Internal Septations Research Articles

Intraabdominal Cystic Lymphangiomas in Children: A Single Center Experience

Congenital intraabdominal cystic lymphangiomas (ICLs) are rare disorders. Only a minority of cases present with acute illness, the majority of patients show unspecific abdominal symptoms, and due to the slow progression of ICL the diagnosis is usually made with delay. We report our single center experience concerning ICL covering a 3-year period from 2009 to 2011. During this time three patients with a mean age of 2.8 years were first seen because of unspecific abdominal symptoms, and were identified to have an ICL, originating from the ligamentum gastrocolicum (diameter 17 cm), gastrolienale (diameter 20 cm) and omentum majus (diameter 7 cm). The following report should emphasize the diagnostic difficulty associated with ICL presenting three patients in excellent condition, showing normal laboratory data despite a considerable persistent intraabdominal fluid accumulation. The persistence of “ascites” in parallel with the follow-up sonographies demonstrating cystic masses and internal septations led to the differential diagnosis of an ICL. To us, it seems to be important to bear in mind ICL as a relevant differential diagnosis in children with unspecific abdominal pain or non-specific ascites. This is to point out that especially the existence of septated intraabdominal fluid and cystic structures are strong signs leading to the diagnosis of an ICL. Due to this, the general use of ultrasonography (US) in children with unspecific abdominal symptoms should be recommended. Int J Clin Pediatr. 2014;3(3):89-93 doi: http://dx.doi.org/10.14740/ijcp163w

A Patient with Left Cardiophrenic Angle Mass Presenting with Intermittent Chest Symptoms

A 42-year-old male shopkeeper presented in the out-patient department (OPD), with intermittent cough for the last six months along with occasional compressive symptoms at the centre of chest and mild dyspnea on exertion. Detailed cardiological history was not contributory. Chest on auscultation showed diminished air entry in the left infra-scapular region with occasional crepitations; the right side of the chest and other systemic examinations were within normal limits. Chest X-ray postero-anterior (PA) view revealed a lobular opacity in the left cardio-phrenic angle. (Fig. 1) Figure 1 Chest X-ray PA view showing a lobular opacity at the left cardio-phrenic angle large enough to obscure the left costo-phrenic angle, shown by the arrow. Routine blood investigations and 12-lead electrocardiography (ECG) revealed no abnormality. Two-dimensional echocardiography revealed a large well defined mass having echo-free space measuring 9.0 × 5.6 cm, resting on the postero-lateral side of the left ventricle (LV) without any connection to ventricular cavity (Fig. 2). But due to poor window, the exact morphological and anatomical nature of the mass could not be substantiated. Later contrast enhanced computed tomography (CECT) scan of the chest confirmed (Fig. 3), a large well circumscribed cystic lesion measuring 9.8 cm (antero-posterior) × 6.4 cm (supero-inferior) × 5.5 cm (transverse) in the left lower hemi-thorax, abutting the lateral aspect of the pericardial cavity, not separable from it and indenting the lateral wall of the LV. It had thin barely perceptible wall, homogeneous fluid attenuation content, without any foci of calcification, contrast enhancement, or internal septa. Figure 2 2-D echocardiography showed a large well defined mass having echo-free space near the postero-lateral side of left ventricle (shown by interrogation mark). Figure 3 CECT chest showing a large well circumscribed cystic lesion in left lower hemi-thorax, abutting lateral aspect of pericardial cavity. Question What is the diagnosis?

Squamoid cyst of pancreatic ducts: a challenging differential diagnosis among benign pancreatic cysts.

In the last years, cystic pancreatic lesions are often detected when clinically silent, because of the wider use of diagnostic imaging techniques. First described by Othman in 2007, "squamoid cyst of pancreatic ducts" represents a cystic dilation of ducts, lined by non-keratinized squamous epithelium. We report the first case of squamoid cyst of pancreatic ducts in Italy.A 68-year-old woman presented a cystic lesion (4 cm) of the pancreatic tail as incidental finding at MRI. It had a thickened wall, no internal septa and no communication with the Wirsung duct were detected. A CT scan showed a lamellar calcification on its posterior wall. A ¹⁸F-FDG-PET was negative. Blood tests were normal, including CEA and CA 19-9. We performed a spleen-preserving distal pancreatectomy. Histology showed a unilocular cyst, with serous fluid and a fibrous wall, with multilayered epithelium without cytological atypias. Immunohistochemistry showed CK 7 positive and CK 5 negative. The patient is still alive and without disease after 42 months of follow-up.In the English literature only seven cases resected for this cyst type have been reported. No preoperative test can achieve a definitive diagnosis, so surgical resection remains the treatment of choice in order to exclude malignancy. However, after intraoperative frozen section, a limited pancreatic resection can be performed.

Appendiceal Mucocele: A Diagnostic Dilemma in Differentiating Malignant From Benign Lesions With CT

The purpose of this study was to assess the feasibility of using CT to differentiate malignant from benign lesions in patients with pathologically confirmed appendiceal mucoceles. CT scans of 18 consecutively registered patients (11 men, seven women; age range, 21-78 years) with pathologically confirmed appendiceal mucocele were reviewed retrospectively. Patients were classified into three groups according to pathologic results: nonneoplastic mucocele (n = 3), mucinous cystadenoma (n = 10), and mucinous cystadenocarcinoma (n = 5). The nonneoplastic and mucinous cystadenoma groups were formed into a benign group, and the mucinous cystadenocarcinoma constituted the malignant group. Two experienced radiologists working in consensus assessed the shape, short diameter, density, contour, and wall thickness of the masses. The presence of calcifications, internal septations, soft-tissue thickening, periappendiceal fat stranding, intraperitoneal free fluid and pseudomyxoma peritonei were also evaluated. The CT results were compared for malignant and benign appendiceal mucoceles. CT showed statistically significant differences in wall irregularity and soft-tissue thickening between malignant and benign cases (p < 0.05). Short diameter of mucoceles, attenuation of intraluminal contents, maximal wall thickness, calcifications, internal septations, periappendiceal fat stranding, intraperitoneal free fluid, and pseudomyxoma peritonei in the lesions did not differ significantly between the benign and malignant groups (p > 0.05). Differentiating malignant from benign mucoceles can be difficult with CT. Irregular walls and soft-tissue thickening are features most likely to be associated with malignancy.

Right Upper Quadrant Abdominal Pain Ten Years Post-laparoscopic Cholecystectomy

Purpose: A 72-year-old woman with past history of laparoscopic cholecystectomy 10 years ago presented with a 6-month history of intermittent right upper quadrant abdominal and flank pain without association with food intake. She denied fever and weight loss. Physical examination revealed erythema and tenderness in the right lateral aspect of the upper abdomen. Labs were unremarkable. Computed tomography (CT) of the abdomen showed a complex 21 x 5.8 x 8.8 cm perihepatic fluid collection with internal septations, which fistulized through the abdominal wall and formed a 5.6 x 2 cm subcutaneous fluid collection in the right flank. HIDA scan and MRCP ruled out bile leak. Ultrasound guided drainage of the abscess drained thick, greenish fluid. The patient was empirically started on ceftriaxone and metronidazole. Bacterial and fungal cultures as well as PPD, Echinococcus, and Entamoeba serology were all negative. Cytology revealed proteinaceous material with few inflammatory cells and many degenerated structures, suspicious for, yet not definitive of, Echinococcus cyst. Patient received a 6-week course of albendazole, and PAIR procedure (puncture, aspiration, injection, and re-aspiration) was performed with no improvement in symptoms. Repeat CT scan showed persistence of the abscess. An exploratory laparotomy was performed with 500 ml of fluid drained and evacuated 28 gallstones, confirmed by pathology, from the cavity. The fluid cultures were again negative. Repeat CT scan performed a month after the surgery showed near complete resolution of the abscess. Gallbladder perforation during laparoscopy cholecystectomy can result in spillage of gallstones into the peritoneal cavity, which may lead to the development of intra-abdominal abscesses that are easily misidentified as tumors or parasitic infections on radiography due to their similar appearance. The rarity and chronicity of this problem makes the diagnosis very challenging. Treatment requires exploratory laparotomy to remove all dropped gallstones. Less invasive procedures such as percutaneous drainage are effective for resolving acute symptoms, but allow recurrence of abscess. Most patients get a short course of antibiotics based on fluid cultures that typically reveal E. coli, Klebsiella pneumoniae, and Enterococcus. Interestingly, in our patient, the cultures were negative, suggesting that the development of the abscess was secondary to foreign body reaction to the dropped gallstones. Our case illustrates the importance of considering dropped gallstones in the differential diagnosis of intra- or extraperitoneal abscesses in any patient with a history of laparoscopic cholecystectomy, regardless of the time elapsed since surgery.

Lymphoepithelial Cyst of the Pancreas: A Challenging Differential Diagnosis among Cystic Pancreatic Tumors

Context First described by Luchtrath and Schriefers in 1985 [1], lymphoepithelial cysts (LECs) of the pancreas are rare true benign cystic tumors of uncertain etiology (0.5% of all pancreatic cysts). They are found mainly in middle-aged males in the tail of the pancreas (size range: 2-10 cm). The challenging preoperative differential diagnosis of pancreatic LECs is among pseudocysts, cystic neoplasms and intraductal carcinomas. Case report During follow up for prostatic cancer, a 66-year-old man presented as an incidental finding at abdomen CT scan, a multiloculated cystic lesion (8x6 cm), located between duodenum and pancreatic head, with a solid component in its lower side, without contrast enhancement. MRI confirmed the lesion, suspected to be a mucinous tumor non com­municating with the Wirsung duct. A pancreatic EUS showed a inhomogeneous cystic mass of the head of the pancreas, which had internal septa and a solid component. The amylase level in the cystic fluid content was 84 U/L, and CEA and CA 19-9 levels were 301 μg/L and 76,579 kU/L, respectively. Histology of the solid component was inconclusive. A 18 FDG-PET was negative for pancreatic malignancy. Blood tests showed a severe increase of creatinine and urea levels, because the patient had an acute renal failure due to the prostatic cancer, and serum CEA and CA 19-9 levels were 2.7 μg/L and 81 kU/L, respectively. After renal function normalization, with the suspicion of a mucinous cystic neoplasm (MCN), the patient underwent surgery. The mass had a tight-elastic thickness and seemed not to involve the pancreatic parenchyma, so a resection of the lesion was performed. The post-operative course was uneventful. Histology revealed a cystic lesion (8x4 cm) containing yellowish fluid, lined by a stratified squamous epithelium with focal sebaceous differentiation, and surrounded by lymphoid tissue. The patient is well and asymptomatic three months after surgery. Conclusion LECs should be considered in the differential diagnosis of cystic pancreatic tumors, whenever a large, well-defined solid or cystic peripheral pancreatic lesion is found. Imaging findings of LECs are non-specific, so surgical resection with pathological examination of the cyst is the gold standard for diagnosis. Cytology from EUS-FNA can help to distinguish LECs from cystic neoplasms.

Radiological and clinicopathological features of pPNET

PurposeTo analyze the radiological and clinicopathological features of peripheral primitive neuroectodermal tumor (pPNET). Materials and methodsWe retrospectively reviewed the computed tomography (CT) and magnetic resonance (MR) imaging of 14 cases of pPNET confirmed immunohistochemically. Relevant clinical data was also obtained. ResultsOf 14 cases, there were 10 male and 4 female with a mean age of 28 years. The main symptoms were the aggravated pain of the lesion site and enlarged palpable masses. Fourteen lesions were located in the chest wall (n=4), retroperitoneum (n=3), pelvic cavity (n=2), intraspinal area (n=2), nasal cavity (n=1), leg (n=1) and iliac bone (n=1). Eleven lesions originating from the soft tissue mainly demonstrated large and infiltrative mass with (n=4) or without (n=7) bony invasion. Ten cases of them showed heterogeneous density with patchy, necrotic foci and moderate heterogeneous enhancement. Four of them with large cystic area contained irregular septations within them. Two intraspinal cases had extradural lesions, extending through the intervertebral foramen and formed paraspinal soft tissue masses with vertebral destruction. The case within iliac bone demonstrated extensive mixed (lytic/osteoblastic) lesion with large adjacent soft tissue mass. After surgery or therapy, 10 patients died of local recurrences or metastases. ConclusionThe diagnosis of pPNET should be suggested in young patient when imaging depicts a large, ill-defined, soft-tissue mass containing area of cystic degeneration with internal septations and extending along the neural route and nearby the middle of the trunk. The key for correct diagnosis is to inosculate imaging to clinical data.

A case of branch duct type intraductal papillary neoplasm of the bile duct treated by open surgery after 11 years of follow-up

The intraductal papillary neoplasm of the bile duct (IPNB) is a novel disease concept that was recently classified as a biliary cystic tumor by the revised World Health Organization classification. This is the case report of a 70-year-old female patient who experienced repeated episodes of obstructive jaundice and cholangitis since 2000, attributed to a mucus-producing hepatic tumor. Surgery was advised due to the repeated episodes; however, the patient refused. In May, 2011, the patient developed jaundice and fever and was treated with antibiotics. Since there was no improvement, the patient was admitted to the Tokyo Rosai Hospital. Abdominal computed tomography (CT) revealed a 50-mm cystic mass with an internal septum in the left hepatic lobe. Although the tumor size had remained almost unchanged compared to the initial CT scan performed in 2000, intra- and extra-hepatic bile duct dilation was more prominent on the second CT scan. Following admission, endoscopic retrograde cholangiopancreatography was performed and revealed an expanded papilla of Vater due to a mucous plug. A balloon catheter was inserted into the bile duct to remove the mucous plug, resulting in the drainage of copious amounts of mucus and infected bile. The patient finally consented to surgery and left hepatic lobectomy was performed. Consequently, the diagnosis of low-grade IPNB was made. Branch duct type IPNB, which is characterized by imaging appearance of a cystic mass and slow progression, is attracting increasing attention. In the present case, a cystic mass was identified in the left hepatic lobe, with no significant change in size after 11 years of follow-up, leading to the diagnosis of branch duct type IPNB. Considering the fact that IPNB is usually treated surgically at the time of diagnosis, the present case, due to the long-term follow-up, provides valuable insight into the natural history of the tumor.

Giant cell tumor with secondary aneurysmal bone cyst: A unique presentation with an ossified extraosseous soft tissue mass

The authors describe a case of giant cell tumor (GCT) with secondary aneurysmal bone cyst (ABC) in a 44-year-old man with chronic, intermittent knee pain. A unique feature is the presentation of GCT with an ossified extraosseous soft tissue mass. Radiograph demonstrates a multiloculated lytic lesion in the distal meta-epiphyseal region of the femur with an adjacent extraosseous soft tissue mass. The soft tissue mass was partially ossified along its margin and internal septa. MRI demonstrates a multiloculated lesion in the distal femur with multiple fluid-fluid levels and cortical penetration of the lesion. Both the intraosseous lesion and extraosseous soft tissue mass have similar MR signal characteristics. At surgery, the intraosseous component was found to be contiguous with the extraosseous soft tissue mass through a cortical perforation. To the best of our knowledge, this is the first case report of GCT with aneurysmal bone cyst initially presenting with an extraosseous soft tissue mass.

Mucinous cystic neoplasm or non-parasitic liver cyst? - A challenging diagnosis.

Mucinous cystic neoplasms (MCN) are rare liver lesions. Radiological features include internal septa or septal thickening. Imaging often fails in the differential diagnosis to non-parasitic liver cysts (NPLC), resulting in inadequate surgery. The aim of the study was to evaluate if both lesions could be differentiated pre-operatively. Retrospective study with literature review. Twenty-six patients (22 female, 68±12 years) underwent laparoscopic deroofing for NPLC. Histo-pathological specimens showed 2 MCN (both female) with recurrence rates of 4% (NPLC) and 100% (MCN), and a time-to-recurrence of 3 months. In both cases no radiological features of MCN were seen pre-operatively. Follow-up time was 7 and 12 years with emergence of radiological features of MCN in one case. PubMed search showed 137 hits for “MCN” and 540 hits for “mucinous cystadenoma” and “liver”; 207 studies were reviewed: one prospective, 13 non-systematic reviews, 57 retrospective, 120 case reports and 16 expert opinions. The largest MCN-series included 44 subjects. If MCN shows no characteristic radiological features, thus mimicking NPLC, pre-operative radiological differentiation is impossible. During long time course characteristic radiological morphology of MCN could appear. Early recurrence of a supposed NPLC is suspicious for MCN. Due to the literature review pre-operative imaging is inaccurate for the differential diagnosis and complete surgical excision of MCN is crucial.

Comparison of Abdominal Ultrasonographic Findings With Endoscopic Ultrasonographic Findings of Solid Pseudopapillary Tumor of Pancreas

Brief Description of the Purpose of the StudyTo compare abdominal ultrasonographic (AU) findings with endoscopic ultrasonographic (EUS) findings of solid pseudopapillary tumor (SPT) of pancreas.MethodsThirteen patients (M:F=3:10; mean age, 36 years) with surgically proven SPT were included, who underwent both preoperative AU and EUS. Ultrasonographic findings of 2 modalities were compared according to internal echogenicity, solid or cystic portion, internal septum, calcification, fluid-fluid level, demarcation and main pancreatic duct dilatation.Main ResultsAmong 13 cases, 8 cases showed hypoechogenicity on both AU and EUS. Remaining 5 cases showed different echogenicity on both modalities; hypoechogenicity (n=3) and isoechogenicity (n=2) on AU, hyperechogenicity (n=2), unremarkable echogenicity due to dense rim calcifications (n=2), isoechogenicity (n=1) on EUS. In two cases with rim calcifications, evaluation of the internal content was more difficult on EUS, compared to AU. Two cases with central punctate calcifications and 1 case with peripheral calcifications were seen. Internal fluid-fluid level was noted in 2 cases on both modalities. All cases showed good demarcation without pancreatic ductal dilatation or internal septum.Importance of the ConclusionsEUS was somewhat superior to AU in the evaluation of internal echo texture (solid or cystic) of pancreatic SPT. However, AU was superior to evaluate the larger size tumor and tumors with dense rim calcifications. Brief Description of the Purpose of the StudyTo compare abdominal ultrasonographic (AU) findings with endoscopic ultrasonographic (EUS) findings of solid pseudopapillary tumor (SPT) of pancreas. To compare abdominal ultrasonographic (AU) findings with endoscopic ultrasonographic (EUS) findings of solid pseudopapillary tumor (SPT) of pancreas. MethodsThirteen patients (M:F=3:10; mean age, 36 years) with surgically proven SPT were included, who underwent both preoperative AU and EUS. Ultrasonographic findings of 2 modalities were compared according to internal echogenicity, solid or cystic portion, internal septum, calcification, fluid-fluid level, demarcation and main pancreatic duct dilatation. Thirteen patients (M:F=3:10; mean age, 36 years) with surgically proven SPT were included, who underwent both preoperative AU and EUS. Ultrasonographic findings of 2 modalities were compared according to internal echogenicity, solid or cystic portion, internal septum, calcification, fluid-fluid level, demarcation and main pancreatic duct dilatation. Main ResultsAmong 13 cases, 8 cases showed hypoechogenicity on both AU and EUS. Remaining 5 cases showed different echogenicity on both modalities; hypoechogenicity (n=3) and isoechogenicity (n=2) on AU, hyperechogenicity (n=2), unremarkable echogenicity due to dense rim calcifications (n=2), isoechogenicity (n=1) on EUS. In two cases with rim calcifications, evaluation of the internal content was more difficult on EUS, compared to AU. Two cases with central punctate calcifications and 1 case with peripheral calcifications were seen. Internal fluid-fluid level was noted in 2 cases on both modalities. All cases showed good demarcation without pancreatic ductal dilatation or internal septum. Among 13 cases, 8 cases showed hypoechogenicity on both AU and EUS. Remaining 5 cases showed different echogenicity on both modalities; hypoechogenicity (n=3) and isoechogenicity (n=2) on AU, hyperechogenicity (n=2), unremarkable echogenicity due to dense rim calcifications (n=2), isoechogenicity (n=1) on EUS. In two cases with rim calcifications, evaluation of the internal content was more difficult on EUS, compared to AU. Two cases with central punctate calcifications and 1 case with peripheral calcifications were seen. Internal fluid-fluid level was noted in 2 cases on both modalities. All cases showed good demarcation without pancreatic ductal dilatation or internal septum. Importance of the ConclusionsEUS was somewhat superior to AU in the evaluation of internal echo texture (solid or cystic) of pancreatic SPT. However, AU was superior to evaluate the larger size tumor and tumors with dense rim calcifications. EUS was somewhat superior to AU in the evaluation of internal echo texture (solid or cystic) of pancreatic SPT. However, AU was superior to evaluate the larger size tumor and tumors with dense rim calcifications.

Multiseptate gallbladder: Clinical and ultrasonographic follow-up for 12 years

There are only a few cases in literature in which a patient with multiseptate gallbladder (MSG) has been followed-up after the diagnosis. A pediatric patient with MSG has been followed-up until adulthood. Diagnosis was made at 10years after an episode of abdominal pain. Ultrasonography showed a gallbladder with many internal septa, without stones or signs of cholecystitis. Laboratory tests were normal. Symptoms receded in a few days, and it was decided to follow the patient's course. Additional painful episodes occurred at 19 and 22years. No changes in ultrasonographic findings were observed. MR cholangiography confirmed MSG and ruled out associated biliary ducts anomalies. Although symptomatic patients with MSG have pain relief after cholecystectomy, patients without severe biliary symptoms and without stones probably do not need immediate surgical treatment.

Sonographic-pathologic correlation of complex cystic breast lesions

ObjectiveTo understand the pathologic basis for sonographic features of complex cystic lesions. MethodsFrom 2646 female patients underwent breast sonography at King Chulalongkorn Memorial Hospital from January 2005 through December 2010, 103 cystic lesions were included. Pathologic confirmation was performed by fine-needle aspiration (n=42), core needle biopsy (n=6), excision (n=54) and mastectomy (n=1). Complex cystic breast masses were classified into 3 types as followings; thick outer wall and/or thick internal septa (type I); thick septation and thick wall were defined as equal or more than 0.5 cm, masses containing mixed cystic and solid components (at least 50% of cystic component) (type II), predominantly solid with eccentric cystic foci (at least 50% of solid component) (type III). ResultsIn 103 complex cystic masses, there are 27 lesions (26%) classified as type I cystic breast masses, 37 lesions (36%) as type II cystic breast masses and 39 lesions (38%) type III cystic breast masses, 26 lesions (25.2%) are proved to be malignant. All of type I cystic breast masses in our study are benign, and 14 (38%) of type II cystic breast masses and 12 lesions (31%) of type III cystic breast lesions are proved to be malignant. ConclusionsType II and III lesions should suggest possibility of malignancy and biopsy should be performed in all lesions. All type I lesion in this study are benign. None of other parameters we included in this study (size or margin) can effectively differentiate between benign or malignant cystic breast lesions. Also, grading of the malignant lesions by using type of cystic breast mass cannot be applied.

Diagnosis and treatment of benign multicystic peritoneal mesothelioma

Benign multicystic peritoneal mesothelioma (BMPM) is a rare cystic mesothelial lesion that occurs predominantly in reproductive aged women. A 56-year-old Caucasian male was admitted to our surgical department with a chief complaint of a painful mass in his right lower abdomen for almost 2 years. The physical examination revealed a palpable painful mass. Computed tomography demonstrated an irregular, cystic tumor in his right lower abdomen. There was no obvious capsule or internal septations. No enhancement after intravenous administration of contrast was noted. An exploratory laparotomy was performed, and a multicystic tumor and adherent to the caecum was noted. The walls of the cysts were thin and smooth, filled with clear fluid, and very friable. An en bloc resection of the tumor, including appendix and caecum, was performed. Histological examination revealed multiple cysts lined with flattened simple epithelial cells, and the capsule walls of the cysts were composed of fibrous tissue. Immunohistochemical analysis documented positive expression of mesothelial cells and calretinin. The final diagnosis was BMPM. The patient was well at 6-mo follow-up. BMPM is exceedingly rare lesion. A complete resection of the tumor is required. The diagnosis of BMPM is based on pathological analysis.

Giant biliary cystadenoma complicated with polycystic liver: A case report

Biliary cystadenoma (BCA) is a rare hepatic neoplasm. Although considered a benign cystic tumor of the liver, BCA has a high risk of recurrence with incomplete excision and a potential risk for malignant degeneration. Correct diagnosis and complete tumor excision with negative margins are the mainstay of treatment. Unfortunately, due to the lack of presenting symptoms, and normal laboratory results in most patients, BCA is hard to distinguish from other cystic lesions of the liver such as biliary cystadenocarcinoma, hepatic cyst, hydatid cyst, Caroli disease, undifferentiated sarcoma, intraductal papillary mucinous tumor, and hepatocellular carcinoma. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) may be necessary. They demonstrate intrahepatic cystic lesions with features such as mural nodules, varying wall thickness, papillary projections, and internal septations. Nevertheless, surgery is still the only means of accurate diagnosis. Definitive diagnosis requires histological examination following formal resection. We describe a 57-year-old woman initially diagnosed with polycystic liver who was subsequently diagnosed with giant intrahepatic BCA in the left hepatic lobe. This indicates that both US physicians and hepatobiliary specialists should attach importance to hepatic cysts, and CT or MRI should be performed for further examination when a diagnosis of BCA is suspected.

Acute Abdominal Pain in an End Stage Renal Disease Patient

An 81-year-old female with history of end stage renal disease on hemodialysis presented with worsening of abdominal pain of 2 days’ duration. The pain started as a dull ache over the lower abdomen 2 months earlier, diffuse but especially prominent over the lower quadrant, and was unrelieved by analgesic medications. On physical examination her whole abdomen was diffusely tender, but the lower quadrant was extremely tender with palpable nodular lesions. Her laboratory work showed a normal amylase and lipase level along with a white cell count of 13.5K/CUMM (3.5–10.6 K/CUMM), calcium of 10.6 mg/dL (8.2–10.6 mg/dL), phosphorus of 5.9 mg/dL (2.3–5.0 mg/dL) and intact PTH 880 pg/mL (18–86 pg/mL). She had a computed tomography of the abdomen and pelvis (Figure), which showed multiple soft tissue densities in the lower quadrant of anterior abdominal wall, while the ultrasound of her abdomen (Video) revealed subcutaneous nodule with internal septations and calcified vessels. Both these findings in the setting of end stage renal disease were consistent with calciphylaxis, a rare, and often fatal, complication. Although ulceration is considered a hallmark of calciphylaxis, it can also present as non-ulcerative nodular lesions, as in our patient.1 Various putative risk factors for calciphylaxis include obesity; serum aluminum is greater than 25 ng/mL and serum calcium phosphorus product more than 70.2 Treatment is multifaceted, including strict control of secondary hyperparathyroidism, maintenance of calcium phosphate product below 55 mg2/dL2 using non-calcium containing phosphate binders, administration of intravenous sodium thiosulfate with each dialysis (6–12 weeks), and a trial of prednisone tapered over a period of a couple of weeks.1 With the above treatment, she had significant improvement of symptoms. Our case highlights the need for emergency physicians to be cognizant of this life-threatening complication in end stage renal disease patients and of the fact that calciphylaxis has different modes of presentation, among which is acute abdominal pain. Figure. Computed tomography of the abdomen and pelvis without contrast showing multiple soft tissue densities in the anterior abdominal wall (A). Calcification of blood vessels within the abdomen and pelvis was also noted (B). Video. Ultrasound of abdomen revealing subcutaneous nodule. Click here to view.(8.9M, mpg)

Giant Subcutaneous Synovial Sarcoma: An Interesting Case

A 45-year-old lady presented to us with a large subcutaneous swelling on her left side of back of 1 year duration. Local examination revealed a 13×12 cm spherical swelling on the left lower paraspinal region. Magnetic resonance imaging of lumbosacral spine revealed a 13×12 cm mass having solid and cystic components with internal septations in the subcutaneous tissue of left posterior paraspinal area. The mass was hetrogenously hyperintense on T 2 weighted images suggestive of synovial sarcoma. Wide local excision of the lump was carried out followed by closure of the defect with a lateral intercostal artery based rotational flap. The histopathology of the excised tumor revealed synovial sarcoma that stained positive for cytokeratin and epithelial membrane antigen. This case highlights an unusually large subcutaneous synovial sarcoma present in para-spinal area.

Multiple Cystic Tumors Throughout the Abdominal and Pelvic Cavity

Question: A 53-year-old man with history of type 2 diabetes mellitus had an elevated serum creatinine level in the routine screening for diabetic nephropathy. He underwent renal ultrasonography, and abdominal masses were incidentally found. Computed tomography showed multiple cystic lesions that have thin walls, internal septations and liquids of different attenuation in the abdominal and pelvic cavity (Figures A and B). The cystic lesions and appendix were resected under the clinical impression of pseudomyxoma peritonei.

Taphonomic differentiation of Oxfordian ammonites from the Cracow Upland, Poland

Taphonomic analysis of Lower and Middle Oxfordian ammonites from the Cracow Upland, southern Poland (localities at Podleze, Zalas, Mlynka) revealed differences in ammonite preservation. The studied ammonites, usually termed as external and internal moulds, show a more complex state of preservation. In the Middle Oxfordian glauconitic marls, ammonites are preserved as internal moulds with neomorphic calcite shells showing relics of the original internal structure. In the Middle Oxfordian platy peloidal limestones, ammonites are preserved mostly as external moulds, without septal suture, however under microscope might show relics of internal whorls and septa and/or subtle differences in sediment filling phragmocone chambers. In sponge–microbial bioherms and biostromes, ammonite internal moulds have shells, which in contrast to ammonites from glauconitic marls are not strictly neomorphic ones, but originated by shell dissolution and subsequent filling of moldic porosity by calcite cement. In sponge–microbial nodular limestones, the ammonites are strongly deformed and the outer wall is usually removed by dissolution under pressure. Other important taphonomic differences include the rate of compaction (highest in platy limestones), sedimentary infillings, microborings, encrustations and preservation of siphuncular tubes. The majority of the ammonites appear to be phragmocones; aptychi in all facies are rare. Siphuncular tubes are fossilized exclusively in oppeliids, only in specimens from glauconitic marls and platy limestones, although their other taphonomic attributes are different. Tubes seem to have fossilized due to microbially mediated phosphatization that could be favoured by a set of parameters which operated rather at the scale of ammonoid carcasses: closed, poorly oxygenated conditions, and reduced pH. Taphonomic processes were controlled by the sedimentary environment (fragmentation, sedimentary filling, phosphatization of siphuncular tubes), as well as by early and late diagenesis (neomorphic transformation, dissolution, cementation, compaction) influenced by lithology.

Clinicopathologic analysis of dysembryoplastic neuroepithelial tumor

To study the clinicopathologic features, radiologic findings, treatment options and prognosis of dysembryoplastic neuroepithelial tumor (DNT). The clinicopathologic and radiologic features were retrospectively analyzed in 10 cases of DNT. Intractable partial seizure was the main presenting symptom in all patients. The tumor was located in temporal lobe (number = 5), frontal lobe (number = 3) or parietal lobe (number = 2). CT scan displayed a hypodense lesion. MRI scan revealed the tumor was non-enhancing T1WI hypointense and T2WI hyperintense, with internal septation and hyperintense ring around the tumor seen on FLAIR image. There was neither peritumoral edema nor mass effect. Histologically, the tumor showed the presence of glioneuronal element, with oligodendrocyte-like cells, floating neurons, astrocytes and associated microcystic changes. Immunohistochemical study demonstrated positivity for NeuN and synaptophysin in the neurons and some oligodendrocyte-like cells. Olig2 and S-100 protein were also expressed in the oligodendrocyte-like cells. Ki-67 index were lower than 1% in all cases. Nine cases were treated by complete surgical excision and the remaining case was subtotally excised. No post-operative chemotherapy or radiotherapy was given. One of the 10 cases recurred on follow up. Correct diagnosis of DNT requires correlation with clinicopathologic, radiologic and immunohistochemical findings. Complete resection of the tumor and epileptogenic foci is the mainstay of treatment for DNT, with intraoperative EEG monitoring. Post-operative chemotherapy or radiotherapy is not required.