and severe pneumonia. During the study period we observed a shift towards non‐albicans species that were less susceptible or resistant to fluconazole. In selected patients with risk factors as immunosuppression, granulocytopenia and long‐term intensive‐care treatment together with the finding of Candida, an antimycotic therapy should be started. A surgical approach offers the possibility to obtain deep tissue biopsies. The antimycotic therapy should start with an echinocandin, as the resistance to fluconazole is growing and to cover non‐albicans Candida species, too.     

Pattern and clinical significance of cancer‐testis gene expression in head and neck squamous cell carcinoma

Cancer‐testis (CT) antigens comprise families of tumor‐associated antigens that are immunogenic in patients with various cancers. Their restricted expression makes them attractive targets for immunotherapy. The aim of this study was to determine the expression of several CT genes and evaluate their prognostic value in head and neck squamous cell carcinoma (HNSCC). The pattern and level of expression of 12 CT genes (MAGE‐A1, MAGE‐A3, MAGE‐A4, MAGE‐A10, MAGE‐C2, NY‐ESO‐1, LAGE‐1, SSX‐2, SSX‐4, BAGE, GAGE‐1/2, GAGE‐3/4) and the tumor‐associated antigen encoding genes PRAME, HERV‐K‐MEL, and NA‐17A were evaluated by RT‐PCR in a panel of 57 primary HNSCC. Over 80% of the tumors expressed at least 1 CT gene. Coexpression of three or more genes was detected in 59% of the patients. MAGE‐A4 (60%), MAGE‐A3 (51%), PRAME (49%) and HERV‐K‐MEL (42%) were the most frequently expressed genes. Overall, the pattern of expression of CT genes indicated a coordinate regulation; however there was no correlation between expression of MAGE‐A3/A4 and BORIS, a gene whose product has been implicated in CT gene activation. The presence of MAGE‐A and NY‐ESO‐1 proteins was verified by immunohistochemistry. Analysis of the correlation between mRNA expression of CT genes with clinico‐pathological characteristics and clinical outcome revealed that patients with tumors positive for MAGE‐A4 or multiple CT gene expression had a poorer overall survival. Furthermore, MAGE‐A4 mRNA positivity was prognostic of poor outcome independent of clinical parameters. These findings indicate that expression of CT genes is associated with a more malignant phenotype and suggest their usefulness as prognostic markers in HNSCC.     

Vocal cord schwannoma: a rare case report

Schwannomas of the larynx are rare benign tumors, most commonly involving aryepiglottic folds or false vocal folds. When a tumor involves vocal cord, it causes clinical symptoms like hoarseness of voice and foreign body sensation. We report the CT and magnetic resonance imaging findings in a 19-year-old male patient with vocal cord mass histologically diagnosed as a vocal cord schwannoma.     

Cystic degeneration of thymic Hodgkin's disease following radiation therapy

A case of thymic Hodgkin's disease presenting with an anterior mediastinal mass is reported. The mass progressively expanded in size on plain chest radiography during and following a mantle radiation therapy. A repeat computed tomographic (CT) scan of the chest in this patient revealed a cystic component to the mass, and thin-needle aspiration of the cyst led to a shrinkage of the mass. An experience in this case and review of literature suggest Hodgkin's disease involving the thymus gland frequently predisposes to cystic degeneration especially following radiotherapy, leaving a stable or progressively enlarging residual mass. A precise diagnosis of such a progressively expanding mass despite the adequate radiation therapy is crucial. CT scan of the chest in such cases and a thin-needle aspiration of the cystic mass offer precise diagnosis and may obviate the need for an open thoracotomy procedure.     

Breast implant-associated anaplastic large cell lymphoma: sensitivity,specificity, and findings of imaging studies in 44 patients

Breast implant-associated anaplastic large cell lymphoma (BIA ALCL) is a newly described clinicopathologic entity. The purpose of this study is to describe the imaging findings of patients with BIA ALCL and determine their sensitivity and specificity in the detection of the presence of an effusion or a mass related to BIA ALCL. A retrospective search was performed of our files as well as of the world literature for patients with pathologically proven BIA ALCL who had been assessed by any imaging study including ultrasound (US), computerized tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)–CT, as well as mammography. The sensitivity and specificity of each imaging modality in the detection of an effusion or a mass around breast implants was determined. We identified 44 patients who had BIA ALCL and imaging studies performed between 1997 and 2013. The sensitivity for detecting an effusion was 84, 55, 82, and 38 %, and for detecting a mass was 46, 50, 50, and 64 %, by US, CT, MRI, and PET, respectively. The sensitivity of mammography in the detection of an abnormality without distinction of effusion or mass was 73 %, and specificity 50 %. Progression-free survival was worse in patients with an implant-associated mass (p = 0.001). Conclusions: Current imaging with US, CT, MR, and PET appears suboptimal in the detection of an imaging abnormality associated with BIA ALCL. This under diagnosis may reflect a lack of awareness of this rare entity suggesting the need for better understanding of the spectrum of imaging findings associated with BIA ALCL by breast imagers.     

Diagnosis of NUT carcinoma of lung origin by next-generation sequencing: case report and review of the literature

NUT carcinoma (NC) is an aggressive squamous tumor characterized by NUT gene rearrangement, and the most common fusion form is BRD4-NUT. However, NC diagnosis is difficult for its rareness and often being confused with a variety of poorly differentiated tumors. A 21-year-old Chinese woman was referred to our hospital for cough and intermittent fever. Chest computed tomography (CT) imaging revealed a left lobe hilar mass. Fiberoptic bronchoscopy results showed that tumor cells were poorly differentiated. In combination with immunohistochemistry staining, she was misdiagnosed with Ewing’s sarcoma/primitive neuroectodermal tumor. Next-generation sequencing (NGS) revealing BRD4-NUT fusion, and NUT immunohistochemistry confirmed the diagnosis of NC. Subsequently, left pneumonectomy and lymph node dissection were performed, and the patient received pemetrexed and lobaplatin treatment. NGS technology played an important role in NC diagnosis in this case, and it may have clinical use for rare cancer diagnosis and guidance of potential targeted therapies.     

Endometrial endometrioid adenocarcinoma associated with primitive neuroectodermal tumour of the uterus: a poor prognostic subtype of uterine tumours

Uterine primitive neuroectodermal tumours are extremely rare tumours. They can occur in pure form or combined with another component including endometrioid adenocarcinoma. We aimed to review the clinical impact of neuroectodermal phenotype in uterine tumours, after we recently diagnosed one such case. A 58-year-old female presented with irregular vaginal bleeding. Ultrasonography and CT showed the presence of a large uterine mass with irregular contours. At laparotomy it was found to extend to the right ureter, sigmoid colon and some small intestinal loops. Microscopic examination revealed that the tumour consisted of an endometrioid adenocarcinoma component merging with an extensive neuroectodermal component. No EWSR1 or FUS rearrangement was found in the two tumour components. The patient received two courses of chemotherapy but died 11 months after the initial diagnosis. We reviewed the morphological and molecular criteria for the diagnosis of uterine primitive neuroectodermal tumours published in the literature. We conclude that regardless of the detection of an EWSR1 rearrangement, the presence of a neuroectodermal differentiation component in these rare uterine tumours is a marker of aggressive behaviour, and its presence should be highlighted in the diagnosis.     

Unusual strains of Microsporum audouinii causing tinea in Europe

We comment on an unusual strain of Microsporum (M.) audouinii. It was isolated from tinea corporis of a boy who lived in Germany and most likely had acquired his infection during a stay on a farm with animal husbandry in Poland. The strain showed features of M. canis (plenty of markedly rough‐walled macroconidia, growth on rice, positive hair perforation) as well as of M. audouinii (white thallus, long macroconidia with central constriction) and in vitro it degraded hair of various mammals. Because its ribosomal internal transcribed spacer region showed 99.9% homology to a M. audouinii reference strain it was finally identified as M. audouinii. We relate these findings with recent observations of M. audouinii causing tinea in Europe. This appraisal suggests that irrespective of an identical ribosomal ITS region distinct M. audouinii strains can display a spectrum of morphological and physiological features that is broader than currently outlined in mycological textbooks. Certain unusual characteristics like an enhanced capacity to utilise keratins may even be associated with unexpected transmission routes. Above all sporadic M. audouinii infections in Europe that bear no relation to an endemic area should be analysed from this perspective.     

Diagnostic performance of computer tomography,magnetic resonance imaging,and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with cervical cancer: Meta‐analysis

We performed a meta‐analysis to compare diagnostic performances of computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET or PET/CT), for detection of metastatic lymph nodes in patients with cervical cancer. We searched MEDLINE (PubMed), EMBASE and the Cochrane Review database in December 2007. All articles were independently reviewed and selected by three evaluators. We estimated a summary receiver operating characteristic (sROC) curve. The area under the curve (AUC), Q*, and pooled weighted estimates of sensitivity and specificity for each modality by patient‐based and region‐ or node‐based data analyses and conducted pair‐wise comparisons between modalities using the two‐sample Z‐test. Forty‐one of 768 initially identified studies were included in the meta‐analysis. In a patient‐based data analysis, PET or PET/CT showed the highest pooled sensitivity (82%) and specificity (95%), while CT showed 50% and 92%; and MRI, 56% and 91%, respectively. The AUC (0.9641) and Q* (0.9106) of PET or PET/CT were significantly higher than those of MRI (AUC = 0.8270; Q* = 0.7599), both P < 0.001. In region‐ or node‐based data analysis, sensitivities of CT (52%) and PET or PET/CT (54%) were higher than that of MRI (38%), P < 0.02 and P < 0.001, respectively, while specificities of MRI (97%) and PET or PET/CT (97%) were higher than that of CT (92%), both P < 0.001. The AUC and Q* showed no significant difference among CT, MRI, and PET or PET/CT. PET or PET/CT had an overall higher diagnostic performance than did CT or MRI in detecting metastatic lymph nodes in patients with cervical cancer. (Cancer Sci 2010)     

Preliminary PET/CT study of 18F-FDG uptake in cervical and supraclavicular brown adipose tissue

Objective  The clinical use of PET/CT in oncology has led to the realization that ¹⁸F-FDG uptake in brown adipose tissue (BAT) can be a common cause of potentially misleading false-positive PET scans. The goal of this study was to study ¹⁸F-FDG uptake in cervical and supraclavicular regions and its characteristics with PET/CT. Methods  All the PET/CT scans obtained at our institution from July 2007 to January 2008 were retrospectively reviewed for increased ¹⁸F-FDG uptake in BAT. The cases in which increased ¹⁸F-FDG in cervical and supraclavicular regions was not localized to a soft-tissue mass or lymph node or muscle on the CT images, were included in this study. The following features were recorded: body weight, body mass index (BMI) and maximal standardized uptake value (SUVmax). In these selected patients, the BAT uptake in other area of the body was also recorded. Results  PET/CT scans were obtained in 457 patients (259 males and 198 females). In all of the scans, cervical and supraclavicular BAT uptake was observed in 12 patients (2 males and 10 females) and was typically bilateral, symmetric and intense. The range of the SUVmax was 3.6∼12.82 (mean 6.9 ± 2.6). BAT uptake was more common in females than in males, showing a significant difference (P = 0.004). Although ¹⁸F-FDG uptake in BAT occurred more often in underweight patients with low BMI, there was no difference in the body weight (P = 0.607) or BMI (P = 0.491) of these patients with hypermetabolic BAT compared with controls. Conclusion  Hypermetabolic BAT uptake can be localized in cervical and supraclavicular regions with it occurring more commonly in females compared to males. Knowledge of this potential pitfall with PET/CT is important in improving diagnostic interpretation and accurate staging.     

Three-Dimensional Helical CT of the Breast: Accuracy for Measuring Extent of Breast Cancer Candidates for Breast Conserving Surgery

Objective. To evaluate the accuracy of three-dimensional (3D) helical computed tomography (CT) for assessing the extent of breast cancer of candidates for breast conserving surgery. Methods. Results of helical CT were studied in 144 lesions of 144 patients with breast cancer before breast-conserving surgery. A lesion was defined as positive if focal enhancement was detected by CT within 100s after contrast material administration. After resection, tumors were histopathologically mapped and correlated with the extent of 3D images. Results. Helical CT enabled detection of 143 tumors but not of one ductal carcinoma in situ (DCIS). The median deviation of the tumor extension revealed by 3D helical CT images from pathological assessment was 7.7mm (range 0–60mm). The extent of tumors was significantly correlated with CT measurements (r=0.714, p<0.0001). By multivariate analysis, the presence of invasive tumors with intraductal extensions beyond the edge of the invasive tumor and histologic type (DCIS) were significant risk factors for deviation of the tumor extension revealed by 3D helical CT images from pathological assessment. Conclusion. Three dimensional helical CT of the breast is an accurate preoperative imaging modality for assessing the extent of breast cancer candidates for breast conserving surgery.     

Gastrointestinal Stromal Tumor Masquerading as a Spontaneous Rectal Hematoma

A 78-year-old Caucasian male with a history of atrial fibrillation and anticoagulation with warfarin presented with a change in bowel habits and weight loss. A computed tomography (CT) scan showed a 3.5 cm rectal mass. After biopsy with colonoscopy and endoscopic ultrasonography, the rectal mass was highly suspicious for rectal hematoma. When the rectal mass did not resolve after 1 month of follow-up, surgery showed the patient to have a rectal gastrointestinal stromal tumor. He is being treated with imatinib and follow-up CT scans. This case illustrates the importance of a high level of suspicion for a gastrointestinal stromal tumor when a rectal mass is found.     

Imaging primary and metastatic cancer of the liver

Either CT or MRI can be used as a primary screening test for liver masses in a patient with a known or suspected malignancy. A number of variations in techniques are available for both CT and MRI, and combinations of these techniques are often required to increase the detectability rate for hepatic lesions. Whether CT or MRI is chosen as an initial screening technique depends upon the particular patient and the institution. After a liver lesion has been identified, attempts should be made to obtain a specific diagnosis. Certain liver masses may have a specific CT appearance, especially when they are calcified. With some benign lesions a specific diagnosis is possible using imaging techniques, and in these instances CT and a supplemental radionuclide study may be of complimentary value. These include cavernous hemangioma, focal fatty liver, and focal nodular hyperplasia. Another group of lesions have a CT or an MRI appearance that is suggestive for a specific diagnosis, but may require confirmation with a biopsy or other tests. These include hepatoma, which may present as a mass with portal vein thrombosis, hepatic adenoma, which may appear as a mass with central hemorrhage, focal nodular hyperplasia may occur as a mass with a central stellate scar (on CT), or a cavernous hemangioma, which fulfills specific CT or MRI criteria. A final group of lesions consists of masses without a characteristic or suggestive CT or MRI appearance. These lesions will require biopsy for final diagnosis.     

CT findings at the primary site of oropharyngeal squamous cell carcinoma within 6-8 weeks after definitive radiotherapy as predictors of primary site control

PURPOSE: To determine whether findings on CT studies, done 6 weeks after radiotherapy (RT), can predict the likelihood of ultimate control at the primary site in oropharyngeal carcinoma. METHODS AND MATERIALS: Forty-six patients with oropharyngeal squamous cell carcinoma underwent RT with curative intent. A minimal 2-year clinical follow-up after RT was required. The primary site CT findings were graded for risk of recurrence on a modified 3-point scale as follows: Grade 0, no detectable focal abnormalities; Grade 1, anatomic asymmetry or focal mass <1 cm; Grade 2, focal mass >10 mm (2a) or <50% shrinkage of the mass as seen on pretreatment studies (2b). RESULTS: No patients with CT findings of Grade 0 (n = 26) or Grade 1 (n = 5) had a primary site recurrence. One of the 13 patients with CT findings of Grade 2a had a primary site recurrence 1 year after completion of RT. None of the 2 patients with CT findings of Grade 2b had a primary site recurrence. Ultimately, 45 of the 46 patients in this study group had disease control at the primary site. CONCLUSION: In the evaluation of oropharyngeal squamous cell carcinoma on post-RT CT studies, diffuse and symmetric post-RT changes of the soft tissue or asymmetry without detectable mass or a discrete mass < or =10 mm always indicated ultimate control at the primary site. Even when post-RT CT shows a discrete mass >10 mm at the primary site, the likelihood of local control is high (93%). The study results indicate that CT findings, based on this relatively small series, may not add incremental information beyond that of clinical examination for predicting local control but may be useful as a baseline if imaging surveillance is contemplated.     

A 66-year-old woman with newly diagnosed oligometastatic non-small cell lung cancer

A 66-year-old woman presented with newly diagnosed stage IV non-small cell lung cancer (NSCLC) and a large adrenal metastasis. She initially had flu-like symptoms and dyspnea and was found to have a right upper lobe (RUL) lung nodule. Chest CT showed a 1.4-cm spiculated RUL lung nodule, peripheral right lung nodule, right perihilar mass, and 10.9-cm left adrenal mass. PET/CT showed enhancement of the RUL nodule, hilar mass, and left adrenal mass. She presented for evaluation of treatment options. This case was thought to represent an instance of oligometastatic stage IV NSCLC. Literature suggests that a select patient population with otherwise resectable disease may benefit from surgical resection of a lung primary and the isolated metastasis with improved survival. This seems to be most effective in patients who have undergone a complete staging evaluation with PET scan; CT of the chest, abdomen, and pelvis; and a brain MRI revealing T1-2, N0-1, M-oligo disease. This radical approach should be reserved for patients with potentially curative disease based on the staging evaluation and who are otherwise good surgical candidates.     

Concurrent Modified PCV Chemotherapy and Radiotherapy in Newly Diagnosed Grade IV Astrocytoma

Adjuvant chemotherapy (CT) in the treatment of grade IV astrocytoma is at best modestly effective. The radiosensitizing effect of CT may confer an advantage to concurrent radiotherapy (RT) and CT. This study investigated concurrent procarbazine, lomustine, and vincristine (PCV) CT in newly diagnosed grade IV astrocytoma patients. Methods: From 1992 to 1997, patients diagnosed with grade IV astrocytoma (Daumas-Duport criteria), Karnofsky performance score (KPS) 70 and age <65 were offered CT. Twenty-seven study patients received concurrent modified PCV plus partial brain RT. Twenty-seven controls treated at the same institution with cranial RT alone were matched for histology, age and KPS. Results: Median age was 49 years and mean KPS was 80 for both groups. Debulking operations were more frequent in study patients than controls (p=0.034). One-year survival was 70% and 56%, while median survival was 82 weeks and 53 weeks for the study and control groups, respectively (p=0.1554). CT complications were predominantly hematologic, grades II and III. Two patients developed febrile neutropenia; one patient died from Pneumocystis carinii pneumonia. Nausea, vomiting and allergic reactions were all grade I. Conclusion: While a trend to increased survival was seen in the study, patients treated with concurrent PCV CT, this did not reach statistical significance. A phase III trial would help delineate the true effectiveness of concurrent CT in this population. Modified PCV is safe and reasonably well tolerated.     

A case report of primary cardiac capillary hemangioma

Background: Hemangioma of the heart, presenting as a primary cardiac tumor is extremely rare. Methods: We present a 20-year-old male with a cardiac tumor which was incidentally discovered during routine clinical examination. Results: Echocardiography showed a large intramyocardial mass attached to the left ventricle, close to the apex. A tumor was shown near the apex of the left ventricle by Cardiac CT. We performed a total resection surgery of the tumor one week after admission and the patient recovered well and discharged from hospital 7 d after surgery. Conclusion: The pathological diagnosis was primary cardiac capillary hemangioma. No tumor recurrence was shown by echocardiography after 20 months follow-up visits.