Increase In Cyst Size Research Articles

Management of cystic lymphangioma in children: experience in Jos, Nigeria

The management of cystic lymphangiomas (CL), especially in the head and neck region, presents challenges to the pediatric surgeon. This is a retrospective study of all children seen with lymphangioma at the Pediatric Surgical Unit of the Jos University Teaching Hospital from 1996 to 2004. There were 27 children, 14 (51.9%) were males and 13 (48.1%) were females (M:F = 1.2:1), with ages ranging from 2 days to 5 years (median 5 months). Majority (84.6%) of the patients were below 1 year. The head and neck region was the most frequent site of involvement. There were three cases of lymphangioma circumscriptum. Six (54.5%) of the 11 children with cervical CL presented with complications including infection in 4, respiratory obstruction in 3, ulcerated lesion in 1 and intracystic hemorrhage with rapid increase in cyst size in 1. Twenty-three children had either surgical excision or marsupialization. The main complications were wound infections and respiratory obstructions, which led to five deaths. Six children had recurrences, some of which occurred at sites which were normal at the initial or previous excision. The mortality rate was high (34.8%), mainly due to respiratory obstruction and asphyxia in the head and neck lesions. Head and neck region was the most commonly involved site by CL. The management of CL at this site is associated with significant morbidity and a high rate of mortality.

Long-term results of single-session percutaneous drainage and ethanol sclerotherapy in simple renal cysts

Purpose: To demonstrate the efficacy and long-term results of the single-session ethanol sclerotherapy in simple renal cysts. Materials and methods: Ninety-eight cysts in 97 patients (range: 18–76 years; mean age, 54 years) were included in the study. Indications were determined as flank pain in 74, hydronephrosis in 12, hypertension in 8, patient reassurance due to increasing cyst size in three patients. Mean follow-up period was 24.4 months. Procedures were performed with the guidance of fluoroscopy and ultrasonography at all times using 5–7 Fr pigtail catheters. After the cystogram that was obtained in all cases, 95% ethanol with a volume of 30–40% of the cyst volume was used as a sclerosing agent on an outpatient basis. Maximum volume of the injected ethanol was 200 ml. Follow-up examinations were performed 1, 3, 6 and 12 months after the procedure and once every year thereafter. Results: Average cyst volume reduction was 93% at the end of the first year. The cysts disappeared completely in 17 (17.5%) patients. After the procedure, in 67 (90%) patients improvement in flank pain was noted. Sixty-one (82%) patients were free of pain and in 6 (8%) of them the pain decreased. Normotension was obtained in 7 (87.5%) of the 8 hypertensive patients and no hydronephrosis was detected in 10 (83.3%) of the 12 patients after the procedure. Second intervention was required in 2 (2%) patients due to recurrence of cysts and related symptoms. One (1%) patient had small retroperitoneal hematoma that resolved spontaneously and in another (1%) patient spontaneous hemorrhage was detected into the cyst 1 year after the procedure. No other complication was detected during the procedure and follow-up. Conclusion: Percutaneous treatment of simple renal cysts with single-session sclerotherapy is a safe, effective and minimally invasive procedure and can be used as an alternative to multiple-session sclerotherapy with comparable results. High volume, up to 200 ml ethanol can be used without adverse effects for large renal cysts.

Video-assisted thoracoscopic surgery of mediastinal bronchogenic cysts in adults: A single-center experience

Background Mediastinal bronchogenic cysts are rarely diagnosed in adults, hence surgical experience is limited particularly with regard to video-assisted thoracoscopic surgery. In support of the thoracoscopic approach we report our single-center experience in this rare entity. Methods Between June 1995 and December 2002, a nonselected series of 12 consecutive patients presenting with mediastinal bronchogenic cysts underwent video-assisted thoracoscopic surgery. Six cysts (50%) had been diagnosed 2 to 22 years prior, only three of which became symptomatic. In asymptomatic patients (n = 7) surgery was performed because of increasing cyst size (n = 3), patient's request (n = 3), or suspected metastasis (n = 1). Results Mediastinal bronchogenic cysts were correctly diagnosed by computed tomography in 83% (10/12) and by magnetic resonance imaging in 100% (9/9). Using a three-trocar technique thoracoscopic surgery was successfully performed in 11 of 12 cases (92%). We noted no signs of acute cyst infection. No serious postoperative complications were observed. In 1 patient conversion to open thoracotomy was necessary due to extensive pleural adhesions. In another case thoracoscopic excision of the cyst wall was incomplete. Patients with thoracoscopic excision were discharged after a median of 5.5 days (range 4 to 14 days). No recurrences or complications were observed during a mean follow-up of 40.5 months. Conclusions Considering the low conversion and complication rate in our series, video-assisted thoracoscopic surgery should be the primary therapeutic choice among adults with symptomatic mediastinal bronchogenic cysts. Surgical intervention in patients with asymptomatic and uncomplicated cysts appears optional.

Microsurgical keyhole approach for middle fossa arachnoid cyst fenestration.

The optimal surgical treatment for symptomatic temporal arachnoid cysts is controversial. Therapeutic options include cyst shunting, endoscopic fenestration, and craniotomy for fenestration. We reviewed the results for patients who were treated primarily with craniotomy and fenestration at our institution, to provide a baseline for comparisons of the efficacies of other treatment modalities. A retrospective review of data for 50 children who underwent keyhole craniotomy for fenestration of temporal arachnoid cysts between 1994 and 2001 was performed after institutional review board approval. During that period, the first-line treatment for all symptomatic middle fossa arachnoid cysts was microcraniotomy for fenestration. Microsurgical dissection to create communications between the cyst cavity and basal cisterns was the goal. All patient records were reviewed and numerous variables related to presentation, cyst size and classification, treatment, cyst resolution, symptom resolution, follow-up periods, and cyst outcomes were recorded. Fifty temporal arachnoid cysts in 50 treated patients were identified. The average age at the time of surgery was 68 +/- 57.2 months. The follow-up periods averaged 36 months. There were 34 male and 16 female patients in the series. Twenty-six cysts were on the left side. Indications for surgery included intractable headaches (45%), increasing cyst size (21%), seizures (25%), and hemiparesis (8%). The symptoms most likely to improve were hemiparesis (100%) and abducens nerve palsies. Headaches (67%) and seizure disorders (50%) were less likely to improve. Nine patients exhibited progressive increases in cyst size in serial imaging studies. Those patients were monitored for a mean of 40 +/- 23 months before intervention. In the entire series, 82% of patients demonstrated decreases in cyst size in serial imaging studies. Of those patients, 18% demonstrated complete cyst effacement. Overall, 83% of patients with Grade II cysts and 75% of patients with Grade III cysts exhibited evidence of decreases in cyst size in long-term monitoring. Two patients required shunting after craniotomy (4%). Hospital stays averaged 3.4 days. Total surgical times averaged 115 minutes. No significant blood loss occurred (5-50 ml). Complications included spontaneously resolving pseudomeningocele (10%), transient Cranial Nerve III palsy (6%), cerebrospinal fluid leak (6%), subdural hematoma (4%), and wound infection (2%). A microsurgical keyhole approach to arachnoid cyst fenestration is a safe effective method for treating middle fossa cysts. This procedure can be performed with minimal morbidity via a minicraniotomy. Compared with an endoscopic approach, better control of hemostasis can be obtained, because of the ability to use bipolar forceps and other standard instruments. The operative time and length of hospital stay were not excessively increased.

Stereotactic Radiosurgery for Well-Circumscribed Fibrillary Grade II Astrocytomas: An Initial Experience

Objective: To examine the role of stereotactic radiosurgery in the management of patients with progressive, well-circumscribed grade II fibrillary astrocytomas. Methods: During a 13-year interval, 12 patients (median age: 25 years) required multimodality management for recurrent or unresectable World Health Organization (WHO) grade II fibrillary astrocytomas. Tumors involved the brainstem (n = 4), thalamus (n = 1), cerebellum (n = 1), frontal lobe (n = 4), temporal lobe (n = 1), and parietal lobe (n = 1). Diagnosis was confirmed by stereotactic biopsy (n = 5), partial resection (n = 5), and near total resection (n = 2). Multimodality management of patients prior to radiosurgery included fractionated radiation therapy (n = 4), stereotactic cyst drainage (n = 1), and ventriculoperitoneal shunt placement (n = 2). Tumor volumes varied from 1.2 to 45.1 cm³. The median radiosurgical dose to the tumor margin was 16 Gy. Results: After radiosurgery, serial imaging showed complete tumor resolution in 1 patient, reduced tumor volume in 4, stable tumor volume in 3, and delayed tumor progression in 4 (3 patients with increase in cyst size only). Therapy after radiosurgery included additional cytoreductive surgery (n = 1) for recurrence of a higher grade tumor, stereotactic cyst aspiration (n = 1), and stereotactic intracavitary irradiation (n = 1). All patients were alive at a median follow-up of 52 months after radiosurgery and 103 months after diagnosis. In 8 patients, follow-up lasted more than 60 months. Conclusion: Stereotactic radiosurgery is a potential alternative or adjunctive strategy in the management of selected patients with WHO grade II fibrillary astrocytomas.

The natural history of adnexal cysts incidentally detected at transvaginal ultrasound examination in postmenopausal women.

To determine the natural history of adnexal cysts incidentally detected at transvaginal ultrasound examination and judged to be benign in postmenopausal women. One hundred and thirty-four postmenopausal women referred for ultrasound examination and found to have an adnexal cyst judged to be benign and not causing any symptoms were followed with transvaginal ultrasound at 3, 6 and 12 months, and then every 12 months. The referring physician treated the patient at his/her own discretion. One hundred and sixty cysts were found, 121 (76%) being unilocular and 39 more complicated. Seventy-two cysts (45%) had a largest diameter of 3-19 mm and 88 (55%) had a largest diameter of 20-80 mm. Median follow-up time was 3 (range, 0.3-8) years. In twelve women (9%) the cysts were removed during follow-up, all their cysts (n = 14) being benign. The indication to operate was a change in cyst morphology or increased cyst size in five (4%) women. In 39 (29%) women, the cysts disappeared; in 18 (13%), new cysts developed; and, in 65 (49%), the number of cysts and their location remained unchanged. Regression of cysts was observed in 54% (33/61) of women < 60 years vs. in 8% (6/73) of those > or = 60 years (P = 0.0001). Ultrasound findings remained unchanged in 34% (21/61) of women < 60 years vs. in 77% (56/73) of those > or = 60 years (P = 0.0001). The results support conservative management of adnexal cysts incidentally detected at transvaginal ultrasound examination and judged to be benign in postmenopausal women. Whether such cysts need to be followed-up at all and, if they do, how often and for how long, remains an open question.

Cervical cystic hygroma: pre-, intra-, and post-operative morbidity and mortality in Zaria, Nigeria.

The management of extensive cystic hygromas in the cervical region (CCH) presents difficult challenges. A retrospective study of 41 children with CCH treated over 24 years in Nigeria was carried out; there were 28 boys and 13 girls with an age range of 3 days to 10 years (median 6.5 months). Thirty-three (80%) presented with 34 life-threatening complications including infection in 11 (27%), rapid increase in cyst size in 10 (24%), respiratory obstruction in 7 (17%), and intracystic hemorrhage in 6 (15%). Complete excision was possible in only 14 of 34 (41%) patients, and injuries to neighboring structures occurred in 6 (18%) (facial nerve 2, recurrent laryngeal nerve 1, internal jugular vein 1, parotid duct 1, pharynx 1). Postoperatively, 8 (24%) patients developed 9 complications. Wound infections occurred in 5 incompletely-excised cysts and 2 patients had respiratory obstruction. One patient with a wound infection developed edema of the tongue lasting several days and drainage was prolonged (> 6 weeks) in 1. Five patients died, 3 from respiratory obstruction and 1 each from wound and chest infection. Four patients (12%) developed a recurrence within 5 years of surgery. The pre-, intra-, and post-operative morbidity were high in this series. Although complete excision is the ideal treatment for CCH, this need not be pursued if neighboring structures are liable to injury. When cysts are incompletely excised, antibiotic prophylaxis is necessary as the incidence of wound infection is high.

Fluctuating visual field defects in Rathke's cleft cysts: MRI analysis

This is the first report that the authors are aware of concerning fluctuating visual field defects in patients with Rathke's cleft cysts. Among 11 patients with histologically proven Rathke's cleft cyst, three patients presented with a visual field defect which spontaneously resolved. The symptom became overt again in the subsequent 1 to 14 month follow-up period and a surgical procedure was then chosen. Magnetic resonance imaging (MRI) observation clearly revealed change in the cyst size without signal intensity change in two cases. In the remaining case, multiple spotty high intensities on T1-weighted images were found corresponding to fluctuations in the clinical course. In the last case, enlargement of the cyst was considered to be due to repeated haemorrhage. In the other two cases, minor haemorrhage, undetectable on MRI, may have played a role in the increased cyst size. Another possible mechanism is an imbalance between secretion from, and absorption into, the cyst wall. The size change and neurological fluctuations were previously unknown aspects of the natural history of this lesion. Surgical indications for such patients with transient symptoms followed by cyst size reduction have been controversial, since pituitary cystic lesions may enlarge again or disappear. Our observations suggest that this change in cyst size may be more frequently noted in cases with iso- or high intensity cysts on T1-weighted images, indicating the need for closer observation of patients with this MRI finding.

Antenatal diagnosis of congenital anomalies of the biliary tract

Background: The accuracy of the technique of antenatal ultrasonography in the diagnosis of congenital bile duct lesions is unknown. Methods: Thirteen patients with proven biliary disease who had abnormal antenatal scans were reviewed. Two infants had type I cystic biliary atresia and one had a noncommunicating segmental dilatation of the bile duct in a type 3 biliary atresia. The remainder had choledochal cysts and included two patients with intrahepatic cysts. The correct diagnosis was made antenatally in only two (15%) cases. Of the remaining patients, seven received a diagnosis of intraabdominal cysts of unknown etiology, three of duodenal atresia, and one ovarian cyst. The median gestational age at the antenatal diagnosis was 20 weeks. Results: Jaundice developed in 11 infants, and dilatation of intrahepatic biliary radicals was noted in four of the choledochal cysts. Obstructive jaundice and increasing cyst size were indications for early surgery, and twelve infants underwent a laparotomy at a median age of 4 weeks. During the median follow-up period of 2 years, 12 of the 13 patients have lost their jaundice of remained anicteric. Antenatal diagnosis offers the possibility of early definitive surgery for uncomplicated choledochal dilatation and the chance of improved outcome for surgically treated biliary atresia. An algorithm is suggested for the management of antenatally detected cystic biliary lesions.

Arachnoid cysts of the middle cranial fossa: experience with 77 patients who were treated with cystoperitoneal shunting.

Our surgical results of middle fossa arachnoid cysts are presented, and advantages and disadvantages of cystoperitoneal shunting are discussed. Seventy-seven patients with middle fossa arachnoid cysts, including 20 cases of asymptomatic cyst, were treated by cystoperitoneal shunting. In cases associated with subdural hematoma, the cystoperitoneal shunt was preceded by irrigation of the hematoma. Follow-up periods ranged from 8 months to 16 years (mean, 7.7 yr). In all cases, postoperative computed tomography and magnetic resonance imaging revealed subsequent expansion of the surrounding brain, concomitant with either the disappearance of or a marked decrease in the size of the cyst. Patients who initially presented with headaches, hemiparesis, choked discs, and diplopia were cured postoperatively. Head enlargement presented preoperatively did not progress after shunting. Mental retardation and behavior problems, however, remained unchanged postoperatively, even though the cyst had disappeared. One cystoperitoneal shunt became infected, and shunt malfunction developed in eight patients. Four of the eight patients presented acute signs and symptoms of intracranial hypertension when the shunt malfunctioned, although the concurrent increase in cyst size was slight and ventriculomegaly was not seen. The observed condition in these four patients could be considered shunt dependency. Cystoperitoneal shunting is a valid method of achieving obliteration of the cyst and clinical improvement and seems to feature low operative risk and few complications. It should be noted, however, that some patients experience shunt dependency after cystoperitoneal shunting.

Severe forms of neurocysticercosis: treatment with albendazole.

Study of 22 patients with the severe form of neurocysticercosis treated with albendazole (ABZ) administered in 6 different schedules ranging from 15 to 30 mg/kg/day for 21 to 60 days. Dextrochloropheniramine and ketoprofen were the adjuvant drugs. Multiple symptoms were observed in 90.9% of patients. Intracranial hypertension was manifested in 90.9%. Hydrocephaly occurred in 86.4%. Evolution was satisfactory in 10 patients, 8 died and 4 had sequelae. Tomographic studies showed the appearance of an isolated IVth ventricle in 9 patients, after ventriculoperitoneal shunt, before ABZ treatment in 3 of them, during in 5 and after treatment in one. Median clinical follow-up duration was 10 months for the patients who died and 3-4 years for survivors. In 3 patients there was an increase in cyst size during the administration of the 15 mg/kg/day ABZ dose, which was not observed in any patient when the 30 mg/kg/day dose was used.

Developmental and Morphological Characteristics of Taenia taeniaeformis (Batsch, 1786) in Clethrionomys rufocanus bedfordiae and Rattus norvegicus from Different Geographical Locations

Developmental and morphological characteristics of 3 isolates of Taenia taeniaeformis isolated from Clethrionomys rufocanus bedfordiae in Abuta (70 km southwest of Sapporo), Japan (isolate ACR), and from Rattus norvegicus in Sapporo, Japan (isolate SRN) and Kuala Lumpur, Malaysia (isolate KRN) were compared. Eggs of 3 isolates were administered to several species of rodents. Isolate ACR infected C. rufocanus bedfordiae, Apodemus speciosus, and Apodemus argenteus, but not rats or mice, whereas isolate SRN and isolate KRN were infective to rats, mice, A. speciosus, and A. argenteus, but not to C. rufocanus bedfordiae. The increase in cyst size of isolate ACR continued during the experimental period, whereas that of the other 2 isolates had ceased growing after 30 days postinfection. However, significant differences were observed in the length of the small rostellar hooks, number and distribution of testes, and the length of the cirrus sac between isolate ACR and the other 2 isolates. Thus it is suggested that isolate ACR is a distinct strain or even a new species.

High recurrence rate following aspiration of colloid cysts in the third ventricle.

Sixteen patients treated between 1969 and 1989 for a colloid cyst of the foramen of Monro by stereotactically guided aspiration (not stereotactic extirpation) were evaluated to assess the long-term outcome of the procedure. Thirteen of these patients required reoperation due to an acute comatose state, failure to achieve permanent reduction of the cyst, or symptomatic hydrocephalus. Of these 13, six were treated twice and two were treated three times by stereotactic aspiration. Five patients underwent microsurgical extirpation and three had a shunt placed following a failed aspiration. Failure of the first procedure was detected within the first 2 months after treatment in eight patients and after more than 6 years in seven. Following stereotactic aspiration, three patients experienced a temporary memory deficit and confusion and one patient suffered a central pain syndrome. Eleven of the 26 procedures were followed by a recurrence 6 to 15 years after treatment; seven recurrent cysts were detected after more than 8 years. Of the patients with recurrences, three did not undergo repeat surgery but showed an increase in cyst size at the latest follow-up examination. It is suggested that radical removal by open or stereotactically guided microsurgery is the method of choice since stereotactic aspiration fails to offer a radical or permanent treatment for colloid cysts of the third ventricle.

MR observations on the effects of praziquantel in neurocysticercosis

Eight patients with neurocysticercosis treated with praziquantel (PZQ) were studied with serial MR imaging to demonstrate the early effects of the drug in brain lesions. Increase in cyst size and appearance of pericystic edema were observed as early as 24 hr, followed by gradual degeneration of the scolex and cyst contents. Cysts showed varied degree of response to the drug and in their rate of disappearance. MRI was found to be a sensitive technique to objectively document early changes in the parasite and patterns of response to the cysticidal drug in brain cysticercosis.

Observations on the suitability and importance of the domestic intermediate hosts of Echinococcus granulosus in Uttah Pradesh, India.

The present study investigated the suitability and importance of buffaloes, camels, sheep, goats and pigs in maintaining the life-cycle of Echinococcus granulosus in Aligarh, India. A total of 565 (36%) of 1556 buffaloes, 20 (2%) of 1208 goats, 5 (1%) of 559 pigs, 6 (6%) of 109 sheep and two of three camels were found to harbour hydatid cysts. The frequency distribution of the hydatid cysts in each intermediate host species was over-dispersed and in buffaloes cyst fertility increased with increasing cyst size. Of 2171, 95 and four buffalo, goat, and camel cysts examined 327 (15%), two (2%) and three cysts respectively were fertile. No pig or sheep cysts were found to contain protoscoleces. The unfenced buffalo abattoir and the large number of dogs allowed access to the abattoir coupled to the number of buffalo slaughtered in comparison to the other potential hosts, indicates that the buffalo is the most significant host for maintaining the life-cycle of the parasite in this area of India. Applicable control measures for the region are suggested.

Survival of Cysts of Echinococcus granulosus after Transplant into Homologous and Heterologous Hosts

Cysts of Echinococcus granulosus were found to survive after transplantation into homologous and heterologous species of hosts. No alterations in the shape of transplanted cysts were observed. Although no increase in cyst size was evident 100 days after implantation, the rates of growth and development to fertility were variable in both homologous and heterologous hosts a year later. Protoscoleces from transplanted cysts produced secondary echinococcosis when inoculated intraperitoneally into homologous hosts. Hydatid cysts became either misshapen or enveloped in a chronic fibrous tissue response when recipient mice were immunized with donor gerbil serum in Complete Freund's Adjuvant (CFA). Identical changes occurred in control animals given CFA alone. These results are discussed in terms of the, current concepts of the mechanisms of prolonged survival of parasites in immunologically competent hosts. The selective contamination hypothesis was developed by Smithers and Terry (1969a, b) and their colleagues (Smithers et al., 1969) to account for their observations on the continued survival of Schistosoma mansoni in mammalian hosts. They postulated that migrating parasites become coated with certain contaminating host antigens which thereby interfere with immunologic recognition and enhance parasite survival. They proposed that rejection of schistosomes transplanted to heterologous hosts was mediated via an immune response to these contaminating antigens and concluded that prior immunization against donor antigens accelerated this response (Smithers and Terry, 1969a; Hockley and Smithers, 1970). Although these workers have since extended their observations to include the demonstration of host antigen uptake by schistosomes both in vivo and in vitro (Clegg et al., 1970, 1971a, b), there is little experimental evidence to support the proposal that selective contamination is involved in the prolonged survival of other tissue-dwelling helminths. Hughes and Harness (1973a, b) successfully transplanted Fasciola hepatica from various donor host species to heterologous recipients but were unable to influence the prolonged Received for publication 23 March 1973. * Present address: Department of Microbiology and Public Health, Michigan State University, East Lansing, Michigan 48824, USA. t Fellow, Instituto Nacional de Farmacologia y Bromatologia, Buenos Aires, Argentina. Present address: Center for Laboratory Animal Resources, Michigan State University, East Lansing, Michigan 48824, USA. survival of transplanted flukes by prior immunization against donor antigens. Schwabe et al. (1970) transplanted cysts of Echinococcus granulosus from a laboratory mouse into the peritoneal cavities of five deer mice (Peromyscus maniculatus) and showed that growth and development to fertility proceeded apparently unimpaired. Homologous surgical transfer of cysts in gerbils was suggested by these authors as a means of laboratory propagation of E. granulosus for experimental purposes. We have applied this technique to the study of transplantation of hydatid cysts to a variety of heterologous hosts and determined the effect of immunization against donor serum proteins on transplanted cysts. MATERIALS AND METHODS One-year-old cysts of E. granulosus in gerbils (Meriones unguiculatus) were derived from pri-mary infections resulting from intraperitoneal inoculation of oncospheres (Williams and Colli, 1970) or from secondary infections produced by inoculation with protoscoleces from fertile sheep hydatid cysts. Donor animals were killed using CO2 vapor. Hydatid cysts which were free in the peritoneal cavity were recovered from donors, washed in sterile physiological saline at 37 C, and transferred to the peritoneal cavities of recipients, usually within a few hours. In some instances cysts were stored overnight at 4 C in Hanks' Balanced Salt Solution and implanted the following day, since preliminary studies showed that this delay did not affect the survival and development of the parasites in recipient animals. Homologous and heterologous hosts were anesthesized with ethyl ether and the cysts inserted singly via a midline abdominal incision which was then sutured in 2 layers. Cysts were implanted in this way into 50 gerbils,