An otherwise healthy 37 day old male presented to dermatology with a pedunculated, friable red glabellar mass. First noticed as a flat, bluish lesion at 10 days, its subsequent rapid growth led to an emergency department visit where dermatology diagnosed a hemangioma and initiated propranolol treatment. Despite this, the mass continued to grow rapidly, encroaching upon the patient’s right eye. The patient was admitted for further workup. Ultrasound findings were consistent with hemangioma while MRI findings were atypical, contributing to a decision to obtain percutaneous biopsy. Pathology was consistent with choriocarcinoma. PET/CT found FDG-avid glabellar, liver and lung lesions. The infant's therapy and clinical course will be briefly described. Clinical photos, ultrasound, MR, and PET/CT before and after therapy will be included. Discussion The unusual predilection of infantile malignancies for cutaneous metastases allows their early discovery and creates vivid clinical stigmata not easily forgotten. While relatively common in infancy, such presentations are exceedingly rare in children and adults. In a series of 208 infants with cutaneous metastases, numerous bluish skin nodules created the so-called “blueberry muffin” baby appearance in 82% of cases. The following diseases presented with cutaneous involvement (ordered most to least common): leukemia, Langerhans cell histiocytosis, neuroblastoma, rhabdoid tumor, rhabdomyosarcoma, primitive neuroectodermal tumor, choriocarcinoma, and adrenocortical carcinoma. Etiology and epidemiology will be discussed. Imaging findings and a companion case in which choriocarcinoma was also misdiagnosed initially as infantile hemangioma will be discussed. Considered one of the fastest growing tumors, infantile choriocarcinoma classically presents with hepatomegaly, anemia, failure to thrive, and precocious puberty between 0 days and 5 months of life. Left untreated, the disease is usually fatal within 3 weeks of presentation. Chemotherapy and delayed surgical excision of metastases can be curative with long-term survival rates of around 80%. Conclusion A solitary cutaneous metastasis can be mistaken for infantile hemangioma both clinically and radiographically. Atypical MRI appearance is one important clue that can suggest an alternative diagnosis. Early diagnosis and treatment of infantile choriocarcinoma is critical for survival. PET/CT may be useful for staging and follow-up. Read More

Meeting name: SPR 2017 Annual Meeting & Categorical Course , 2017

Authors: Dance Logan, Patel Mittun

Keywords: choriocarcinoma, cutaneous metastases, infantile

Calcifying nested stromal epithelial tumor (CNSET) is a very rare primary liver tumor in children. To our knowledge, about 30 cases have been reported in literature. We describe the imaging appearance and histopathologic features of this tumor detected in a 2 year old girl who presented with an incidentally detected calcified liver lesion on a chest x-ray which was obtained for cough. Computed tomography (CT) demonstrated a 5.5 centimeter sized heterogeneous mass with large coarse calcifications. MRI better demonstrated the margins of the lesion, which was predominantly hyper-intense on T2-weighted images. Large areas of signal void were seen in the superior aspect of the lesion, corresponding to the calcifications seen on CT. The lesion demonstrated restricted diffusion. Post-contrast, the lesion demonstrated enhancement in the portal venous phase with washout on the delayed phase. Initial diagnosis based on imaging findings and patient’s age was hepatoblastoma. However, serum alpha- fetoprotein (AFP) was normal, which is unusual with hepatoblastoma. Patient underwent subsequent wedge biopsy, which was proven to represent calcifying nested stromal epithelial tumor of the liver. PET/CT, obtained to evaluate for metastatic disease, demonstrated increased FDG activity within the primary hepatic lesion, with SUV Max of 3.5, with no evidence of FDG avid metastatic disease. She then underwent right hepatectomy and cholecystectomy. No sign of tumor recurrence has been noted to date on the follow up abdominal ultrasound examination in the past 2.5 years. Calcifying nested stromal epithelial tumor should be considered in the differential when a large heterogeneous liver tumor with coarse/ chunky calcifications is identified at imaging in the absence of elevated serum AFP in a child. Currently the standard treatment in complete surgical excision and liver transplantation if excision is not possible. Read More

Meeting name: SPR 2018 Annual Meeting & Postgraduate Course , 2018

Authors: Biyyam Deepa, Youssfi Mostafa, Mandell Gerald, Taylor Steve, Patel Mittun

Keywords: nested stromal epithelial, tumor, liver

The purpose of this case report is to alert the reader to a rare differential diagnosis for infra- as well as intradiaphragmatic lung sequestration. A 38-year-old G2P0010 pregnant patient was referred for fetal magnetic resonance imaging (MRI) due to a 14.2 x 20.2 x 18 mm left paraspinal hyperechogenic mass with no internal vascularity and no convincing systemic arterial feeding vessel concerning for neuroblastoma as seen by ultrasound (US) performed at 34 weeks. Fetal MRI performed the same week showed a homogeneous T2-hyperintense left paraspinal mass in close apposition to and associated with a small area of loss of continuity in the diaphragm. This has been previously reported by postnatal computerized tomography as the "split diaphragm" sign in a case of intradiaphragmatic lung sequestration (Meier AH, Eggli KD, Cillei RE. Intradiaphragmatic extralobar sequestration: a rare pulmonary anomaly. Pediatr Surg 200;44:e27-29). Thus, the differential diagnosis provided at the time was congenital intradiaphragmatic sequestration and neuroblastoma. The fetus delivered via uncomplicated spontaneous vaginal delivery at term. Postnatal US performed at the age of 15 days showed a left hyperechogenic mass extending from the left lower chest to the ipsilateral retroperitoneum through a small defect in the diaphragm, favored to represent an extrapulmonary lung sequestration. The left adrenal gland was normal. A follow-up CT performed at 7 months of age showed a 2.6 cm left paraspinal mass with no systemic arterial blood supply to support the diagnosis of sequestration. The differential diagnosis at the time included neurogenic tumor or a myofibroma arising from the diaphragm. Follow-up CT at 13 months of age showed similar findings. The patient underwent uneventful laparoscopic removal of the mass with a final pathological diagnosis of congenital adrenal rest. Congenital adrenal rest presenting as a diaphragmatic mass is rare and as been reported once in an adult patient with an adenoma in heterotopic adrenal tissue located in the left diaphragm, diganosed because of mass effect in the gastric fundus during an uper gastrointestinal series (Keirns MM. Two unusual tumors of the diaphragm. Radiology 1952; 52:542-547). We hope this report raises awareness of this entity as a potential differential diagnosis for prenatal masses seen in close relationship with the adrenal gland and/or diaphragm. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Goncalves Luis, Jamshidi Ramin, Biyyam Deepa, Patel Mittun, Cornejo Patricia

Keywords: lung sequestration, neuroblastoma, adrenal rest

The purpose of this study is to report visualization rates for standard cardiac axial views by FCMR using a prospective ECG pseudogating method and compare visualization rates for acquisitions performed in 1.5 and 3T. Secondary aims include a comparison of image quality between 2 observers and between 1.5 and 3T. Specific absorption rates (SAR) are also compared. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Goncalves Luis, Lindblade Christopher, Cornejo Patricia, Patel Mittun, Wishah Fidaa, Bardo Dianna

Keywords: fetal cardiac MRI, 3T, image quality

The objective of this work was to determine whether a 3D gradient echo-based mDIXON T1-weighted sequence can replace a TSE-based mDIXON sequence in the evaluation of bone and musculoskeletal soft tissue lesions. Read More

Meeting name: IPR 2016 Conjoint Meeting & Exhibition , 2016

Authors: Peterson Michael, Patel Mittun, Dance Logan, Keehn Brian, Pokorney Amber, Barnes Craig

Keywords: mDixon, Gradient Echo, MRI Techniques, mDixon FFE, mDixon TSE

Our educational exhibit will be an ultrasound pictorial review of the normal and pathologic conditions of the orbit in children. Read More

Meeting name: SPR 2017 Annual Meeting & Categorical Course , 2017

Authors: Willard Scott, Patel Mittun, Bailey Smita, Miller Jeffrey, Plotnik James, Biyyam Deepa

Keywords: orbit, globe, retina

Kagami-Ogata syndrome (KOS) is a rare and potentially underdiagnosed imprinting disorder caused by paternal uniparental disomy for chromosome 14 or microdeletions and epimutations involving differentially methylated regions (DMRs) at 14q32.2. Depending on phenotypic expression, KOS may mimic trisomy 18 and asphyxiating thoracic dysplasia. Therefore, awareness is essential for prenatal diagnosis. Coat hanger ribs as seen by x-rays have been reported as s pathognomonic sign but have not been reported prenatally. Herein we present images of the coat hanger ribs as seen by low-dose computerized tomography (CT) as well as detailed imaging of the multiple phenotypic features by ultrasound and MRI of KOS in two cases seen prenatally. Case 1: G1P0 singleton pregnancy had fetal echocardiogram at 25 weeks due to concern for congenital heart disease, thickened nuchal fold and thickened skin of the thoracic wall. The exam showed left superior vena cava draining to coronary sinus, dilated right atrium and right ventricle, total anomalous pulmonary venous return, and hydrops. Skin edema was redemonstrated by follow up US at 29 weeks. Fetal MRI and follow-up US at 32 weeks showed polyhydramnios, diffuse skin edema, prominent cheeks and frontal bossing by 3D US, mild shortening of the ulna and right clubfoot, and a bell-shaped thorax by MRI. Chromosomal microarray was positive for terminal deletion of 14q32.2, consistent with KOS. Coat hanger ribs were present on postnatal x-rays. The patient is G-tube and tracheostomy tube dependent, has global developmental delay, neuromuscular scoliosis, left hip subluxation, wrist contractures and planovalgus feet at the age of 2 ½ years. Case 2: G3P1, singleton pregnancy with negative non-invasive prenatal testing (NIPT). US performed at 29 weeks showed polyhydramnios, clenched hands, and bell-shaped small thorax. Multimodality fetal imagin (US, MRI and CT) at 32 weeks showed a narrowed elongated thorax by US and MRI but ribs were poorly visualized. Additional anomalies included polyhydramnios, rhizomelic bone shortening, clenched hands, and prominent cheeks by 3D US. Low-dose CT showed coat hanger ribs. Postnatal x-rays confirmed coat hanger ribs and other abnormalities. Postnatal genetic testing showed paternal uniparental disomy for chromosome 14, consistent with KOS. The patient has restrictive lung disease due to hypoplastic thoracic cage, hypotonia, scoliosis, developmental delay, and umbilical hernia at 13 months. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Goncalves Luis, Patel Mittun, Wermers Josh, Simmons Curtis, Vaughn Jennifer, Pfeifer Cory, Cornejo Patricia

Keywords: kagami-ogata, fetal MRI, fetal CT

Radiologists have classically been taught the imaging findings of skeletal “Don’t touch lesions” on radiographs. The radiologist's goal is to best characterize these boney lesions and avoid tissue biopsy, especially since some bone lesions are misleading when viewed histologically, with nonaggressive lesions appearing aggressive. Many of these classical “Don’t touch lesions” are now being further evaluated with contrast enhanced magnetic resonance imaging (MRI). MRI findings of these radiographically classical lesions are not as well understood by radiologists with less MRI experience. We will provide an education exhibit to display MRI and corresponding radiographic appearances of characteristic “Don’t touch lesions”. Read More

Meeting name: IPR 2016 Conjoint Meeting & Exhibition , 2016

Authors: Keehn Brian, Patel Mittun, Peterson Michael, Dance Logan, Biyyam Deepa, Pokorney Amber, Barnes Craig

Keywords: Don't touch lesions, benign bone lesions

Purpose is to describe how FCMR is instrumental in diagnosis of congenital heart disease (CHD) and to present imaging findings and correlation in 50 fetuses with CHD. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Bardo Dianna, Lindblade Christopher, Wishah Fidaa, Patel Mittun, Cornejo Patricia, Ellsworth Erik, Awerbach Jordan, Goncalves Luis

Keywords: fetal cardiac MRI, congenital heart disease

The purpose of this educational exhibit is to show FCMR images of congenital heart disease (CHD) and anatomical findings associated with CHD. We will describe currently available FCMR image acquisition techniques and use a case-based approach to show a variety of CHD diagnosis with teaching points to highlight the added value of FCMR in diagnosis and prognosis. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Bardo Dianna, Lindblade Christopher, Wishah Fidaa, Cornejo Patricia, Patel Mittun, Ellsworth Erik, Awerbach Jordan, Goncalves Luis

Keywords: Fetal cardiac MRI, congenital heart disease

3D mDIXON Gradient Echo (GRE) technical superiority has already been established: improved fat saturation, faster acquisition time, high spatial resolution, and volumetric data acquisition allowing for a comprehensive multiplanar and 3D post-contrast evaluation of vessels and soft tissue lesions. Vascular malformation imaging requires large field of view images that can adversely affect fat saturation, is frequently performed with a non-sedated patient resulting in motion artifact, and requires higher spatial resolution to better characterize a lesion and evaluate lesion extent. Additionally the interventional radiologists at our institution prefer 3D post-contrast imaging to assist in treatment planning. We believe that this sequence is well suited for vascular malformation MRI imaging. The primary purpose is to illustrate the clinical utility and superior image quality of the 3D mDIXON GRE sequence over more conventional mDIXON TSE sequence through a series of cases of a variety of vascular malformations in different body regions. The secondary purpose of this presentation is to validate the clinical superiority of this sequence through a blinded reviewer comparison to the more conventional mDIXON TSE sequence. Read More

Meeting name: IPR 2016 Conjoint Meeting & Exhibition , 2016

Authors: Dance Logan, Keehn Brian, Patel Mittun, Pokorney Amber, Peterson Michael, Aria David, Barnes Craig, Bailey Smita

Keywords: vascular malformation, MRI, water fat imaging