Brinda Rao Korivi

Cross-sectional imaging work-up of adrenal masses.

Advances in medical imaging with current cross-section modalities enable non-invasive characterization of adrenal lesions. Computed tomography (CT) provides characterization with its non-contrast and wash-out features. Magnetic resonance imaging (MRI) is helpful in further characterization using chemical shift imaging (CSI) and MR spectroscopy. For differentiating between benign and malignant masses, positron emission tomography (PET) imaging is useful with its qualitative analysis, as well as its ability to detect the presence of extra-adrenal metastases in cancer patients. The work-up for an indeterminate adrenal mass includes evaluation with a non-contrast CT. If a lesion is less than 10 Hounsfield Units on a non-contrast CT, it is a benign lipid-rich adenoma and no further work-up is required. For the indeterminate adrenal masses, a lipid-poor adenoma can be differentiated from a metastasis utilizing CT wash-out features. Also, MRI is beneficial with CSI and MR spectroscopy. If a mass remains indeterminate, PET imaging may be of use, in which benign lesions demonstrate low or no fluorodeoxyglucose activity. In the few cases in which adrenal lesions remain indeterminate, surgical sampling such as percutaneous biopsy can be performed.

Malignant renal epithelioid angiomyolipoma with liver metastasis after resection: a case report with multimodality imaging and review of the literature.

Renal epithelioid angiomyolipoma (EAML) is a perivascular epithelioid cell tumor. Although the overwhelming majority of renal EAMLs are benign, cases of aggressive behavior and malignancy have been reported. Here, we report the case of a 62-year-old woman with a 12.5-cm renal EAML, who underwent resection and developed a 10.5-cm hepatic EAML 15 months after the surgery. Although multicentric disease is a possibility, the temporal course is consistent with metastasis from the poorly differentiated primary tumor. This is the only report with multimodality imaging to detail new metastatic disease during surveillance after intended curative resection of an EAML.

Ewing Sarcoma of the Kidney: A Rare Entity

Ewing sarcoma and primitive peripheral neuroectodermal tumor (PNET) are high-grade malignant tumors typically found in children and adolescents. These tumors belong to the family of small round cell tumors and are of neuroectodermal origin. Primary Ewing sarcoma of the kidney is rare and because of that is an infrequent differential diagnosis in urologic malignancies. Renal PNET mostly presents with nonspecific symptoms such as hematuria and abdominal pain. The imaging findings are uncharacteristic. The diagnosis is based on the histology, immunohistochemistry, and molecular pathologic findings. Once PNET has been diagnosed, multimodal treatment is indicated. Despite all treatment options, the prognosis of those with metastatic disease is poor.

Erythema nodosum-like panniculitis mimicking disease recurrence: A novel toxicity from immune checkpoint blockade therapy—Report of 2 patients

Immunotherapies targeting cytotoxic T‐lymphocyte‐associated antigen 4 (CTLA‐4) and the programmed cell death 1 (PD‐1) receptor and its ligand (PD‐L1) have showed substantial therapeutic benefit in patients with clinically advanced solid malignancies. However, autoimmune toxicities are common and often significant adverse events with these agents. While rash and pruritus remain the most common cutaneous complications in treated patients, novel dermatologic toxicities related to immune checkpoint blockade continue to emerge as the number of patients exposed to immunotherapy increases. Here, we describe 2 patients treated with combination immunotherapy with ipilimumab and nivolumab who developed painful subcutaneous nodules. Although the findings were clinically concerning for disease recurrence, histopathologic examination of biopsies from the lesions revealed a subcutaneous mixed septal and lobular erythema nodosum‐like panniculitis. Notably, neither patient received immunosuppressive therapy for these lesions, which subsequently remained stable, and both patients’ cancer remained controlled. These cases show that the dermatologic toxicity profile of immune checkpoint blockade is diverse and continues to expand, and illustrates that recognition of such toxicities is critical to optimal patient management.

Pancreatic Calcifications and Calcified Pancreatic Masses: Pattern Recognition Approach on CT

OBJECTIVE The purpose of this article is to review a spectrum of calcified pancreatic masses and propose an algorithm for diagnostic radiologic evaluation. CONCLUSION Pancreatic calcifications are being detected more frequently because of the widespread use of imaging, particularly CT. Pancreatic calcifications are most commonly associated with chronic pancreatitis related to alcohol abuse. Several other pathologic entities, however, can cause pancreatic calcifications. Familiarity with these entities and their CT appearance is helpful in making an accurate diagnosis.

Chronic myelomonocytic leukemia masquerading as cutaneous indeterminate dendritic cell tumor: Expanding the spectrum of skin lesions in chronic myelomonocytic leukemia

Chronic myelomonocytic leukemia (CMML) is a hematopoietic stem cell neoplasm exhibiting both myelodysplastic and myeloproliferative features. Cutaneous involvement by CMML is critical to recognize as it typically is a harbinger of disease progression and an increased incidence of transformation to acute myeloid leukemia. Cutaneous lesions of CMML exhibit heterogeneous histopathologic features that can be challenging to recognize as CMML. We describe a 67‐year‐old man with a 3‐year history of CMML who had been managed on single‐agent azacitidine with stable disease before developing splenomegaly and acute onset skin lesions. Examination of these skin lesions revealed a dense infiltrate of histiocytic cells morphologically resembling Langerhans type cells (lacking frank histopathologic atypia), and with the immunophenotype of an indeterminate cell histiocytosis (S100+ CD1a+ and langerin−). Given the history of CMML, next‐generation sequencing studies were performed on the skin biopsy. These revealed a KRAS (p.G12R) mutation identical to that seen in the CMML 3 years prior, establishing a clonal relationship between the 2 processes. This case expands the spectrum for and underscores the protean nature of cutaneous involvement by CMML and underscores the importance of heightened vigilance when evaluating skin lesions of CMML patients.

Cushing Syndrome: Diagnostic Workup and Imaging Features, With Clinical and Pathologic Correlation

OBJECTIVE Cushing syndrome (CS) is a constellation of clinical signs and symptoms resulting from chronic exposure to excess cortisol, either exogenous or endogenous. Exogenous CS is most commonly caused by administration of glucocorticoids. Endogenous CS is subdivided into two types: adrenocorticotropic hormone (ACTH) dependent and ACTH independent. CONCLUSION Cushing disease, which is caused by a pituitary adenoma, is the most common cause of ACTH-dependent CS for which pituitary MRI can be diagnostic, with bilateral inferior petrosal sinus sampling useful in equivocal cases. In ectopic ACTH production, which is usually caused by a tumor in the thorax (e.g., small cell lung carcinoma, bronchial and thymic carcinoids, or medullary thyroid carcinoma) or abdomen (e.g., gastroenteropancreatic neuroendocrine tumors or pheochromocytoma), CT, MRI, and nuclear medicine tests are used for localizing the source of ACTH. In ACTH-independent CS, which is caused by various adrenal abnormalities, adrenal protocol CT or MRI is usually diagnostic.

An Update of Practical CT Adrenal Imaging: What Physicians Need to Know

Computed tomography (CT) is increasingly being utilized for patient care, with a subsequent increase in the detection of incidental adrenal masses. It is important for physicians to be familiar with the various current and investigational CT techniques used to image and characterize adrenal masses, including noncontrast CT, dual-energy CT, post-contrast imaging with percentage washout calculations, and investigational techniques including histogram, perfusion, and biphasic CT analyses. Once an incidental adrenal mass is detected, it is important to utilize current CT adrenal imaging techniques to characterize adrenal masses and differentiate the indolent adrenal masses that may be left alone from malignant and symptomatic masses that need timely medical or surgical management. Current CT imaging techniques can be utilized to differentiate benign adrenal masses from malignant counterparts. In this article, we describe the common CT features of benign adrenal masses, including hyperplasia, adenoma, pheochromocytoma, and myelolipoma. We also describe the common CT features of malignant adrenal masses, including metastases, and adrenal cortical carcinoma.

FDG-PET Assessment of Other Gynecologic Cancers

PET and PET/computed tomography play a role in the staging, monitoring of response to therapy, and surveillance for cervical and ovarian cancers. Currently, it is also an integral part of the assessment of patients with endometrial cancer and other gynecologic malignancies, such as vaginal and vulvar cancers and uterine sarcomas. In this article, we discuss in detail and highlight the potential role of PET and PET/computed tomography in evaluating these gynecologic malignancies using illustrative cases with relevant imaging findings.

Metastatic melanoma to the testis

This case report presents the ultrasound and positron emission tomography-computed tomography (PET-CT) imaging findings related to a patient with metastatic melanoma to the testis. We review this very rare entity and discuss the role of imaging.