Cystic Cavity Research Articles

S3022 Hepatic Cerebrospinal Fluid Pseudocyst: A Rare Complication of Ventriculoperitoneal Shunt

Introduction: Ventriculoperitoneal shunts (VPS) are commonly used in the management of hydrocephalus to drain cerebrospinal fluid (CSF) into the peritoneal cavity. The placement of VPS has prolonged the survival of patients with hydrocephalus. Abdominal pseudocysts are long-term complication of VPS that are identified later in life. Hepatic CSF pseudocyst is a rare long-term complication of VPS that should be differentiated from other cystic lesions of liver. Case Description/Methods: A 49-year-old man with intellectual disability from congenital hydrocephalus s/p placement of right and left-sided VPS at age of 3 months and 7 years respectively presented with exertional dyspnea and abdominal distension. On presentation his vitals were unremarkable except tachycardic (115/min)., He had abdominal distention, hepatomegaly but no tenderness. Initial labs showed D-dimer 2.20 mcg/mL, AST 27 u/L, ALT 38 u/L, alkaline phosphate 126 u/L and total bilirubin 0.5 mg/dL. Chest CT with IV contrast was negative for pulmonary embolism, however revealed a large 18x13x13.5 cm cyst in right hepatic lobe. CT abdomen and pelvis demonstrated a 17.5x12.6x12.7 cm cystic lesion in the right hepatic lobe with the tip of VP shunt catheter within cyst cavity. Hepatobiliary nuclear scan was unremarkable for any biliary leak or sphincter of oddi dysfunction. CT head was negative for any acute abnormalities. Shunt series x-rays were negative for disruption of VPS catheter. Robotic laparoscopic cyst fenestration with partial hepatectomy was performed and catheter was repositioned to the right lower quadrant of abdomen. Patient was discharged home two days later with significant reduction of cyst size on follow up imaging. (Figure) Discussion: This case illustrates a rare complication of VPS that result in hepatic CSF pseudocyst. If hydrocephalus is absent, patients with hepatic CSF pseudocyst are asymptomatic at earlier stages., or they may present with abdominal pain, distention, or palpable right upper quadrant abdominal mass. A subset of patients with hepatic CSF pseudocyst are complicated with bacterial or parasitic infection and present with abdominal pain, distention, or right upper quadrant mass. Abdominal ultrasound and CT scan assist in diagnosis by identifying the tip of VPS catheter in the pseudocyst cavity. Asymptomatic patients are managed conservatively while surgical repositioning of VPS catheter with or without cyst fenestration or surgical excision of cyst may be required for complete resolution of symptoms.Figure 1.: CT of abdomen showing a large right hepatic lobe cyst with evidence of tip of right VPS catheter within the cavity of the cyst (arrows) on transverse (A), axial (B) and lateral (C) views. CT scan of the head (D) showing VPS catheters both in right and left lateral ventricles without evidence of ventricular dilation. Shunt series x-ray (E) shows now distortion of VPS catheter. Robotic laparoscopic cyst fenestration (F) shows VPS catheter within cyst cavity containing CSF.

S1990 Colonic Lymphangiomatosis

Introduction: Colonic Lymphangiomatosis Case Description/Methods: A 73-year-old male with history of diabetes mellitus and chronic kidney disease underwent CT abdomen and pelvis with IV contrast (for the evaluation of hematuria and renal cyst), which showed incidental finding of free intraperitoneal air. The patient had a history of recent colonoscopy which showed a large concentration of ‘polyps’ in the sigmoid, not amenable for endoscopic removal. Subsequently the patient developed abdominal pain and nausea, and labs showed worsening leukocytosis 17K/uL. Repeat computed tomography (CT) abdomen revealed moderate free intraperitoneal air and innumerable colonic mucosal cysts of the very redundant sigmoid colon in the right upper quadrant. The patient underwent exploratory laparotomy, and although no perforation was seen, the sigmoid colon exhibited soft-tissue fullness, prompting partial sigmoid colectomy with primary anastomosis. The resected specimen showed large contiguous well circumscribed and simple cystic structures (up to 3 cm size) giving a sessile “polypoid” appearance of the mucosa ( Figure a). Histologic sections demonstrated overlying unremarkable colonic mucosal surface without epithelial dysplasia or serrated neoplasia, large cystic spaces extending into the submucosa, focally separated by thin fibrous septae (Figure b). The contiguous cystic spaces within the muscularis propria were noted to be lined by a bland and attenuated cell layer, showing immunoreactivity for CD31, CD34 and D2-40 (podoplanin – an immunostain defining lymphatic space endothelium) (Figure c); compatible with dilated lymphatic spaces and consistent with colonic lymphangiomatosis (CL). Discussion: CL should be considered as a differential in patients with multiple aggregated mucosal lesions that appear as polyps on endoscopy. Speculation on etiology has ranged from developmental (failure to establish connections to lymphatic drainage sites), or seen secondarily after trauma, prior surgeries, radiation, lymphatic obstruction possibly secondary to adjacent mass lesion, or previous inflammatory processes. Free intraperitoneal air may suggest impending clinical decline in such patients. Surgical resection is the treatment of choice in symptomatic patients.Figure 1.: (a) Gross image of the sigmoid colon, bottom aspect showing partial deroofing of the mucosa of a simple cystic cavity (b) Hematoxylin and Eosin (H&E) stain 40X (c) D2-40 positivity (brown membranous and cytoplasmic staining) 100X.

S378 EUS-Guided Cyst Gastrostomy for Treatment of a Pancreatic Pseudocyst Extending Into the Mediastinum Resulting in Acute Respiratory Failure

Introduction: Mediastinal pseudocysts are the result of a rare drainage tract formation that develops more often in patients with a history of alcohol related chronic pancreatitis. The current evidence suggests favorable outcomes using endoscopic transmural drainage in the management of pancreatic pseudocysts. Here, we present a challenging approach to an unusual complication of a pancreatic pseudocyst extending into the mediastinum using EUS guided creation of a cyst gastrostomy. Case Description/Methods: A 50-year-old female with a history of alcohol related chronic pancreatitis presented to our hospital in severe respiratory distress requiring intubation for acute hypoxemic respiratory failure. A CT scan demonstrated a pseudocyst extending through the esophageal hiatus into the mediastinum and right lower lung where it measured 69.7mm. Multidisciplinary consensus between gastroenterology and interventional radiology was to proceed with EUS assisted creation of a cyst gastrostomy with placement of a metal stent. A curvilinear echoendoscope was passed and advanced into the proximal stomach. Here, a 55mm anechoic cystic cavity with layering debris was brought into stable view. Using standard endo cut settings, a 10mm x 10mm lumen apposing axios metal stent was successfully placed using a cauterized technique. The echoendoscope was then exchanged for the gastroscope and the stent was seen to be in good position draining cystic fluid. Four days after the procedure, a CT scan showed the stent extending from the proximal stomach to the pseudocyst, which had decreased in size from 69.7mm to 43.6mm. One week following the initial procedure, the patient underwent upper endoscopy, which showed the lumen-apposing metal stent in the cardia along with an empty cavity and scant fluid drainage when suction was applied through the stent. A CT scan performed 8 weeks later showed complete resolution of the pseudocyst. The patient then underwent upper endoscopy with EUS, which confirmed resolution of the pseudocyst and the stent was removed using rat tooth forceps. Discussion: In this case, we have demonstrated the utility of EUS in the creation of a cyst gastrostomy to successfully treat a patient with acute respiratory failure secondary to pancreatic pseudocyst extension into the mediastinum and right lower lung. Further studies are needed to evaluate for pseudocyst recurrence following this procedure to determine its long-term efficacy in the management of mediastinal pseudocysts. Watch the video at https://tinyurl.com/ACGAbstractS378Figure 1.: (A) CT scan showing a pseudocyst extending through the esophageal hiatus into the right lower lobe of the lung where it measured 69.7 mm and appeared to contain gas. (B) CT scan showing a stent extending from the stomach to the pseudocyst which decreased in size to 43.6 mm and an enlarging moderate right pleural effusion. (C) CT scan demonstrating the stent placed on prior admission with interval resolution of the previously demonstrated large pseudocyst.

S2890 A Case for Endoscopic Ultrasound-Directed TransGastric ERCP (EDGE) Procedure: Removal of Choledocholithiasis in Gastric Bypass Patient

Introduction: Due to rise in obesity, there has been an increased number of gastric bypass surgeries. Around 36% morbidly obese patient develop cholelithiasis or choledocholithiasis (CDL) in their lifetime. Due to the anatomy, a conventional Endoscopic Retrograde Cholangio Pancreatography (ERCP) is often challenging and not possible. We present a case of an altered anatomy ERCP in a patient with CDL and Roux-en-Y gastric bypass (RYGB) who underwent Endoscopic ultrasound Directed trans-Gastric ERCP(EDGE) procedure. Case Description/Methods: A 69-year-old female with a history of RYGB admitted for Hartmann’s procedure. During the hospitalization, she complained of RUQ pain and CT abdomen showed a distended gallbladder with cholelithiasis and CBD dilation of 8.3mm; MRCP confirmed five or more CDL. A traditional attempt at an ERCP using a pediatric colonoscope was unsuccessful in reaching the papilla. She underwent cholecystectomy with an intraoperative cholangiogram re-demonstrating the CDL. Options were to do a laparoscopy assisted ERCP v/s double balloon assisted ERCP v/s EDGE. Due to already multiple surgeries patient opted for EDGE procedure. For stage 1 of the EDGE, the excluded stomach was identified under EUS and punctured using a 19-gauge-needle followed by a radiocontrast dye injection into the excluded stomach confirmed under fluoroscopy. Subsequently, a guidewire was advanced through the needle into the pylorus and duodenum to verify the patency of pylorus. After confirming access to the excluded stomach, a 20 x 10 mm (AXIOSTM) lumen apposing metal stent (LAMS) was placed and a gastro-gastric fistula between the gastric pouch and the excluded stomach was formed. The lumen of the stent was subsequently dilated using a CRE balloon confirming the direct visualization of the gastric rugae. (Figure). The LAMS was left for 4 weeks for the tract to mature. Stage 2 of the EDGE procedure was then completed by passing the duodenoscope through the LAMS and completion of the traditional ERCP followed by removal of the LAMS. Overall patient did well. Discussion: EDGE is a minimally invasive EUS guided technique for doing an ERCP in patients with RYGB. Comparison studies have shown EDGE to have similar or better technical success when compared to laparoscopy-assisted ERCP and balloon Enteroscopy-assisted ERCP. Due to the high technical skill required in doing an EDGE, it is best advisable to offer this at institutions where a trained advanced endoscopist well versed with a therapeutic EUS is available.Figure 1.: A: EGD showing gastric pouch post-RYGB B: EUS suggests decompressed excluded stomach C: Injecting contrast into the excluded stomach - to make cystic cavity D: 20 x 10 mm(AXIOS) lumen apposing metal stent placement E: CRE Baloon dilation of LAMS F: Confirmed visualization of excluded gastric mucosa - gastrogastric fistula

Fluid aspirates of ameloblastoma

Background: Ameloblastoma is a benign cystic odontogenic tumor common in Nigeria. The cystic cavities frequently contain tumor fluids, which may be obtained by needle aspiration. The tumor fluids help in the clinical differential diagnosis. The types, prevalence, and relevance of ameloblastoma fluid aspirates have been mostly unreported. Objectives: The aim of this study was to identify the types and prevalence of fluid aspirates of ameloblastoma and evaluate its prognostic relevance. Materials and Methods: This was a 7-year retrospective study of consecutive patients with ameloblastoma at a tertiary hospital in Enugu, Nigeria. The tumor fluids obtained by needle aspiration are categorized based on visual appearance. The data retrieved from case files, biopsy forms, histopathologic reports, and other records in the departmental archives were analyzed with IBM SPSS Statistics, version 24.0. Results: Tumor fluid aspirate yield was positive in 80.4% ((n=74) of patients with ameloblastoma. There were aspirates from 82.4% (n=61) cases of primary ameloblastoma and 17.6% (n=13) cases of recurrent ameloblastoma. The aspirates obtained were dark-brown 41.9%, straw-colored 37.8%, serosanguinous 10.8%, and purulent 9.5%. The type of aspirate was influenced by the primary or recurrent status of ameloblastoma (P = 0.04). Straw-colored aspirate was obtained from 92.9% of primary ameloblastoma and in 73.1% of patients <20 years of age. Recurrent ameloblastoma typically yielded dark-brown aspirates in 76.9% of recurrences. Conclusion: The association of some tumor fluids with primary and recurrent ameloblastoma could improve the understanding of the recurrence potential of the disease and influence treatment planning.

S366 Endoscopic Marsupialization of a Large Duodenal Duplication Cyst

Introduction: Duodenal duplication cysts are rare congenital malformations of the gastrointestinal tract. These malformations are usually diagnosed in infancy and childhood. Only one-third of adults are diagnosed after twenty years of age. Presenting symptoms and signs include abdominal pain and intestinal obstruction. These are generally found in the first and second parts of the duodenum. Although the majority are benign, case reports have demonstrated a risk of malignancy. The ideal treatment is complete surgical resection. Due to the proximity of structures including the biliopancreatic ducts, excision of the duodenal duplication cyst may require total pancreaticoduodenectomy. Advances in therapeutic endoscopy provide an alternative option for patients who are at a high risk of surgical complications. Endoscopic marsupialization is a management option in which the cyst cavity contents are drained into the duodenum. Complications include duodenal perforation and bleeding. However, the overall morbidity is low. Endoscopic surveillance is recommended in these patients to assess for recurrence. Case Description/Methods: We present a case of a 38-year-old female who was diagnosed with a large duodenal mass in the second part of the duodenum measuring 8 cm in the largest diameter. This was found incidentally during an upper endoscopy which was performed in July 2020 for hematemesis. The duodenal mass was cystic in appearance on cross-sectional imaging. She was offered endoscopic marsupialization in October 2020 due to morbid obesity which increased the risk of perioperative complications. Discussion: The procedure was performed successfully. Pathology from the lateral wall of the duodenal cyst was consistent with a duodenal duplication cyst. There were no early or delayed complications. The patient had a follow-up endoscopy one year later which did not demonstrate evidence of recurrence on biopsies. Watch the video at https://tinyurl.com/ACGAbstractS366

S1718 Delayed Gastrointestinal Hemorrhage From Visceral Artery Pseudoaneurysm in Necrotizing Pancreatitis After LAMS Removal

Introduction: Delayed bleeding from visceral artery pseudoaneurysm (PA) formation is an uncommon complication of lumen-apposing metal stent (LAMS) placement. Risk factors for gastrointestinal bleeding (GIB) in patients with LAMS remain largely undefined. We report a case of delayed GIB due to rupture of a splenic artery PA 16 months after LAMS removal. Case Description/Methods: A 34-year-old female with a history of severe necrotizing pancreatitis presented to our hospital with massive hematemesis. 23 months prior to presentation, she underwent uncomplicated placement of a 15x10 mm LAMS and 2 7 Fr x 4 cm double pigtail plastic stents for drainage of walled-off pancreatic necrosis. She was briefly lost to follow-up and returned for LAMS removal 5 months later. Contrast was injected into the residual cyst cavity and contrast filling was noted of what appeared to be a splenic vessel without active bleeding (Figure A). CT angiogram showed no PA but proximity of the splenic hilar vasculature to the LAMS (Figure B). The LAMS was successfully removed 2 months later without complication. On presentation, she was tachycardic but normotensive. Laboratory studies were notable for hemoglobin 8.8 g/dL (baseline 14 g/dL). Upper endoscopy showed brisk bleeding in the proximal gastric body near the area of prior LAMS. Her bleeding was refractory to endoscopic hemostatic maneuvers, and she underwent emergent mesenteric angiography. Angiography revealed active arterial extravasation arising from the inferior segmental branch of the splenic artery ( Figure C) which was successfully embolized with no further bleeding. Discussion: Visceral artery PA development after LAMS placement is thought to occur due to friction of the inner flange against regional vasculature surrounding the necrotic cavity as it collapses. Close anatomical proximity of LAMS to regional vasculature increases the risk of PA development. In our case, the LAMS was placed near the rich vascular supply of the splenic hilum. Most reported bleeding events related to LAMS have occurred within 8 weeks of placement. Our case is notable for the prolonged delay between LAMS removal and bleeding presentation. Adherent scar tissue between the gastric wall and vasculature could potentially cause delayed PA development after LAMS removal. This case reinforces that high clinical suspicion for PA bleeding is necessary for patients who have previously undergone distant LAMS removal who present with massive GIB.Figure 1.: (A) Fluoroscopic image of contrast injection into residual cyst cavity demonstrating opacification of likely splenic vasculature; (B) Coronal images demonstrating the proximity of the LAMS to the vasculature of the splenic hilum (yellow arrow); (C) Super-selective angiography demonstrating active extravasation into the lateral aspect of the stomach from a pseudoaneurysm (White arrow) involving an inferior segmental branch of the splenic artery.

COL4A1 with Cerebral Small Vessel Disease and Multiple Anomalous cerebral vascular origins: A case report

Cerebral small vessel disease (cSVD) is a main cause of stroke, cognitive impairment, and vascular dementia. COL4A1 mutations have been identified as a cause of hereditary cerebral small vessel disease. COL4A1 mutation is associated with nephropathy, aneurysms, and muscle cramps, which we call the HANAC syndrome. Mutations in COL4A1 have recently been identified in both a mouse model and families, characterized by cystic brain cavities and cerebral white-matter lesions. But it has not been reported with vascular malformations. We here first report a case of COL4A1 with cerebral small vessel disease and multiple anomalous cerebral vascular origins.

RARE CASE OF INFECTED MESENTERIC CYST WITH POST OPERATIVE DUODENAL FISTULA- A CASE REPORT

Mesenteric Cysts are rare intra-abdominal tumors occurring in the mesentery of intestine, may contain chyle or serous uid, and have variable presentations[1]. One such case was managed at our institution. A 70-year-old male patient presented with history of mass per abdomen associated with pain for 10 days. On clinical examination palpable mass of size approximately 10*10cm in the epigastric, umbilical region, along with an incisional hernia at the same site. CECT abdomen revealed a collection of size 13*12*7cm in mesentery extending from epigastric to umbilical region, with a midline defect in the rectus of size 10*7cm. Emergency exploratory laparotomy was performed and cyst identied, oozing of pus was noted. Marsupialization of cyst cavity was done. Postoperatively, bilious output noted through the RFD. Oral contrast CT revealed contrast leak from D3 of duodenum, with stulous communication into the cyst. Under uoroscopic guidance, NJ tube was passed beyond the site of stulous communication. Subsequent drop in RFD output was observed. Patient was followed up for 6 months, subsequent course was uneventful.

Prolonged postoperative urine leakage due to a calyceal diverticulum mimicking a renal cyst: A case report and literature review

BackgroundThe calyceal diverticulum is a rare cystic cavity that communicates with the collecting system via a narrow neck or infundibulum. In clinical practice, part of the calyceal diverticula is difficult to differentiate from simple renal cysts even after contrast-enhanced CT. To date, there have been few kinds of literature works on the diagnosis and treatment of calyceal diverticulum combined with renal pelvis dilatation, especially concerning the treatment of prolonged postoperative urine leakage.Case descriptionA 53-year-old woman with calyceal diverticulum and renal pelvis dilatation mimicking a simple renal cyst suffered urine leakage after receiving laparoscopic unroofing of the renal cyst. A persistent urine leakage was observed immediately after surgery, with about 200 ml of drainage fluid per day. We first attempted to place a double-J ureteral stent and indwell a catheter. After failing that, conservative treatment was performed. The core idea of the conservative treatment is retaining the drainage tube for more than 1 month, then clamping the drainage tube for 1 week, and finally removing the drainage tube. By 3 weeks of follow-up, the urine leakage disappeared, and the CT scan showed hydronephrosis of the right kidney without perirenal exudation and the lower pole cyst of the right kidney shrank significantly.ConclusionThis case, we reported here, is to attract the attention of clinicians. Renal cysts should exclude the possibility of the calyceal diverticulum. If urine leakage is inevitable after surgical treatment, our conservative treatment strategy is also an alternative method.

METACARPAL ANEURYSMAL BONE CYST, A RARE LOCALIZATION IN CHILDREN: ABOUT A CASE

An aneurysmal bone cyst (ABC) is a benign lesion that often arises eccentrically from the metaphysis of long bones and which can expand bone tissue as it grows. It is a rare lesion, frequently appearing in the long bones of the lower limb. Localizations on the hands and feet are rarer and often limited to tubular bones.We report the case of a 2-years-old girl initially admitted for a hard dorsal immobile and slightly painful swelling of the 5th metacarpal of the left hand, which didnt limit the metacarpo-phalyngeal joint mobility and which was evolving since 4 months. The standard hand x ray and CT-Scan showed a central lytic multiseptatedmetaphyseal-diaphyseal lesion, with a well-defined appearance, expansile but without extending beyond the cortices. The biopsy confirmed the diagnosis of an aneurysmal cyst that was surgically curetted then auto-grafted.A follow-up of 1 year showed a filling of the cystic cavity and bone remodeling which resulted in an almost normal clinical appearance of the patients hand.A metacarpal location of an ABC is rare. The performance of a biopsy is fundamental to confirm the diagnosis before that any treatment is undertaken.

Effect of Intracapsular Pressure on Decompression Effectiveness

The objective of this research was to analyse the correlation between intracapsular pressure and shrinkage rate of cystic lesion volume at different time points after decompression and to evaluate the relationship between the concentration of interleukin-1α (IL-1α) in cystic fluid and intracapsular pressure. Fifty patients with jaw cystic lesions who underwent decompression were included. We measured the intracapsular pressure and IL-1α concentration in the cyst fluid. Moreover, we calculated the rate of shrinkage (RS) of cystic cavity volume at different time points. In addition, data on age, sex, preoperative cystic cavity volume, and lesion location were collected. Linear correlation analysis and variance analysis were used for statistical analysis. Fastest volume decline was observed between 0 and 3 months after surgery; the average RS0-3 was 45.71%. RS3-6 presented the second-fastest volume decline, with an average of 17.46%, and RS6-12 presented the slowest volume decline, with an average of 3.933%. A statistically significant difference in RS was observed amongst the 3 time points (P < .0001). RS0-3 was negatively correlated with intracapsular pressure (r=-0.6326, n=50, P < .0001). A negative correlation between the preoperative cystic cavity volume and intracapsular pressure (r=-0.6384, n=50, P < .001) was also observed. A significant positive correlation was observed between preoperative cystic cavity volume and RS0-3 (r=0.611, n=50, P < .0001). Moreover, a significant positive correlation was observed between the intracapsular pressure and IL-1α concentration in the cystic fluid (r=0.03477, n=50, P < .0001). Intracapsular pressure and the preoperative volume were the factors that affected the RS during the first 3 months after surgery. Therefore, the effectiveness of decompression can be evaluated by the intracapsular pressure and preoperative volume.

Reconstruction with Mucosal Graft Reduces Recurrence After Endoscopic Surgery of Rathke Cleft Cyst

Rathke cleft cysts (RCCs) arise from the development of the Rathke pouch. Recurrence is common after either drainage or cyst removal. The endoscopic endonasal approach (EEA) is increasingly utilized for the management of RCC. Various techniques have been described to try to reduce the rates of recurrence. We studied the effect of fenestration with a nasoseptal flap (NSF) on recurrence rates by comparing a cohort of patients undergoing this technique to a cohort of patients undergoing conventional drainage. Patients who underwent EEA for RCC between 2011 and 2020 were identified and divided into 2 cohorts: conventional fenestration versus fenestration with NSF. Surgical approach, reconstructive method, and recurrences were recorded. Primary end point was symptomatic or radiographic recurrence. 21 patients were identified undergoing EEA. An NSF was used to line the cyst cavity in 11 cases. Conventional fenestration without mucosal reconstruction was performed in the remaining 10 cases. In the cases without NSF, 5 (50%) developed recurrence requiring revision surgery, while there was only one recurrence in the NSF group (P < 0.05). In patients requiring revision, all had an NSF placed and none had a second recurrence of their RCC. NSF placement into a fenestrated RCC is useful to prevent cyst reaccumulation and reoperation. Typical fenestration carries an unacceptably high rate of recurrence.

Combined therapy of marsupialization and enucleation for maxillary dentigerous cyst management

Dentigerous cyst is a one of the most common cysts in oral and maxillofacial field. The goal of dentigerous cyst treatment is to eliminate pathological abnormalities and preserve the tooth with minimal surgical intervention. One of the treatment is marsupialization which will reduce the pressure on the cyst which will reduce the size of the bone defect. The case study aimed to present the advantages of enucleation following marsupialization on large maxillary dentigerous cysts in terms of preservation of vital structures around the cyst cavity. This study is a serial case reports of an 18-year-old female and 15-year-old male that had their dentigerous cyst removed by using combined therapy of marsupialization and enucleation. Dentigerous cyst was treated with marsupialization followed by cyst enucleation. The combination of marsupialization and enucleation therapy can be used in the treatment of extensive maxillary dentigerous cysts because it can provide advantages in preserving the teeth and important surrounding structures and provide a good prognosis.

SURGICAL CILIATED CYST: A CASE REPORT

This report describes a case of surgical ciliated cyst (SCC) in maxilla. A 25-year-old male patient was referred for diagnosis of a maxillary swelling with a duration of 6 months. During anamnesis, the patient reported having undergone orthognathic surgery 4 years ago. Imaging exams showed a unilocular radiolucent/hypodense lesion in the right maxilla associated with a rigid fixation plate. The main diagnostic hypothesis was radicular cyst. Therefore, excisional biopsy was performed under local anesthesia. Histopathologic examination revealed a cystic cavity lined mainly by ciliated pseudostratified columnar epithelium. Simple cuboidal epithelium was also observed. The fibrous connective tissue capsule was infiltrated by a moderate chronic inflammatory reaction. The histopathologic findings confirmed the diagnosis of SCC. No clinical or imaging signs of recurrence were observed after 4 years of treatment. SCC should be considered in the differential diagnosis of maxillary radiolucent images in patients who have previously undergone surgery.

AMELOBLASTOMA RECURRENCE ASSOCIATED WITH AMELOBLASTIC FIBROMA: A RARE CASE REPORT

Ameloblastoma is an aggressive odontogenic tumor with a relatively high recurrence rate. A 60-year-old male patient presented, in a follow-up computed tomography, an osteolytic isodense lesion obliterating the left maxillary sinus and involving the orbit floor, zygomatic bone, and infratemporal fossa. The lesion was asymptomatic, and no facial asymmetry was observed. His past medical history revealed ameloblastoma in the left ramus of the mandible, coronoid process, which was surgically treated 10 years prior. The clinical diagnosis was recurrent ameloblastoma. Excisional biopsy revealed areas of benign epithelial odontogenic neoplasm characterized by a cystic cavity lined by ameloblastomatous epithelium and stroma of fibrous connective tissue, and areas of benign mixed odontogenic tumor composed of ameloblastic cells in a myxoid and cell-rich mesenchyma. The final diagnosis was ameloblastoma associated with ameloblastic fibroma. The patient underwent rehabilitation and has been followed up, showing no signs of local complications.

UNICYSTIC MURAL AMELOBLASTOMA IN THE MAXILLA: REPORT IN A PEDIATRIC PATIENT

A 6-year-old Black female patient attended the stomatology clinic with her mother, reporting a tumor with 2 months of evolution. During the history of the current illness, the mother described the asymptomatic appearance of the maxillary tumor. On extraoral physical examination, the patient presented an expansion in the middle third of the face (right side). On intraoral physical examination, the patient presented a normochromic/erythematous tumor, smooth, irregular, with a firm consistency located in the alveolar ridge up to the hard palate. An incisional biopsy was performed, and the histologic sections revealed a benign neoplasm of odontogenic origin with ameloblastomatous epithelium that formed cystic cavities and exhibited tumor infiltration in fibrous connective tissue. Computed tomography exam revealed an expansive maxillary lesion. The final diagnosis was a unicystic mural ameloblastoma. The patient was referred to the maxillofacial surgeon, who decompressed the lesion and placed a drain for later enucleation.

DENTIGEROUS CYST: CASE REPORT

The dentigerous cyst is common among odontogenic cysts. The objective is to report the case of a dentigerous cyst submitted to marsupialization to minimize damage to adjacent structures after total enucleation. A 14-year-old male patient arrived at the stomatology service reporting a nodule in the region of tooth 12 3 months ago. On intraoral examination, a nodule was noted, infiltrative, normochromic and violet, unique, with sharp limits, spherical shape, smooth surface, soft consistency, fixed, and tender, measuring 2 × 3 × 1.5 cm. Computed tomography revealed a well-defined, hypodense lesion with a hyperdense halo surrounding tooth 12. Incisional biopsy was performed with marsupialization of the lesion. Histopathology revealed a lesion of the cystic cavity, covered by a stratified squamous epithelium, which was not keratinized. After 3 months the lesion decreased and the patient was referred for enucleation of the lesion. The dentigerous cyst is common among odontogenic cysts. The objective is to report the case of a dentigerous cyst submitted to marsupialization to minimize damage to adjacent structures after total enucleation. A 14-year-old male patient arrived at the stomatology service reporting a nodule in the region of tooth 12 3 months ago. On intraoral examination, a nodule was noted, infiltrative, normochromic and violet, unique, with sharp limits, spherical shape, smooth surface, soft consistency, fixed, and tender, measuring 2 × 3 × 1.5 cm. Computed tomography revealed a well-defined, hypodense lesion with a hyperdense halo surrounding tooth 12. Incisional biopsy was performed with marsupialization of the lesion. Histopathology revealed a lesion of the cystic cavity, covered by a stratified squamous epithelium, which was not keratinized. After 3 months the lesion decreased and the patient was referred for enucleation of the lesion.

DENTIGEROUS CYST IN AN EDENTULOUS ELDERLY PATIENT WITH TOOTH DILACERATION

An 87-year-old female patient complained of a severe pain and swelling in the anterior maxilla with a 1-month history. There were no changes in the extraoral clinical examination on the day of the appointment. The patient was edentulous for several years. The intraoral examination revealed swelling of firm consistency covered by an intact mucosa in the left anterior maxilla, extending to the hard palate and buccal vestibule. Radiographic examination showed a tooth with severe dilaceration within a well-defined unilocular radiolucency measuring 2 × 2.5 cm. The differential diagnosis included benign odontogenic cyst or tumor. Aspiration puncture revealed a yellowish, opaque liquid. Excisional biopsy and extraction of impacted tooth was carried out. Microscopic examination showed a cystic cavity limited by two-layered cubic epithelium and areas of hyperplasia. The cystic capsule exhibited dense mononuclear inflammatory infiltrate. The diagnosis of dentigerous cyst was established. After 6 months of follow-up, no recurrences were detected. An 87-year-old female patient complained of a severe pain and swelling in the anterior maxilla with a 1-month history. There were no changes in the extraoral clinical examination on the day of the appointment. The patient was edentulous for several years. The intraoral examination revealed swelling of firm consistency covered by an intact mucosa in the left anterior maxilla, extending to the hard palate and buccal vestibule. Radiographic examination showed a tooth with severe dilaceration within a well-defined unilocular radiolucency measuring 2 × 2.5 cm. The differential diagnosis included benign odontogenic cyst or tumor. Aspiration puncture revealed a yellowish, opaque liquid. Excisional biopsy and extraction of impacted tooth was carried out. Microscopic examination showed a cystic cavity limited by two-layered cubic epithelium and areas of hyperplasia. The cystic capsule exhibited dense mononuclear inflammatory infiltrate. The diagnosis of dentigerous cyst was established. After 6 months of follow-up, no recurrences were detected.

Endoscope-Assisted Resection for Cystic Cerebellar Hemangioblastomas

Hemangioblastomas are benign, often cystic tumors occurring most commonly in the cerebellum. We describe resection of cystic cerebellar hemangioblastomas using an endoscope-assisted technique. We present a series of 9 cases and discuss the endoscopic technique for resection of cystic hemangioblastoma. Frameless neuronavigation was used in all cases. A small 1- to 1.5-cm corticotomy lined with Surgicel and patties allows access to the peritumoral cyst. Using bimanual microsurgical techniques and the 30-degree rigid endoscope to provide visualization, the mural nodule can be resected and the cyst cavity inspected. Complete resection of the mural nodule was achieved in all cases. One patient had a postsurgery pseudomeningocele requiring ventriculoperitoneal shunt. Hospital length of stay was short for all the patients. Endoscope-assisted resection is a safe and effective technique for surgical resection of cystic hemangioblastoma.