Metastasis to the female genital tract from extragenital primaries is uncommon, with breast and gastrointestinal malignancies representing the predominant sources. Uterine involvement accounts for fewer than 10% of genital tract metastases and most frequently occurs in the setting of disseminated disease with concomitant ovarian involvement. Invasive lobular carcinoma (ILC), despite comprising only 5%-20% of breast malignancies, accounts for over 80% of breast cancer metastases to the female genital tract, a predilection attributed to loss of E-cadherin expression-facilitating tumor cell detachment and hematogenous dissemination-and its diffuse infiltrative growth pattern. Metastasis to uterine leiomyomas is exceptionally rare, with approximately 30 cases reported to date. The underlying pathophysiologic mechanism is postulated to involve the hormonally enriched microenvironment of leiomyomas, wherein tissue concentrations of estrogen and progesterone receptors significantly exceed those of the surrounding myometrium, thereby conferring preferential tropism for circulating hormone receptor-positive breast carcinoma cells. Supporting this, 92.3% of reported cases were estrogen receptor positive. Concurrent lymphatic and hematogenous dissemination pathways are implicated based on patterns of organ involvement, with isolated uterine metastasis in the absence of ovarian disease favoring hematogenous spread. We report a case of metastatic invasive ductal/lobular carcinoma (ER+/PR+/HER2-) infiltrating a uterine leiomyoma, identified incidentally on histopathologic examination six years after primary treatment, in an asymptomatic African American woman undergoing hysterectomy for pelvic organ prolapse-representing, to our knowledge, the first such case reported in an African American patient. Immunohistochemical profiling confirmed breast origin and receptor concordance with the primary tumor.

BackgroundGastrointestinal metastases from primary lung malignancies occur in 0.2-11.9% of autopsy series; symptomatic colonic involvement is exceedingly rare (0.1%), portending a dismal prognosis with a reported median survival of approximately 2 months.Case PresentationA 60-year-old woman with a 40 pack-year smoking history, chronic obstructive pulmonary disease, and prior cervical malignancy presented with a refractory acute exacerbation. In the absence of a discrete pulmonary parenchymal lesion, computed tomography pulmonary angiography incidentally identified mass-like left upper lobe bronchial wall thickening. Bronchoscopic evaluation revealed high-grade endobronchial stenosis. Mediastinal fine-needle aspiration confirmed non-small cell lung carcinoma; colonic metastases identified on staging PET-CT demonstrated TTF-1/Napsin-A positivity with a CK7+/CK20-/CDX2- immunophenotype, consistent with pulmonary adenocarcinoma. Sequential adrenal resection revealed divergent squamous differentiation (p40+/CK5/6+; TTF-1-/Napsin-A-) with KRAS/MYC and NF-1 amplification, supporting a final diagnosis of pulmonary adenosquamous carcinoma-an aggressive NSCLC variant comprising 0.4-4% of lung malignancies.Management and OutcomeTreatment followed evidence-based, histology-guided sequencing: concurrent carboplatin-pemetrexed chemoradiation, nivolumab upon platinum resistance, and cytotoxic salvage with docetaxel followed by vinorelbine. Palliative adrenalectomy addressed refractory pain. The patient survived 42 months from diagnosis, the clinical course was shaped by adequate tissue sampling, diagnostic challenges, and multidisciplinary histology-guided treatment acquisition.ConclusionThis case underscores the diagnostic and therapeutic complexity of lung adenocarcinoma presenting with synchronous colonic metastases without a discrete parenchymal mass, compounded by intratumoral heterogeneity and phenotypic divergence across metastases. Comprehensive tissue sampling enabling serial immunohistochemical and molecular characterization, coupled with coordinated multidisciplinary management, is essential to optimize diagnostic accuracy and therapeutic sequencing in this rare and clinically challenging disease entity.

Mesenchymal hamartomas are rare benign liver tumors located in the embryonic mesenchymal tissue, most frequently affecting male infants and young children. While clinical presentation is typically asymptomatic, rupture, hemorrhage, infection, and malignant transformation are possible. Biliary hamartomas are benign lesions most frequently in patients >35 years. Imaging for both entities is typically nonspecific; a broad differential between solid and cystic lesions of the liver makes histologic evaluation critical. Both hamartomas are treated by liver resection, with most patients recovering fully with no further treatment. Here, we report a rare case of a mesenchymal hamartoma in an adult and provide a systematic review of mesenchymal and biliary hamartomas utilizing PRISMA guidelines; this review highlights the reported diagnostic and treatment paradigms and utilizes these to develop a diagnostic algorithm to assist in the definitive identification of these benign lesions with the potential to avoid surgical resection in appropriately selected patients.

Leiomyosarcomas of the inferior vena cava (IVC) are the most common primary malignancy of the IVC; however, these lesions are extremely rare. These lesions are slow-growing, often asymptomatic and, present late in the disease course portending a poor prognosis. Surgical resection is considered the standard of care and only potential curative treatment. Progression free survival rates after surgical resection have been estimated to be 31.4% after five years and 7.4% after 10 years. To date, there have been a total of 418 cases documented within small and large single center institutional case series. Here, we present a case series from a single institution and a comprehensive literature review to investigate the presentation, treatment, and outcomes of this rare lesion. A surgically relevant designation of tumor location to include involvement of the renal veins is proposed.

To the Editor:Biliary stricture formation at the bilioenteric anastomosis is an infrequent complication （2%-3%） after pancreaticoduodenectomy;the average presentation is within 13-14 months （range from 1 month to 9 years） after surgery [1, 2].

Evaluation of lesions of the biliary tract are essential to diagnose given the dismal outcomes of cholangiocarcinoma. Historically, these diagnoses were made using brush biopsies obtained under Endoscopic Retrograde Cholangiopancreatography (ERCP). To increase the accuracy of biliary biopsies, SpyGlassTM Discover cholangioscopy guided biopsy has been developed, providing greater tissue yield and direct visualization of the biliary epithelium. We evaluated the diagnostic accuracy of ERCP guided brushings and SpyGlassTM Discover guided biopsies at a single institution. Following IRB approval, all diagnostic biliary biopsies utilizing both ERCP guided brushings and/or SpyGlassTM Discover between 8/2015 and 6/2022 were retrospectively evaluated. Demographic and clinicopathologic data were collected. Fischer’s t-tests and Chi-square analyses were completed as appropriate (p < 0.05). Overall, 46 patients with an average age of 61 years were included in this study; 59

Acquired benign tracheoesophageal fistulas and bronchoesophageal fistulas (TEF) are typically associated with granulomatous mediastinal infections, 75% of which are iatrogenic. Candida albicans and Actinomyces are commonly occurring organisms, but are uncommon etiologies of TEF. Normal colonization and the slow growth characteristics of some species of these agents rarely result in infection, mycetoma, and broncholithiasis, and thus, delays in diagnosis and treatment are likely. Few reports describe C. albicans or Actinomyces spp. as the etiology of TEF or broncholithiasis. Herein, we report a case of benign acquired TEF secondary to coinfection of Candida and Actinomyces complicated by the formation of an actinomycetoma and broncholithiasis and a comprehensive literature review to highlight the unique nature of this presentation and offer a diagnostic algorithm for diagnosis and treatment of TEFs. Following a presentation of three months of productive cough, choking sensation, night sweats, and weight loss, a bronchoscopy revealed a fistulous connection between the esophagus and the posterior right middle lobe. Pathology identified a calcified fungus ball and a broncholith secondary to the co-infection of Candida and Actinomyces. This unique presentation of Candida and Actinomyces co-infection and the associated diagnostic algorithm are presented as education and a useful tool for clinicians.

Undifferentiated round cell sarcomas (URCS) are an extremely rare form of cancer, comprising a heterogeneous group of bone and soft tissue tumors occurring primarily in young adults (but distributed across all ages; range 2mo-81 years) and displaying a slight male predominance. URCS are primarily identified by their genetic abnormalities, with three recurrent oncogenic fusion rearrangements associated in the literature and recently added to the WHO classifications: EWSR1-non-ETS, BCOR-CCNB3, and CIC-DUX4. We present/describe a rare case of an URCS diagnosed in a 27-year-old female following six years of non-specific symptoms including pain and swelling of the third proximal phalanx. This case is only the third reported in a digit and, based on FoundationOne genotyping, was uniquely treated with tamoxifen. This patient also received radiation therapy, surgical resection, and palliative chemotherapy. Metastases were noted in the lungs and mediastinum, and the patient died of disease 89 months after the first treatment. While diagnosis of these tumors is becoming increasingly dependent on molecular profiles, treatment remains mostly unchanged and does not largely reflect the use of genetic results in treatment plans. A comprehensive review of the literature was completed to examine URCS and assist in the development of a diagnostic/treatment algorithm.

ABSTRACT:Prostate artery embolization is a minimally invasive treatment for benign prostatic hyperplasia, and imaging is indispensable for the technical success of this procedure; however, imaging is a major source of radiation exposure for patients and healthcare providers. Radiation emission during prostate artery embolization procedures at a single institution was evaluated to determine radiation exposure with the goal to work toward minimizing exposure. All patients at a single institution that underwent outpatient unilateral/bilateral prostate artery embolization between 4 January 2019 and 16 November 2021 were retrospectively evaluated; data collected included body mass index, prostate volume, and indications for prostate artery embolization. Technical parameters recorded were air kerma, procedure time, fluoroscopy time, number of acquisitions, and intra-procedural imaging modalities. Fisher's t-test, ANOVA, and chi-square analyses were used as appropriate for statistical analysis (P < 0.05). Overall, 56 patients were included in the study. Body mass index (obesity; P = 0.0017) was a significant predictor of increased air kerma; prostate size and bilateral vs. unilateral prostate artery embolization were not significantly associated with increased air kerma despite the number of acquisitions being significantly different between bilateral and unilateral embolization (P = 0.0064). When evaluating radiation exposure during prostate artery embolization, increased body mass index significantly predicted increased air kerma. Contrary to the literature, the extent of embolization (bilateral vs. unilateral) was not associated with increased air kerma regardless of higher acquisitions and procedure time associated with bilateral prostate artery embolization. Increased radiation protection efforts should be considered for patients with higher body mass index to protect patients and practitioners.Health Phys. 124(0):000-000; 2023.

PURPOSE:To access if the (MC)2 scoring system can identify patients at risk for major adverse events following percutaneous microwave ablation of renal tumors. METHODS:Retrospective review of all adult patients who underwent percutaneous renal microwave ablation at two centers. Patient demographics, medical histories, laboratory work, technical details of the procedure, tumor characteristics, and clinical outcomes were collected. The (MC)2 score was calculated for each patient. Patients were assigned to low-risk (<5), moderate-risk (5-8) and high-risk (>8) groups. Adverse events were graded according to the criteria from the Society of Interventional Radiology guidelines. RESULTS:A total of 116 patients (mean age = 67.8 [95%CI 65.5-69.9], 66 men) were included. 10 (8.6%) and 22 (19.0%) experienced major or minor adverse events, respectively. The mean (MC)2 score for patients with major adverse events (4.6 [95%CI 3.3-5.8]) was not higher than those with either minor adverse events (4.1 [95%CI 3.4-4.8], p = 0.49) or no adverse events (3.7 [95%CI 3.4-4.1], p = 0.25). However, mean tumor size was greater in those with major adverse events (3.1 cm [95%CI 2.0-4.1]) than minor adverse events (2.0 cm [95%CI 1.8-2.3], p = 0.01). Patients with central tumors were also more likely to experience major adverse events compared to those without central tumors (p = 0.02). The area under the receiver operator curve to predict major adverse events was 0.61 (p = 0.15), indicating a poor ability of the (MC)2 score to predict major adverse events. CONCLUSION:The (MC)2 risk scoring system does not accurately identify patients at risk for major adverse events from percutaneous microwave ablation of renal tumors. The mean tumor size and central tumor location may serve as a better indicator for risk assessment of major adverse events.

Corona mortis is a variant vessel located posteriorly against the superior pubic ramus, “crowning” the pelvis; actual prevalence is unknown due to broad definitions: A connection between the obturator artery and an external iliac artery branch or the external iliac artery anastomosis, or any variant vessel behind the superior pubic ramus. Rapid identification and immediate treatment of injury to an arterial corona mortis resulting from pelvic trauma or pelvic surgeries are essential as hemorrhage or death may result. Interventional radiology can selectively target corona mortis and obstruct hemorrhage through catheter-guided embolization. We present four cases of corona mortis and pelvic trauma with successful embolization and include a comprehensive literature review to further educate regarding the morbidity and potential mortality associated with this important anatomic variant.

Phyllodes tumors (PTs) are rare fibroepithelial malignancies of the breast, accounting for less than 1% of malignant breast tumors. PTs are usually solitary tumors but can be associated with other malignancies, such as DCIS or invasive carcinomas and sarcomas. Osteosarcomatous differentiation of a malignant phyllodes tumor is rare, and differentiation of this rare breast tumor from other entities is of vital importance to clinicians due for appropriate treatment and prognosis. We present a case of rare high-grade phyllodes tumor with osteosarcomatous differentiation presenting on mammogram as a calcified lobulated mass; ultrasound revealed a 1.5 cm irregularly calcified mass, suggestive of bone. An ultrasound-guided core biopsy and subsequent lumpectomy revealed a cellular stroma with osteoid stromal matrix and cytologic atypia with bone formation. At 18 months postprocedure, a recurrence was identified at the previous surgical site, and the patient underwent a mastectomy. Here we present a single case of high-grade PT with osteosarcomatous differentiation and a comprehensive literature review, highlighting the mammographic and histologic characteristics of this rare presentation.

Introduction: Peliosis hepatis (PH) is a rare benign vascular condition characterized by dilatation of hepatic sinusoids with occasional involvement of other organs. While associated with chronic immunosuppression, anabolic steroid use, oral contraceptive (OCP) use, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and infection with Bartonella, most PH patients are asymptomatic and, thus, identified incidentally. Compromised liver function is sometimes evident through laboratory tests; however, mortality results from cyst rupture and hemorrhage spontaneously or during surgical procedures. Case Report: We report a case of PH identified in a 33-year-old Black female radiologically evaluated for abnormal liver function tests. Computed tomography (CT) revealed enhancement of >100 lesions throughout both liver lobes; a CT-guided biopsy revealed mild macrovesicular steatosis and marked sinusoidal dilation, consistent with peliosis hepatis. Conclusion: We also present a comprehensive literature review describing the associated conditions, pathology, diagnostic methods, and treatment options for PH patients.

Introduction: Neuroendocrine tumors (NET) are increasing in incidence, and the use of 68Ga-DOTOTATE PET/CT to specifically identify NET has aided with early diagnosis, with 83%-100% sensitivity. Case: Here, we present a case in which a suspected small bowel obstruction by CT was 68Ga-DOTOTATE PET/CT avid in both the mass and adjacent nodes, suggestive of NET. However, the mass was not consistent with NET during surgical resection and the intra-operative frozen section revealed heterotopic pancreatic tissue and necrotic fat. Surgical resection would have been extensive and morbid; given the lack of a malignant diagnosis, it was aborted. Discussion: A comprehensive literature review demonstrated few false positive lesions identified by 68Ga-DOTOTATE; most frequently lymph nodes, pancreas, and prostate. Our case is the only reported false positive in a necrotic lesion. These cases highlight the importance of evaluating 68Ga-DOTOTATE PET/CT imaging for NET in the global context and presentation of the patient.

Jejunal feeding is indicated in patients with functional or physical abnormalities that prevent gastrostomy tube placement or feeding. J-tubes are most often placed using one of four techniques: Open surgical, laparoscopic, needle catheter, or direct percutaneous placement, depending on the patient needs and expertise of the surgeon. Minimally invasive techniques are considered standard of care, and thus, J-tube placement most often occurs through laparoscopic methods. While percutaneous insertion using balloon dilation rather than serial dilation has shown greater success rates, lower complication rates, and alleviates patient discomfort in G-tube placement, this procedure has not been utilized for J-tube placement. Here, we report a balloon-assisted jejunostomy placement technique utilized to replace a previous surgical jejunostomy tube that the cutaneous tract had healed over.

Background. Ciliated hepatic foregut cyst (CHFC) is a rare, benign cyst of the liver, derived from the embryonic foregut epithelium. Although CHFCs are typically asymptomatic, some present with nonspecific abdominal symptoms. Imaging modalities alone are insufficient for diagnosis, with intrahepatic cholangiocarcinoma included in the differential due to nonspecific imaging features; definitive diagnosis relies on histologic confirmation. These lesions are often benign; however, larger lesions can have malignant transformation into squamous cell carcinoma (SCC), which carries a poor prognosis, thus making a definitive diagnosis, no matter what size, essential. Here, we present a case of CHFC as well as a comprehensive literature review. Given these data, we propose an algorithm for definitive diagnosis.

AbstractA pseudoaneurysm of an aortic branch artery is a potentially life-threatening uncommon occurrence, which may result in retroperitoneal hemorrhage. Imaging-guided percutaneous thrombin injection has a high technical success and effectiveness rate for treating pseudoaneurysms of the femoral, iliac, and popliteal arteries. We present a case of a retroperitoneal hemorrhage in a patient with a periaortic branch pseudoaneurysm, potentially from an avulsed lumbar artery. Anatomy prevented fixation with a covered stent; the comorbidities eliminated safe surgical repair, and endovascular embolization was not an option due to the avulsion. Computed tomography (CT) fluoroscopy-guided thrombin injection provided a safe, successful embolization with no postprocedural complications.

Aim: Atrial fibrillation is a common arrhythmia, with a prevalence of 37.574 million cases worldwide. Atrioesophageal fistula is a rare but potentially fatal complication of ablation of atrial fibrillation developing up to 60-days post-ablation with a prevalence of 0.07% to 0.25%, and a 63% mortality. While chest CTs are abnormal in most of these patients (76%-93%), definitive atrioesophageal fistula is noted in only 23-35% of cases, complicating pre-intervention diagnosis. Surgical repair of the left atrial and primary esophageal defect is essential for these patients, resulting in reduced mortality compared to nonsurgical management (33.71% vs. 94.19%). Methods: Our case series and comprehensive review of the literature highlights the diagnostic and treatment challenges of atrioesophageal fistula. Results/Conclusions: For symptomatic patients within 60-days post-ablation, IV contrast-enhanced helical chest CT with thin section collimation as initial imaging and axial reconstruction utilizing a 1mm-mm detector with sagittal and coronal reformats should be completed to allow for optimal identification of abnormalities consistent with atrioesophageal fistula. Patients with neurologic symptoms with the presence of pneumocephalus, infarcts involving one or more vascular territories, or diffuse air emboli that are highly suggestive of atrioesophageal fistula, warrant a chest CT with IV contrast to evaluate the presence of AEF. An initial unremarkable chest CT does not rule out atrioesophageal fistula and repeat chest CT with IV contrast within 1-3 days increases the likelihood of a definitive AEF diagnosis. Surgery is the only recommended management in patients with atrioesophageal fistula who are clinically stable enough to endure the procedures.