CASES Dr Mayur Pankhania R 2 Dept of

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CASES Dr Mayur Pankhania, R 2 Dept of Radiodiagnosis SSG Hospital. ( 12/09/07 )

CASES Dr Mayur Pankhania, R 2 Dept of Radiodiagnosis SSG Hospital. ( 12/09/07 )

CASE 1

CASE 1

n 10 yr old boy presents with acute abdominal pain, nausea, vomiting.

n 10 yr old boy presents with acute abdominal pain, nausea, vomiting.

Stomach is markedly distended with particular material. Dilated loops of proximal jejunum & right

Stomach is markedly distended with particular material. Dilated loops of proximal jejunum & right colon at the right upper quadrant.

Malposition of SMA to the right of SMV Distended stomach and proximal jejunum loops.

Malposition of SMA to the right of SMV Distended stomach and proximal jejunum loops.

caused by the wrapping of the superior mesenteric vein (SMV) and its tributaries around

caused by the wrapping of the superior mesenteric vein (SMV) and its tributaries around the superior mesenteric artery (SMA), creating the “whirlpool” sign Dilatation of distal SMV

Finding n X-ray : Stomach is markedly distended with particular material. Dilated loops of

Finding n X-ray : Stomach is markedly distended with particular material. Dilated loops of proximal jejunum & right colon at the right upper quadrant. n CECT : Malposition of SMA to the right of SMV Distended stomach and proximal jejunum loops. caused by the wrapping of the superior mesenteric vein (SMV) and its tributaries around the superior mesenteric artery (SMA), creating the “whirlpool” sign Dilatation of distal SMV

Differentials includes n Malrotation n Midgud volvulus n Ladd’s Band

Differentials includes n Malrotation n Midgud volvulus n Ladd’s Band

Normal rotation After entering the midabdomen at 12 o’ clock, the cecum rotates counterclockwise

Normal rotation After entering the midabdomen at 12 o’ clock, the cecum rotates counterclockwise into the rt lower quadrant. n The mesentery secures the small bowel to the posterior abdominal wall. n Therefore, it is difficult for midgut to twist around this broad fan mesentery. n

Normal position of ligament of Trietz

Normal position of ligament of Trietz

Malrotation n n The term Malrotation is used to describe any variation in the

Malrotation n n The term Malrotation is used to describe any variation in the position of the intestines. In an attempt to fix the gut in place, malrotation is invariably accompanied by malfixation in the form of PERITONEAL (LADD) BANDS. These bands can cause duodenal obstruction. In addition, the abnormal positions of the duodenojejunal junction and the cecum mean that the base of the small-bowel mesentery is short. The midgut has a propensity to twist around this narrow base, compromising its blood supply, resulting in midgut volvulus.

Complication of malrotation n Ladd’s bands, midgut volvullus. n Most patients presents during neonatal

Complication of malrotation n Ladd’s bands, midgut volvullus. n Most patients presents during neonatal period with bilious vomiting, abdominal distention. Hovever it can occurs at any age. Ladd’s band usually cause incomplete obstruction of 3 rd & 4 th portion of duodenum. n Malrotation alone is asymptomatic n n The more turns midgut twist around the SMA, the higher risk of strangulation, & as a result bowel necrosis. Intermittent compromise of venous & lymphatic drainage can cause episodic abdominal pain & nausea vomiting.

Ladd’s Bands Attempt to fix the colon to posterior abdominal wall results in the

Ladd’s Bands Attempt to fix the colon to posterior abdominal wall results in the peritoneal bands ( ladds bands) crossing & extrinsically obstructing the duodenum.

UGI shows incomplete obstruction of the duodenum usually in the 3 rd & 4

UGI shows incomplete obstruction of the duodenum usually in the 3 rd & 4 th parts, with evidence of extrinsic compression.

Midgut Volvulus bowel and mesenteric vessels twist around the short mesenteric pedicle with resultant

Midgut Volvulus bowel and mesenteric vessels twist around the short mesenteric pedicle with resultant bowel obstruction and ischemia Malrotation with midgut volvulus showing torsion around the narrow mesenteric stalk.

whirlpool sign • whirlpool sign on sonography, directly indicates the anatomic alteration of midgut

whirlpool sign • whirlpool sign on sonography, directly indicates the anatomic alteration of midgut volvulus characterized by wrapping of the SMV and mesentery around the SMA. • On color Doppler sonography, the whirlpool sign consists of a side-byside arrangement of vessels with opposing flow direction • Other US sign of midgut volvulus: • duodenal obstruction with a tapering configuration • thickened bowel loops to the right of the spine, • a hyperdynamic pulsating SMA, Color Doppler image showing twisting of the SMV around the SMA, giving the whirlpool sign. • a truncated SMA, • free peritoneal fluid

 Upper gastrointestinal series showing dilatation of the stomach and proximal duodenum with a

Upper gastrointestinal series showing dilatation of the stomach and proximal duodenum with a corkscrew appearance of the distal duodenum and proximal jejunum.

UGI shwos “crock-screw”sign or “twisted-ribbon” sign.

UGI shwos “crock-screw”sign or “twisted-ribbon” sign.

Contrast-enhanced CT showing wrapping of the SMV around the SMA. Computed tomography also depicts

Contrast-enhanced CT showing wrapping of the SMV around the SMA. Computed tomography also depicts the complications of volvulus like bowel ischemia leading to necrosis and perforation

Diagnosis n Intermittent midgut volvulus.

Diagnosis n Intermittent midgut volvulus.

CASE 2

CASE 2

65 yr woman with a palpable rt breast mass & a mammogram which shows

65 yr woman with a palpable rt breast mass & a mammogram which shows no evidence of maligancy, Birads 1 n Also c/o intermittent pain in Rt breast & shoulder & skin chages. n O/E: n – Entire Rt breast is encompassed with tumor. Skin is thinned with vascular markings. – However no skin breakdown. No peau d’orange. No e/o adenopathy. No nipple retraction.

Findings n US: § The anterior & superior aspect of the rt breast is

Findings n US: § The anterior & superior aspect of the rt breast is occupied by a large fungating mass. The mass measures 16 -15 -13 cm & has heterogenous echotexture with solid & cystic areas. § No evidence of axillary, infraclavicular or internal mammary LAD.

differentials includes n Invasive Ductal Carcinoma n Inflammatory Carcinoma n Medullary Carcinoma n Phyllodes

differentials includes n Invasive Ductal Carcinoma n Inflammatory Carcinoma n Medullary Carcinoma n Phyllodes tumor n Sarcoma n Fibroadenoma n Papilloma

Mammographic signs of malignancy n Mass with spiculated ill defined margin n Malignant calcifications

Mammographic signs of malignancy n Mass with spiculated ill defined margin n Malignant calcifications n Architectural distortion n Skin or nipple changes n Abnormal ductal patterns n Asymmetry n LAD

Invasive ductal carcinoma. n Most common form of breast ca. ( 80%) n C/by

Invasive ductal carcinoma. n Most common form of breast ca. ( 80%) n C/by n No mass or calcification & Lymphadenopathy was demonstrated on this pt’s mammogram. – a visible mass or calcifications on mammography. – Typically 2 cm size when diagnosis and soft to palpation. – Desmoplastic response of breast tissue causes radiographically visible spiculations. – Invasive ductal CA often metastasizes to the axillary lymph nodes ( MC) , bone, lung, liver and brain.

Rt craniocaudal & mediolateral oblique view with Spot craniocaudal view, demonstrate a 1. 5

Rt craniocaudal & mediolateral oblique view with Spot craniocaudal view, demonstrate a 1. 5 cm spiculated hyperdense mass in the right upper outer quadrant. c/o invasive ductal ca

Medullary carcinoma n Rare cancer of ductal origin, comprising only 2% of all invasive

Medullary carcinoma n Rare cancer of ductal origin, comprising only 2% of all invasive breast cancers. n Mean age of incidence is 46 -54 years. n Distinctive features include large size at detection, soft texture on palpation, and mobility due to lack of invasion. n On mammography the tumor is well-circumscribed or lobulated and may have a partial or complete halo. They may be dense due to hemorrhage. n Sonographically they are usually hypoechoic due to uniform cellular composition. Some may shows posterior enhancement.

Right MLO (A) and CC (B) views show scattered fibroglandular densities. An indistinct mass

Right MLO (A) and CC (B) views show scattered fibroglandular densities. An indistinct mass is seen on the MLO view only, overlying the pectoralis muscle, but the lesion is not seen on the CC view. A directed ultrasound (C) of the right upper-inner quadrant was performed based on the suspected position of the mass. Ultrasound demonstrates that the lesion is solid and slightly irregular in contour. .

Phylloides Tumor ( cystosarcoma phyllodes ) n Rapidly growing stromal tumor n Most are

Phylloides Tumor ( cystosarcoma phyllodes ) n Rapidly growing stromal tumor n Most are indolent and benign. Or malignant ( low or high variety ) with lung mates. n women all ages, (peak prevalence between ages 30 - 50 years occurs earlier than breast cancer) n It normally has smooth, lobulated contours and remains relatively mobile even when very large. Although sharply defined, it does not have a true capsule. n n Mammographic Appearance. – margins may be obscured by the surrounding parenchyma, – generally well-defined lesions. – Spiculations does not occur, and – Micro-calcifications are not a feature of this lesion. – A halo may be seen surrounding the tumor, but once again, this is merely related to the macroscopically smooth margin. Ultrasound Appearance. They are generally well-circumscribed lesions, distinguished only by their relatively large size. Variable low-amplitude internal echoes are present.

Craniocaudal mammogram shows the breast replaced by a large radiodense mass lesion which shows

Craniocaudal mammogram shows the breast replaced by a large radiodense mass lesion which shows Tubular, amorphous areas of calcification in the retroareolar region (arrows). (Collimated craniocaudal mammogram shows a large, well circumscribed mass containing fat and soft tissue in the area within.

Real-time sonogram of a palpable right breast lump in a 57 -year-old woman. A

Real-time sonogram of a palpable right breast lump in a 57 -year-old woman. A lobulated, hypoechoic, solid mass with heterogeneous internal echoes and posterior acoustic enhancement is noted. A malignant phyllodes tumor was identified at biopsy.

Fibroadenoma n 2 nd most common solid tumor after ca breast & MC Benign

Fibroadenoma n 2 nd most common solid tumor after ca breast & MC Benign tumors in woman, composed of stromal and epithelial elements. n occur in girls and women of any age during their reproductive years. After menopause, the tumors often regress. n On mammograms, – circumscribed smooth marginated oval or round masses, – coarse calcifications ( which suggest infarction and involution ) n On ultrasonograms, – circumscribed, homogeneous, oval, hypoechoic masses that may have gentle lobulations; their width is larger than their anteroposterior diameter – a smooth, thin, echogenic pseudocapsule; – variable acoustic enhancement; and n the vascularity of solid masses does not help distinguish a cancer from a fibroadenoma

Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer

Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer part of the breast.

Spot compression mammogram of the outer part of the breast demonstrates a new mass

Spot compression mammogram of the outer part of the breast demonstrates a new mass as smooth, margined, and oval. Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins with coarse calcifications within with outer echogenic capsule, a typical of a fibroadenoma.

Inflammatory Carcinoma n It is an infrequent form of invasive breast carcinoma n c/f

Inflammatory Carcinoma n It is an infrequent form of invasive breast carcinoma n c/f – – – n increased volume and induration of the breast, increased temperature, tenderness or pain, peau d’orange or cutaneous edema, redness of the skin, and the presence of a palpable ridge at the margin of induration. Pathologically, any subtype of primary breast carcinoma may be present, but dermal lymphatic vessels must be involved.

n On Mammographic: – inflammatory signs, – skin thickening (skin of the involved breast

n On Mammographic: – inflammatory signs, – skin thickening (skin of the involved breast thicker than that of the contralateral breast); – trabecular coarsening and increased density of breast parenchyma; – nipple retraction, – presence of a mass, – asymmetric focal density – microcalcifications, and – axillary lymphadenopathy. (Axillary lymphadenopathy was identified on the basis of two or more of the following criteria: size larger than 2 cm, replacement of fatty hilum, round shape, and generalized increased density. ) (Simillar finding is assess by ultrasonography)

Images obtained in a 47 -year-old woman with peau d’orange. (a) Craniocaudal mammogram of

Images obtained in a 47 -year-old woman with peau d’orange. (a) Craniocaudal mammogram of the right breast shows skin thickening (arrows), parenchymal edema, and focal asymmetric density (*) in the outer quadrant. (b) Craniocaudal mammogram of the left breast is normal. (c) Transverse US scans of the lower inner quadrant of the right breast show marked skin thickening (*), dilated lymphatic channels (arrowheads), and focal areas of parenchymal acoustic shadowing (arrows). c/o inffa ca

Sarcoma n n Sarcomas are the rare breast malignancies ( 0. 7 %). MC

Sarcoma n n Sarcomas are the rare breast malignancies ( 0. 7 %). MC histological types of breast sarcomas are: n highly malignant tumors that enlarge rapidly and metastasize hematogenously. They most commonly manifest as a painless, mobile mass. The only mammographic finding that is diagnostic for breast sarcoma is osteoid matrix, which indicates osteogenic sarcoma. n n – – – – Angiosarcoma, High grade undifferentiated sarcoma, liposarcoma, and fibrosarcoma. Metastatic rabdomyosarcoma Radiation induced sarcoma Kaposi’s sarcoma

Carcino-osteosarcoma in a postmenopausal woman who presented with a palpable mass in the right

Carcino-osteosarcoma in a postmenopausal woman who presented with a palpable mass in the right breast. Spot magnification mammogram shows amorphous mineralization of osteoid matrix (arrow). Excisional biopsy revealed a carcino -osteosarcoma.

The key point of information regarding this pt were the normal mammogram, no adenopathy

The key point of information regarding this pt were the normal mammogram, no adenopathy & large heterogeneous mass. This should raise concern of breast sarcoma. On histology, pt diagnosed HIGH GRADE UNDIFFERENTIATED SARCOMA

CASE 3

CASE 3

n 30 yrs old female patient presented with pain and swelling at angle of

n 30 yrs old female patient presented with pain and swelling at angle of jaw on left side.

Left side of a PR showing a large mulitlocular cyst occupying the angle and

Left side of a PR showing a large mulitlocular cyst occupying the angle and ramus of the mandible

Main categories of pathological radiolucent lesions n Localised infection n Spreading infection (osteomyelitis) n

Main categories of pathological radiolucent lesions n Localised infection n Spreading infection (osteomyelitis) n Cysts – odontogenic or nonodontogenic n Tumours – odontogenic or nonodontogenic n Giant cell lesions n Fibro-cemento-osseous lesions (early stages)

D/D OF THE JAW LESION

D/D OF THE JAW LESION

ODONTOGENIC KERATOCYSTS n n Age: Very variable, peak incidence between 20 -40 years Frequency:

ODONTOGENIC KERATOCYSTS n n Age: Very variable, peak incidence between 20 -40 years Frequency: <5% of all cysts n Site: Posterior body/angle of the mandible extending into the ramus Anterior maxilla in canine region n Size: Variable but often large in the mandible n Shape: Oval, extending along the body of the mandible with little mediolateral expansion Pseudolocular or multilocular Outline: Smooth Well defined Often well corticated n Radiodensity: Uniformly radiolucent n Effects: Adjacent teeth: minimal displacement, rarely resorbed Extensive expansion within the cancellous bone n

A B A: Oblique lateral of the left side of the mandible showing a

A B A: Oblique lateral of the left side of the mandible showing a typically extensive pseudolocular cyst which has developed instead of the 3 rd molar B: PA jaws of the same patient showing that it has caused minimal mediolateral expansion, c/o odontogenic keratocysts

Odontogenic keratocyst PR showing a very large multilocular odontogenic keratocyst occupying all of the

Odontogenic keratocyst PR showing a very large multilocular odontogenic keratocyst occupying all of the right side of the mandible

AMELOBLASTOMAS n n Peak Age: Adults about 40 years old Frequency: Rare, but commonest

AMELOBLASTOMAS n n Peak Age: Adults about 40 years old Frequency: Rare, but commonest odontogenic tumour n Site: Posterior body/angle/ramus of mandible Rarely maxilla n Size: Variable, dependent on age of lesion, may become very large if neglected causing gross facial asymmetry n Shape: Multilocular, distinct septa divides the lesion into compartments which is referred to as a soap bubble appearance. Occasionally unilocular in early stages n Outline: Smooth and scalloped , Well defined & Well corticated n Radiodensity: Radiolucent with internal radiopaque septa n Effects: Adjacent teeth: displaced, loosened, often resorbed Extensive expansion in all directions

Ameloblastoma Part of a PR showing the typical mulitlocular appearance of a large ameloblastoma

Ameloblastoma Part of a PR showing the typical mulitlocular appearance of a large ameloblastoma at the angle of the mandible, with extensive expansion and resorpiton of adjacent teeth (black arrow)

ANEURYSMAL BONE CYSTS n n Age: Adolescents <20 years Frequency: Rare n Site: Body/Posterior

ANEURYSMAL BONE CYSTS n n Age: Adolescents <20 years Frequency: Rare n Site: Body/Posterior mandible. Maxilla occasionally n Size: Variable, up to several cms in diameter n Shape: Unilocular or multilocular Faint internal trabeculation may produce a soap-bubble appearance n Outline: n Radiodensity: Radiolucent with internal trabeculations n Effects: Adjacent teeth: displaced, rarely resorbed Buccal and lingual expansion of the cortex, often marked and described as ballooning or blow-out Smooth and undulating Moderately well defined Peripheral cortex retained even when large

Aneurysmal Bone Cyst Part of a PA radiograph showing a large multilocular aneurysmal bone

Aneurysmal Bone Cyst Part of a PA radiograph showing a large multilocular aneurysmal bone cyst in the ramus of the mandible causing marked ballooning expansion

BROWN TUMOURS IN HYPERPARATHYROIDISM A few patients with this disease, in addition to the

BROWN TUMOURS IN HYPERPARATHYROIDISM A few patients with this disease, in addition to the generalised decrease in bone density, also develop circumscribed, cyst-like radiolucencies.

Brown tumours in hyperparathyroidism Part of a periapical showing a unilocular smooth outlined radiolucency

Brown tumours in hyperparathyroidism Part of a periapical showing a unilocular smooth outlined radiolucency causing tooth displacement Part of a 90 o occlusal showing the same radiolucent lesion causing buccal expansion

Step-by-step guide to producing a radiological differential diagnosis Describe the radiolucency Normal Anatomical Structure

Step-by-step guide to producing a radiological differential diagnosis Describe the radiolucency Normal Anatomical Structure Pathological Acquired • Localised infection • Spreading infection (osteomyelitis) • Cysts – odontogenic or non-odontogenic • Tumours – odontogenic or non-odontogenic • Giant cell lesions • Fibro-cemento-osseous lesions (early stages) Artefactual Idiopathic Stafne’s bone cavity

CASE 4

CASE 4

n A 26 yr male was brought to the emergency room following an assault

n A 26 yr male was brought to the emergency room following an assault with loss of consciousness. An NCCT of the brain was obtained.

Findings n In the left posterior frontal lobe, there is an abnormal grey-matter lined

Findings n In the left posterior frontal lobe, there is an abnormal grey-matter lined cleft, extending superiorly from the sylvian fissure. The cleft terminates near the body of the left lateral ventricle, where there is an irregularity in the ependymal lining. The septum pellucidum is absent.

Differentials: n Closed-lip schizencephaly n Open-lip Schizencephaly n Holoprosencephaly n Septooptic dysplasia

Differentials: n Closed-lip schizencephaly n Open-lip Schizencephaly n Holoprosencephaly n Septooptic dysplasia

SCHIZENCEPHALY n It’s a migrational anomaly which appears as a cleft b/w the pial

SCHIZENCEPHALY n It’s a migrational anomaly which appears as a cleft b/w the pial surface of the brain & the ventricular ependyma. n The cleft is lined by grey matter & is usually near the sylvian fissure. n Cleft divided into: – Closed-lip ( if two sides are apposed) – Open-lip (if the two sides are open)

The grey matter lining distinguisheds schizencephaly from enchalomalacic defect & porencephaly, which are lined

The grey matter lining distinguisheds schizencephaly from enchalomalacic defect & porencephaly, which are lined by white matter. A clue to finding a subtle closed-lip Schizencephaly is the dimple on the ventricular surface.

Other association includes: n n n Focal cortical dysplasias, Grey matter heterotopias, Agenesis of

Other association includes: n n n Focal cortical dysplasias, Grey matter heterotopias, Agenesis of septum pellucidum ( in 80 to 90% cases ) n Frontal & frontoparital lobes are the most common locations(75%) n B/L involvement is asso with seizures & developmental delay. n Open-lip schizeancephaly is more often associated with motor dysfunction.

SEPTOOPTIC DYSPLASIA n Absent of SP is also noted in septooptic dysplasia & holoprosencephaly.

SEPTOOPTIC DYSPLASIA n Absent of SP is also noted in septooptic dysplasia & holoprosencephaly. Both of this conditions may involve other midline structures, including the optic tracts, hypothalamic-pituitary axis & CC. n C/t Finidings in SD: – Pt pr with visual problems & seizures. – Complete or partial absence of the SP results in squaring off of the frontal horns of lateral ventricles. – Hypoplastic optic nerve & chiasm – CC may be absent. – Pituitary abnormalities resulting in GH diminished.

Absent of the septum pellucidum & hypoplastic optic nerves in this pt with septooptic

Absent of the septum pellucidum & hypoplastic optic nerves in this pt with septooptic dysplasia

HOLOPROSENCEPHALY n Group of congenital disorders characterized by incomplete separation of rt & lt

HOLOPROSENCEPHALY n Group of congenital disorders characterized by incomplete separation of rt & lt cerebral hemispheres & abnormalities of the lateral ventricles & falx cerebri. n 3 types: Lobar, semilobar and alobar

Lobar holoprosencephaly Minor variant in which the separation of the cerebral hemisphere & lateral

Lobar holoprosencephaly Minor variant in which the separation of the cerebral hemisphere & lateral ventricles is almost complete, but the interhemispheric fissure & falx cerebri do not completely form. n Fusion of midline structures like hypothalamus & caudate nuclei. n Partial fusion of frontal lobe. n Absent of the falx & interhemispheric fissure posteriorly, with fusion of the posterior cortical structures & ventricles. The septum pellucidum is also absent.

Semilobar holoprosencephaly n Partial development of the falx & interhemispheric fissure & partial separation

Semilobar holoprosencephaly n Partial development of the falx & interhemispheric fissure & partial separation of the lateral ventricles. n basal ganglia & thalami are fused. The anterior falx and interhemispheric fissure absent, with fusion of the frontal lobes across the midline. The frontal horns of the lateral ventricles are absent.

Alobar holoprosencephaly n n n In some cases it may be difficult to distinguished

Alobar holoprosencephaly n n n In some cases it may be difficult to distinguished alobar holoprosencephaly frm hydranecephaly ( where no cortex around the dilated CSF space ) & severe hydrocephalus ( where well formed falx & separated ventricles with a septum pellucidum is present) n n most severe form. Absent CC & septum pellucidum, resulting a single, large “monoventricle” with preservation of small amount of brain parenchyma at periphery. No separation of the lateral ventricles & cerebral hemispheres. No falx or interhemispheric fissure. Fused basal ganglia and thalami

n Closed lip schizencephaly

n Closed lip schizencephaly

THANK YOU. . .

THANK YOU. . .