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ABSTRACT: INTRODUCTION Dermatofibrosarcoma protuberans (DFSP) is a rare locally aggressive tumor of the dermis and subcutaneous tissue that commonly appears on upper extremities and on the trunk. There is a slight male predominance and the lesion is commonly seen between the second and fifth decades of life. The tumor grows slowly over years and rarely metastasizes; however, local recurrence is frequent. The most common sites for metastasis are lymph nodes and the lungs. The treatment of the tumor is resection with wide margins (1,2). Here we present radiologic findings of DFSP with unusual presentation located in the deep skin over the breast, which was excised successfully and without local recurrence during a 36-month follow-up period. CASE REPORT A 36-year-old female with a palpable right breast mass located in the upper inner quadrant and change in skin color without a significant history was admitted to surgery department. She claimed that the mass had first appeared two years before and was slowly growing. She had no history of recent trauma or surgical operation. On inspection, a well circumscribed, plaque type lesion was observed, along with a violet-purple change in color of the skin over the right breast (Fig. 1). The patient reported neither systemic disease or known illness nor continuous drug usage. Physical examination was unremarkable except for a well-defined non-tender mass on the right breast. The left breast and bilateral axillaries were normal. The patient was referred for radiologic examination to exclude a primary breast tumor. Bilateral breast ultrasound (US) and color Doppler ultrasound (CDUS) was performed with a Toshiba, Powervision 6000 SSA-370A (Tokyo, Japan) with 6-11 MHz high frequency linear transducer.US demonstrated a 3.5x1.5 cm sized solid, hyperechogenic lesion with sharp margins in the subcutaneous fat tissue, without marked vascularity on CDUS (Fig. 2). The left breast and both axillaries were unremarkable. The right mammography (HFXPlus-Fischer Imaging, Denver, USA) on mediolateral oblique (MLO) projection showed a well-defined bilobulated density with irregular margins and no calcifications (Fig. 3). Based on the mammography and sonography findings, the mass was considered suspect of malignancy and breast magnetic resonance imaging (MRI) study was planned for further examination. A contrast-enhanced breast MRI was performed using a 1.5 tesla MR unit (Somatom Vision Plus, Siemens, Erlangen, Germany) at our institution. Unfortunately, the mass could not be demonstrated on either T1, T2 or postcontrast subtracted images (Fig. 4). The patient was referred to surgery department and wide excision of the mass was performed. On pathologic evaluation, spindle cells were seen to be arranged in a storiform pattern, with minimal pleomorphism (Fig. 5). Immunohistochemical stain with CD34 was positive (Fig. 6) and definitive histologic diagnosis was DFSP. On follow-up, 36 months after surgical treatment, the patient continued to be symptom free, with no signs of tumor recurrence. DISCUSSION Dermatofibrosarcoma protuberans is a rare fibrous tumor of the soft tissue, commonly arising from dermis and subcutaneous tissue, which was first described by Darier and Ferran in 1924 (3). It accounts for 0.1% of all malignant tumors and 1% of all soft tissue sarcomas. The tumor is mostly located on the trunk skin (50%-60%) and is more common in men than women. The majority of these tumors are less than 5 cm in diameter. It can be seen at any age but it is much more common between ages 20 and 50, however, there are few cases reported in early childhood. DFSP has an indolent growth pattern and its symptoms are mostly long lasting, spanning over months and years (1,2,4). DFSP poses a diagnostic challenge as the clinical symptoms and the radiologic signs are nonspecific. The tumor usually causes a red-purple change of color on the overlying skin on inspection, and if it presents with a red and irregular bordered lesion, it can mimic a hemangioma. When DFSP is located in the breast, it can be mistaken for primary breast tumor and the accurate diagnosis is difficult to reach. Usually after clinical evaluation, US is the first choice for imaging and CDUS is very helpful for vascular situation but neither of the modalities is specific for diagnosis. Shin et al. report that a diagnosis of DFSP should be considered if US reveals an oval mass in the subcutaneous tissue that is abutting against the skin and has a focal lobulated margin with hypoechogenicity or an irregular margin with mixed echogenicity (5).Although an echogenic macrolobulated oval mass located over the breast lying in the deep dermis and the subcutaneous tissue without marked vascularization was demonstrated, an exact diagnosis could not be made in the present study. Unfortunately, mammography was also found to be nonspecific, with macrolobulated density on MLO projection. Considering mammography and sonography findings, a primary breast tumor could not be excluded and the present case was classified as BI-RADS category 4. Computed tomography is not indicated unless bony invasion or pulmonary metastasis is suspected in some occasional cases. Although MRI is also nonspecific for the exact diagnosis of DFSP, it is useful for identifying the extent and location of the mass, especially in large recurrent tumors. In addition, the areas of hemorrhage within the tumor may be demonstrated by use of MRI and can suggest the diagnosis (6,7). Another current imaging modality, multivoxel proton [1H]) MR spectroscopy (MRS), is accepted as an adjunctive method to breast MRI on differential diagnosis of benign versus malignant tumors. A recent case study of DSFP located on the breast, reported by Ivanovic et al., did not show significant cholin peak on [1H] MRS (8). In the present case, the mass could not be demonstrated on either T1 or T2 weighted images, and there was no significant enhancement on post-contrast subtracted images on breast MRI examination. It is considered that the discrimination failed both on pre- and post-contrast images as the mass was probably carrying similar signal characteristics of the adjacent subcutaneous fat tissue in which the lesion developed. Complete surgical resection is accepted as the optimal treatment for primary or recurrent DFSP. Studies have shown that resection with wide margins is essential and recurrence rates after local resection are reduced while the excision margins are widened. The combination of adjuvant radiotherapy before or after the surgery is a treatment option, particularly in those who cannot undergo wide surgical excision for several reasons. In addition, there are some successful clinical reports on imatinib, a tyrosine kinase inhibitor, which can induce regression in patients with unresectable or metastatic DFSP (1,2,4). Proper follow-up seems critical since the most significant characteristic of the tumor is recurrence, and local recurrence generally occurs in the first 3 years after surgery. Sonographic evaluation and re-biopsy is advisable if suspicion occurs. In addition, mammography might be helpful in the diagnostic work-up in breast located tumors for periodic control of recurrence. In conclusion, DFSP is a rare soft tissue tumor of cutaneous origin that mostly occurs on the trunk and might be rarely seen on the breast skin and can be confused with primary breast tumors. We believe that the importance of the present case is to upgrade the awareness of this soft tissue tumor while keeping in mind the differential diagnosis of other breast tumors.
Acta dermatovenerologica Croatica : ADC. 04/2012; 20(1):50-4.
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ABSTRACT: To assess the most effective magnetic resonance imaging (MRI) sequence for the visualization of the 9th, 10th, and 11th cranial nerves (glossopharyngeal, vagus, and accessory nerves, respectively) in their intraforaminal/canalicular courses.
Balanced fast-field echo (b-FFE), 3D-T2W DRIVE, T2W 2D TSE and post-contrast T1W MRI sequences were all applied and we tried to get the best sequence for the exact assessment of the 9th, 10th, and 11th cranial nerves. Six hundred nerves of 100 patients without symptoms of neurovascular compression were examined using the above sequences. Imaging analysis was graded as: a) nerves analyzed by certainty (score of 2), b) nerves analyzed partially (score of 1), and c) nerves not identified (score of 0).
In all three nerves, the best sequence for the visualization of the cisternal and intraforaminal course was b-FFE, with 58%, 73%, 62%, and all together 64.3% success in showing the fascicles of the 9th-11th nerves. This sequence with a very short time of repetition, symmetrical and balanced gradient around the echo time allowed very fast imaging and a high signal to noise ratio. T2W TSE sequence was superior to the DRIVE T2W sequence in assessing the cisternal and intraforaminal part of all three nerves. Post-contrast T1W sequence was probably the worst sequence in showing all three nerves.
b-FFE gradient echo MRI sequence with high spatial resolution is the optimal sequence for determining the courses of 9th-11th cranial nerves.
Diagnostic and interventional radiology (Ankara, Turkey) 03/2011; 17(1):3-9. · 1.10 Impact Factor
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Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 08/2010; 29(8):1243-5. · 1.25 Impact Factor
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ABSTRACT: Splenogonadal fusion is a rare congenital anomaly in which the spleen is abnormally connected to the gonad. Two types of splenogonadal fusion have been described: continuous and discontinuous. Splenogonadal fusion is frequently associated with cryptorchidism and/or congenital orofacial/limb anomalies. We describe the ultrasound findings in a case of continuous-type splenogonadal fusion associated with ipsilateral testicular atrophy with correlation with MRI.
Journal of Clinical Ultrasound 10/2009; 38(3):161-3. · 0.81 Impact Factor
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ABSTRACT: The aim of this study was to define the sonographic evaluation and morphometric measurements of the suprascapular notch.
The suprascapular notch was evaluated by ultrasound on both sides in 50 volunteers (25 males, 25 females). By means of ultrasound, the notch width, the notch depth and the distance between the skin and the notch base (skin-notch base interval) were measured and imaging of the superior transverse scapular ligament was attempted. Furthermore, imaging of the suprascapular artery and vein was performed by Doppler ultrasound.
On the measurements performed, the notch was found to be deeper in men than in women on both the right (P = 0.022) and the left (P = 0.011) sides. Taking all volunteers into account without grouping sex, no differences were detected between the two sides with respect to the measurements of the notch width, notch depth and distance between the skin and the notch base. The superior transverse scapular ligament was demonstrated in 48 (96%) of 50 volunteers. On color Doppler ultrasound, the artery-vein complex was visualized in a total of 43 (86%) volunteers.
Suprascapular notch measurements and the visualization of the anatomical neighborhood, which may be beneficial for the suprascapular nerve blockade procedure, can be successfully performed by the use of high-frequency ultrasound imaging.
Anatomia Clinica 02/2009; 31(6):409-14. · 0.93 Impact Factor
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ABSTRACT: We report a patient who developed a large arteriovenous fistula in right lower extremity after gunshot injury. Because other endovascular methods failed, the patient was successfully treated with concomitant use of detachable latex balloon and N-butyl-2-cyanoacrylate (NBCA). The combination of detachable balloon and NBCA can be effectively used for endovascular treatment of peripheral arteriovenous fistulas in selected cases when effective embolization could not be achieved with other embolizing agents or their various combinations.
CardioVascular and Interventional Radiology 11/2007; 31 Suppl 2:S111-4. · 2.09 Impact Factor
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ABSTRACT: Patients with Lenke type 1 single thoracic idiopathic scoliosis were included in this prospective study. All patients had preoperative magnetic resonance imaging (MRI).
To examine the frequency of neural axis abnormalities and the need for preoperative MRI in this group of patients.
Because of the increasing use of MRI, neural axis abnormalities have been reported in association with certain clinical and radiologic findings in idiopathic scoliosis cases.
A total of 104 patients (49 juvenile onset and 55 adolescent onset), older than 10 years, were included in the study. The association of neural axis abnormalities with pes cavus, abnormal deep tendon reflexes, age of onset, presence of pain, severity of the frontal plane deformity, and sagittal contours were investigated.
All 7 patients with a neural axis abnormality on MRI had an early onset disease, and 6 of them had back pain. Thus, age of onset and back pain seem to be predictive of these abnormalities. Frequency of MRI abnormalities was as high as 45% for patients with back pain in addition to a type IC curve.
In patients with juvenile idiopathic scoliosis and back pain, preoperative MRI should be performed to eliminate the risk of postoperative neurologic deficits, even if the scoliosis is Lenke type 1. However, in patients with Lenke type 1 idiopathic scoliosis, preoperative MRI studies seem unnecessary if intraoperative neural monitoring is to be performed.
Spine 08/2006; 31(16):1828-33. · 2.08 Impact Factor
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ABSTRACT: Central nervous system aspergillosis has increased dramatically in recent years. Most of the cases are immunocompromised patients infected from a primary site, usually the lungs or paranasal sinuses, and the organism may spread to the central nervous system. Different neuroimaging patterns that have been reported vary depending on the immunological status of the patients and on the age of the lesions. Description of typical radiological patterns in cerebral aspergillosis patients may be helpful in establishing early diagnosis and treatment. In this case report, we present magnetic resonance images of cerebral aspergillosis and the contribution of diffusion-weighted magnetic resonance imaging to the diagnosis.
Diagnostic and interventional radiology (Ankara, Turkey) 01/2006; 11(4):199-201. · 1.10 Impact Factor
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ABSTRACT: Radionuclide renography with angiotensin converting enzyme (ACE) inhibition plays an important role in the diagnosis of haemodynamically significant renal artery stenosis. Angiotensin receptor antagonists inhibit the renin angiotensin system at different levels from ACE inhibitors by selectively blocking the binding of angiotensin II to AT1 receptors. The AT1 angiotensin receptor antagonist losartan has recently been used clinically in the treatment of hypertension. However, the available data on the use of losartan with renography for the detection of renovascular hypertension are limited and contradictory. The purpose of this prospective study was to compare the effectiveness of losartan renography and captopril scintigraphy in revealing renal artery stenosis.
A total of 61 renal units in 32 patients with hypertension were studied in two groups based on the losartan dosage (50 mg in group A and 100 mg in group B). Group A consisted of 17 patients, in whom 19 renal units had angiographically proven renal artery stenosis (>or=50%). In group B, there were 15 patients, in whom 20 renal arteries were stenotic. All of the patients underwent three renographies (baseline, captopril renography and early losartan renography). Early losartan renography was performed at 1 h after oral losartan administration in both groups. In group B, seven patients underwent additional losartan renography (late losartan) performed 3 h after oral losartan administration; these patients composed group B1.
The sensitivities of captopril and losartan studies were 63.2% and 42% in group A, 65% and 65% in group B and 55.6% and 66.6% in group B1, respectively.
From our preliminary results, we conclude that losartan is not superior to captopril renography for the detection of haemodynamically significant renal artery stenosis. However, a high dose (100 mg) of losartan provided higher sensitivity than the lower dose (50 mg). Late losartan scintigraphy provided similar diagnostic efficacy to early losartan renography.
European journal of nuclear medicine and molecular imaging 09/2005; 32(9):1064-74. · 4.99 Impact Factor
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ABSTRACT: Portal venous aneurysms are very rare entities, which are described as focal dilatations of the portal venous system. There are two types: intrahepatic and extrahepatic. Portal hypertension is the most important etiologic factor in the development of portal vein aneurysm. In this case report, ultrasonography, color Doppler ultrasonography and magnetic resonance angiography findings of two cases with portal vein aneurysms and portal hypertension are presented and correlated with the literature. Consequently, color Doppler ultrasonography in the demonstration of portal vein aneurysm is highlighted.
Tanısal ve girişimsel radyoloji: Tıbbi Görüntüleme ve Girişimsel Radyoloji Derneği yayın organı 04/2004; 10(1):52-5.
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Acta Radiologica 03/2004; 45(1):109-10. · 1.37 Impact Factor
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ABSTRACT: The "twinkling" artifact is a color-flow sonographic artifact presenting as a rapidly changing color encoding behind a strongly reflecting structure. Recently, "twinkling" artifact has been described behind calcifications in various tissues, urinary and gallbladder stones, encrustated indwelling ureteral stents, strongly reflecting orbital structures and an intracranial microcoil. It is important to recognize this artifact as it could lead to misdiagnosis of vascular flow within a tissue. "Twinkling" artifact could be considered as an additional sonographic feature in the diagnosis of urinary and bile duct stones and encrustated indwelling ureteral stents. "Twinkling" artifact could also play a role in detecting the morphology or biochemical composition of urinary stones.
Tanısal ve girişimsel radyoloji: Tıbbi Görüntüleme ve Girişimsel Radyoloji Derneği yayın organı 01/2004; 9(4):407-10.
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ABSTRACT: The aim of this study was to evaluate color Doppler ultrasonography in assessing hand collateral circulation before radial artery harvesting for coronary artery bypass grafting.
The hand circulation of 30 patients scheduled for coronary artery bypass grafting was assessed by means of the modified Allen test and Doppler ultrasonography dynamic test. The test was performed by recording the flow in the superficial palmar branch of the radial and ulnar arteries with and without compression of the radial artery. In the postoperative period hemodynamic changes in the ulnar artery were also detected by means of Doppler ultrasonography.
Among the 30 patients, one had abnormal and the other 29 had normal Doppler ultrasonography dynamic test results. All the patients' modified Allen test results were also normal. In 14 patients radial artery graft was used in the coronary artery bypass operation.
Doppler ultrasonography dynamic test is an effective and noninvasive method in the preoperative evaluation of the hand collateral circulation for the safe removal of a radial artery graft.
Tanısal ve girişimsel radyoloji: Tıbbi Görüntüleme ve Girişimsel Radyoloji Derneği yayın organı 10/2003; 9(3):377-81.
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ABSTRACT: The authors report on a case in which a carotid-cavernous fistula and an associated cavernous-carotid dissection developed in a 48-year-old man following a motor vehicle accident. The fistula was treated with coil embolization via a combined transarterial-transvenous approach. The dissected carotid artery segment was treated with a balloon-expandable stent, which restored normal caliber and hemispheric flow. There was no recurrence of the fistula and the postoperative wide patency of the carotid artery indicates that stent placement is an effective method of treating traumatic intracranial artery dissections.
Journal of Neurosurgery 10/2003; 99(3):584-6. · 2.96 Impact Factor
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ABSTRACT: We compared the preoperative findings of high resolution computed tomography (HRCT) and magnetic resonance imaging (MRI) with those observed during surgery to determine their value for cochlear implant patients.
A retrospective assessment was made on preoperative HRCT and MRI scans of 124 cochlear implant patients (71 males, 53 females; mean age 15 years; range 2 to 63 years). Congenital cochlear anomalies, cochlear ossification, new bone formation in the middle ear, and structures in the internal auditory canal were evaluated and compared with intraoperative findings.
Cochlear anomalies detected in five patients by HRCT and MRI were confirmed intraoperatively. Cochlear ossification encountered in six patients during surgery was only demonstrated in four patients; HRCT and MRI scans only showed a narrow basal turn in the remaining two patients. During surgery, eight patients were found to have cochlear fibrosis: this finding was documented in five patients (62.5%) by MRI, and in none by HRCT scans.
Although HRCT provides valuable information for surgical planning, its limitations may justify the additional use of MRI before cochlear implantation.
Kulak burun bogaz ihtisas dergisi: KBB = Journal of ear, nose, and throat 04/2003; 10(3):98-104.
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ABSTRACT: Mondor's disease, or acute thrombophlebitis of superficial veins of the breast, occurs rarely, and little information is available in the medical literature on imaging findings in this disease. We present the case of a 59-year-old woman who underwent evaluation of a palpable, painful cord in her left breast associated with discoloration of the overlying skin. Mammography revealed a 10-cm-long linear density in her left breast. Gray-scale sonography showed a noncompressible, hypoechoic, undulating tubular structure in the subcutaneous fat. Color Doppler imaging revealed no flow signal in this structure, although we observed arterial flow signals adjacent to it. We diagnosed Mondor's disease and treated the patient symptomatically; 6-week follow-up examinations demonstrated resolution of the venous thrombosis. The use of sonography, particularly color Doppler imaging, can aid in diagnosing Mondor's disease and in monitoring its resolution.
Journal of Clinical Ultrasound 03/2003; 31(2):103-7. · 0.81 Impact Factor
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ABSTRACT: Lead is toxic to many organ systems, among them bone marrow, muscles, kidneys, endocrine glands, joints, and nervous system. Encephalopathy is a rare but severe complication of lead poisoning. Lead toxicity is much less common in adults. Adult lead poisoning results primarily from exposure by inhalation in the workplace. In this report, two cases of adult toxic encephalopathy due to lead poisoning are presented with CT and MR findings.
Journal of Computer Assisted Tomography 04/2002; 26(3):479-81. · 1.22 Impact Factor
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ABSTRACT: We investigated the presence of neural axis abnormalities by magnetic resonance imaging (MRI) in patients with clinically and radiologically confirmed absolute flexible thoracic curves (King-Moe type III).
Preoperative MRI scans of 84 patients (34 males, 50 females; mean age 14.1 years; range 11 to 17 years) with adolescent idiopathic scoliosis and a flexible thoracic curve (King-Moe type III) were prospectively evaluated to determine neural axis abnormalities. Clinical and radiologic indications for preoperative MRI examination were sought. All patients were treated with posterior fusion. All patients were intraoperatively monitored by means of motor evoked potentials by magnetic transcortical stimulation and somatosensory evoked potentials. The mean follow-up was 50.1 months (range 24 to 105 months).
Neural axis abnormalities were detected in six patients (7.1%), including syringomyelia in five patients (5.9%) and diastometamyelia in one patient (1.2%). Of 84 patients, 51 patients (60.7%) had a relatively decreased spinal cord diameter, and an increased epidural distance. No clinical or radiologic indicators were found for preoperative MRI examination. No neurologic deficits developed during operation and in the postoperative period.
The detection of neural axis abnormalities implies the necessity of intraoperative neurologic monitoring to minimize the risks for neurologic deficits. Where this is not available, preoperative MRI seems to be an essential tool in the prevention of surgery-associated neurologic risks.
acta orthopaedica et traumatologica turcica 02/2002; 36(4):354-61. · 0.34 Impact Factor
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ABSTRACT: The aim of this prospective study was to determine and compare the orbital Doppler ultrasonography parameters of patients with Behçet's disease (with or without ocular involvement) with those of healthy subjects. We evaluated ophthalmic artery (OA), central retinal artery, posterior ciliary artery (PCA), central retinal vein, and superior ophthalmic vein (SOV) flow velocities and resistance indices (RIs). Detection of the decreased flow velocities in the OA and SOV and the increased RI in the OA and PCA might allow the identification of active period of patients with Behçet's disease.
Clinical Imaging 30(5):303-8. · 0.75 Impact Factor
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CardioVascular and Interventional Radiology 28(6):850-3. · 2.09 Impact Factor
