TEACHING FILE

1. TEACHING FILE Dr Payal Damor R2 Radiodiagnosis S.S.G.H BARODA

2. CASES 1

3. 8 year male presented with a one year history of progressively worsening knee pain.

4. X ray both keee (AP) showing depression & irregularity of the proximal tibial metaphyses posteromedially.

5. DIAGNOSIS Blount's Disease (Bilateral Tibia Vara)

6. Causes of lower limb bowing • Developmental [physiological bowing] • Congenital Bowing • Tibia vara [Blount disease] • Neurofibromatosis • Osteogenesis Imperfecta • Rickets • Camptomelic Dysplasia • Achondroplasia

7. TIBIA VARA (Blount disease) A common condition, believed to be result from abnormal stress on the posteromedial proximal tibial physis, causing growth suppression. The growth at the epiphysis becomes asymmetric, leading to the typical varus angulation. Usually unilateral or asymmetric.

8. Predisposing factors Early walking and obesity - exaggerate the physiological varus angulation and African-American children – they are believed to have excessive ligamentous laxity and begin to walk earlier. Three types of the tibia vara [depending on the age at presentation] • Infantile - the most common • Juvenile • Adolescent The later onset types may represent an unrecognized and untreated variants of infantile form.

9. Radiography (standing anteroposterior radiography) of both limbs will demonstrate Genu varum and Depression and irregularity or fragmentation of the proximal tibial metaphyses posteromedially and deficiency of the epiphysis medially. The physis may be widened medially due to traction injury. More advanced cases may show lateral subluxation of the tibia. To diagnose this condition and to differentiate it from the developmental bowing, measurement of the metaphyseal-diaphyseal angle has been used.

10. The metaphyseal-diaphyseal angle is the angle between a line drawn parallel to the top of the proximal tibial metaphyses and the another line drawn perpendicular to the long axis of the tibial shaft. Physiological bowing - 50 + 2.8 [ range 0-11] Blount disease - 160+ 4.3 [range 8-22]. It has been suggested that the children with angle greater than 110 have Blount disease. Children with intermediate angles [ 80 – 110] may require the follow up radiography to clarify the diagnosis.

11. A line is drawn prepandicular to the longitudinal axis of the tibia & another is drawn through the two beaks of the metaphysis to determine the transverse axis of tibial metaphysis. The metaphyseal-diaphyseal angle is bisected by these two lines.

12. Infantile Blount disease in a 23-month-old boy. (a) Radiograph shows asymmetric depression of the proximal tibial metaphyses, particularly on the affected left side. (b) Radiograph obtained 7 months later demonstrates increased metaphyseal depression bilaterally and fragmentation of the medial tibial metaphysis on the left side. Black lines illustrate abnormally increased metaphyseal-diaphyseal angles measuring 13° and 26° on the right and left sides, respectively.

13. A six stage classification system for Blount disease [ proposed by langenskiold ] is commonly used. This classification is not intended to determine the prognosis or the treatment, however osteotomies of the tibia and fibula is usual treatment of choice in stage 3 disease or higher.

14. LANGENSKIOLD CLASSIFICATION Drawings illustrate the six stages of the Langenskiold classification system for Blount disease. Note the progressive depression, beaking, and fragmentation of the medial tibial metaphysis, also involving the epiphysis in the higher stages.

15. MR imaging has been performed to evaluate the growth plate in Blount disease and may be useful in the surgical planning. It may also be used to predict development of Blount disease in patient with severe physiological bowing.

16. Adolescent Blount disease in a 12-year-old boy. (a) Radiograph shows metaphyseal changes in both the proximal tibia and the distal femur. Physeal widening is noted in the proximal tibia medially (arrow). (b) T1-weighted MR images show abnormal metaphyseal signal intensity in the distal femur and proximal tibia (arrowheads).

19. CASES 2

20. 7 Yrs old boy presentated with c/o dribbling.

21. On cystgram film snows overdistended bladder with bladder wall irregularity,saculation & small diverticuli On mcug film shows acystic collection of contrast,post to prostratic urethra,communicating with prostatic urethra at verumonetum.

22. Longitudinal images of pelvis shows well denifed cystic lesion deep to the prostate.

23. DIAGNOSIS UTRICLE CYST

24. Now disscusing about cystic lesion around prostate.

25. Most Commonly Seen Prostatic and Periprostatic Cystic Lesions and Their Mimics

26. A. Intraprostatic Cystic Lesions 1.Müllerian duct cysts and prostatic utricle cysts 2. Ejaculatory duct cysts 3. Prostatic retention cysts 4. Cystic degeneration of benign prostatic hypertrophy 5. Cysts associated with tumors 6. Infectious, inflammatory, and parasitic cysts 7. Ejaculatory duct diverticulum

27. B. Periprostatic Cystic Lesions 1.Seminal vesicle cysts 2. Cysts of the vas deferens 3. Cowper's duct cysts

28. C. Entities That May Mimic Prostatic and Periprostatic Cystic Lesions 1.Defect from transurethral resection of the prostate 2. Hydroureter and ectopic insertion of the ureter 3. Bladder diverticulum 4. Prominent seminal vesicles

29. Intraprostatic Cystic Lesions

30. Müllerian Duct Cysts & Prostatic Utricle Cysts

31. Although these conditions are believed to be two different entities, it is difficult to differentiate them from one another on imaging and clinical studies . Both occur in the midline. When infected , may contain pus or hemorrhage, which can cause confusion on imaging because the appearances overlap those of abscess & cystic tumor of the prostate.

32. Both cause obstructive urinary symptoms, hematuria, and pelvic pain. Ejaculatory impairment by obstruction of the ejaculatory ducts . As utricle cysts communicate with urethra, it may result in postvoid dribbling. Prostatic utricle cysts are associated with some genitourinary abnormalities such as hypospadias, incomplete testicular descent, and unilateral renal agenesis

34. 51-year-old man with prostate cancer. Transverse (A), coronal (B), and sagittal (C) T2-weighted MR images show prostatic utricle cyst (UC) that is located in midline, arising from verumontanum and communicating with urethra (U in C). Transverse image (A) shows focal low-signal-intensity area representing tumor (T in A).

35. 65-year-old man with prostate cancer. Transverse (A) and sagittal (B) T2-weighted MR images show müllerian duct cyst (M) that is slightly lateral to midline and extends above prostate

36. MCUG Film:shows a cystic collection of contrast post to prostatic urethra & communicating with prostatic urethra at verumontanum.

37. Images of the pelvis from the bladder ultrasound revealed a 3.5-cm midline fluid collection posterior to the bladder and superior to the prostate gland. The cystic fluid collection appears contiguous with the prostate. Echoes are noted within the cyst fluid.

38. Ejaculatory Duct Cysts

39. They are rare & Patients often present with hematospermia or dysuria. Occur due to obstruction of the ejaculatory duct , may be congenital or acquired . On imaging: lesions appear to be cystic structures along ejaculatory duct just lateral to midline in the central zone of the prostate. However, when large, may extend cephalad to the prostate & appear to arise centrally .

40. On aspiration : contain fructose or spermatozoa. Commonly contain calculi, but Sometimes may contain pus or hemorrhage. There may be associated cystic dilatation of the seminal vesicle on the same side.

41. 35-year-old man with azoospermia. Coronal (A) and transverse (B) T2-weighted MR images show ejaculatory duct cyst (EDC) that extends from verumontanum to left of midline above prostate (P in A) along course of ejaculatory duct. Hemorrhage (arrow,B) layering at dependent aspect of cyst is also seen

42. Prostatic Retention Cysts

43. They are acquired cysts. Rarely cause symptoms. Result from obstruction of the glandular ductules, causing dilatation of acini. Occur in any glandular zone of prostate. Never contain spermatozoa on aspiration. Appear as smooth-walled, unilocular simple cysts .

44. 66-year-old man with prostate cancer. Transverse (A) and coronal (B) T2-weighted MR images show unilocular, smooth, and thin-walled prostatic retention cyst (RC) in peripheral zone (PZ in B) of prostate

45. Cystic Degeneration of Benign Prostatic Hypertrophy (BPH)

46. Cystic degeneration of BPH nodules is common & accounts for most prostatic cystic lesions. Patients with these cysts usually have urinary obstructive symptoms due to BPH. Cystic lesions resulting from cystic degeneration of BPH are located in the transition zone of the prostate along with BPH nodules. They seen as irregular shapes & various sizes & may contain hemorrhage or calculi.

47. 59-year-old man with prostate cancer. Sagittal (A) and transverse (B) T2-weighted images show hypertrophic transition zone (TZ) indenting urinary bladder (B in A). Note that one of benign prostatic hyperplasia nodules (N) has a cystic component (arrows).

48. Cysts Associated with Tumors

49. Both benign and malignant prostate neoplasms may contain cystic components. Multilocular prostatic cystadenoma is a rare benign tumor that can grow to a large size. Prostatic adenocarcinoma may show cystic features from time to time. Other tumors of the prostate gland that exhibit cystic components include papillary cystadenocarcinoma and combined transitional cell/adenocarcinoma. Rarely, leiomyoma or liposarcoma in the prostate may have cystic elements. On MRI, the heterogeneity of signal intensity of the cystic components and the presence of soft-tissue elements in the lesion indicate a neoplastic cause.

50. 68-year-old man with mixed tumor of prostate containing high-grade ductal adenocarcinoma, with transitional cell and nonkeratinizing squamous cell differentiation. Transverse (A) and coronal (B) T2-weighted MR images show tumor (T) with cystic and solid components. Fluid-fluid level (arrow,A) is also seen at dependent portion of cystic component of tumor.