Tulika Singh

2015 RAD-AID Conference on International Radiology for Developing Countries: The Evolving Global Radiology Landscape

Abstract Radiology in low- and middle-income (developing) countries continues to make progress. Research and international outreach projects presented at the 2015 annual RAD-AID conference emphasize important global themes, including (1) recent slowing of emerging market growth that threatens to constrain the advance of radiology, (2) increasing global noncommunicable diseases (such as cancer and cardiovascular disease) needing radiology for detection and management, (3) strategic prioritization for pediatric radiology in global public health initiatives, (4) continuous expansion of global health curricula at radiology residencies and the RAD-AID Chapter Network’s participating institutions, and (5) technologic innovation for recently accelerated implementation of PACS in low-resource countries.

An Unusual Cause of Postabortal Fever Requiring Prompt Surgical Intervention: A Pyomyoma and its Imaging Features.

Pyomyoma is an unusual complication of leiomyoma, occurring most commonly in the postpartum, postabortal, and post-menopausal periods. It develops due to infection in necrotic foci within leiomyoma, which is more common during pregnancy due to rapid growth, and in postmenopausal women due to vascular insufficiency. Other contributing factors are curettage, gynecological surgery, cervical stenosis, immunodeficiency, and recently, uterine artery embolization. It presents with a typical triad of sepsis, leiomyoma, and absence of any apparent source of infection. We report a case of persistent postabortal fever in a 26-year-old female due to a pyomyoma, which resolved after a myomectomy. Pyomyoma may become life threatening in the event of intraperitoneal rupture resulting in pyoperitoneum and septic shock. Hence, gynecologists should consider this diagnosis in women with a leiomyoma and sepsis in the absence of any apparent source of infection.

Comparison of Absolute Apparent Diffusion Coefficient (ADC) Values in ADC Maps Generated Across Different Postprocessing Software: Reproducibility in Endometrial Carcinoma

OBJECTIVE Apparent diffusion coefficient (ADC) maps are usually generated by builtin software provided by the MRI scanner vendors; however, various open-source postprocessing software packages are available for image manipulation and parametric map generation. The purpose of this study is to establish the reproducibility of absolute ADC values obtained using different postprocessing software programs. MATERIALS AND METHODS DW images with three b values were obtained with a 1.5-T MRI scanner, and the trace images were obtained. ADC maps were automatically generated by the in-line software provided by the vendor during image generation and were also separately generated on postprocessing software. These ADC maps were compared on the basis of ROIs using paired t test, Bland-Altman plot, mountain plot, and Passing-Bablok regression plot. RESULTS There was a statistically significant difference in the mean ADC values obtained from the different postprocessing software programs when the same baseline trace DW images were used for the ADC map generation. CONCLUSION For using ADC values as a quantitative cutoff for histologic characterization of tissues, standardization of the postprocessing algorithm is essential across processing software packages, especially in view of the implementation of vendor-neutral archiving.

Functioning left uterine horn with cervico-vaginal atresia and ovarian maldescent – an unclassified Müllerian anomaly treated with horn-vaginal anastomosis

Congenital cervical atresia is a rare M€ ullerian anomaly which presents with primary amenorrhoea and cyclical abdominal pain due to retrograde menstruation, haematometra and formation of endometriotic cysts (Hampton et al. 1990; Anttila et al. 1999; Chakravarty et al. 2000). Its management ranges from hysterectomy to fertility-conserving procedures like cervico-vaginal canalisation or uterovaginal anastomosis (Suganuma et al. 2002; Zhihong et al. 2003, 2014; Rampone et al. 2008; Shirota et al. 2009). Following cervico-vaginal canalisation, the atretic cervix rarely remains patent. Hence, bypassing the atretic cervix to perform a uterovaginal anastomosis may be a better option. The success rate of uterovaginal anastomosis is only around 50% due to restenosis at the site of anastomosis, but successful pregnancies following it have been reported (Fujimoto et al. 1997; Deffarges et al. 2001; El Saman 2009; Keepanasseril et al. 2011). Pre-operative counselling to explain the benefits and problems associated with fertility-conserving surgery, the need for follow-up and the regular use of vaginal mould is important. In girls with cervico-vaginal atresia and a single functioning uterine horn, horn-vaginal anastomosis can restore menstruation (El Saman et al. 2011). We report a girl with a left-sided functioning non-communicating uterine horn, a right rudimentary horn, cervical and upper vaginal atresia, a right maldescended ovary and a left endometriotic cyst treated with uterine hornvaginal anastomosis.

Role of perfusion CT in the evaluation of adnexal masses

Abstract The objective of this study was to evaluate the role of perfusion computed tomography (PCT) in differentiating benign from malignant adnexal masses. Twenty patients, each of pathologically proven malignant and benign adnexal masses who had undergone PCT on 64–slice CT scanner, were included in the study. The PCT parameters, viz. blood volume (BV), blood flow (BF), permeability surface index area (PS) and time to maximum of the tissue residue function (Tmax) of the adnexal masses were calculated. Statistical analysis to study the association between PCT parameters and histopathological diagnosis was done. In the malignant group, the mean PS, BV and BF values were elevated. The mean Tmax of the benign lesions was higher compared to that of the malignant lesions. There was a significant statistical difference in the PCT parameters between the malignant and benign groups (p value = .001). PCT can be a useful tool for differentiating benign and malignant adnexal masses. Impact statement What is already known on this subject? It is not always possible to distinguish benign from malignant adnexal lesions despite the application of various imaging techniques. Perfusion CT (PCT) is an imaging technique with which we can obtain both the morphological and functional information of tumours. Perfusion-based imaging enables us to objectively evaluate the neovascularity in a lesion. This helps in differentiating the benign lesions from aggressive malignant lesions. What do the results of this study add? The PCT parameters, viz. blood volume (BV), blood flow (BF), permeability surface index area (PS) and time to maximum of the tissue residue function (Tmax) were calculated from adnexal masses on a 64–multi-slice CT scanner and correlated with their histopathological diagnoses. The values of the mean PS, BV and BF values were significantly higher in the malignant adnexal masses. The mean Tmax in the benign masses was more compared to that of the malignant lesions. Significant statistical difference was seen in PCT parameters between malignant and benign groups. What are the implications of these findings for clinical practice and/or further research? PCT can be a useful tool for differentiating benign from malignant adnexal masses. However, more collaborative research and robust validation are imperative to further evaluate this innovative evolving technique.

An alternate surgical approach to reduce hemorrhage and complications during cesarean hysterectomy for adherent placenta

BACKGROUND Cesarean hysterectomy for adherent placenta is associated with increased maternal morbidity due to massive hemorrhage requiring large volume blood transfusion, bladder or ureteric injury, intensive care unit (ICU) admission and prolonged hospital stay. There is an ongoing effort to improve the outcome of these women and measures to reduce blood loss. OBJECTIVE The purpose of the present study was to develop an alternate surgical approach for performing a Cesarean hysterectomy in women with adherent placenta in order to reduce hemorrhage and urinary tract injuries, and thereby improve the maternal outcome. STUDY DESIGN A prospective observational study in a tertiary care hospital in North India. The surgical approach described in the present study was practiced in 12 women who underwent Cesarean hysterectomy for adherent placenta previa. In this approach, dissection of the bladder flap as close as to the cervix was made prior uterine incision and delivery of the baby. During dissection of the bladder flap, the blood vessels traversing between uterus and bladder were ligated and divided. RESULT These 12 women underwent Cesarean hysterectomy under general anesthesia. The interval from induction of anesthesia to delivery of the baby ranged from 40 to 79 min, and none of the babies had birth asphyxia. No woman had bladder or ureteric injury. All women had histopathological proven adherent placenta, 5 had placenta percreta, one had placenta increta and 6 had placenta accreta. The average blood loss was 1.46 l and the mean number of blood transfusions was 2.1 units. None of the women required post-operative ventilatory support or ICU admission, and all women were discharged from hospital between 4 to 7 days following Cesarean hysterectomy CONCLUSION: The present series describes an alternate surgical approach for Cesarean hysterectomy in adherent placenta. Dissection of the bladder flap prior to delivery of the baby followed by hysterectomy reduced the hemorrhage and there was no bladder or ureteric injury. This surgical approach requires no additional resources and may easily be followed in a low-resource setting.

Breast density in screening mammography in Indian population - Is it different from western population?

Mammography is the only method presently considered appropriate for mass screening of breast cancer. However, higher breast density was strongly associated with lower mammographic sensitivity. Breast density is also identified as independent and strongest risk factors for breast cancer. Studies have shown women with high breast density have four to six times increased risk of breast cancer as compare to women with fatty breast. It varies between different age group it generally decreases with increasing age in postmenopausal women and it can be different in different ethnic groups and people from different geographical areas. This study evaluates the breast density in Indian population and its relationship with the age. We reviewed of all screening mammography examinations performed from May 2012 to January 2015 at our institute PGIMER, Chandigarh, INDIA. Descriptive analyses were used to examine the association between age and breast density. A total of 6132 screening mammograms were performed. Each subgroup categorized by decade of age. There was a significant inverse relationship between age and breast density (P < .001). Twenty‐two percent of patients between 40 and 49 years old had dense breasts. This percentage decreased to 9% of women in their 50s. Only 7% of women in their 60s and 8% of women in their 70s had dense breasts. This data has been compared with the Western study done in New York University (NYU) shows there is significant difference (P value <.05) in the breast density in Indian and Western population with more Indians having ACR Grade 1 and 2 and Western population having 2 and 3. We found an inverse relationship between patient age and mammographic breast density. However, there were a large proportion of young women who had lower grades of mammographic density which could potentially benefit from the use of routine screening mammography in this subgroup of patients. Moreover, the breast density of Indian population is less when compared to the Western population. This might suggest that mammography is a good modality of choice for screening Indian population.

Automated detection of microcalcification clusters in mammograms

Mammography is the most efficient modality for detection of breast cancer at early stage. Microcalcifications are tiny bright spots in mammograms and can often get missed by the radiologist during diagnosis. The presence of microcalcification clusters in mammograms can act as an early sign of breast cancer. This paper presents a completely automated computer-aided detection (CAD) system for detection of microcalcification clusters in mammograms. Unsharp masking is used as a preprocessing step which enhances the contrast between microcalcifications and the background. The preprocessed image is thresholded and various shape and intensity based features are extracted. Support vector machine (SVM) classifier is used to reduce the false positives while preserving the true microcalcification clusters. The proposed technique is applied on two different databases i.e DDSM and private database. The proposed technique shows good sensitivity with moderate false positives (FPs) per image on both databases.

Primary Mucormycosis of the Breast: A Rare Entity

noma because of excessively similar imaging features. We want to indicate that if a mass with irregular shaped and indistinct margins on radiological images, has a diagnosis of lymphocytic lobulitis or mastopathy, clinicians and radiologists should be alert for accuracy of the diagnosis in terms of proposing rebiopsy or excision. Because this mass may mimic a breast malignancy or even worse this situation can be in a neighborhood of an invasive carcinoma.

Breast cancer in a patient with neurofibromatosis type 1

A 45-year-old female, known case of neurofibromatosis type 1 (NF1), presented to our hospital with complaint of progressively enlarging lump in the right breast. Local breast examination revealed retracted right nipple with multiple skin neurofibromas in bilateral breasts, including in nipple-areolar complex region (Figure 1A, B). On palpation, a hard, immobile mass was noted in the upper outer quadrant of right breast about 3.5 9 3.0 cm in size. Mammography revealed extremely dense bilateral breast parenchyma. A high to equal density, oval mass with mostly circumscribed and partly indistinct margins, was seen in the upper outer quadrant of the right breast. Fine pleomorphic calcification in segmental distribution, was seen adjacent to it. There was associated skin thickening in the upper outer quadrant region and retraction of the right nipple. An enlarged lymph node, with fatty hilum, was seen in the right axilla. Neurofibromas were seen on mammography as multiple, low to equal density, oval to round, circumscribed masses in both breasts, outlined by thin radiolucent air halo, indicating their cutaneous location. The mass in upper outer quadrant in right breast and pleomorphic calcification adjacent to it, were suspicious for malignancy and categorized according to Breast Imaging Reporting and Data System (BIRADS) as BIRADS-4. (Figure 2A-D). Core biopsy was performed from the palpable mass in upper outer quadrant of right breast. It revealed tumor cells arranged in the form of ducts, nests and surrounded by desmoplastic stroma, involving more than 60% of the areas of the core. The tumor cells were moderately pleomorphic with vesicular nuclei, conspicuous nucleoli and occasional mitotic figures (Figure 3A, B). Tumor cells were positive for estrogen and progesterone receptors and the overall features were consistent with infiltrating ductal carcinoma. Patient underwent modified radical mastectomy with axillary lymph node dissection followed by postoperative chemoendocrine therapy. Neurofibromatosis type 1 is the most common neurocutaneous syndrome. There is four to five fold greater risk of malignancy in these patients compared to general population. The most common malignant tumors are the neurogenic tumors. However, there is scientific literature describing association of breast carcinoma with NF1. The risk of developing breast cancer in NF-1 patients who are less than 50 years is higher, as compared to general population in this age group. Breast cancer 1, early onset and NF-1 genes are located in close proximity on chromosome 17 suggesting a possible interactive role of both genes in etio-pathogenesis of breast cancer.