Patient with Lingual Thyroid and Squamous Cell Carcinoma of the Tongue Base – Case Report

We demonstrate a rare case of lingual thyroid together with squamous cell carcinoma of the base of tongue. 54-year old patient presented with left sided lymph node enlargement in regions II, III and IV, without any clinical symptoms. Physical examination revealed semicircular bulge at the base of tongue measuring 30x20 mm and tumorous lesion was suspected. Neck ultrasound showed pathological enlargement of lymph nodes and FNA of lymph node revealed squamous carcinoma cells in the smear. Further investigation included CT and MRI of the neck depicted ectopic thyroid tissue in base of tongue and enlarged and necrotic lymph nodes in regions II and III. Primary carcinoma could not be depicted. Biopsy of the lingual mass was performed and histology confirmed ectopic thyroid tissue. Physical examination of the oral cavity was repeated and suspicious area on the left side of the tongue base near ectopic thyroidal tissue was identified. Histology after biopsy confirmed squamous cell carcinoma with superficial growth. This case emphasizes the important role that collaboration of radiologist and otorhinolaryngologyst has in correctly diagnosing oropharyngeal pathology. Also, we underline the importance of careful oropharyngeal region screening in case of unknown pathologic lymphadenopathy, when the possibility of oropharyngeal cancer has to be considered

Computed tomography and magnetic resonance imaging of adrenal lesions

Od ranije je poznato kako učestalost ekspanzivnih lezija nadbubrežnih žlijezda na obdukcijama značajno nadilazi broj klinički potvrđenih adrenalnih lezija. Zbog sve učestalijeg korištenja slojevnih tehnika snimanja posljednjih godina otkriva se značajno veći broj suprarenalnih tvorbi koje zahtijevaju karakterizaciju i endokrinološku obradu. Većina tih lezija su nefunkcionalni (silentni) adenomi, tzv. incidentalomi, no potrebna je slikovna karakterizacija lezija kako bi se isključio maligni tumor i odredili daljnji terapijski postupci. U radu prikazujemo pregled literature o slikovnoj dijagnostici najčešćih benignih i malignih lezija nadbubrežnih žlijezda, s fokusom na kompjutoriziranu tomografiju i magnetsku rezonanciju s prikazom primjera iz vlastite kliničke prakse. U nastavku prikazujemo algoritam temeljen na preporukama ACR-a (American College of Radiology) i algoritmu koji je sastavio Incidental Findings Committee o optimalnom odabiru slikovne metode i daljnjim postupcima s novootkrivenim lezijama nadbubrežnih žlijezda.The incidence of adrenal lesions on autopsy significantly overcomes the number of clinically diagnosed adrenal lesions. Due to increasing use of cross-sectional imaging in the past few years, a significantly higher number of adrenal lesions is detected, which require characterisation and endocrinological workup. Although a majority of these lesions are nonfunctional (silent) adenomas, imaging characterisation is required to exclude malignant process and determine further management. In this article we present the review of current litterature on imaging of benign and malignant adrenal lessions, with emphassis on computed tomography (CT) and magnetic resonance imaging (MRI) characteristics, presenting images from our clinical practice. Furthermore, we present the algorithm based on the recommendations of American College of Radiology Incidental Findings Committee on how to select optimal imaging method and further management of adrenal lesions

Magnetic resonance and computed tomography imaging of cystic pancreatic lesions

Cistične lezije gušterače su raznovrsna grupa lezija s vrlo širokom histološkom diferencijacijom, od benignih tvorevina do invazivnih malignih tumora. Predstavljaju klinički problem budući da je etiologija tih promjena vrlo raznolika, tijek bolesti često asimptomatski, a potencijalno su malignog karaktera. Tijekom godina broj pacijenata s dijagnosticiranim cističnim lezijama gušterače je značajno porastao prvenstveno zbog napretka radioloških tehnika i starenja populacije. Kompjutorizirana tomografija i magnetska rezonancija predstavljaju izvrsne slojevne slikovne metode za otkrivanje i karakterizaciju cističnih lezija te su predvodnice u dijagnostici i temelj odluke o terapijskom pristupu. U radu ćemo ukratko prikazati spektar najčešćih cističnih lezija gušterače i njihovu radiološku prezentaciju.Cystic lesions of the pancreas are histologically diverse group of lesions, from benign to the invasive malignant lesions. Due to diverse etiology, sometimes asymptomatic course of the disease and potentially malignant character they represent significant clinical problem. With the development of radiological techniques and aging of population the number of diagnosed cystic lesion increases. Computed tomography and magnetic resonance imaging are excellent modalities for both initial detection and later characterization of cystic pancreatic lesions and they have leading role both in diagnostic and therapy planning. In this article we will present the spectre of most common cystics lesion of the pancreas and their radiologic presentation

Mysterious atrial mass mimicking severe mitral stenosis

Introduction: The differential diagnosis of an intracardiac mass include benign and malignant primary heart tumors, metastatic tumors and thrombi. Primary tumors of the heart consist mainly of myxomas, with an incidence of less than 0.5%. Clinical manifestations are consequence of embolic phenomena, intracardiac obstruction or constitutional symptoms. In rare instances, myxomas can cause a mass effect, resulting in mitral valve obstruction1. Case report: 68-year-old male with a history of ulcerative colitis complained to his gastroenterologist about having exercise intolerance. Undergoing regular colitis evaluation, CT thorax and abdomen scan was performed incidentally revealing a large intracardiac mass. Echocardiogram ordered by the consulting cardiologist demonstrated a large ellipsoid left atrial cyst (50×31 mm), occupying nearly the entire left atrium (Figure 1). The mass was protruding across the mitral valve orifice in diastole causing functional stenosis with an elevated mean diastolic gradient of 10,9 mmHg. Mitral valve area calculated by pressure half-time was 1.0 cm2. Doppler showed moderate tricuspid regurgitation with a systolic pulmonary artery pressure of 50 mmHg. The systolic function was preserved with an estimated left ventricular ejection fraction of 58%. Transesophageal echocardiography described a cavitating lesion (measuring 15,1 cm2, attached to interatrial septum with 24 mm base), having characteristics consistent with a hemorrhagic cyst (Figure 2). Preoperative coronary angiography displayed coronary artery disease and a rare condition of dual coronary artery supply with left circumflex artery (LCx) providing two (Figure 3) and right coronary artery (RCA) one tumor branch (Figure 4) producing a characteric "tumor blush". CT showed large intracardiac mass (Figure 5 and Figure 6). Patient underwent cardiothoracic surgery with successful excision of the tumor (4,5x3x2 cm), the pathohistology confirmed myxoma. Postoperative course was uneventful, exercise intolerance symptoms improved, and echocardiographic follow up showed no intracardiac mass. Conclusion: We described a rare case of cystic-appearance cardiac myxoma with dual coronary supply mimicking mitral valve stenosis. There are not many patients reported with left atrial myxoma being vascularized from both RCA and LCx as seen in our case2. Although more than half of atrial myxomas show obstructive symptoms, severe mitral valve obstruction is rare1. Early echocardiographic examination of patients presenting with exertional dyspnea is advised, as myxomas have an excellent prognosis following surgical excision, preventing complications and improving quality of life

Sacral metastasis of hepatocellular carcinoma – the only manifestation of the disease

Cilj: Cilj je bio prikazati kako se ponekad uznapredovali hepatocelularni karcinom (HCC) može klinički prezentirati isključivo simptomima ekstrahepatalne metastaze. U pacijenata sa sumnjom na hepatocelularni karcinom (HCC), bez histološke potvrde iz intrahepatalnog uzorka tkiva, treba tražiti ekstrahepatalna sijela i njihovom biopsijom potvrditi ili isključiti dijagnozu. Prikaz slučaja: 57-godišnjem pacijentu s dugogodišnjim hepatitisom C u obradi je učinjena kompjutorizirana tomografija (CT), a potom i magnetska rezonancija (MR) abdomena koje su pokazale nodularnu pregradnju jetre i trombozu desne grane portalne vene. Iako bez sasvim jasne demarkacije slikovnim metodama, postavljena je sumnja na masivni tip intrahepatalnog HCC-a s invazijom vaskularnih struktura. U uzorcima biopsije pronađene su promjene u sklopu uznapredovale ciroze, bez histološkog dokaza maligne bolesti. Budući da se pacijent klinički prezentirao slikom kroničnog bolnog sindroma leđa te imao simptome parestezije po tipu „jahaćih hlača” i osjećaj smanjene kontrakcije analnog sfinktera, učinjen je MR lumbosakralne kralježnice koja je otkrila osteolizu sakruma s mekotkivnom tvorbom. CT-om vođena biopsija potvrdila je metastazu HCC-a. U daljnjem liječenju učinjena je supraselektivna embolizacija lateralnih sakralnih arterija sa zadovoljavajućim učinkom. Zaključak: U ovom slučaju sakralna lezija bila je jedina detektabilna metastaza HCC-a iz koje se dobila histološka potvrda bolesti. Kod ekstrahepatalno proširenog HCC-a treba uzeti u obzir i ekstrahepatalne metastaze za uzimanje uzoraka tkiva, ako se ne dobije potvrda maligne bolest iz intrahepatalnog uzorka.Aim: Rare patients with advanced hepatocellular carcinoma (HCC) exclusively present with symptoms of distant metastasis. If there is no histological confirmation of the disease from liver tissue sample, extrahepatic lesion biopsy can confirm or exclude clinical suspicion. Case report: A 57-year-old male with long history of hepatitis C infection underwent computed tomography (CT) and magnetic resonance (MR) imaging which revealed nodular liver rearrangement with thrombosis of the right portal vein branch. Large intrahepatic HCC with vascular invasion was suspected, although without clear demarcation on imaging or histological verification. Only severe cirrhosis was found in several biopsy specimens. Since the patient suffered from simultaneous chronic lower back pain, and paresthesia with incontinence emerged, he underwent pelvic MR which demonstrated osteolitic destruction and large soft tissue mass in the sacrum. CT-guided biopsy confirmed HCC metastasis. Supraselective embolization of irrigating lateral sacral arteries was performed. Conclusion: Diagnosis of HCC sometimes can be challenging despite diagnostic procedures performed in accordance with current guidelines. In our patient sacral lesion was the only detectable metastasis of HCC and the target for histological confirmation of the disease. In patient with clinical suspicion on HCC but without histological confirmation from liver tissue, detection and biopsy of distant metastases is the only way to diagnose the disease

The role of computerized tomography in the diagnosis of acute abdomen

Cilj: Cilj ovog retrospekti vnog istraživanja bio je ispitati dijagnosti čku vrijednost kompjutorizirane tomografi je (CT) kod neoperiranih pacijenata koji su se prezenti rali kliničkom slikom akutnog abdomena u procjeni potrebe kirurškog liječenja te u detekciji uzroka nastanka kliničke slike. Ispitanici i metode: Retrospekti vno istraživanje obuhvati lo je neoperirane pacijente starije od 18 godina koji su upućeni na CT pretragu s kliničkom slikom i uputnom dijagnozom akutnog abdomena u razdoblju od 31. 10. 2014. do 31. 10. 2015. godine. Isključeni su pacijenti s laparotomijom ili laparoskopijom učinjenom unutar 30 dana prije CT pretrage te pacijenti koji su preminuli ti jekom hospitalizacije bez učinjenog kirurškog zahvata. Osim operacijskog nalaza, referentna metoda je bila kliničko praćenje ti jekom 30 dana nakon CT-a u neoperiranih pacijenata. CT nalaze neovisno su analizirala dva radiologa s više od 5 godina iskustva s abdominalnim CT pretragama, a nesuglasja su rješavana konsenzusom. Rezultati : Od ukupno 81 pacijenta (dobni raspon od 19 do 91 god., medijan 69 godina, omjer muškaraca i žena 45/36), 51 pacijent podvrgnut je hitnom kirurškom liječenju. Perforacija duodenalnog/želučanog ulkusa, diverti kuliti s i apendiciti s s komplikacijama, perforacija crijeva i komplikacija akutne upale žučnog mjehura bile su najčešće indikacije za operaciju. Osjetljivost i specifi čnost CT pretrage u ispiti vanoj skupini iznosila je 94,6 % i 84,0 %, dok su poziti vna i negati vna predikti vna vrijednost bile 93,0 % i 87,5 %. U stvarno poziti vnih nalaza CT-om smo uspješno procijenili uzrok nastanka kliničke slike u 83 % pacijenata. Zaključak: CT pretraga abdomena i zdjelice u pacijenata s kliničkom slikom akutnog abdomena pouzdana je dijagnosti čka metoda u procjeni indikacije za kirurško liječenje i detekciji uzroka nastanka kliničke slike.Aim: The aim of this retrospecti ve study was to determine the diagnosti c value of computerized tomography (CT) in pati ents without prior surgery who presented with clinical signs and symptoms of acute abdomen with the goal of assessment of the need for surgery and the detecti on of causes of acute abdomen. Pati ents and methods: This retrospecti ve study included all adult pati ents without prior surgery who were referred to perform abdominal CT scan with the diagnosis of acute abdomen in the period from October 31st 2014 ti ll October 31st 2015. Pati ents who had laparotomy of laparoscopy performed within 30 days prior to CT examinati on and those who died during hospitalizati on aft er the CT examinati on and without surgery were excluded. Reference standards in this study were surgery report and hospital observati on during 30 days aft er CT exam in pati ents who had no surgery. CT exams were independently analysed by two radiology specialists with more than 5 years of experience in abdominal CT imaging and all disagreements were sett led with consensus. Results: Out of 81 pati ents (age 19-91, median 69 years, male/female rati o 45/36) 51 had emergency surgery. Duodenal/gastric ulcer perforati on, diverti culiti s and appendiciti s with complicati ons, bowel perforati on and complicati ons of acute cholecysti ti s were the most common causes for surgery. Sensiti vity and specifi city of abdominal CT were 94.6% and 84.6%, while positi ve and negati ve predicti ve values were 93.0% and 87.5%, respecti vely. In pati ents with true positi ve results, CT successfully assessed the localizati on of the cause of acute abdomen in 83% of pati ents. Conclusion: Abdominal CT examinati on in pati ents with signs and symptoms of acute abdomen is a reliable diagnosti c method in the assessment of indicati on for surgery and the detecti on of causes of acute abdomen

Osteosarcoma of the Mastoid Process Following Radiation Therapy of Mucoepidermoid Carcinoma of the Parotid Gland – A Case Report

Radiation therapy is frequently used method in treatment of the head and neck malignancies. Osteosarcoma is a rare complication of radiation therapy and usually occurs after a long latent period. We report the case of 75-year-old female with osteosarcoma of the mastoid process. Twelve years before presentation she received radiation therapy after total parotidectomy and radical neck dissection in treatment of mucoepidermoid carcinoma of the parotid gland. Diagnostic procedures included contrast – enhanced CT and MRI of the head and neck and HRCT of the temporal bone. The final diagnosis of the low grade osteosarcoma was confirmed by biopsy. Diagnostic criteria were fulfilled and the lesion was classified as a radiation induced osteosarcoma

Cherry Pit as a Cause of Ileus in Colonic Stenosing Carcinoma - a Case Report

Cilj: Cilj ovog rada je podići svijest o tome kako koštice trešnje mogu uzrokovati opstrukciju crijeva kod pacijenata koji boluju od karcinoma debelog crijeva. Prikaz slučaja: Muškarac starosti 68 godina javio se u hitnoći s anamnezom konstipacije i boli paraumbilikalno lijevo. Nativni radiogram abdomena u stojećem stavu pokazuje aerolikvidne nivoe tankog i debelog crijeva koji upućuju na ileus te se indicira CT pregled na kojem se potvrdi distenzija vijuga tankog i debelog crijeva s aerolikvidnim nivoima te stenozirajuća neoplazma silaznog kolona. Uzak, nepravilan lumen tumora bio je opstruiran okruglim stranim tijelom. Na CT pregledu okruglo strano tijelo ima hipodenzno ovoidno središte i hiperdenzni pokrov, što po opisu odgovara koštici trešnje. Napravljen je kirurški otvor na trbušnoj stijenci kroz koji je izveden segment crijeva (anus praeter) te je pacijent nakon oporavka otpušten iz bolnice. Dva mjeseca kasnije pacijent je zaprimljen na odjel kirurgije. Nakon učinjene prijeoperacijske obrade pristupilo se planiranom operacijskom zahvatu. Međutim, intraoperacijski je pronađena karcinoza peritoneuma te se odustalo od planiranog radikalnog zahvata. Upućen je na Kliniku za radioterapiju i onkologiju gdje su uvedeni ciklusi kemoterapije. Iduće godine u rujnu pacijent dolazi na aplikaciju 12. ciklusa. Osjećao se dobro te je otpušten kući uz preporuku da nastavi s dosadašnjom terapijom. Zaključak: Ileus izazvan košticom trešnje rijetko je stanje, ali treba biti uključeno u diferencijalnu dijagnozu u pacijenata s rizičnim čimbenicima kao što je zloćudna novotvorina debelog crijeva. Karcinom debelog crijeva ozbiljna je bolest koja zahtijeva pažljivu prehranu i brigu o prohodnosti crijeva.Aim: The aim of this paper is to raise awareness of how cherry pits can cause bowel obstruction in patients with colon cancer. Case report: A 68-year-old male presented to the emergency department with a history of constipation and left paraumbilical pain. A standing abdominal x-ray revealed air-fluid levels in the small and large bowel suggestive of ileus, and the CT scan confirmed the dilation of the small and large bowel with air-fluid levels and a stenosing neoplasm in the descending colon. The narrow, irregular lumen of the tumor was obstructed by a round foreign body. The CT scan showed a hypodense oval center and hyperdense shell consistent with a cherry pit. A surgical opening was made in the abdominal wall and a segment of the bowel was extracted (anus praeter), and the patient was discharged after recovery. Two months later, the patient was readmitted to the surgical department, and a planned surgery was performed after preoperative evaluation. However, peritoneal carcinomatosis was found intraoperatively, and the planned radical procedure was abandoned. He was referred to the Department of Radiotherapy and Oncology where he received chemotherapy cycles. The following year in September, the patient returned for the 12th cycle application. He felt well and was discharged with the recommendation to continue his current therapy. Conclusion: Bowel obstruction caused by a cherry pit is a rare condition but should be included in the differential diagnosis in patients with risk factors such as colon cancer. Colon cancer is a serious disease that requires careful nutrition and bowel management

Pancreatic Iodine Density and Fat Fraction on Dual-Energy Computed Tomography in Acute Pancreatitis

The aim of our study was to investigate iodine density (ID) and fat fraction (FF) on dual-energy computed tomography (DECT) in patients with acute pancreatitis (AP). This retrospective study included 72 patients with clinically confirmed AP and 62 control subjects with DECT of the abdomen. Two radiologists assessed necrosis and measured attenuation values, ID, and FF in three pancreatic segments. We used receiver operating characteristic (ROC) analysis to determine the optimal threshold for ID for the differentiation between AP groups. The ID was significantly higher in interstitial edematous AP compared to necrotizing AP and the control group (both p 0.05) for the head, body, and tail, respectively. The FF was significantly higher for pancreatitis groups when compared with the control group in the head and body segments (both p < 0.001). In the tail, the difference was significant in necrotizing AP (p = 0.028). The ID values were independent of attenuation values correlated with the FF values in pancreatic tissue. Iodine density values allow for differentiation between morphologic types of AP

The role of computerized tomography in the diagnosis of acute abdomen.

Cilj: Cilj ovog retrospektivnog istraživanja bio je ispitati dijagnostičku vrijednost kompjutorizirane tomografije (CT) kod neoperiranih pacijenata koji su se prezentirali kliničkom slikom akutnog abdomena u procjeni potrebe kirurškog liječenja te u detekciji uzroka nastanka kliničke slike. Ispitanici i metode: Retrospektivno istraživanje obuhvatilo je neoperirane pacijente starije od 18 godina koji su upućeni na CT pretragu s kliničkom slikom i uputnom dijagnozom akutnog abdomena u razdoblju od 31.10. 2014. do 31.10.2015. godine. Isključeni su pacijenti s laparotomijom ili laparoskopijom učinjenom unutar 30 dana prije CT pretrage te pacijenti koji su preminuli tijekom hospitalizacije bez učinjenog kirurškog zahvata. Osim operacijskog nalaza, referentna metoda je bila kliničko praćenje tijekom 30 dana nakon CT- a u neoperiranih pacijenata. CT nalaze neovisno su analizirala dva radiologa s više od 5 godina iskustva s abdominalnim CT pretragama, a nesuglasja su rješavana konsenzusom. Rezultati: Od ukupno 81 pacijenta (dobni raspon od 19 do 91 god., medijan 69 godina, omjer muškaraca i žena 45/36), 51 pacijent podvrgnut je hitnom kirurškom liječenju. Perforacija duodenalnog/ želučanog ulkusa, divertikulitis i apendicitis s komplikacijama, perforacija crijeva i komplikacija akutne upale žučnog mjehura bile su najčešće indikacije za operaciju. Osjetljivost i specifičnost CT pretrage u ispitivanoj skupini iznosila je 94, 6 % i 84, 0 %, dok su pozitivna i negativna prediktivna vrijednost bile 93, 0 % i 87, 5 %. U stvarno pozitivnih nalaza CT-om smo uspješno procijenili uzrok nastanka kliničke slike u 83 % pacijenata. Zaključak: CT pretraga abdomena i zdjelice u pacijenata s kliničkom slikom akutnog abdomena pouzdana je dijagnostička metoda u procjeni indikacije za kirurško liječenje i detekciji uzroka nastanka kliničke slike