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IRIA Kerala in Association with IRIA Alleppey - Case Presentations

May 09 | 2:00 PM

IRIA Kerala, in association with IRIA Alleppey, brings an amazing session for radiology residents and budding consultants. Join us for interesting case presentations by 2 PG students, with Dr. Josey Verghese & Dr. Beenamol S. from Government TD Medical College, Alappuzha. Let us brush up on some fantastic concepts and discover some new ones

[Music] good evening to all of you uh i'm very happy that uh we are progressing our studies for our residents starting from january first onward so i'm happy to have a kerala ira organizing this academic session with a great effort and it's fruitful also and this month we have dr josie burgess who's professor and hodi medical college who has a wonderful career and he does lot of academics in his department he's a very good faculty for teaching the residents i'm very happy that he has come over with his residence to take up the session so i welcome dr josie to this academic session uh i welcome dr uh tisa who's a jr of halpi medical college who's going to show the cases and we'll have the discussion on the case then i welcome dr rijo of secretary of kerala ira who has helped us a lot to continue this session and dr anisha verges who's today's coordinator for the session i welcome dr anisha also thank you so our program coordinator who's always behind us helping us in all days is still hiding i welcome him also image to join the session i welcome all the residents who are hearing this talk to the residents uh to the session so welcome all thank you over to you and dr anisha okay thank you dr gomez for the kind introduction good evening dr josie i think we can go ahead to dr tesa's presentation she can share her screen okay good evening um a 50 year old female she presented with complaints of defective vision for two weeks and she's a non-diabetic on oral hypoglycemic agent uh hfa showed bi temporal healing option and her hormonal essays were normal so an uh mri brain was suggested so what is uh in the history uh a 50 year old female uh she presented with defective vision and uh houndsfield uh uh for two weeks sir yeah and uh it is uh it should localize to the region of optic asthma yeah um um so uh so um uh scalaxa latin yeah uh so you have uh started the imaging with the radiographs yes yeah uh skeletory lateral view showing ballooning of the cellar with a soft tissue opacity which is causing undercutting of the anterior clinic process with erosion of dorsal cellular and posterior clinic process and the lesion there is downward protrusion into the spinoid sinus because of the erosion of the cellar floor and the spinoid sinus is not separately visualized and no areas of calcification or fat density areas are noted within the soft tissue opacity uh the rest of the calvarial bones are grossly normal and degenerative changes are noted in the visualized cervical vertebra okay that is the description uh you said the sunlight balloon. why why do you say uh this is a larger million doubts uh because of the uh uh average dimension is uh 12 uh 12 mm and the vertical dimension average dimension is 8 okay so you have taken [Music] [Music] then there is a pa view and townsview uh do you know how to take it outside [Music] okay uh what are the boundaries of the the reversal uh peak petri fossa it is uh the anterior boundaries uh tuberculum cell uh the uh lesser anterior clinic process from the lesser being of sphenoid and chiasmatic sulcus posteriorly it was bounded by uh dorsen stella posterior clinic process and ah android inferiorly by the spinoid sinus uh posteriorly by the dorsum seller and a brain stem and basilar artery superiorly [Music] reflection that is the laminar dura how much thick it is in the city it should be actually if it is less than one millimeter you can say that i'm gonna do right okay and uh what are the lateral [Music] okay and uh what is in between the cavernous sinus and repeated [Music] um for uh for the neural undercoverness intercalator sinus connection connections yeah and uh what is a last actually uh from the posterior body of spinoid there is a bony protrusion into the uh pituitary fossa into the uh fossa it can mimic a pseudo lesion yeah is there anything called the middle uh client process yes there is it can be very tight yes yeah and uh when the the chiasma is prefixed and uh there is a pituitary relation what can be the a clinical presentation [Music] anterior and posterior border of cellular it could be due to a pituitary lesion yeah um possibly a pituitary macroadenoma and what are the other other relations or other other things you can see in radiographs plain radiograph if there is any calcification yeah calcifications it could be due to any craniopharyngioma yeah usually at this age what type of gymnastics capillary type capillary is calcification common in capillary type no it is not very common types in factories that can be seen in lesions uh there can be smooth smooth or type of calcification yeah uh and uh in uh usually in craniopharyngeal punctate or diffuse calcification or a curvilinear pattern of calcifications can be seen and [Music] then what other things we can see in radiographs um and also in a two percent cases of macro adenomas it can uh cause calcification any fat density areas yeah if there is a fat density what do you think it could be due to a teratoma or a dermoid cell tumors yes then the beginning of the the bones thickening of the dura hyperosteosis is usually associated with meningiomas uh sclerosis uh usually it is uh associated with uh nasopharyngeal malignancies it's usually sclerosis yeah i did so we are attaining yes sir uh axial uh non-contrast or ct sections of the brain uh at the level of stellar it shows up iso to hype there is widening of seller with an isotope hyperdense lesion compared to the cortex is uh noted in the uh in the which is an ill-defined lesion in the cellular and parasite aspect which is causing erosion of the anterior clenoid process and dorsan selena and posterior clinic process on left side and towards the rostral aspect of the lesion there is a fluid density area with a posterior dependent leveling it could be a cystic area within deletion and sagittal and coronal non-contrast ct sections are showing widening of the cella with involvement of the spinoid sinus with erosion of the cellar floor and adorasim seller and posterior clinic for process and ah the anterior clenoid process the coronal ct is also with uh depicting uh the erosion with paracel or extension and a cystic area towards its cranial aspect of the lesion and bond window axial sections showing erosion of the anterior clinic process and dorsal cell and posterior clinic process the sagittal era showing cellular flow erosion with uh involvement of the sphenoid sinus and also uh extending into the clivers uh the coronal ct showing erosion of the clinoid anterior and posterior clinic process why do you take ct just after telegraph is it a do you think in terms of uh with relation uh pituitary relations usually mris is a superior modality however ct is taken uh to look for any uh to look for the bony erosions calcifications and also for specified sinus uh pneumatization patterns uh that will help in uh the uh the surgical approach so have you taken a an mri yes sir yeah so uh axial uh deteriorated sections of mr brain uh there is widening of the cellar and with an ill-defined uh lesion which is t2 heterogeneously hyperintense on comparison with the cortex with hyperintense areas uh noted within and there is a t2 hyperintense uh area with fluid fluid leveling uh noted uh towards the rostral aspect of the nation and on t1 the lesion is iso uh iso isotope hypointense to the cortex uh and the the syst that previously described cystic areas appearing t1 hyperindents and there is there are no areas of restricted diffusion however there is there are areas of blooming uh noted in the within the uh towards its and uh also there are some areas of blooming noted within the nation uh a coronal uh t1-weighted uh image uh showing a t1 iso indents and you'll define t1 iso intense lesion which is having a figure of it appearance uh with cellar supracellular and image the lesion uh the posterior pituitary bright spot is not separately visualized the infundibulum is not visualized and also the hypothalamus tubercenarium lamina uh laminar terminal is uh suboperationalized and the lesion is abiting the mammillary body clearly and also there is involvement of their clivers as there is uh the the marrow signal is lost and on coronal uh two weighted images the lesion is causing uh compression of the optic asthma with elevation of the same and and also there is elevation of the bilateral anterior anterior cerebral arteries and the uh this is the uh the lesion is having uh there is paracelar extension where a lesion is causing uh encasement of the uh uh left uh in a cavernous segment of the left internal carotid artery uh uh suggesting a nose strainer great for encasement of the left cavernous ica and on right side there is a great one encasement there is a great one involvement and there is uh [Music] a suggestion this is the lateral dural wall there is a uh suggestion of discontinuity in the lateral dural wall uh with the extension of the lesion into the adjacent temporal lobe uh [Music] uh uh following uh contrast administration the lesion is showing heterogeneous post-contrast enhancement with non-enhancing area suggestive of necrosis and a cystic area is showing predominant peripheral post contrast enhancement and with uh paracellular infracellular and supracellular extinction is uh noted um so uh uh so uh summarize you said the nose classification what is the nose classification uh nas uh strainer grading is uh to look for the uh the uh the environment of cavernous sinus uh so basically we ah it is looked on coronal images uh there is uh three lines are being drawn medial tangent line uh inter-carotid line and lateral tangent line along the cavernous segment of the uh ica and if the lesion is seen medial to the medial tangent line then it is a grade zero environment if it is seen between uh the medial uh tangent line and inter-carotid line that is grade one involvement if it is between the in the carotid and lateral tangent grade two lateral to lateral tangent line is great tree with uh three as superior involvement and four or three bs inferior environment and great for us uh encasement of the internal carotid artery what is the breakdown uh it is actually sir it is uh made between a medial tap between medial tangent line and inter-carotid line it is grade one and uh we think the mission is going to involve the temporal lobe there is a focal uh discontinuity in the lateral dural wall but uh how is the enhancements my enhancement is not uh it's not uh there is no any differential enhancement in that area here in the post contrast this i think it's uh uh it's the dual sinus wall but your wall can be seen in this in this [Music] uh in diffusion weighted images it is uh it is to look for any uh early pituitary infection and also it is uh also for the consistency of the tumor if there is an adidas importance uh it is uh to uh guide in the surgical approach yeah if adc score is uh 0.6 uh if if if ad6 correspond between the range of 0.6 into 10 raised to 2 millimeter square then it means it's a soft lesion it can be easily uh resected or if it is if the ad6 scores uh is about a point eight uh then it is an intermediate uh consistency and if it is more than one point three that means deletion is hard and it will be uh very difficult to remove uh via the surgery surgery means uh and spinodal transphenoidal hyperphysectomy okay so but [Music] why this lesions are soft um because uh soft and hard based on the composition uh if it is consisting of more collagen and ridiculing composition then it becomes hard yeah actually the pediatric gland is having so much verticality and it is hard yes and when methodology this [Music] loss uh the most important uh feature feature is that if there is abnormal soft tissue between the uh the between the internal carotid artery and the lateral wall of kavanaugh sinus that is the most important uh feature of kavanaugh sinus invasion and the other features would be uh displacement of the cavernous segment of ica and also there is uh any lateral bulge of the uh lateral dural wall um these are the uh signs of kavanaugh sinus engage okay so uh you think uh this is a first diagnosis [Music] homogeneous post contrast enhancement with dural tailing hyperosiosis and it constricts the internal carotid artery rather than it compresses it compresses the other uh dd's could be an aneurysm uh usually from the supracline or cavernous ic but aneurysms usually they have a flow void uh with a uh fluoroid and usually will will have a merim calcification and a laminated pattern of clot and the stretch of bone erosion associated with an aneurysm and uh the other dd could be a hypothyroidism uh like a lymphocytic hypoxide so the gland will be diffusely enlarged with homogeneous contrast investment and it will be usually seen [Music] after a slightly younger age group pregnant uh patients are postpartum any other [Music] in metastasis and or and also the star um and amethyst usually involves infundibula and uh the uh craniopharyngioma uh could be a deity but uh the uh the the it is most commonly seen in uh the younger age group between five to fifteen years although a second peak can be seen in this age group it but it is usually solid and uh the uh and uh the other dd's could be a spinodal mucosal uh deletions so deletions uh but in spinodal lesions the pituitary gland can be separately visualized or a cyanonasal malignancies uh which causing uh erosion of the spinodal wall with extension into the cellar region but in those cases also pituitary plant may be separately visualized will be separately visualized okay any other granulomas can you think of anything uh any invasive fungal granulomas uh uh usually it is seen in uh immunocompromised diabetic patients uh with uh with with the erosion of the uh the the wall and there will be cavernous sinus involvement with associated thrombosis with adjacent bone erosions so [Music] any epidermoids or uh epidermoids and uh dharmoids are uh can be seen in intracellular and suprasalah location but epidermoids usually shows diffusion restriction and that won't be any post contrast enhancement um [Music] can also occur uh supracellular arachnoid cyst and it usually cause the deviation of the stock uh and it usually follows the csf signal intensity in all the sequences um so finally what is the conclusion uh uh can you summarize this 50 year old female who presented with uh complaints of defective vision hfa showing uh by temporal hemianopia and mri of the brain showing an uh widening of the enlarged cella with an ill-defined uh lesion which is t1 iso intense e2 hyperindents uh with a supracellular infrastellar and paracellular extinction with uh erosion of the uh the uh the the uh the cellar floor uh dawson stella posterior clinic process and involvement of the uh clivers uh with uh heterogeneous book and showing heterogeneous force contrast enhancement with necrosis cystic areas uh so the possibility of a uh pituitary invasive pituitary macroadenoma to be considered invasive means uh what do you mean by invasive metabolism invasion i mean others there is invasion into the cavernous sinus and there is erosion of the cellar floor that is a criteria for invasion uh what are the environmental modalities or methods of uh imaging there is dynamic contrast enhanced mri in which uh there is uh [Music] based on the concentration of the macro molecules and uh there is a magnetization transfer score and it is usually higher for the pituitary adenoma prolactin secreting adenomas more than the normal pituitary gland and it is usually lowest for the non-functioning adenomas and other imaging modalities could be uh pet city 18 fpga pit it will be usually to distinguish between uh residual or recurrent lesions from post operative changes and also uh it is uh and also for uh adenomas it uh pituitary adenomas usually uh there is it shows activity and it is highest is for non-functioning adenomas [Music] any other advancements in imaging during during the surgeries uh intraoperative mri and interoperative ultrasound [Music] and [Music] what is this hyper density of positivity uh the hyperintensity is due to the neurosecretary granules uh oxytocin and vasopressin how will uh how do you identify the uh ectopic pituitaries are the usual locations are uh the spinoid sinus nasopharynx the infundibulum uh third ventricle uh these are the usual sites and uh usually new bonds pituitary gland is uh hyperintense on p1 rated images and it usually normalizes by uh four to six months of age and uh so in this case uh what do you prefer which which type of surgery [Music] [Music] yes okay i think you've done it very well uh madam for your cabins please yeah yeah yeah i'm listening to your all the questions you've been asking i know how will you differentiate this from pituitary carcinoma uh pituitary carcinomas madam it is uh it it is very difficult to differentiate radiologically between an invasive adenoma and pigmetric carcinoma however in pituitary carcinoma there will be associated craniospinal metastasis there will be csf seeding yeah yeah yeah that's correct okay will you comment on the sweet body of the sphenoid and the clean out process and the lesser wing of the sphenoid that is what is optic structure what do you mean the obstacle um that is very important in this isn't it yeah yes the region of the uh [Music] because the neurosurgeon may go through trans nasal root or he may go through trans phenol usually nowadays they prefer transmission group and they take the help of the ent surgeons isn't it that's very important okay so whenever you describe a pituitary you have to give all these details to the neural surgeon about the internal carotid artery about deficiency nuts and as whole okay so what are the parts of this phenotype where all it can extend anteriorly uh it there can be a lateral extension into the uh uh uh into the uh lesser wing of spinoid uh and also into the uh pterygoid process it can extend uh there can be and also there can be pneumatization of the anterior clinoid process there is a pneumatization of the dorsum cell um very good now that what are the parts of the sphenoid sinus you have the parts anteriorly in the sphenoid bone itself isn't it you should identify the plan of spinodal you should have and by the jog of spina bifida because the optic asthma is very important isn't it okay uh then one more question usually will be asked for the examination also uh the cellar you described isn't it now uh how will you suppose you have a confusion whether it's a craniopharyngioma or it is a pituitary tumor and you are given an extra skull is there any clue for you to tell in a x-ray skull to say it is a craniopharyngioma or a pituitary humor in craniopara will be elongated and the dorsum seller will be [Music] it will be um the or sim seller will be short which is more important for you that is craniopharyngeal is more often a supracellular relation whereas pituitary is a cellular lesion isn't it so always there is a growth of craniopharyngioma to go towards the seller and whereas cellular nation grow upwards isn't it so what happens the clean oil process if it's a cranial pharyngeal what will happen there'll be a bowing of the cleaner process inferior isn't it meracin supress and selection the linear process will turn up it will be seen very clearly in the next crystal and the calcifications more important is the calcification remember so these are the questions also very gross has asked all the questions for the future for the examination this i added the points so why do we do it late studying people dream malignancy uh delayed enhancement will be seen for pituitary microadenomas after 30 to 60 minutes they'll be delayed enhancement yeah isn't it okay you're covered everything josie dr josie has done a wonderful session with you thank you so much dr pisa thank you okay okay gayatri second guess so good evening so uh coming to my case [Music] later and uh she said the thorax and abdomen was done which was unremarkable there was no evidence of any primary and myeloma work was done which was also negative and there is no significant family history and the distal femur of a skeletally mature patient is uh shown and in the uh there is a well-defined lying declaration involving the metaphases of the proximal right tibia which is uh got a well-defined margin as well as an arrow zone of transition with the uh no significant uh matrix not uh they may be a non-ossified matrix and the overlying cortex appears impact the lesion is also not extending into the epiphysis however the subparticular bone is not involved and there is no significance of tissue component noted and also the adjacent knee joint appears normal and there is no evidence of any other lighting creation in the visualized bone and the generalized uh bone density appears normal there is no diffuse osteopenia noted okay what about the matrix the matrix appears to be ah not occipied there is no significant matrix there is a slight citation of a ground plastic noted between the central however no evidence of any punctate or osha cloud-like matrix noted between the lesion any pediatric reaction there is no significant periosteal reaction vertex whatever what do you think about cortex there is uh no evidence of cortical erosion uh there is adjacent uh there is mild expansion of the bone and the lesion is also noted involving the medullary cavity uh overlying cortex that is impact okay and they uh there is also surrounding oh yes what is the sound of transition the honor transition is narrow do you think about this solution so uh since the lesion is available formulation with sclerotic margin with an arrow zone of transition and there is absence of a significant periosteal reaction particle break or uh or significant soft tissue component i would think of this to be a a non-aggressive lesion yeah not like this may be lipid english maybe penile the first difference and uh the first differential would be infection so if think about abroad is happening you can also present like this it can be a light explanation with a sclerotic margin and ah another difference and however a soft tissue component will be larger for the lesion and cortical erosion can also be seen for the same and uh and the next difference i'll consider is fibrous displacement fibrous displacement and also present in this age group it can uh doesn't have some articulation it can have varying uh meaning appreciations sign and will not be any as a periosteal reaction if there is a periosteal reaction that is a point of opposing fibrosis we uh do not consider fibrosis we say uh periosteum and margin and also the a group it can be seen in the uh this age group and another differential i think about is encore drama um margin however in the long runs uh the presence of a convoy matrix calcifications will be seen usually in the long bones however the proximal table metaphases can be uh about 10 to 15 percent of cases can be seen and chondroma can be seen in this location then since coming to other differentials the uh since the age is above 40 and if there is a light equation involving the bond so i would always consider the metastasis to be one of the differences and since there is a healing lighting metastasis can be a possibility usually metastasis won't be having a clerotic margin and if the if you because if it is healing maybe it can save and another difference be as a similar healing brown tumor however there are there are no other light equations to such as brown tumor noted in the radiograph another differential i will consider in the malignant tolerance is undifferentiated free homomorphic sarcomere because uh uh here uh how the the deletion from the software will be slowly eroding into the adjacent bone so it will present as a light declaration with a sclerotic margin however the absence of the cortical erosion does not favor the uh the diagonal process in this case and do you consider uh i i'm not considering because of the age group usually i abc's and also it will be a lighting with a significant expansion here only there is mild expansion and also in if it is above 40 years i think there is no need to consider any original bonuses okay and no i know if we'll be having it my first differential enough would have been there because i know patient is in the proximal tibial metaphases with a uh with a sclerotic ring light equation eccentrically placed however in in this case because the age group is above 40 years i do not consider the same because it usually annoys spontaneously results by this age group or it gets ossified or it is continuously resolved uh do you think of the gcp gcp let's say age group age group is uh not favoring the same at all it will be definitely involving the subparticular surface yeah the uh lesion is not uh reaching up to the subparticular surface even though it is reaching the preferences it does it is not reaching the submarine modalities uh ct images now here axial uh bone window and soft tissue window of the uh of the same uh uh lesion is provided so here we can see there is a light lesion involved with the significant light equation involving the proximal tibial metaphysis causing erosion of the inner as well as outer cortex with the adjacent sclerosis of the board it ah significance of tissue component and uh erosion of the overlying bone as well as other irregular periosteal reactions also noted there is also suggestion of a ground glass matrix noted in the adjacent bone the the indus coronal images we can see that the relation is immediately involving eccentric eccentrically placed and involving the middleware cavity in in the metaphysic extending it into the epiphyses however the particular bone is bad and there is cortical erosion as well as significant soft tissue component with the displaced calcified bone density is noted between the soft tissue possibly the displaced eroded boneless fragments and uh so uh after taking this considering ct images here we are seeing some features of aggregation here there is a significant particle erosion soft tissue component as well as areas of video still reaction so radiograph it must be named and uh by ct it is aggressive what is the difference of a time difference between this stereograph and it is only actually about two weeks okay so now you are thinking in terms of an aggressive edition yes uh and now i i'm thinking about an aggressive lesion possibly a malignant transformation of a previous non-aggressive lesion why why ah because in x-ray we are seeing a well-defined sclerotic margin with a narrow zone of transition so a sclero if at all that it should be a square rooting margin it should have been a slow growing tumor a slow growing lesion suggesting a non-aggressive [Music] [Music] so i might so uh mostly this might have been amalgam transformation of a pre-existing pre-existing uh non-aggressive lesion um which uh which solution can you think of any english yes so here in uh the ct majors we are seeing area and also in the exterior seeing areas of ground glass or basically so uh so maybe a malignant transformation of your previous fibrous lesion so my first two uh differentials would be a fibrosarcoma and sarcoma secondary fiber secondary osteosarcoma which developed in the previous fibrosis region so this both [Music] [Music] sarcoma that is uh that is that which was previously called as malignant fibrocystocytoma uh that can also be a differential because of the uh because of the uh cortical erosion soft tissue component and also the steroid margin here uh the typical appearance is seen here because of the soft tissue lesion eroding into the board uh with a periodic model that can also be a fitting into the differential set of different juice okay okay okay so coming to the mr images here we can even sagittal uh sections of the uh tbr uh shows there is a uh even uh irregular lobulated iso predominantly iso intense relations involving the dpl areas and as well as a significant a soft tissue component noted uh with the erosion of the overlying cortex the lesion is also clean extending into the epiphysis however the subparticular bone appears to be normal and in the axial b2 canister images shows that the lesion is uh predominantly a heterogeneous in signal heterogeneous in signaling densities with the peripheral intermediate signal intensity and central high pressure signaling densities and also deletion is a significance of or significant soft tissue extension of the lesion is note that the lesion is seen extending into the tibialis and area posterior lobe latest as well as the medial gastrointestinal particles posterior and the also there is significant steer higher density is noted in the adjacent soft tissue skin as well as in the adjacent bones okay uh and in the diffusion weighted you can see that there is a peripheral restricted diffusion with the central uh uh central area uh not showing any restricted diffusion and in the post contrast immediately we can see that the relation is showing significant post contrast enhancement with the central non-enhancing areas suggestive of necrosis and yeah in the subtracted images also the same diagnosis uh same uh findings are noted by malaysia is [Music] erosion and extension in the the soft tissues is showing significant post contrast enhancement with the areas of central non-enhanced with central non-enhancing areas of the sleeve of necrosis uh so here um after the mr images um one of my first differential in after the x-ray radiograph was broad is completely ruled out because there is no central restricted diffusion or any uh central restricted diffusion and there are central non-enhancing areas to suggest necrosis so uh at this point of time i uh my broad is not uh included in the in in case of it is seen in the case of there will be one high point and slime uh so what do you think now ah so uh now i will consider the same differences as after ct so i will consider an algorithm transformation of a previous uh uh non-aggressive relation possibly a fibrous reaction so again my first differentials would be fibrosarcoma or osteo secondary osteosarcoma [Music] because um because of the um aggressive appearance and also the previous uh the most common malignancy to occur in a previously not a previously existing uh oceanflation is osteosarcoma and however the age group is actually um age group is actually a bit less favoring because uh secondary stuff is usually seen about after the age of 50 to 60 years another election is actually another thing is a periosteulus sarcoma can be seen in this age group secondary uh and fibro sarcoma is generally rare [Music] yeah age group and also if you are thinking about the fibrous dysplasia that can be a change into uh undifferentiated yes sir so uh what do you do next so i'll uh anyway we can't say definitely a diagnosis but uh what is your uh diagnosis now uh my uh i'll definitely suggest the bone hdr uh bone biopsy so uh why do you suggest can do you do can you do uh one website if we can do it yeah okay and then actually yeah yeah i got the pathology yes what is it okay so the histopathology came to be a conventional ocean sarcoma so uh that may be uh so fibroblastic variant uh this is actually pathological diagnosis uh that is uh based on the uh whether um a major matrix produced whether it's fibrous or chondroid and the fiber first painting is generally rare and that may be the reason because uh we didn't see any osha's matrix in the radiographs simply this fibroblastic variant okay you have done it well uh in this case uh madam this case was personal because we can't say from the radiographer this is a malignant solution and the histopathology very good very good yeah even fibroblastic variant i am not good it is not so common you have heard of osteoblastic variant yeah telling you that the types isn't there etcetera right it's very unusual to have a private plastic variant i've not heard because even the uh plain x-ray which she wrote yeah first in my mind came as uh because it had his periodic margin isn't it first the clearing symmetry so my diagnosis was or whether it could be even a broad abscess yeah we were also thinking of uh after example uh different yeah because it can go for uh chronic hostile analytic changes also isn't it okay and you know it was very good presentation how why how you because the age was not fitting for osteosarcomas in it can be seen uh however in the sage group and it can maybe it was not definitely fitting for the same what does the age of the patient you say so fibroblastic usually this fibroblastic variant which i have known is actually in the sinus tract fibrous sarcoma like that you can get an osteomyelitis sinus cracks like that you can get fibroblasts this is the first time i'm hearing another thing fibroblastic ocean sarcoma then uh uh this malignant fibrous system phytoma fibrosarcoma all this can uh pathologists can actually uh uh can make mistakes because this can uh these are actually looking the same in the pathology actually they actually had another like uh xpr for the same because which are sending an outside lab that came out to be uh undifferentiated cleomorphic molecular coma in our department hpr came out to be conventional fibroblastic area okay surrounding ground glass opacities actually there is much of fibrous tissue is also some ground lasting i mean all these uh made us think of some fiber i mean a fibrosis lesion that is pre-existing and now turning malignant actually madam i'm so sorry because i had some technical issues here and i know it's all that i'm happy you joined later also next time we'll make it sure and then you're doing a very good job one more question to guy three my last question uh okay uh you said about secondary osteosarcoma if not from there you can get secondary surgery uh secondly osteosarcoma can develop in uh you know pages disease in uh chronic osteomyelitis uh in fibrous dysplasia in chronic osteomyelitis born in foster [Music] that is actually it comes in soft tissue intra-abdominal osteosarcoma has been reported understood it came from the retroperitoneal tissues it can come from the spleen also sometimes very rarely reported but extraordinary from the uh mental structures that is misentry also you can get extraordinary very rare but but you should whenever you get a question like this you can answer also all right when you declassify those just okay all the signs all you know isn't it yeah that's all even a mbps student will answer all the seconds okay how you did it very well thank you okay okay thank you thank you guys for watching one question i mean not history in osteosarcoma it can be uh associated with some familial syndrome such as syndrome thompson syndrome then uh retinoblastoma so uh like any history of any other uh like retinal cancer like that and all if it's present liver many syndrome is also suited with many other cancer syndromes so uh if that another person we can actually think about uh osteoporosis non-occupying fibromas are associated with neurofibromatosis then attention and muscular syndrome uh it's actually seen with multiple uh enchondromas hemangiomas and yet another uh there are fibrous dysplasia this can be seen with the machine albright syndrome any more questions mina okay actually i end here no she answered she did very beautiful gayatri did wonderful yeah they are passed out now it's giving the past whenever you get a bone case always think of the mnemonic which i always tell when i take class for the students that is stance s-t-a-m-p-s you know how to elaborate stands uh i think five yes think the inside one very important side t stands for t stands for transmission zone transition zone very good a stands for eight age yeah this always keep in your mind you'll never never uh come you'll be back in your diagnosis because this will help you for all your diagnosis understood thank you thank you thank you so much wonderful i'm very happy that you all participated i want more and more to come [Music] okay dr anisha are you online yeah i am listening very very good presentations by both tissa and gayatri wonderful yeah i think uh the stamps m you can include matrix also matrix that is yeah marrow and matrix yeah very good i think you can conclude and give the author thanks alisha okay so yeah so it was a uh one more uh wonderful academic session from uh team alleppey headed by dr josie thanks for the very wonderful presentations by dr tissa and dr gayatri i think it will be very encouraging to the other pgs who are attending uh hope for thanks dr bhinamul dr gomethi they were inspiring shining light of radiology i hope uh this will uh set the pace for further good pg sessions in future thank you

BEING ATTENDED BY

Dr. Sasikanth Reddy & 377 others

SPEAKERS

dr. Beenamol S

Dr. Beenamol S

Additional Professor Department of Radiodiagnosis Government TD Medical College, Alappuzha

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dr. Beenamol S

Dr. Beenamol S

Additional Professor Department of Radiodiagn...

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