Cystic Space-occupying Lesion Research Articles

Pediatric sellar teratoma – Case report and review of the literature

BackgroundIntracranial teratoma represents a rare neoplasm, occurring predominantly during childhood. Characteristic symptoms depend on the location but are mainly hydrocephalus, visual disturbances, hypopituitarism, and diabetes insipidus. Initial diagnosis can be challenging due to similar radiological features in both teratomas and other lesions such as craniopharyngiomas. Gross total resection is recommended if feasible and associated with a good prognosis.Case descriptionA 10-year-old girl presented with newly diagnosed growth retardation, fatigue, cephalgia and bilateral hemianopia. Further laboratory analysis confirmed central hypothyroidism and hypercortisolism. Cranial magnetic resonance imaging showed a cystic space-occupying lesion in the sellar and suprasellar compartment with compression of the optic chiasm without hydrocephalus present, suspicious of craniopharyngioma. Subsequently, an endonasal endoscopic transsphenoidal near-total tumor resection with decompression of the optic chiasm was performed. During postoperative recovery the patient developed transient diabetes insipidus, the bilateral hemianopia remained unchanged. The patient could be discharged in a stable condition, while hormone replacement for multiple pituitary hormone deficiency was required. Surprisingly, histopathology revealed conspicuous areas of skin with formation of hairs and squamous epithelia, compatible with a mature teratoma.ConclusionsWe present an extremely rare case of pediatric sellar teratoma originating from the pituitary gland and a review of literature focusing on the variation in presentation and treatment. Sellar teratomas are often mistaken for craniopharyngioma due to their similar radiographic appearances. However, the primary goal of treatment for both pathologies is to decompress eloquent surrounding structures such as the optic tract, and if applicable, resolution of hydrocephalus while avoiding damage to the pituitary stalk and especially the hypothalamic structures. If feasible, the aim of surgery should be gross total resection.

Primary Cerebral Hydatidosis in a Child: A Case Report with a Rare Site of Occurrence

Hydatid cyst of brain in an extremely rare entity. A case of primary hydatidosis of brain without any involvement of other areas is even rarer. Most commonly involved areas are liver and lung because of rich vascularity and vicinity to portal circulation. Central Nervous System (CNS) or most importantly cases of hydatid cysts of brain are very rare. This case report is about a 7-year- old girl, from eastern India, who presented with multiple hydatid cysts in cranial cavity. She presented with headache, sudden loss of balance, short time memory loss. On Magnetic Resonanace Imaging (MRI), multiple cystic lesions were noted in cranial cavity. Magnetic Resonance (MR) Spectroscopy findings were suggestive of hydatid disease. These cysts were removed through neurosurgical intervention. The diagnosis was confirmed by gross and microscopic examination. Importance of keeping hydatidosis as a differential diagnosis while working up cases of cystic Space-occupying Lesion (SOL) of the brain in children is evident here.

Twisted Adnexa in a Premenarchal Girl

An 11-year-old premenarchal girl was admitted with a complaint of 1 day of acute right lower quadrant pain radiating toward her right leg, accompanied by nausea, vomiting, and fever. Tachycardia was observed upon admission, with normal bowel and bladder habits. There was tenderness on palpation in the right lower quadrant. Ultrasonography showed a cystic space-occupying lesion in the right ovary, which measured 7.0 × 5.3 cm2. Color Doppler did not show diminished blood flow. Laparoscopy was proposed for confirmation of the diagnosis and treatment.

Cystic adventitial disease of femoral vein presenting as enlarging lower limb swelling and pain: Two case reports and review of the literature.

Cystic adventitial disease (CAD) is a condition that mainly affects the arterial system but rarely involves the venous system. The present study reported on two cases of CAD of femoral veins. The clinical manifestations in the two patients included pain and swelling of the lower limbs, but they had no risk factors for venous thrombosis. Color ultrasonography indicated cystic space-occupying lesions around the femoral veins, and enhanced computed tomography (CT) revealed vascular compression and space-occupying properties of the femoral veins. The two patients underwent open surgery, the postoperative treatment was uneventful, and swelling and tenderness were completely resolved. The pathological examination confirmed CAD of femoral vein in the two patients. The enhanced CT venography scan indicated patency of the femoral vein in the two patients following the operation. The circumferences of the two patients' lower limbs had returned to normal at the 2-month follow-up. A review of the literature was performed, and the presentation, diagnosis, treatment and pathology of this rare condition were discussed.

Cystic lesions of the pancreas : Differential diagnostics and treatment

Cystic space-occupying lesions of the pancreas represent incidental findings in most cases. As there is apotential risk of malignant transformation further evaluation of the lesions as well as afollow-up of these patients is usually recommended. Before this work-up is initiated the clinical situation of the patient as awhole and comorbidities, age and personal preferences have to be taken into account. So far there are no biomarkers that reliably predict the risk of malignant transformation. Imaging by magnetic resonance tomography (MRI) in combination with magnetic resonance cholangiopancreatography (MRCP) is more accurate than computed tomography to identify worrisome features. During follow-up, endoscopic ultrasound (EUS) can be used as complementary method to MRI/MRCP. Using contrast enhancement or endoscopic fine needle aspiration (EUS-FNA) may influence the therapeutic strategy in some patients. Whereas for some cystic pancreatic lesions consensus has been reached, varying recommendations exist for intraductal papillary mucinous neoplasms (IPMN). There is consensus that in main-duct as well as in mixed-type IPMN surgery is recommended. The management of branch-duct type IPMN, however, remains controversial. Amultidisciplinary expert panel including gastroenterologists, visceral surgeons, radiologists and pathologists is essential to discuss all cases of patients with cystic pancreatic lesions and to guarantee an optimal, patient-centered treatment recommendation.

Importance of Virchow-Robin spaces

Virchow-Robin spaces are perivascular fluid-filled cavities that surround perforating arteries and veins in the brain parenchyma. As a rule in healthy people they are approximately 5mm in diameter. Typical localizations are brainstem ganglia, mesencephalon and the white matter of the brain. Morphological imaging characteristics of Virchow-Robin spaces are round or tubular, smoothly bordered areas which are hyperintense in T2-weighted sequences. Virchow-Robin spaces represent a physiological structure in normal brain parenchyma. It is assumed that they contain interstitial fluid filled with macrophages and play an important role in the drainage of interstitial fluid in the direction of the cervical lymph system. In many diseases, such as Alzheimer's disease, cerebrovascular diseases and traumatic brain injuries, an association with Virchow-Robin spaces is assumed. In the differential diagnostics lacunar infarcts, cystic space-occupying lesions, low-grade malignant tumors and arachnoid cysts must be considered. In individual studies an association with frequently occurring expanded perivascular spaces in patients with arterial hypertension and patients with CADASIL disease was established. Rarely, Virchow-Robin spaces are so expanded that they lead to compression of the aqueduct or the foramina of Monro with subsequent hydrocephalus.

Complicated pneumothorax and congenital lung cystic malformation

Congenital cystic adenomatoid malformation, also named congenital pulmonary airway malformation (CPAM), is a congenital lung abnormality which is uncommon in adults. The usual radiological appearance of CPAM is a cystic space-occupying lesion. We present one case of CPAM with unusual clinical and radiological findings, a complicated spontaneous pneumothorax with intracystic haemorrhage with successful conservative initial treatment, despite acute haemodynamic instability.

Sudden Death in a Patient With Spinal Cystic Space-occupying Lesion Presenting as Elevated Cerebrospinal Fluid Protein

Elevated cerebrospinal fluid (CSF) protein concentration usually occurs in CSF of patients with meningitis and leptomeningeal carcinomatosis. We identify patients at risk of prolonged illness and those with a benign course. However, sudden death has been rarely reported. We report a case of sudden death presented as elevated CSF protein. Magnetic resonance imaging of the 61-year-old man spine revealed that L4, L5, and S1 of the spinal cord were compressed by the cystic space-occupying lesions. On admission day 2, the examination of CSF showed severe elevated CSF protein. Known causes of elevated CSF protein were carefully excluded before the planned operation. During the diagnostic period for elevated CSF protein, multiple organ dysfunction syndrome suddenly occurred and caused death on admission day 8. Acute pandysautonomia, which is not familiar to neurosurgeons, might explain the pathogenesis of this unusual evolution.

Pituitary hormone deficiency due to racemose neurocysticercosis

Neurocysticercosis is the most common parasitic infection of the brain. Infestation is with the larva of Taenia solium and occurs after faecal–oral contamination with its eggs. Neurocysticercosis often aff ects the highly vascular grey–white matter junction, basal cisterns, subarachnoid space, and ventricles. Involvement of the sella turcica is very rare. Racemose neurocysticercosis is a rare variant of neurocysticercosis that is characterised by the presence of abnormally large growths of many cystic membranes without a scolex. The growths are seen in grape-like clusters, mainly in the ventricles and basal cisterns, and often cause obstructive hydrocephalus (secondary to meningeal infl ammation and fi brosis), which can necessitate their surgical removal. Racemose neurocysticercosis of the pituitary gland has not previously been reported. We diagnosed racemose neurocysticercosis in a 29-year-old woman with amenorrhoea and recurrent vomiting for 5 months, and headache and increased fatigue for 3 months. Our examination found postural hypotension, a loss of axillary and pubic hair, and breast atrophy. Investigation revealed secondary hypo cortisolism (0800 h cortisol 121·39 nmol/L [132·42–535·21 nmol/L]; adrenocorticotropic hormone 1·98 pmol/L [1·58–13·93 nmol/L]), secondary hypothyroidism (free thyroxine 9·01 pmol/L [11·58–23·17 pmol/L]; thyroid-stimulating hormone 0·01 mU/L [0·40–4·20 mU/L]), and secondary hypogonadism (luteinising hormone <0·8 IU/L [1·14–5·75 IU/L], follicle-stimulating hormone 1·1 IU/L [1·37–13·56 IU/L]). Brain MRI showed racemose neurocysticercosis of the pituitary gland (fi gure), many single cysts in the midbrain, cerebellum, and cerebral cortex, and lateral and third ventricle dilation. ELISA of the CSF was positive for neurocysticercosis. Our patient declined surgery. We gave hydrocortisone, albendazole, and valproic acid, followed by levothyroxine. Treatment resolved the headache and functional improvement was seen. Racemose neurocysticercosis should always be considered in the diff erential diagnosis of cystic spaceoccupying lesions in the sella turcica. Other options include cystic pituitary adenoma, craniopharyngioma, and dermoid cysts.

Clinical analysis of 42 cases of chronic expanding intracerebral hematoma

To summarize our own experiences of managing chronic expanding intracerebral hematoma (CEICH) and discuss its diagnosis and treatment. The courses of CEICH, clinical and imaging features, intraoperative findings, pathological examinations and follow-up outcomes were reviewed retrospectively. The relevant literatures were reviewed simultaneously. The course of CEICHs ranged from 22 days to 10 years. Twenty-three cases (54.8%) were misdiagnosed as cystic gliomas, cystic gliomas, brain cysticercoses, brain abscesses and tumor strokes, etc. The misdiagnostic rate had decreased to 19.0% since June 1997. Thirty-eight patients underwent surgical operations and 4 had puncture drainage of hematoma. There was no operative death. Thirty-three cases achieved an excellent recovery and 9 cases had varying degrees of nervous dysfunctions. The follow-up period was 1-21 years. One patient had recurrence after 10 years. Among the cases of multiple CEICH, two lesions underwent no surgical treatment. One increased obviously after 7 years and another disappeared. The following five points may be used as the diagnostic criteria of CEICH: (1) intracerebral cystic space-occupying lesions on brain images; (2) circular or circle-like enhancement around lesions; (3) a mixed signal of concentric circular lamellar structures on MRI T1WI; (4) abnormal vascular lesions on CTA, MRA or DSA; (5) clinical signs and symptoms of slow progress of intracranial pressure. CEICHs with clinical symptoms of local mass effect shall be obliterated surgically. The abnormal tissues in cyst wall of hematoma should be resected. Small hematomas (< 2 cm) may be followed up.

Affecting factors for diagnosis of benign or malignant pancreatic cystic lesions

Objective To determine the effecting factors for diagnosis of binign or malignant in cystic lesions of pancreas（CLP）.Methods One hundred twenty-six patients undergoing operations for CLP or suspected CLP in this hospital from January 1984 to June 2008 were reviewed.Patients were divided into two groups according to lesion＇s histological features after operation.The predictive effect of various preoperative factors on the malignant potential of CLP was evaluated.Results One hundred twenty-six patients underwent operations for suspected pancreatic cystic neoplasms.There were 89 benign and 37 malignant CLPs.The univariate analysis showed that gender, clinical symptoms（jaundice and weight loss）, elevated serum CA199, and presence of one or more of three morphologic features such as solid component, nodule or septation were significantly different between benign and malignant cystic neoplasm of pancreas.The multivariate analysis indicated that imaging features and gender were independent predictors of malignancy.Conclusion In patients with suspected pancreatic cystic neoplasms, elevated serum CA199, clinical symptoms（jaundice and weight loss）and presence of suspicious morphologic features on imaging are predictors of malignant potential of CLP.Patients with a high likelihood of a potentially malignant or malignant lesion based on these three factors should undergo operation without additional investigations. Key words: Pancreas; Cystic space-occupying lesion; Malignancy; Sudden milk like pro-tuberance; Tumor marker

Hydatid disease: a cause of renal cystic masses in children

Sirs, Primary hydatidosis of the kidney is very rare, even in endemic areas such as our country [1–4]. Diagnosis of the hydatid cyst is mainly on the basis of serologic tests and/or imaging studies [1–3]. Ultrasound and computed tomography (CT) are the important imaging modalities for hydatid disease and may clearly demonstrate the floating membranes, and typical daughter cysts in the cystic lesions [1, 2]. A 9-year-old boy was referred to our center with the chief complaint of right flank pain and weight loss. He had no history of fever. On physical examination a mildly tender bulging at the right flank area was palpated. Laboratory investigations, including those for blood sugar, blood urea nitrogen, creatinine, liver enzymes, and urinalysis, gave normal findings. Complete blood count was normal except for mild leukocytosis [white blood cells (WBCs): 12,000]. On transabdominal ultrasound, multiple anechoic cystic masses were demonstrated in the right kidney. For further delineation of the cystic masses computed tomography (CT) was performed, the scan revealing multiple cystic space-occupying lesions and excellently depicting the daughter cysts in the kidney (Fig. 1a). On the 7th day of admission, after we had obtained informed consent, the patient underwent surgical exploration under general anesthesia for confirmation of the diagnosis of hydatid disease and for the ruling out of other renal masses such as cystic renal cell carcinoma or cystic nephroma. During the operation, one of the cysts was completely removed, and the surgical specimen was diagnosed as the hydatid cyst. Owing to extensive involvement of the kidney and high risk of life-threatening rupture, complete removal of the cysts was very difficult; therefore right-sided nephrectomy was carried out. The rest of the abdomen and pelvis showed no evidence of involvement. Microscopic examination disclosed the scolices of Echinococcus granulosus, with adjacent laminated membrane, and confirmed the diagnosis (Fig. 1b). CT may be superior to ultrasonographic examination because of its capability of better evaluation of the cystic masses and for its demonstration of any enhancement in other lesions such as renal abscess, tumors, and focal pyelonephritis. In our case we observed that the CT scan could detect the daughter cysts more satisfactorily. The possibility of a striking clinical resemblance between a hydatid cyst and malignant disease of the kidney such as cystic renal cell carcinoma or cystic nephroma has been emphasized in the English literature [3–6]. We also indicate this important point in our patient. In conclusion, the most important factor in the diagnosis of hydatid disease is the high index of suspicion about its possibility. Primary hydatidosis of the kidney should always be considered in the differential diagnosis of any cystic renal mass in the pediatric groups, even in the absence of accompanying involvement of liver or other visceral organs. Pediatr Nephrol (2009) 24:1251–1252 DOI 10.1007/s00467-008-0963-2

Spontaneous rupture of an infected renal cyst and external drainage through a lumbar surgical scar in a male patient with cervical spinal cord injury: a case report

IntroductionThe spontaneous rupture of an infected renal cyst is a rare event. Spontaneous rupture with drainage to the exterior through a surgical scar has not been reported previously.Case presentationA 49-year-old male with tetraplegia had undergone extended right pyelolithotomy in 1999. Deroofing and marsupialisation of a cyst in the upper pole of the right kidney was performed in 2003. Subsequently there was recurrence of a thick-walled cystic space-occupying lesion in the upper pole of the right kidney. Thick pus was aspirated from the renal cyst on six occasions between September 2003 and November 2004. In March 2006, ultrasound examination revealed a cyst measuring 6.2 cm in diameter in the upper pole of the right kidney. Aspiration was planned when the renal cyst reached 7.5 cm in diameter. However, 11 months later, the cyst ruptured spontaneously and drained through the previous surgical scar in the flank, while the patient was recovering from a severe chest infection in the spinal unit. Ultrasound examination showed a fistulous tract running between the renal cyst and the abdominal wall. Repeated minor trauma sustained during turning, hoisting and chest physiotherapy all may have contributed to the rupture of the infected renal cyst and drainage through a weak spot in the abdominal wall.ConclusionIn hindsight, we might have prevented rupture of the renal cyst had we considered aspiration of the renal cyst before it reached 7.5 cm in diameter, although this 7.5 cm diameter, as the threshold for percutaneous aspiration, is an arbitrary setting. This patient could have been advised to wear an abdominal corset to protect the right flank from pressure applied unintentionally during turning, hoisting or assisted coughing.

Papillary glioneuronal tumour: a report of a rare case and review of literature

Amongst the mixed glioneuronal tumours, 'papillary glioneuronal tumour', a new variant, has been described recently. We report a case of papillary glioneuronal tumour in a 4-year-old boy who presented with fever, weakness of left upper and lower limbs and headache for the last 2.5 month. Radiologic examination showed a cystic space-occupying lesion with mural nodule in the right frontal lobe with extension into white matter. Surgical excision of a large cystic mass with small solid nodule was done. Pathological examination revealed a well-circumscribed tumour showing predominantly papillary architecture with focal aggregates of cells in sheets. The papillae were composed of hyalinised blood vessels lined by single to multi-layered cells. The tumour cells showed mild pleomorphism without any necrosis. The individual tumour cells had scant eosinophilic cytoplasm, round to oval hyperchromatic nucleus with occasional mitoses. The tumour cells were immunopositive for glial fibrillary acidic protein, synaptophysin, vimentin, and S-100 protein, but negative for neurofilament, epithelial membrane antigen, cytokeratin and CD34. MIB-1 labelling index was approximately 12% in the highest proliferating areas. In view of subtotal excision of the tumour and high MIB-1 labelling index (LI), the patient was given chemotherapy and he is doing well at 1-year follow-up. This report supports the existence of this rare tumour. Some of its rare clinicopathological features like young age, cyst with mural nodule, presence of mitoses and raised MIB-1 LI need to be documented.

Rare Presentations of Delayed Radiation Injury: A Lobar Hematoma and a Cystic Space-occupying Lesion Appearing More Than 15 Years after Cranial Radiotherapy: Report of Two Cases

Radiation vasculopathy and radionecrosis, constituting delayed radiation injury, are rare but recognized complications of radiation therapy occurring at a peak incidence of 3 years after treatment. Little information is available about these complications occurring more than 15 years after radiotherapy and presenting as other than solid intracranial masses. We describe two patients who presented with space-occupying cerebral lesions. Patient 1 presented as an emergency with a sudden loss of consciousness. Computed tomography revealed a large left intracerebral hemorrhage; cerebral angiography disclosed nothing abnormal, and a primary spontaneous hemorrhage was presumed. Twenty-seven years earlier, this patient had received adjuvant whole-brain and spine radiotherapy and concomitant chemotherapy after excision of a vermis medulloblastoma. Patient 2 presented with a left frontal cystic lesion (presumed malignant glioma) as the cause of personality and behavioral changes for some months. She had previously received external beam radiation for a basal cell epithelioma, which had been excised from her left forehead 19 years earlier. Both patients recovered well after undergoing craniotomies and removal of their lesions; they were discharged home with no neurological deficit. Even after long intervals after radiotherapy, it is important to consider radiation vasculopathy and radionecrosis as differential diagnoses of more common conditions. Histological confirmation of a delayed radiation injury in the absence of any evidence of neoplasia or vascular abnormality has allowed appropriate prognosis and management to be formulated with confidence in each of these patients.

Single-stage bilateral minimally invasive approach for pulmonary hydatid disease: An alternative technique

J Thorac Cardiovasc Surg 2002;124:1021-4

Metastatic adenocarcinoma in cerebral astrocytoma: Clinicopathological and immunohistochemical study with review of the literature

Metastatic spreading of carcinoma into a pre-existing cerebral glioma is extremely rare and only a few well-documented cases have been reported in the literature. Here we report a 53-year-old man who at the age 49 was first operated on for a frontal astrocytoma (WHO-grade II). This tumour was completely resected and no post-operative radio- or chemotherapy was applied. About five years later the patient presented again with a large partially cystic space-occupying lesion at the same site, which pre-operatively appeared as a recurrence of the astrocytoma. Histologically, however, this tumour proved to be a metastatic adenocarcinoma into a recurrent astrocytoma. Further clinical examinations revealed a bronchial carcinoma as the primary lesion responsible for this unusual metastatis. The clinical and neuropathological findings of this interesting case including immunohistochemistry are presented and discussed.