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CONTEXT: Arterial stimulation and venous sampling (ASVS) is the most sensitive diagnostic method for occult insulinoma localization. We present our experience with this method and modifications used that proved to ensure greater safety and sensitivity with this rare pathology. Relationship between tumour size and changes in peak insulin values and release curves were also tested. SUBJECTS AND METHODS: Six consecutive patients with biochemically established diagnosis of endogenous hyperinsulinism underwent preoperative non-invasive diagnostic tests with sensitivities calculated and compared for all methods. Certain modifications were used in ASVS procedure that included hepatic vein catheterization, order of arterial stimulation, time intervals between each stimulation, diagnostic insulin gradient level and the time frame for diagnostic rise of insulin. Peak insulin values and insulin gradients were compared with tumour size in each patient. RESULTS: In all patients, calcium stimulation accurately localized the insulinoma, with higher sensitivity than any other method. A more than 4-fold increase in insulin level was observed in all patients, after injection into the tumour feeding artery, while 2 to 4-fold increase was observed in the tumour neighbouring areas. Tumour size showed an inversely proportional correlation to peak insulin values in each artery that correctly located the tumour. CONCLUSION: ASVS presents the most accurate and safe method for localization of occult insulinomas. A four-fold insulin gradient can be used as a limit for positive preoperative localization in order to secure a higher specificity.

Rak jajnika i jajovoda po učestalosti je peta zloćudna bolest žena u Hrvatskoj. Histološki je rak jajnika najčešće epitelnog podrijetla, i to seroznog podtipa. Rjeđi su različiti neepitelni malignomi jajnika, a posebnu skupinu čine epitelni karcinomi niskoga zloćudnog potencijala karakterizirani neinvazivnošću, klinički indolentnim tijekom i dobrom prognozom te primarni rak potrbušnice i rak jajovoda. Klinički su ovi zloćudni tumori u ranim stadijima razvoja uglavnom asimptomatski, zbog čega se najčešće dijagnosticiraju u kasnijim stadijima bolesti. Dijagnoza se potvrđuje patohistološkim nalazom, a iznimno citološkim nalazom nakon provedene dijagnostičke obrade. O liječenju odlučuje multidisciplinarni tim uzimajući u obzir dob, opće stanje i komorbiditete bolesnice, kao i obilježja samog tumora uključujući stadij bolesti, histološki tip i gradus tumora. Principi liječenja primarnog raka potrbušnice i jajovoda temelje se na principima liječenja epitelnog raka jajnika koji obuhvaćaju primjenu kirurških zahvata, kemoterapije, imunoterapije i hormonske terapije, kao i suportivno-simptomatskih mjera tijekom cijelog liječenja. Razlikuje se terapijski pristup rjeđim, neepitelnim histološkim tipovima tumora koji se češće dijagnosticiraju u ranim stadijima bolesti, imaju indolentniji tijek pa se kod ovih bolesnica češće primjenjuju poštedni kirurški zahvati s ciljem očuvanja plodnosti. U tekstu koji slijedi predstavljene su kliničke upute s ciljem standardizacije postupaka i kriterija postavljanja dijagnoze, liječenja te praćenja bolesnica s rakom jajnika, jajovoda i potrbušnice u Republici Hrvatskoj., Ovarian cancer together with fallopian tube represents the fifth most common female cancer in the Republic of Croatia. Epithelial ovarian cancer, serous subtype, encompasses most of malignant ovarian neoplasms. Less common are various non-epithelial ovarian malignancies. A special group consists of epithelial carcinomas of low malignant potential with clinically indolent flow, good prognosis and no invasion, and primary cancer of the peritoneum and fallopian tube cancer. Clinically, these malignant tumors are generally asymptomatic in early stages, and usually diagnosed in advanced stages. The diagnosis is confirmed by pathological examination, and occasionally, cytological findings after completing diagnostic procedures. Multidisciplinary team makes treatment decisions, taking into account age, general condition and comorbidities of the patient and characteristics of the tumor itself, including disease stage, histological type and grade of the tumor. The principles of treatment of primary peritoneal and fallopian tube cancer are based on the principles of treatment of epithelial ovarian cancer involving surgery, chemotherapy, immune and hormone therapy, and symptomatic-supportive care throughout the treatment. Less common histological types have a different treatment approach being more frequently diagnosed in the early stages of the disease, have more indolent flow, so in these patients conservative surgeries with the goal of preserving fertility are more often employed. The following text presents the clinical guidelines in order to standardize the procedures and criteria for the diagnosis, management, treatment and monitoring of patients with ovarian carcinoma, fallopian tube and primary peritoneal cancer in the Republic of Croatia.

Atypical presentation of S1 radiculopathy in a 53- year-old man is presented. Patient noticed calf swelling associated with pain. Extensive radiological diagnostic procedure and muscle and bone biopsy were performed in order to exclude the presence of tumor. Electromyography of the muscles was diagnostic for radicular lesion of S1 segment. After surgical laminectomy, calf enlargement and pain remained. This case provides further evidence that chronic radiculopathy could be responsible for development of neurogenic muscle hypertrophy and focal myositis, and that careful diagnostic evaluation is needed to exclude asymmetric presentation of systemic neuromuscular condition or tumor. This is the first case describing PET/CT finding in focal myositis associated with lumbosacral radiculopathy.

The differences in apparent diffusion coefficient (ADC) between typical and atypical meningiomas and schwannomas were investigated, with 41 patients included in the study. There were no significant differences in ADC values or ADC ratios between typical and atypical meningiomas. The discrimination between schwannomas and the typical and atypical meningiomas on ADC maps was reliable, with significant differences in ADC values and ratios and with the narrow range of ADC values in meningiomas.

Fibrom lijevog ventrikula koji se prezentira u obliku akutnog koronarnog sindroma

Different conditions within the pelvis are presented with very few symptoms. Likewise, their imaging characteristics are usually non-specific, implying high chance of misinterpretation. The aim of this paper is to point to the misinterpretation possibilities in computed tomography (CT) and magnetic resonance (MR) studies of the pelvic lesions and to outline their differential diagnosis. CT (11), MR (seven) or both (four patients) were performed in 22 female patients (age 23-69) with suspicious pelvic masses. Relevant laboratory and medical history data were available for most of the patients. Twenty patients underwent subsequent surgery and pathological findings were available in 18 cases. After radiological examinations different diagnoses were proposed in respect to imaging findings and available clinical data: pelvic inflammatory disease (one), ovarian tumor (six), uterine tumor (eight), metastatic or recurrent tumor (four), lymphocele (one), and post-irradiation and post-chemotherapy changes (two) patients. Postoperative results of the pathological analysis differed from radiological diagnosis in three of 18 pathologically examined materials: one benign tumor was falsely characterized as possibly malignant by the radiologist, one surgically transposed ovary was described as tumor, and one case of post-irradiation changes was described as recurrent tumor. Aside from knowing imaging characteristics, it is of great importance for radiologists to be aware of clinical, laboratory, and surgical protocols information as well as to have insight in patients’ prior imaging material in order to be able to correctly interpret imaging findings of the pelvic lesions., Simptomi različitih stanja u zdjelici neznatni su pa su prema tome i njihove značajke na snimkama obično nespecifične, što podrazumijeva i veliku mogućnost pogrešnog tumačenja. Cilj ovoga rada jest upozoriti na mogućnosti pogrešnog tumačenja komjutorizirane tomografije (CT) i magnetske rezonancije (MR) lezija u zdjelici te u glavnim crtama prikazati i razmotriti diferencijalnu dijagnozu. CT (11), MR (sedam) ili oboje (četiri bolesnice) obavljeno je u 22 bolesnice (dob 23-69) sa sumnjivim tvorbama u zdjelici. Za većinu su bolesnica na raspolaganju bili njihovi prethodni relevantni laboratorijski i medicinski podaci. Dvadeset bolesnica bilo je podvrgnuto kirurškom zahvatu i za 18 bili su dostupni patološki nalazi. Nakon radiološkog pregleda predložene su različite dijagnoze s obzirom na snimke i raspoložive kliničke podatke: upalna bolest zdjelice (jedan), tumor jajnika (šest), tumor maternice (osam), metastatski tumor ili recidiv (četiri), limfokela (jedna), te postiradijacijske i postkemoetrapijske promjene (dvije bolesnice). Postoperativni nalazi patološke analize razlikovali su se od radiološke dijagnoze u tri od 18 pregledanih materijala: jedan dobroćudni tumor radiolog je pogrešno opisano kao vjerojatnom zloćudni, jedan kirurški transponirani jajnik opisan je kao tumor, a u jedne su bolesnice postiradijacijske promjene opisane kao recidiv tumora. Osim prepoznavanja značajaka na snimkama, za ispravno tumačenje snimaka lezija u zdjelici radiolozima su vrlo važni i podaci dobiveni kliničkim, laboratorijskim i kirurškim postupcima te uvid u prethodne snimke pacijenata.

A 68-year-old Caucasian woman was admitted to the Department for construction of vascular access for dialysis after thrombosis of arteriovenous fistula. Temporary dialysis catheter was inserted in the left internal jugular vein while she had permanent pacemaker implanted on the right thoracic side. The patient signalized pain in the left breast. Postprocedural chest x-ray revealed that the catheter was malpositioned in the right internal mammary vein. The catheter was immediately pulled out and temporary catheter was inserted in the left femoral vein. Malposition of central venous catheter into small tributaries of central vein is a rare complication which can be hazardous and needs to be quickly recognized.