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   Table of Contents - Current issue
Coverpage
January-March 2017
Volume 27 | Issue 1
Page Nos. 1-114

Online since Monday, March 27, 2017

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EDITORIAL  

Quality program in radiology: Persue or perish p. 1
Chander Mohan
DOI:10.4103/ijri.IJRI_99_17  
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PRESIDENTIAL ADDRESS Top

Presidential address p. 4
Bhupendra Ahuja
DOI:10.4103/ijri.IJRI_74_17  
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ABDOMINAL IMAGING Top

Imaging in ductal plate malformations Highly accessed article p. 6
Binit Sureka, Archana Rastogi, Chhagan Bihari, Kishore G S Bharathy, Vikrant Sood, Seema Alam
DOI:10.4103/0971-3026.202966  
Ductal plate malformations are a heterogenous group of congenital fibrocystic liver diseases resulting from insult to the ductal plate at various stages of embryogenesis. As a result various biliary malformations, cysts, hamartomas and congenital hepatic fibrosis may be seen. We present a radiological pictorial of ductal plate malformations, accurate diagnosis of which is important for clinical management.
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Multimodality imaging of adult gastric emergencies: A pictorial review Highly accessed article p. 13
Abhijit Sunnapwar, Vijayanadh Ojili, Rashmi Katre, Hardik Shah, Arpit Nagar
DOI:10.4103/0971-3026.202957  
Acute gastric emergencies require urgent surgical or nonsurgical intervention because they are associated with high morbidity and mortality. Imaging plays an important role in diagnosis since the clinical symptoms are often nonspecific and radiologist may be the first one to suggest a diagnosis as the imaging findings are often characteristic. The purpose of this article is to provide a comprehensive review of multimodality imaging (plain radiograph, fluoroscopy, and computed tomography) of various life threatening gastric emergencies.
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THORACIC IMAGING Top

Infectious pneumonia in the immunocompetent host: What the radiologist should know p. 23
Rohini G Ghasi, Sunil K Bajaj
DOI:10.4103/0971-3026.202967  
Lung infections are an important cause of morbidity and mortality, particularly because of the rising antimicrobial resistance. According to the clinical setting, they can be categorized as community-acquired pneumonia and hospital-acquired pneumonia. Radiological patterns of lung infections are lobar consolidation, bronchopneumonia, interstitial pattern, and nodular pattern. In addition, typical imaging features of several infections serve as “red flag signs” in reaching a diagnosis or altering the management. It would be prudent for the radiologist to be well informed regarding these aspects of lung infections to be able to make a valuable contribution to the management.
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Castleman's disease: A rare indication for endovascular therapy for hemoptysis p. 33
Mohammad A Husainy, Farhina Sayyed, Simon J McPherson
DOI:10.4103/0971-3026.202960  
Castleman's disease (CD) is a rare lympho-proliferative disorder due to faulty immune regulation resulting in proliferation of lymphatic tissue. The vascular supply to these lesions have been reported to arise from the bronchial, internal mammary and the intercostal arteries. We report a case of hemoptysis secondary to intrathoracic CD with vascular supply arising from the left inferior phrenic artery which was successfully embolised with polyvinyl alcohol (PVA) particles.
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NEUROIMAGING AND HEAD & NECK Top

Evaluation of MR perfusion abnormalities in organophosphorus poisoning and its correlation with SPECT p. 36
K Uday Bhanu, Niranjan Khandelwal, Sameer Vyas, Paramjeet Singh, Anuj Prabhakar, BR Mittal, Ashish Bhalla
DOI:10.4103/0971-3026.202961  
Aim: Acute organophosphate (OP) pesticide poisoning causes substantial morbidity and mortality worldwide. Many imaging modalities, such as computerized tomography (CT), magnetic resonance imaging (MRI), and single photon emission computed tomography (SPECT) of the brain, have been used for quantitative assessment of the acute brain insult caused by acute OP poisoning. Perfusion defects on SPECT in acutely poisoned patients with OPs have been described, however, MR perfusion abnormalities have not been described in the literature. MR perfusion Imaging has the advantage of having higher spatial resolution, no radiation, and better availability. Materials and Methods: In this prospective study, 20 patients who ingested OP compounds were included. All the patients underwent brain SPECT on a dual head SPECT gamma camera and MRI brain on a 1.5T MR system. Neurocognitive tests were performed for all patients. Results: SPECT showed perfusion defects in 7 patients and total number of perfusion defects were 29. On MR perfusion, based on the cut-off values of normalized cerebral blood volume (nCBV) ratios and normalized cerebral blood flow (nCBF) ratios, the total number of patients showing perfusion defects were 6 and 8; and the total number of perfusion defects were 29 and 45, respectively. There was significant difference of the nCBV ratios and nCBF ratios between the control group (n = 20) and positive patients group (n = 6 and n = 8, respectively) (P > 0.05). All the defects seen on SPECT were well appreciated on nCBF maps (MRI perfusion) suggestive of 100% correlation. Conclusion: MR perfusion imaging can be used as an effective modality for evaluation in acute OP poisoning.
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Cavernous sinus melanoma: A rare tumor p. 43
Shaileshkumar Garge, Sunithi Mani, Alfred Inbaraj, Vedantam Rajshekhar, Priyanka Mohapatra
DOI:10.4103/0971-3026.202970  
Primay melanoma of the cavernous sinus is very rare with only few cases reported in the literature. We present the cross-sectional imaging findings of this rare tumor. The differential diagnosis for cavernous sinus mass lesion is wide as it contains vital neurovascular structures that may be affected by vascular, neoplastic, infective, and infiltrative lesions arising in the cavernous sinus proper or via extension from adjacent intra and/or extracranial regions. Radiologic imaging can narrow the differential diagnosis, however, imaging cannot definitely reach single diagnosis if they present in atypical form with hemorrage and cystic degeneration. This case report illustrates that primary cavernous sinus melanoma may present as a atypical tumor with diagnostic dilemma.
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Frontal sinus osteoma with pneumocephalus: A rare cause of progressive hemiparesis p. 46
Ashwini Bakde Umredkar, Amit Disawal, Aarti Anand, Prajwalit Gaur
DOI:10.4103/0971-3026.202972  
Osteomas of paranasal sinuses are common benign tumors and are diagnosed incidentally. However, osteomas complicated by pneumocephalus with air fluid level presenting with progressive hemiparesis is rare. Here, we present a case report of a 22-year-old male who presented with left-sided progressive hemiparesis with history of generalized headache since 2 years.
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Calcification of the submandibular gland in a patient with chickenpox p. 49
Cetin Celenk, Peruze Celenk
DOI:10.4103/0971-3026.202954  
The pneumonia virus of chickenpox is now known to cause scattered calcified foci in the lungs, however to our knowledge, recent literature has not discussed calcification in the salivary glands. A 15-year-old boy consulted the department of radiology because of a swelling on the right side of the submandibular area. Radiological assessment included an ultrasonography and computerized tomography scan of the neck area, which demonstrated intraparenchymal amorph calcification, with approximately 13 mm diameter in the right submandibular gland. General condition and oral intake was good without distress in the patient, and hence he was discharged on the seventh day of follow-up treatment.
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WOMEN’S IMAGING Top

Utility of supplemental screening with breast ultrasound in asymptomatic women with dense breast tissue who are not at high risk for breast cancer p. 52
Geetika A Klevos, Fernando Collado-Mesa, Jose M Net, Monica M Yepes
DOI:10.4103/0971-3026.202962  
Objective: To assess the results of an initial round of supplemental screening with hand-held bilateral breast ultrasound following a negative screening mammogram in asymptomatic women with dense breast tissue who are not at high risk for breast cancer. Materials and Methods: A retrospective, Health Insurance Portability and Accountability Act compliant, Institutional Research Board approved study was performed at a single academic tertiary breast center. Informed consent was waived. A systematic review of the breast imaging center database was conducted to identify and retrieve data for all asymptomatic women, who were found to have heterogeneously dense or extremely dense breast tissue on screening bilateral mammograms performed from July 1, 2010 through June 30, 2012 and who received a mammographic final assessment American College of Radiology's (ACR) Breast Imaging Reporting and Data System (BI-RADS) category 1 or BI-RADS category 2. Hand-held screening ultrasound was performed initially by a technologist followed by a radiologist. Chi-square and t-test were used and statistical significance was considered at P< 0.05. Results: A total of 1210 women were identified. Of these, 394 underwent the offered supplemental screening ultrasound. BI-RADS category 1 or 2 was assigned to 323 women (81.9%). BI-RADS category 3 was assigned to 50 women (12.9%). A total of 26 biopsies/aspirations were recommended and performed in 26 women (6.6%). The most common finding for which biopsy was recommended was a solid mass (88.5%) with an average size of 0.9 cm (0.5–1.7 cm). Most frequent pathology result was fibroadenoma (60.8%). No carcinoma was found. Conclusion: Our data support the reported occurrence of a relatively high number of false positives at supplemental screening with breast ultrasound following a negative screening mammogram in asymptomatic women with dense breast tissue, who are not at a high risk of developing breast cancer, and suggests that caution is necessary in establishing wide implementation of this type of supplemental screening for all women with dense breast tissue without considering other risk factors for breast cancer.
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Fetal intra abdominal umbilical vein varix: Case series and review of literature p. 59
Meenakshi Lallar, Shubha R Phadke
DOI:10.4103/0971-3026.202964  
Fetal intraabdominal umbilical vein varix (FIUV) is focal dilatation of the intrabdominalumbilical vein of thefetus.It appears as a round or fusiform cystic structure in thefetal abdomen, which shows continuity with the umbilical vein ongrayscale andcolor Dopplerimaging. The diagnostic criteria include the FIUV varix diameter at least 50% wider than the diameter of the intrahepatic umbilical veinand an intraabdominal umbilical vein diameter exceeding 9 mm orgreater than twostandard deviations above the mean for gestational age. We report three cases, two cases with isolated FIUV and favorable outcome and the third case with FIUV and atrioventricular septal defect, where trisomy 21 (Down syndrome) was diagnosed.
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Placental mesenchymal dysplasia: What every radiologist needs to know p. 62
Disha Mittal, Rama Anand, Neha Sisodia, Smita Singh, Ratna Biswas
DOI:10.4103/0971-3026.202949  
Placental mesenchymal dysplasia (PMD) is an uncommon vascular anomaly of the placenta characterized by placentomegaly with multicystic placental lesion on ultrasonography and mesenchymal stem villous hyperplasia on histopathology. Placental mesenchymal dysplasia should be considered in the differential diagnosis of cases of multicystic placental lesion such as molar pregnancy, chorioangioma, subchorionic hematoma, and spontaneous abortion with hydropic placental changes. However, lack of high-velocity signals inside the lesion and a normal karyotype favor a diagnosis of PMD. PMD must be differentiated from gestational trophoblastic disease because management and outcomes differ. We report the case of an 18-year-old female at 15 weeks of gestation with sonographic findings suggestive of placental mesenchymal dysplasia. The diagnosis was confirmed on histopathology.
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CARDIOVASCULAR IMAGING Top

Spectrum of pulmonary valve morphology and its relationship to pulmonary trunk in tetralogy of Fallot p. 65
Binita R Chacko, George K Chiramel, Leena R Vimala, Devi A Manuel, Elizabeth Joseph, K Reka
DOI:10.4103/0971-3026.202959  
Background: Tetralogy of Fallot (TOF) is a complex congenital heart disease with anatomic variations. Although the pulmonary valve in TOF is abnormal, it has not been studied well, especially on newer imaging modalities such as multidetector computed tomography (CT), which gives excellent anatomic detail. Aims: The aim of this study was to assess the morphology of pulmonary valve in TOF on CT and evaluate its association with the degree of hypoplasia of infundibulum and pulmonary trunk. Materials and Methods: The cardiac CT scans of 30 patients with TOF were reviewed to evaluate the morphology of the pulmonary valve, infundibulum, and pulmonary arteries. Fisher's exact test was performed to examine the association between pulmonary valve morphology and degree of hypoplasia of the infundibulum and pulmonary trunk. Results: 16.7% of patients with TOF had pulmonary atresia. The prevalence of tricuspid, bicuspid, and absent valves were 10%, 53.3% and 6.7%, respectively. In another 13.3% of patients, although valve tissue was present, exact morphology could not be determined on CT. The commissures of 62.5% of the bicuspid valves were at 12 o'clock and 6 o'clock or slightly off the midline. There was statistically significant association between valve morphology and degree of infundibular hypoplasia (P < 0.001) and calibre of pulmonary trunk (P < 0.001). Conclusion: Morphological abnormality of the pulmonary valve is common in TOF. The most common type of pulmonary valve in TOF patients is bicuspid valve with commissures at 12 o'clock and 6 o'clock or slightly off the midline. Fewer cusps of the pulmonary valve are associated with a more severe degree of pulmonary artery hypoplasia.
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Prenatal diagnosis of a rare aortic arch anomaly with left aortic arch and right ductus arteriosus: Cross ribbon sign p. 70
S Boopathy Vijayaraghavan, Sathiya Senthil, K Latha
DOI:10.4103/0971-3026.202963  
Here, we report a fetus with a rare aortic arch anomaly with left aortic arch and right ductus arteriosus, which has not been reported so far. In this condition, the aorta extends to the left of the trachea as in normal, while the ductus arteriosus extends to the right of the trachea and joins the descending aorta posterior to the trachea, with a cross-ribbon sign.
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PAEDIATRIC IMAGING Top

The current status of pediatric radiology in India: A conference-based survey p. 73
Jacob Therakathu, Vikas K Yadav, Shyamkumar N Keshava, Sridhar Gibikote, Govind B Chavan, Manohar Shroff
DOI:10.4103/0971-3026.202965  
Introduction: Like most other developing countries, India has a large proportion of children among its population. However, the facilities for adequate treatment of this large population is inadequate. The development of pediatric radiology as a subspecialty is still at an infant stage in India. The goal of our study was to assess the awareness about the current status of pediatric radiology in India. Materials and Methods: A questionnaire was handed over to all attendees of a pediatric radiology conference to assess their opinion regarding the adequacy of pediatric training and practice in India. The questionnaire consisted of 10 multiple-choice and two descriptive questions. Descriptive statistical methods were used for analyzing the results. Results: Eighty-one out of 400 delegates responded to the questionnaire. Among these 81 respondents, 50 (61.7%) felt that exposure to pediatric cases during postgraduate course was inadequate. Sixty-three out of 81 (77.7%) respondents thought that specialized training is required for practicing pediatric radiology, and 79 respondents (97%) felt that the number of such training programmes should increase. Forty-five out of 81 respondents (55.5%) were interested in pursuing pediatric radiology as a career. Conclusion: According to the opinion of the respondents of our survey, pediatric radiology remains an underdeveloped speciality in India. Considering the proportion of the population in the pediatric age and the poor health indicators in this age group, elaborate measures, as suggested, need to be implemented to improve pediatric radiology training and the care of sick children in India.
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Inguinoscrotal hernia in infants: Three case reports in ultrasound diagnosis p. 78
Dharmraj Meena, Richa Jhuria, Sangeeta Saxena, Umesh Saini
DOI:10.4103/0971-3026.202951  
An inguinal hernia occurs when an intestinal loop or part of the omentum or genital organs passes into the scrotal cavity or labia through an incompletely obliterated processus vaginalis. Inguinal hernias are most common in preterm neonates, especially at 32-weeks gestation. Content of hernia is mostly bowel and ovary/testicles. Presence of uterus in herniated sac is rare, and only few cases are reported in literature. Hernia is more frequently located on the right side because the right processus vaginalis closes later than the left. Physical examination is sufficient to enable diagnosis in most cases. Ultrasound examination is indicated in patients with inconclusive physical findings, in patients with acute scrotum, and to investigate contralateral involvement in patients in whom only a unilateral hernia is clinically evident. Routinely, color or power Doppler imaging is used in inguinal-scrotal hernia to investigate intestinal and testicular/ovarian perfusion. Urgent surgery is indicated in patients with an akinetic dilated bowel loop (a sign of strangulation) or impaired testicular/ovarian perfusion.
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INTERVENTIONAL RADIOLOGY Top

Role of penumbra mechanical thrombectomy device in acute dural sinus thrombosis p. 82
Suraj Mammen, Shyamkumar Nidugala Keshava, Vinu Moses, Sanjith Aaron, Munawwar Ahmed, George K Chiramel, Sunithi E Mani, Mathew Alexander
DOI:10.4103/0971-3026.202956  
Background: In dural venous sinus thrombosis (DVST), the mortality ranges 5–30%. Deep venous system involvement and septic dural sinus thrombosis have a higher mortality rate. In acute occlusion, collateral flow may not be established, which may result in significant edema and mass effect. Endovascular interventions may be considered as a treatment option in appropriate high-risk patients with DVST. Materials and Methods: Eight patients with magnetic resonance imaging (MRI)-confirmed dural sinus thrombosis, who did not respond to the conventional standard medical treatment, were subsequently treated with mechanical thrombectomy using the Penumbra System®. In all cases, medical treatment including anticoagulants were continued following the procedure for a minimum period of 1 year. Results: Recanalization of the dural sinus thrombosis was achieved in all 8 cases. There were no immediate or late endovascular-related complications. One death occurred due to an unrelated medical event. At 6 months, there was notable improvement in the modified Rankin Score (mRS), with 5/8 (62%) patients achieving mRS of 2 or less. The follow-up ranged between 3 months and 26 months (mean: 14.5 months), and there were no new neurological events during the follow-up period. Conclusion: Cerebral venous sinus thrombosis is a rare but life-threatening condition that demands timely diagnosis and therapy. In cases of rapidly declining neurological status despite standard therapy with systemic anticoagulation and anti-edema measures, mechanical thrombectomy could be a lifesaving and effective option. In this study, good outcomes were observed in the majority of patients at long-term follow up.
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Radiofrequency ablation of osteoid osteoma in common and technically challenging locations in pediatric population p. 88
Shaileshkumar Garge, Shyamkumar N Keshava, Vinu Moses, George K Chiramel, Munawwar Ahmed, Suraj Mammen, Vrisha Madhuri
DOI:10.4103/0971-3026.202955  
Context: Percutaneous radiofrequency ablation (RFA) of osteoid osteoma has a high technical and clinical success rate. However, there is limited data on its use in the pediatric population, especially in technically challenging locations. Objective: To assess the safety and efficacy of computed tomography (CT)-guided percutaneous RFA of osteoid osteoma in pediatric population. Patients and Methods: From June 2009 to May 2014, 30 patients with osteoid osteoma were treated with CT-guided RFA in common (25 cases) and technically challenging (five cases: four near articular surface and one in sacrum) locations. Therapy was performed under general anesthesia with a three-array expandable RF probe for 6 min at 90°C and power of 60–100 W. The patients were discharged next day under instruction. The treatment success was evaluated in terms of pain relief before and after (1 day, 1 month, and 6 months) treatment. Results: Technical success was achieved in all patients (100%). Primary clinical success was 96.66% (29 of total 30 patients), despite the pediatric population and atypical location. One patient had persistent pain after 1 month and was treated successfully with a second procedure (secondary success rate was 100%). One patient had immediate complication of weakness of right hand and fingers extension. No delayed complications were observed. Conclusions: CT-guided RFA is relatively safe and highly effective for treatment of osteoid osteoma in pediatric population, even in technically difficult locations.
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Percutaneous transhepatic techniques for management of biliary anastomotic strictures in living donor liver transplant recipients p. 92
Chinmay B Kulkarni, Nirmal K Prabhu, Nazar P Kader, Ramiah Rajeshkannan, Sreekumar K Pullara, Srikanth Moorthy
DOI:10.4103/0971-3026.202950  
Aim: To retrospectively analyze the percutaneous transhepatic techniques and their outcome in the management of biliary strictures in living donor liver transplant (LDLT) recipients. Materials and Methods: We retrieved the hospital records of 400 LDLT recipients between 2007 and 2015 and identified 45 patients with biliary strictures. Among them, 17 patients (37.8%) (Male: female = 13:4; mean age, 36.1 ± 17.5 years) treated by various percutaneous transhepatic biliary techniques alone or in combination with endoscopic retrograde cholangiopancreatography (ERCP) were included in the study. The technical and clinical success of the percutaneous management was analyzed. Results: Anastomotic strictures associated with leak were found in 12/17 patients (70.6%). Ten out of 12 (83.3%) patients associated with leak had more than one duct-duct anastomoses (range, 2–3). The average duration of onset of stricture in patients with biliary leak was 3.97 ± 2.68 months and in patients with only strictures it was 14.03 ± 13.9 months. In 6 patients, endoscopic-guided plastic stents were placed using rendezvous technique, plastic stent was placed from a percutaneous approach in 1 patient, metallic stents were used in 2 patients, cholangioplasty was performed in 1 patient, N-butyl- 2-cyanoacrylate embolization was done in 1 child with biliary-pleural fistula, internal-external drain was placed in 1 patient, and only external drain was placed in 5 patients. Technical success was achieved in 12/17 (70.6%) and clinical success was achieved in 13/17 (76.5%) of the patients. Posttreatment mean time of follow-up was 19.4 ± 13.7 months. Five patients (29.4%) died (two acute rejections, one metabolic acidosis, and two sepsis). Conclusions: Percutaneous biliary techniques are effective treatment options with good outcome in LDLT patients with biliary complications.
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Balloon occluded retrograde transvenous obliteration for bleeding gastric varices: Eyes see what the mind knows p. 100
Pushpinder S Khera, Lee Myungsu, Choi Joonsung
DOI:10.4103/0971-3026.202952  
Approximately one in six patients with portal hypertension who develop varices at sites of portosystemic venous collaterals has gastric varices due to hepatofugal flow into the gastric veins. Bleeding from gastric varices, though less common, has a higher mortality and morbidity compared to bleeding esophageal varices, which are easier to manage endoscopically. The efferent channel for gastric varices is mostly the gastrorenal shunt (GRS) which opens into the left renal vein. Balloon-occluded transvenous obliteration (BRTO) involves accessing the GRS with an aim to temporarily occlude its outflow using a balloon catheter and at the same time injecting sclerosant mixture within the varix so as to cause its thrombosis and thereby obliteration. BRTO is one of the mainstays of minimally invasive treatment for bleeding gastric varices. In the minority of cases where the GRS is absent, conventional BRTO is technically not possible. However, accessing the small alternate shunt from the inferior phrenic vein may be possible if one is aware of its existence.
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MISCELLANEOUS Top

Tibial periosteal ganglion cyst: The ganglion in disguise p. 105
Anjuna Reghunath, Mahesh K Mittal, Geetika Khanna, V Anil
DOI:10.4103/0971-3026.202953  
Soft tissue ganglions are commonly encountered cystic lesions around the wrist presumed to arise from myxomatous degeneration of periarticular connective tissue. Lesions with similar pathology in subchondral location close to joints, and often simulating a geode, is the less common entity called intraosseous ganglion. Rarer still is a lesion produced by mucoid degeneration and cyst formation of the periostium of long bones, rightly called the periosteal ganglion. They are mostly found in the lower extremities at the region of pes anserinus, typically limited to the periosteum and outer cortex without any intramedullary component. We report the case of a 62 year-old male who presented with a tender swelling on the mid shaft of the left tibia, which radiologically suggested a juxtacortical lesion extending to the soft tissue or a soft tissue neoplasm eroding the bony cortex of tibia. It was later diagnosed definitively as a periosteal ganglion in an atypical location, on further radiologic work-up and histopathological correlation.
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LETTERS TO THE EDITOR Top

Gorham's syndrome vs generalized lymphagiomatosis: A close call p. 110
Animesh Ray
DOI:10.4103/0971-3026.202968  
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Author's reply p. 111
Tharani Putta, Aparna Irodi, Balamugesh Thangakunam, Ashwin Oliver
DOI:10.4103/0971-3026.202969  
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A novel presentation of tubular adenoma of the breast as an intraductal mass: Diagnostic considerations and pathologic correlation p. 112
Suzanne M Smith Iorfido, Mahendra Shah, S Yasir Zaidi, Stephen Iorfido
DOI:10.4103/0971-3026.202958  
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