Search Results (74)

Soft tissue masses are predominantly benign, with a benign-to-malignant ratio exceeding 100:1, often located around joints. They may be contiguous or adjacent to joints or reflect systemic diseases or distant organ involvement. Clinically, they typically present as palpable swellings. Evaluation should consider duration, size, depth, and mobility. Also assess consistency, growth rate, symptoms, and history of trauma, infection, or malignancy. Laboratory tests are generally of limited diagnostic value. The primary clinical goal is to avoid unnecessary investigations or procedures for benign lesions while ensuring timely diagnosis and treatment of malignant ones. Imaging plays a central role: it confirms the presence of the lesion, assesses its location, size, and composition, differentiates between cystic and solid or benign and malignant features, and can sometimes provide a definitive diagnosis. Imaging is also crucial for biopsy planning, treatment strategy, identification of involved structures, and follow-up. Ultrasound (US) is the first-line imaging modality for palpable soft tissue masses due to its low cost, wide availability, and lack of ionizing radiation. If findings are inconclusive, magnetic resonance imaging (MRI) or computed tomography (CT) is recommended. This review aims to discuss the most common causes of periarticular soft tissue masses in the appendicular skeleton, focusing on clinical presentation and radiologic features. Full article

Background: Acute phosphate nephropathy (APN) is an underrecognized cause of acute kidney injury (AKI), typically associated with the use of oral sodium phosphate (OSP)-based bowel preparations. It is characterized by calcium phosphate crystal deposition within the renal tubules and may result in permanent renal impairment. Despite known risks, phosphate-containing solutions are still widely used without sufficient risk stratification. Methods: We retrospectively evaluated 517 native kidney biopsies performed in our nephrology clinic between 2017 and 2022. Among these, 12 patients with unexplained AKI and recent colonoscopy history were identified. In nine cases, non-specific tubular deposits on routine staining prompted further histochemical analysis. All had a history of recent OSP-based bowel cleansing. The use of von Kossa staining confirmed calcium phosphate deposition, consistent with APN. Results: Out of 517 kidney biopsies performed during the study period, 9 patients were diagnosed with APN based on histopathological findings following recent colonoscopy and OSP-based bowel cleansing. The mean age was 58.7 years, and three were female. Hypertension was present in seven patients, diabetes mellitus in three, and epilepsy in two; one patient had no comorbidities. Baseline renal function was normal (mean serum creatinine 0.86 mg/dL) and increased to 1.76 mg/dL at three months post-exposure. All biopsies revealed tubulointerstitial calcium phosphate deposits and interstitial inflammation; mesangial hypercellularity was observed in five cases, tubular atrophy in three, and acute tubular necrosis in one. All samples stained positive with von Kossa staining. Over time, all patients developed chronic kidney disease, and one progressed to end-stage renal disease requiring dialysis. Conclusions: In patients presenting with unexplained AKI and recent OSP-based bowel preparation, APN should be considered in the differential diagnosis. When routine histology is inconclusive, definitive diagnosis may require special histochemical staining. Risk-based restrictions on phosphate-containing agents are warranted to reduce preventable kidney injury. Full article

Background and Objectives: Many diagnostic methods exist for identifying thyroid malignancy, but most of them resemble an odyssey, as the journey from palpating a nodule to receiving a definitive diagnose is often long and costly. The aim of the present study is to investigate the role of Sestamibi scintigraphy in the characterization of cytological indeterminate thyroid nodules. Materials and Methods: A focused literature review was conducted, emphasizing the comparison between Fine Needle Aspiration Biopsy (FNAB), the main diagnostic method for thyroid cancer, and Sestamibi. Results: It is widely accepted that Sestamibi is the primary alternative for patients with non-diagnostic FNAB. As shown in the literature, Sestamibi has a high negative predictive value in excluding thyroid malignancy. Conclusions: Much like Odysseus’ adventurous 10-year journey returning to Ithaca, the path to diagnosing thyroid cancer is not straightforward. Molecular imaging with 99mTc-Sestamibi may serve as a valuable adjunct in evaluating thyroid nodules with inconclusive cytological findings. Full article

Background/Objectives: Diagnosing biliary obstructions is challenging, especially when histopathology is inconclusive. Non-malignant biliary strictures often require additional tests and a personalized approach. This study investigates the prevalence, characteristics, and natural history of indeterminate biliary strictures. Methods: A retrospective analysis was conducted on 510 treatment-naive patients with hyperbilirubinemia due to biliary strictures or obstruction, who were all candidates for endoscopic retrograde cholangiopancreatography (ERCP). Patients with a known etiology before the procedure were excluded. Diagnosis was made via brush cytology or intraductal biopsy during ERCP, with follow-up for indeterminate cases. Statistical analysis was performed with Statistica software (version 13.3; TIBCO Software Inc. (2017), Palo Alto, CA, USA). Results: Out of 510 patients, 186 (36.5%) had non-malignant biliary strictures. Strictures were located in the liver hilum (29.6%), common bile duct (11.8%), and peripancreatic ducts (58.1%). Follow-up ERCP identified malignancy in 21.5% of cases initially deemed benign. Non-malignant causes were confirmed in 41.4% of initially benign strictures, while 37.1% remained indeterminate. After six months, 25.8% of cases remained unresolved. Conclusions: A quarter of benign biliary strictures remain indeterminate despite follow-up, and 20% are later identified as malignant. Improved diagnostic protocols are needed to better manage and expedite the diagnosis of indeterminate biliary strictures. Full article

The diagnostic evaluation of interstitial lung diseases (ILDs) remains challenging due to their heterogeneous etiologies and overlapping clinical and radiographic patterns. A confident diagnosis often necessitates histopathological sampling, particularly when high-resolution computed tomography and serologic assessments are inconclusive. While surgical lung biopsy (SLB) has long been considered the diagnostic gold standard, its invasiveness, associated morbidity, and limited feasibility in high-risk patients have driven the pursuit of less invasive alternatives. Here, we review the current applications, diagnostic yield, procedural techniques, and complications of several bronchoscopic modalities. Bronchoalveolar lavage (BAL) aids in characterizing inflammatory profiles and differentiating among conditions such as hypersensitivity pneumonitis, sarcoidosis, and eosinophilic pneumonia. Endobronchial biopsies (EBBs) and endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) are valuable in diagnosing granulomatous diseases with lymphadenopathy. Transbronchial lung biopsy (TBLB) is effective for peribronchial and centrilobular diseases but is limited by small sample size and tissue distortion. Transbronchial lung cryobiopsy (TBC) enables acquisition of larger, well-preserved parenchymal tissue samples from the peripheral lung. Over recent years, studies have demonstrated that TBC, when interpreted within a multidisciplinary discussion (MDD), achieves diagnostic concordance rates with SLB exceeding 75%, and up to 95% in cases where high diagnostic confidence is reached. When performed in experienced centers using standardized protocols, TBC is considered a viable first-line histopathologic tool in the diagnostic evaluation of ILD. Adequate training and standardization of the TBC procedure are needed to ensure low complication rates and a high yield. Full article

Background/Objectives: Anastomosing hemangioma (AH) is a rare, benign vascular tumor predominantly found in the genitourinary tract and often associated with impaired renal function. Due to its nonspecific radiological features, AH is frequently misinterpreted as a malignant vascular neoplasm, particularly angiosarcoma (AS), leading to potentially unnecessary surgical interventions. This study presents a systematic review of AH cases and describes a rare instance of retroperitoneal AH arising from the left gonadal vein, which was resected due to diagnostic uncertainty. Methods: A 68-year-old man underwent imaging for benign prostatic hyperplasia, incidentally revealing a 15-mm hypervascular retroperitoneal nodule adjacent to the left psoas muscle. Imaging findings, including moderate metabolic uptake on 18FDG-PET/CT, raised suspicion for AS. Given the diagnostic uncertainty and high-risk location, the multidisciplinary team (MDT) recommended surgical resection. Laparoscopic excision was performed, and histopathological analysis confirmed AH. The patient remained asymptomatic at a 22 month follow-up. In addition, a systematic review of 159 cases from 64 studies (2009–2024) was conducted to analyze radiological features, treatment approaches, and outcomes. Results: Among the reviewed cases, 68% were incidentally diagnosed, with AH occurring predominantly in the genitourinary system (70%), especially in the kidney, adrenal gland, and ovary. Chronic kidney disease (CKD) was present in 23.3% of cases, while 19.5% had a history of malignancy. Imaging was inconclusive in differentiating AH from malignancies: CT (71.9%) and MRI (6.1%) were the most used modalities, but none could reliably exclude AS. Management strategies included upfront surgical resection in 85%, while a growing proportion (9%) of cases underwent biopsy-based observation rather than immediate surgery. No cases were followed with imaging alone. Conclusions: AH remains a diagnostic challenge due to its overlap with malignant vascular tumors. While surgical excision is often performed, our review highlights an increasing trend toward conservative management with biopsy-based diagnosis. Improved awareness and the integration of histopathology, molecular markers, and MDT-based decision-making are crucial to prevent overtreatment in cases of suspected AH. Full article

While locally advanced rectal cancer is the first clinical suspicion for severe rectal stenosis, in extremely unusual cases a lower bowel obstruction may be related to bladder metastasis. We present the case of a 64-year-old male who was admitted for occlusive rectal tumor (4 cm from the anal verge), for which an emergency loop-colostomy was performed. After two inconclusive endoscopic biopsies, a transanal rectal tru-cut biopsy allowed for the detection of high-grade urothelial carcinoma with signet ring cells. Furthermore, primary origin was detected in a small bladder tumor. In imaging reassessment after neoadjuvant chemotherapy, regression of the lesions both from the bladder and rectum was observed. Radical surgery with total pelvic exenteration was considered in the absence of other secondary tumors, but the patient declined and continued with radiotherapy. Subsequently he developed malignant chylous ascites and unfortunately died three months later. Reviewing the literature, we found twenty-five cases of urothelial metastasis to the rectum, originating from the bladder, including this newly present case. Rectal metastasis of urothelial origin poses a two-fold challenge in terms of both diagnosis and treatment. Determining the specific features of this uncommon manifestation of a common disease will improve future approaches. Full article

Objectives: This study aims to assess the potential role of the ultrasound (US) monochromatic Superb Microvascular Index (mSMI) to predict malignancy of solid focal lesions, correlating the vascular index (VI) with bioptic histological results. Methods: In this single-center retrospective analysis, patients undergoing percutaneous US-guided biopsy of solid lesions were considered. Biopsy indication was given by a multidisciplinary team evaluation based on clinical radiological data. Exclusion criteria were: unfeasible SMI evaluations due to poor respiratory compliance, locations not appreciable with the SMI, previous antiangiogenetic chemo/immunotherapies, and inconclusive histological reports. The mSMI examination was conducted in order to visualize extremely low-velocity flows with a high resolution and high frame rate; the VI was semi-automatically calculated. All bioptic procedures were performed under sole US guidance using 16G or 18G needles, immediately after mSMI assessment. Results: Forty-four patients were included (mean age: 64 years; 27 males, 17 females). Liver (15/43), kidneys (9/43), and lymph nodes (6/43) were the most frequent targets. At histopathological analysis, 7 lesions were benign and 37 malignant, metastasis being the most represented. The VI calculated in malignant lesions was statistically higher compared to benign lesions (35.45% and 11% in malignant and benign, respectively; p-value 0.013). A threshold VI value of 15.4% was identified to differentiate malignant lesions. The overall diagnostic accuracy of the VI with the mSMI was 0.878, demonstrating a high level of diagnostic accuracy. Conclusions: In this study, the mSMI analysis of solid focal lesions undergoing percutaneous biopsy significantly correlated with histological findings in terms of malignant/benign predictive value, reflecting histological vascular changes in malignant lesions. Full article

Background/Objectives: The diagnosis of hepatocellular carcinoma (HCC) mainly relies on imaging, with biopsy reserved for cases where imaging results are inconclusive. While biopsy offers histological confirmation and can guide treatment decisions, its impact on survival outcomes in HCC patients remains uncertain. This study aimed to examine biopsy practices and evaluate their effects on survival rates in HCC patients. Methods: We analyzed data from 18,304 HCC patients in the Korean Primary Liver Cancer Registry from 2008 to 2019. We compared overall survival (OS) and transplant-free survival (TFS) between patients who underwent a biopsy and those diagnosed solely based on imaging. Results: From 2008 to 2019, liver biopsy rates varied, reaching a peak of 12.44% in 2009 and declining to 8.18% in 2012, with the majority of patients (90.3%) diagnosed through imaging. Trans-arterial chemoembolization was the most common treatment overall (40.5%), especially in the non-biopsy group. Sorafenib use increased significantly in both groups after 2015. Patients who underwent biopsy had lower OS (43.1 ± 1.29 months) and TFS (42.45 ± 1.28 months) compared to those diagnosed via imaging (OS: 54.5 ± 0.48 months, TFS: 52.57 ± 0.47 months, p < 0.001 for both). However, Cox regression analysis indicated that biopsy was not a significant risk factor for OS (HR: 1.021, p = 0.502) or TFS (HR: 1.013, p = 0.674). Subgroup analysis suggested that biopsy may benefit patients with advanced stage IV-B by enabling more aggressive treatment strategies. Conclusions: Liver biopsy rates fluctuated over time, with the majority of HCC diagnoses made through imaging. Although biopsy does not significantly affect OS or TFS, it may provide advantages in advanced cases, such as stage IV-B, by guiding more aggressive treatment strategies. Full article

Introduction: With around 25 different salivary gland tumor entities described by the World Health Organization, the correct preoperative identification of masses as benign or malignant remains a challenge. If preoperative needle biopsy is inconclusive, frozen section analysis is a possible alternative for accurate histological identification. The purpose of our study was to evaluate the diagnostic effectiveness of frozen section performed for primary submandibular gland masses. Methods: In addition to acquiring epidemiological data from patients who underwent submandibular gland excision over a 20-year period, we analyzed the diagnostic effectiveness of frozen section performed for submandibular gland masses. We also examined the impact of frozen section on overall survival. Furthermore, we investigated whether there was an impact on the surgical revision rate for malignant submandibular gland masses that required additional neck dissection within the submandibular triangle. Results: Frozen section was performed for 54 submandibular gland tumors, with a specificity of 100% and a sensitivity of 81.3%. Frozen section was conducted in 12 cases of primary salivary gland malignancies, of which 9 cases were identified correctly. In three cases, the frozen section results were inconclusive. We calculated a relative risk reduction of 27% for revision surgery by performing frozen section. There was no significant association between frozen section results and overall survival. Conclusions: Frozen section demonstrates a significant reduction in the need for revision surgery. With a specificity of 100%, frozen section is especially suited to identifying benign masses. It is a valid diagnostic tool when preoperative sampling is not possible or is inconclusive. Full article

Calcified lung nodules are frequently encountered on chest imaging, often as incidental findings. While calcifications are typically associated with benign conditions, they do not inherently exclude malignancy, making accurate differentiation essential. The primary diagnostic challenge lies in distinguishing benign from malignant nodules based solely on imaging features. Various calcification patterns, including diffuse, popcorn, lamellated and eccentric, provide important diagnostic clues, though overlap among different conditions may persist. A comprehensive diagnostic approach integrates clinical history with multimodal imaging, including magnetic resonance and nuclear medicine, when necessary, to improve accuracy. When imaging findings remain inconclusive, tissue sampling through biopsy may be required for definitive characterization. This review provides an overview of the imaging features of calcified lung nodules, emphasizing key diagnostic challenges and their clinical implications. Full article

Periprosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty. Synovial fluid aspiration and preoperative tissue biopsy cultures can be helpful diagnostic tools for PJI. The aim of this study is to evaluate the diagnostic value of synovial fluid aspirations in general, and preoperative biopsies after inconclusive or dry tap aspiration in patients undergoing revision hip arthroplasty in particular. Patients who underwent diagnostic aspiration and subsequent preoperative biopsy and/or revision surgery between January 2015 and January 2024 were included in the study. Synovial fluid aspirations and tissue samples obtained from biopsy and revision surgery were interpreted using the European Bone and Joint Infection Society criteria for PJI. In total, 207 patients were included with 231 synovial fluid aspirations. The sensitivity and specificity of synovial fluid aspiration cultures were 76% and 98%. In 62 cases, tissue biopsies were performed, of which 23 were after dry tap aspiration. Tissue biopsies after dry tap aspiration had a sensitivity of 44% and a specificity of 93%. Tissue biopsies after dry tap aspiration led to the confirmation of PJI in 7/23 cases. Synovial fluid aspiration yields reliable results when evaluating a patient for suspicion of PJI. Diagnosing PJI can, however, be troublesome if the synovial fluid aspiration provides a dry tap or inconclusive result. Tissue biopsy cultures after dry tap aspiration are a feasible way to confirm PJI. Full article

Background: The objective of this study was to compare the value of ultrasound (US), magnetic resonance imaging (MRI), and US-guided fine-needle aspiration biopsy (FNAB) in the preoperative evaluation of parotid tumors. Methods: A three-year prospective study, including 35 patients, was conducted. Preoperative ultrasound, MRI, and US-guided FNAB were performed on each patient, after which an imaging and cytological diagnosis was obtained. Each patient underwent surgical treatment. The imaging and cytological diagnoses were compared with the histopathological reports. Results: Ultrasound and MRI showed the same diagnostic performance in discriminating benign from malignant parotid tumors: sensitivity—80%, specificity—97%, and accuracy—94%. In this regard, FNAB registered a sensitivity, specificity, and accuracy of 100%, 97%, and 97%, respectively. US, MRI, and FNAB were recorded as having high diagnostic accuracy in the detection of pleomorphic adenoma and Warthin tumors. Conclusions: Ultrasound and US-guided FNAB allow for the preoperative differential diagnosis of parotid tumors located in the superficial lobe. When US and FNAB results are inconclusive, MRI becomes mandatory. Full article

Autoimmune pancreatitis (AIP) is a rare chronic pancreatitis subtype that often mimics pancreatic cancer due to the overlapping clinical and radiological features, posing significant diagnostic challenges. Similarly, distinguishing AIP from pancreatic neuroendocrine neoplasms (PanNENs), which present with nonspecific symptoms, adds complexity to clinical evaluations. We present the case of a 46-year-old male with recurrent acute idiopathic pancreatitis. Abdominal computed tomography (CT) revealed a 25 mm hypodense mass in the pancreatic tail with mild arterial contrast enhancement. Magnetic resonance imaging (MRI) showed the mass to be hypointense on T2-weighted sequences, with no diffusion restriction and an enhancement pattern akin to normal pancreatic tissue. The endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) was inconclusive. Gallium-68 DOTATATE positron emission tomography–CT (Ga-68 DOTATATE PET-CT) showed an increased tracer uptake, leading to a distal pancreatectomy with a splenectomy. Histopathology demonstrated chronic sclerotic pancreatitis with inflammatory infiltrates. Elevated serum IgG4 levels confirmed the diagnosis of type 1 AIP Differentiating AIP from pancreatic malignancies, including PanNENs, is both critical and complex. This case highlights a misdiagnosis of PanNENs in a patient with focal AIP, where neuroendocrine hyperplasia and islet cell clusters within fibrotic areas mimicked PanNENs, even on Ga-68 PET-CT. The findings emphasize the potential for false positives with Ga-68 DOTATATE PET-CT and the importance of integrating clinical, radiological, and histological data for an accurate diagnosis. Full article

Background and clinical significance: Phyllodes tumors (PTs) are rare stromal neoplasms originating in the connective tissue of the breast, distinct from carcinomas that arise from the ducts or lobules. These tumors exhibit a broad spectrum of morphologic features and are traditionally classified as benign, borderline, or malignant. Case presentation: We present the case of a 71-year-old female diagnosed with a malignant PT and treated at our hospital. The patient noticed a gradually enlarging lump in her right breast over several months. Mammography was inconclusive, but an ultrasound later revealed a lobulated, firm mass, classified as BIRADS 5. Physical examination identified a 20 cm mass, and core needle biopsy suggested a borderline PT. Following lumpectomy, pathology confirmed a malignant tumor with narrow surgical margins (0.1 cm). Although mastectomy was recommended to achieve wider margins, the patient opted for adjuvant radiotherapy. She received 50 Gy in 25 fractions to the whole breast, followed by a 16 Gy boost to the tumor bed in 8 fractions. The treatment was well tolerated and completed successfully. Initially, the patient’s therapeutic management was delayed due to a combination of personal and organizational factors. However, the process was later streamlined through the use of a novel digital tool developed to facilitate the entire patient journey within our hospital system. Conclusions: This case highlights the diagnostic complexities of PTs, the critical need for effective collaboration between specialties, and the importance of timely treatment planning for optimal patient outcomes. Full article