Experience in the Surgical Management of Two Cases with Acromegaly

Acromegaly is a chronic disorder that usually develops over many years due to long term exposure to elevated levels of growth hormone (GH) most typically caused by a somatotrophic cell pituitary adenoma. It has an annual incidence of approximately 3-4 cases / million. A diagnosis of acromegaly is made based on the clinical presentation, biochemical and radiologic finding. The classical feature is the change in appearance and acral enlargement. No single therapy is comprehensively successful in controlling the disease. Surgical, medical and radiation treatments are available for lowering GH and insulin-like growth factor I (IGF-I) hypersecretion, controlling pituitary tumor mass effects, and lowering morbidity.

Case Report: Gastric Wall Thickening: Radiological Diagnostic Challenges in Gastric Malignancy

Gastric abnormalities show nonspecific gastrointestinal symptoms and similarly radiological findings. Intra and extra luminal gastric wall thickening are the most common finding in benign and malignant pathologic process. This aim of this case report was to describe several characteristics such as the location and size of the lesion, involvement of the gastric wall and surrounding structures, calcifications, and contrast enhancement pattern which can assist in radiological diagnosis. Several cases at our institution have similar gastrointestinal complaints, however, there were different lesions characteristic found in contrast enhanced abdominal CT scan. The first case 72-years-old man experienced hematemesis with radiologic finding diffuse gastric mucosal thickening as well as homogenous contrast enhancement but without calcification. The second case 37-years-old man complaint dizziness and melena with radiologic finding large tumor more than 10 cm in size, amorph calcification and heterogenous contrast enhancement. The last 60-years-old man case experienced melena and hematemesis, from abdominal CT scan showed irregular gastric mucosal thickening with heterogenous contrast enhancement and fat stranding around the lesion, without calcification. Methods used in these cases were contrast-enhanced abdominal CT scan, esophagogastroduodenoscopy (EGD), and biopsy in order to determine the diagnosis. Contrast-enhanced abdominal CT scan plays a vital role in describing the lesion characteristics which affects the determination of treatment options and future prognosis.

Management of Occult Spondylolisthesis in a Case of Low Back Pain

Spondylolisthesis is a condition of the spine that causes lower back pain. It is a vertebra slippage that occurs at the base of the spine, in most instances. We report a case of occult spondylolisthesis of a patient with grade 1 spondylolisthesis (L4 over L5). We presented the radiologic finding, diagnosis, and treatment here. A 45-year-old female was presented with the complaints of low back pain with sciatica for 4 years. The radiologic finding showed that she had dysaesthesia on both L5 dermatome and MRI of LS Spine revealed prolapsed disc at L4/5. The patient underwent decompression, stabilization via pedicle screw at L4 and L5 with fusion at L4/5 and after constant follow-ups, she was symptom-free with a full range of motion of the spine. Posterior fusion with instrumentation of the pedicle screw is commonly considered the gold standard method of lumbar spinal fusion. Non-surgical treatment is effective in relieving low back pain of the patient in most cases however, symptomatic patients need to be treated with the surgical method.

Pneumatosis Intestinalis in Adult Bilateral Lung Transplant Patients: A Single Institution Experience and Literature Review

Pneumatosis intestinalis (PI) is a radiologic finding which is characterized by the accumulation of gas within the bowel wall. This radiologic finding is traditionally thought of in the sense of intestinal ischemia. An uncommon cause of this finding is post organ transplantation. We did an institutional and literature review of this finding to demonstrate its distinct imaging features and benign nature. It was observed to occur in approximately 5.2% of patients post lung transplant (23/442). On imaging, it displays an expansile/bubbly appearance of gas within the bowel wall that is distinct from the traditional findings seen in intestinal ischemia. Clinical review showed that posttransplant patients with PI can be successfully managed conservatively with early enteral nutrition, oxygen, antibiotics, and limited follow-up imaging. With the increasing use of organ transplantation, PI is being diagnosed with increased frequency. It is important to let clinicians know of this entity and its potential outcomes.

“Mosaic Pattern” Foreign Bodies in Computed Tomography of the Head: A Specific Sign to Detect Tempered Glass-Related Head Injury

A 40-year-old male patient presented to us with a history of road traffic accident, followed by loss of consciousness and vomiting. Noncontrast computed tomography (NCCT) scan revealed frontal bone defect along with multiple “mosaic pattern” homogenously hyperdense foreign bodies of nearly similar size in the right frontoparietal region within the extradural space. Debridement craniectomy was done, and multiple pieces of glass were retrieved. The extremely unique radiologic finding and probably first in the English literature prompted us to report this interesting case. Unfortunately, the patient died of myocardial infarction 3 days after the injury. Further, this new “mosaic pattern” radiologic finding on NCCT of the head may help in determining the mechanism of injury due to tempered glass-related head trauma. Window glass may not be always safe as it is thought by commuters.

Gastrointestinal (GI) Involvement with Non-Hodgkin's Lymphoma (NHL) Impacts Outcome; A Retrospective Single Tertiary Care Center Analysis of Clinico-Pathologic Characteristics Provides an Alternate Insight to Presentation and Outcome

Introduction Historically, the GI tract is involved in 10-15% of patients with newly diagnosed NHL. Despite being the predominant extranodal site for lymphoma involvement little is known about its pathophysiologic presentation given its overall rarity. Nonetheless its evaluation, diagnosis, prognosis and management is distinct from lymphomas at other sites hence their recognition irrespective of whether being the primary site is prudent. Methods We performed a single center retrospective study of patients to describe clinical characteristics and outcome of newly diagnosed NHL presenting with GI involvement defined by tissue biopsy between January 2003 and April 2019. Descriptive statistics were calculated by Fisher's exact test and Chi2 test for categorical variables and rank-sum analyses for continuous variables. Results We identified 91 patients with one patient presenting with 2 different GI NHL involvement. The median age at presentation was 70 years (range 33-92) and 61 were male. 41 (45%) patients had diffuse large B cell lymphoma (DLBCL) and 5 had concomitant low grade component, 28 (30.8%) mucosal associated lymphoid tissue (MALT) lymphoma, 10 (11%) mantle cell lymphoma (MCL), 4 (4.4%) enteropathy associated T cell lymphoma (EATL), 3 (3.3%) follicular lymphoma, 2 (2.2%) Burkitt's lymphoma and 2 (2.2%) EBV driven lymphoproliferative disorder (LPD). There were 1 case each of plasmablastic lymphoma and extranodal NK/T-cell lymphoma, nasal type. 37 with DLBCL and 2 with MCL had primary GI involvement. Gastric involvement was the commonest site, 43 (55.8%) cases followed by the large intestine, 22 (28.6%). PET-CT scan was done in 42 cases with high grade NHL; GI involvement by FDG avidity was noted in 23 cases and negative in 19 (45.2%). Serum albumin at presentation was available in all patient. Patients with presenting serum albumin < 25 g/L were more likely to die in the first 30-days post diagnosis; p<0.0001. A total of 20 patients died as a result of lymphoma; presenting serum albumin was significantly lower in that group (mean 29 g/L versus 37 g/L; p=0.0077). H pylori status was assessed by either antigen testing in stool and/or histology. This was known in 50 patients and was available by the 2 assessment methods in 31 cases but discordant in 17. A positive result was more likely noted with the antigen test. None of the T-cell LPD were H pylori positive. 12 of the 26 DLBCL and 9 (53%) of the 17 MALT lymphoma patients were H pylori status was known were positive. Nonetheless all H pylori negative MALT lymphoma cases were localized to the stomach and responded to triple eradication therapy and Rituximab monotherapy +/- surgical resection. In the DLBCL cohort, the cell of origin was known in 22 of 39 cases; 17 were non-germinal center phenotype. In the MCL cohort, all patients whom underwent surveillance endoscopies irrespective of symptoms and/or radiologic finding had histologic evidence of GI involvement with lymphoma with only 3 (18%) patients being symptomatic +/- had radiologic finding in keeping with GI involvement. Conclusions Despite the relatively small sample size this real-world data of GI lymphomas outlines some of its recognized features; advanced age at diagnosis, male prevalence and gastric involvement as the commonest site of involvement. Presenting serum albumin <25 g/L was associated with higher 30-day mortality highlighting its relevance and need for its inclusion as a biomarker in risk stratification of NHL where GI tract is involved. There is however several other significant findings not previously recognized; the incidence of GI involvement in MCL is much higher than reported; 100% in all patients whom have undergone endoscopy in our cohort suggesting that GI involvement is a feature of MCL. With only 53% of MALT lymphoma being H pylori positive which is much lower than previously described this renders the prototypical association of H pylori infection in MALT lymphoma pathogenesis void and suggests an alternate etiology. Nonetheless their response to antibiotic therapy with only minimal additional systemic therapy in some indicates that H pylori status does not necessary predict its efficacy and should be considered when treating MALT lymphomas irrespective of H pylori status. CT scans but also PET-CT scans are insensitive in detecting GI involvement even in high grade NHL. Endoscopy with random mapping biopsies even with normal macroscopic GI findings remains the gold standard. Disclosures No relevant conflicts of interest to declare.

Subcutaneous calcification as a supportive radiologic finding for diagnosis of rhinofacial entomophthoromycosis

Rhinofacial entomophthoromycosis is an uncommon chronic fungal infection of the head and neck. The diagnosis is usually based on clinical manifestations; however, diagnosis of this infection based on early manifestations is difficult and occasionally rhinofacial entomophthoromycosis is mistaken for other diseases. Therefore, computed tomography is introduced to support the diagnosis. Radiologic findings were nonspecific with swelling of the sinonasal mucosa and perinasal region. However, subcutaneous calcification, that was observed in all our cases, may be a supportive radiologic evidence for diagnosis. The diagnosis should be confirmed definitively using histopathology or fungal culture. Early diagnosis allows prompt and appropriate treatment that will achieve excellent outcomes. We suggest that subcutaneous calcification radiologic finding may guide the aware physician to an early diagnosis of rhinofacial entomophthoromycosis.