Intratumoral Hemorrhage Research Articles

Specific Features of Primary Central Nervous System Lymphoma in Comparison with Glioblastoma on Conventional MRI

Background: The treatments of primary central nervous system lymphoma (PCNSL) and glioblastoma (GBM) are different; therefore, accurate diagnosis is crucial for the therapeutic planning. Although there is overlap of features on conventional magnetic resonance (MR) images between PCNSL and GBM, the PCNSL has specific features, which are different from those of GBM on conventional MR images. Objectives: The current study aimed at characterizing specific features of PCNSL by comparing them with conventional MR images of GBM, and improving diagnostic accuracy at the time of initial presentation. Patients and Methods: The current study retrospectively evaluated the conventional MR images of 21 immunocompetent patients with PCNSL and 13 patients with GBM pathologically proven in Renmin Hospital of Wuhan University, Wuhan, China from January 2014 to March 2017. All patients were subjected to non-contrast and contrast enhanced MRI. Tumor location, quantity, and morphology, as well as common and specific features and patterns, peritumoral edema, and hemorrhage were recorded and compared. Results: Twenty-one patients with PCNSL exhibited 44 lesions, and 13 patients with GBM exhibited 16 lesions. PCNSL affected both infra- and supratentorial regions, while GBM only affected supratentorial regions. Deep white matter, basal ganglia, periventricular areas, and the corpus callosum were the most common sites in PCNSL. Homogeneous enhancement was presented in 95.2% of PCNSL, and all GBM lesions showed heterogeneous enhancement. PCNSLs had various appearances, whereas most of the GBMs (81.3%) had a mass-like appearance. Differences in intratumoral hemorrhage (P < 0.001), necrotic or cystic components (P < 0.001), and intratumoral vascular enhancement (P < 0.001) between PCNSL and GBM were statistically significant. “Notch sign” and open-ring enhancement were specific features for PCNSL. Conclusion: PCNSL has specific features, patterns, and locations. These features and patterns can be helpful to differentiate PCNSL from GBM at the time of initial presentation.

Functioning Pituitary Adenoma with Xanthogranulomatous Features: Review of Literature and Case Report.

Objectives We present a patient with a prolactin-secreting adenoma with extensive secondary, noninfectious, xanthogranulomatous changes due to remote intratumoral bleeding and provide a literature review of xanthogranulomas (XGs) of the sellar region with emphasis on prolactinomas with xanthogranulomatous features. Design Case report, with PubMed search of cases of sellar XG, focusing on neuroimaging and surgical approach. Results A 35-year-old male was found to have a large sellar/suprasellar calcified/cystic mass. Endoscopic transsphenoidal approach for extradural resection was performed and diagnosis made. Review generated 31 patients with the diagnosis of sellar XG. In a minority (6 patients), the underlying lesion for the XG was a pituitary adenoma. Headache was the most common presenting symptom and panhypopituitarism the most common endocrinological abnormality. Examples of hyperprolactinemia associated with sellar XG are also uncommon and due to stalk effect. Neuroimaging of XG on T1-weighted magnetic resonance imaging (MRIs) showed 18 cases (56.3%) were hyperintense, 1 case (3.13%) was isointense, 4 (12.5%) had mixed-signal intensity, and 2 (6.25%) were hypointense. On T2-weighted MRIs, five lesions (15.6%) were hyperintense, three (9.38%) were isointense, nine (28.1%) were heterogeneous, and nine (28.1%) were hypointense. Only one case (3.1%) had calcifications on computed tomography scan similar to ours. In 14 cases (43.7%), the lesions enhanced with contrast administration on MRI. Conclusion Prolactinomas with secondary xanthogranulomatous change represent a rare cause of XG of the sella. With no radiological or clinical signs specific for XG of the sellar region, preoperative diagnosis can be challenging, if not impossible.

Predictive factors of overall survival in primary intracranial pure choriocarcinoma

The incidence of primary intracranial pure choriocarcinoma (PIPC) is extremely rare. Only several case and case series have been previously reported; therefore, there is still lack of knowledge about the prognosis and its standard treatment. We performed a collective study of all reported cases of PIPC to identify the predictive factors related with OS. A comprehensive search was performed on Pubmed’s electronic database using the terms “primary intracranial choriocarcinoma” and “malignant germ cell tumor”. Data about gender, various location, the presence of intratumoral hemorrhage, metastasis and treatment modalities were extracted from the published articles and we analyzed the overall survival based on this predictive factors. 51 cases were eligible and met the inclusion criteria. The majority of the patients were in the child population (44.7%) age between 6 and 12 years old. 77.1% of the patient were male and 22.9% were female. Tumor located other than suprasellar and pineal area showed better prognosis. Median OS of PIPC was 22 months. Patient underwent gross total resection had better outcomes compared with those who only had partial or subtotal resection. Adjuvant therapy (especially chemotherapy) significantly improved OS (p = 0.000, log-rank test). PIPC is chemosensitive and metastasis is the predictive factor for poor prognosis.

Sellar Atypical Teratoid/Rhabdoid Tumor Presenting with Subarachnoid and Intraventricular Hemorrhage

Atypical teratoid/rhabdoid tumors (ATRT) are uncommon malignancies of the central nervous system and are often difficult to distinguish radiographically and pathologically from other common tumors. We present the first case of sellar ATRT presenting with subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH). A 62-year-old woman, who had presented with symptoms of headache, diabetes insipidus, hypothyroidism, and seizures, was found to have a sellar tumor with hemorrhagic transformation. Surgical resection was performed. The pathological examination findings were consistent with ATRT. Despite early surgical intervention, she later died before starting craniospinal radiotherapy and chemotherapy. To the best of our knowledge, although known to present with intratumoral hemorrhage, to date, no cases of sellar ATRT have presented with SAH or IVH have been reported. Considering our finding that ATRT can present with SAH and IVH, establishing the correct diagnosis using radiographic imaging, gender, pathological findings, and molecular markers is paramount for speedy treatment and management.

Dural arteriovenous fistula associated with intratumor hemorrhage

Dural arteriovenous fistula (dAVF) associated with an intracranial tumor is a relatively rare condition. Furthermore, to our knowledge, this is the first case report of dAVF associated with intratumor hemorrhage. We experienced this very rare case and report it here, along with a literature review. A 59-year-old woman presented with transient aphasia and dysgraphia. Computed tomography, magnetic resonance imaging, and angiography showed left anterior cranial fossa dAVF and a tumor with an intratumor hemorrhage. Cerebral angiography demonstrated AV shunts from the left ethmoidal artery via cortical vein flow into the superior sagittal sinus. She underwent shunt-point extirpation for the dAVF and removal of the tumor. The histological finding indicated transitional meningioma. The patient was discharged without any neurological deficit. A dAVF with intratumor hemorrhage is very rare and may be due to the venous congestion of the tumor draining vein by venous hypertension caused by the dAVF.

Sudden neurological deterioration due to repeated intratumoral hemorrhage in a patient with a vestibular schwannoma

Vestibular schwannomas (VS) are the most common tumors involving the cerebellopontine angle (CPA) and the internal auditory canal (IAC). These tumors are usually slow-growing and commonly present with cranial nerve dysfunction such as hearing loss. Repeated intratumoral hemorrhage (ITH) is extremely rare with only four cases previously reported.We report the case of a 30 year old female with a right sided CP angle tumor who presented with vertigo and ataxia due to ITH. Her symptoms initially improved; however, three weeks later, she had acute onset of facial palsy and imaging confirmed rebleeding. Surgical pathology reported typical features of schwannoma.A literature review performed using the PubMed and EMBASE databases yielded four previous reports. A summary of these cases is presented and the features of ITH are discussed. Patients affected by repeated ITH present with sudden headache and ataxia. Rapid worsening of cranial nerve dysfunction such as hearing loss or facial nerve palsy is suggestive of ITH.

Clinical utility of susceptibility-weighted MR sequence for the evaluation of uterine sarcomas

PurposeHigh intensity intra-tumoral hemorrhagic necrosis on T1-weighted images is a suggestive finding for uterine sarcomas, however, the reported prevalence varies. The purpose of this study is to evaluate the capability of susceptibility-weighted MR sequences (SWS) for the diagnosis of uterine sarcomas. Materials and methodsMR imaging of surgically proven 10 uterine sarcomas and 24 benign leiomyomas were retrospectively evaluated for the presence of high intensity areas on T1-weighted images and signal voids on SWS (T2 star-weighted angiography: SWAN). ResultsHigh intensity areas on T1-weighted images and signal voids on SWS were observed in 40% and 100% of sarcomas, whereas 0% and 4% of leiomyomas, respectively. The accuracy, sensitivity, and specificity for T1-weighted images were 82%, 40%, and 100%, and for SWS were 97%, 100%, and 96%, respectively. ConclusionThe demonstration of intra-tumoral hemorrhage in patients suspected with uterine sarcomas by SWS may provide valuable diagnostic findings.

CT, conventional, and functional MRI features of skull lymphoma: a series of eight cases in a single institution.

With the hypothesis that the combination of CT, conventional, and functional MRI can indicate a possible diagnosis of skull lymphoma, this study aimed to systematically explore CT, conventional, and functional MRI features of this rare entity. This retrospective study included eight patients with pathologically confirmed skull lymphomas. CT and conventional MRI findings, including the location, size, attenuation/signal intensity, cystic/necrosis, hemorrhage, calcification, enhancement, skull change, brain parenchyma edema and adjacent structure invasion, were reviewed. We also reviewed multi-parametric functional MR imaging features obtained from diffusion-weighted imaging (DWI, n = 4), susceptibility-weighted imaging (SWI, n = 3) and dynamic susceptibility-weighted contrast-enhanced perfusion-weighted imaging (DSC-PWI, n = 1). The eight patients in this series consisted of five males and three females, with a mean age of 51.1years. All skull lymphomas showed the tumors extending to extra- and intra-cranial spaces with permeative destruction of the intervening skull. Intratumoral cystic/necrosis was seen in one case. Hemorrhage or calcification was absent. Dural mater infiltration was detected in all cases. Two clivus lymphomas encased internal carotid artery without narrowing the lumen. Three cases invaded brain parenchyma with moderate edema. The tumors demonstrated high signal on DWI with low ADC values comparing to muscles. SWI images showed little intratumoral hemorrhage and vessel. Low relative cerebral blood volume (rCBV) value was detected. Skull lymphomas commonly presented as a homogenous solid tumor extending either intra- or extra-cranially with permeative bone destruction. Restricted diffusion, little intratumoral susceptibility signal, and lower perfusion may indicate a specific diagnosis. Multi-parametric functional MRI may be a promising tool for the diagnosis of skull lymphomas.

P3.CR-33 Trichoptysis, Hemoptysis and Chest Pain: A Very Rare Presentation of Anterior Mediastinal Teratoma in a Young Patient

1/Case History: A 28-year old patient who presented to the Emergency Department for a 2-week history hemoptysis, right chest pain and intermittent sebaceous expectorations. He had such intermittent chest pain for the last 2 months. He had no fever, breathlessness, loss of weight, joint pain or renal symptoms. He had no significant personal or family history of tuberculosis. On examination, he was afebrile.Full clinical examination revealed decreased breath sound in the left lung with a dull-percussion note. 2/Investigations: Laboratory investigations were normal.The coagulation tests were normal. The Tuberculin skin test was negative. The Chest CT-scan revealed a large well-circumscribed anterior mediastinal mass with heterogeneous mixed density (fat, soft tissue and calcifications), in the left hemi-thorax. It also showed intra-tumoral bleeding associated with a left massive hemomediastinum. This radiological aspect suggested a teratoma. Preoperative labs showed normal carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), CA-125 and beta-HCG level were normal. 3/Treatment: The multidisciplinary team decision was to perform surgery. A standard posterolateral thoracotomy was performed in the 5th intercostal space. Immediately upon entering the thoracic cavity, a bulky mediastinal mass was found to have a strong adhesion to the upper left lobe. The mass itself was originating from the thymus and extending down to the left lung. A complete thymectomy with a total removal of the tumor was therefore performed. The total amount of bleeding was about 900ml.This was completely evacuated from the thoracic cavity. The patient is currently doing well one year from his initial diagnosis. Although he had a benign teratoma, he was referred to a medical geneticist for further evaluation and management. 4/Discussion and conclusion: Teratomas are germ cell tumors arising from pluripotent cells. Most of them are asymptomatic. Hemoptysis is rare. It may result either from communication with tracheobronchial tree or they may result from bronchial bleeding due to the irritation caused by the tumor. In this case, the presence of hypervascularisation depending on the left internal mammary artery in the chest CT-scan suggests that the teratoma developed systemic blood supply which make our case original. Another pathognomonic symptom is Trichoptysis which is extremely rare . All these symptoms may mimic a pulmonary tuberculosis in young patients especially in our tuberculosis-endemic country. In our case, the tuberculin tests were negative. To conclude, it is a rare case of Teratoma of the anterior mediastinum. It should be considered in the differential diagnosis of Hemoptysis..

Fibrous Pituitary Macroadenomas: Predictive Role of Preoperative Radiologic Investigations for Proper Surgical Planning in a Cohort of 66 Patients

The endoscopic technique is in many cases the technique of choice for the removal of pituitary adenomas. Extended endoscopic approaches make it possible to remove lesions with suprasellar and parasellar extension and fibrous consistency. We identify some characteristics that might point to the adoption of an expanded approach in the preoperative phase. We considered 66 consecutive cases treated for pituitary macroadenomas. All patients underwent preoperative magnetic resonance imaging and computed tomography, as well as postoperative magnetic resonance imaging. From the analysis of surgical reports and preoperative radiologic investigations, we extracted data related to size, extension, morphologic characteristics, consistency, and type of approach used (sellar or expanded). The degree of removal was judged to be total, near total, subtotal, or partial. The data showed that in some cases it is possible to assume in advance that there is a need for an expanded endoscopic approach. The features that led to an extended approach for extracapsular dissection of the lesion were the size of the tumor; an hourglass/dumbbell shape; lateral extension to the suprasellar carotid artery; Knosp degree 3 or 4; contrast enhancement heterogeneity; intratumoral hemorrhage, erosion, or discontinuity of the sellar floor; and increased sellar depth, which predicts increased thickness. The ability to predict the consistency of pituitary adenomas allows the surgeon to design a surgical procedure tailored to the patient. This approach has advantages concerning the extent of resection and allows a radical strategy with a single surgical procedure to be pursued.

Thoracic spinal schwannoma with massive intratumoural haemorrhage

Thoracic spinal schwannoma with massive intratumoural haemorrhage

Imaging characteristics of cerebral extraventricular neurocytoma with pathological correlation.

Extraventricular neurocytoma (EVN) is an exceedingly rare tumor. In this study, we sought to characterize the imaging and pathological features of this uncommon tumor. Retrospective review of 18 patients (9 male; 9 female) with pathologically confirmed EVN treated at a single center between 2005 and 2017. All patients had a solitary lesion. Sixteen lesions were found in hemispheres. The greatest tumor diameter ranged from 2.6 to 8cm. The lesions were generally solid with cystic components; the solid portion appeared isodense or hyperdense on CT, isointense to hypointense on T1WI, and slightly hyperintense on T2WI. Heterogeneous hyperintensity interspersed with isointense or hypointense areas suggestive of hemorrhage, calcification or vascular flow voids were seen on T2WI. Heterogeneous enhancement was noted in 17 lesions; no enhancement was observed in one lesion. Cystic components were observed in 13 lesions; 9 of these showed characteristic perilesional cysts (9/13). Mild to moderate peritumoral edema (15/18), calcification (4/16), intratumoral hemorrhage (11/18) and vascular flow voids (10/16) were observed in some lesions. Pathologically, tumor cells showed round nucleus and fine neuropil matrix. Foci of calcification in the solid portion of the tumor were seen in five cases. Microcystic changes were observed in almost all cases. Some lesions exhibited positive staining for synaptophysin (Syn) (15/16) and neuronal nuclei (NeuN) (7/8). MIB-1 was determined for 10 patients; seven of these had an MIB-1 ≥ 3. These six patients experienced recurrence; four of them relapsed twice. EVNs occur as single intracranial solid mass with cystic components (especially peripherally located cysts); solid portion exhibits slight hyperintensity or heterogeneous signal intensity. Mild to moderate peritumoral edema, calcification, intratumoral hemorrhage and vascular flow voids were characteristic features of extraventricular neurocytoma. Positive staining for synaptophysin and neuronal nuclei confirmed the diagnosis. A combination of atypical pathologic features and atypical radiologic features should be considered for prognostic assessment.

MRI Phenotype of RELA-fused Pediatric Supratentorial Ependymoma.

Epigenetic profiling has recently identified clinically and molecularly distinct subgroups of ependymoma. The 2016 World Health Organization (WHO) classification recognized supratentorial ependymomas (ST-EPN) with REL-associated protein/p65 (RELA) fusion as aclinicopathological entity. These tumors represent 70% of pediatric ST-EPN characterized by recurrent C11orf95-RELA fusion transcripts, which lead to pathological activation of the nuclear factor 'kappa-light-chain-enhancer' of activated B-cells (NF-κB) signaling pathway. Cyclin-dependent kinase inhibitor 2A (CDKN2A) inactivation has also been reported to correlate with poor prognosis. Here, we systematically describe magnetic resonance imaging (MRI) characteristics of RELA-fused ST-EPN, with respect to CDKN2A deletion status. Our cohort of patients with ST-EPN (n = 57) was obtained from the database of the German Brain Tumor Reference Center of the German Society for Neuropathology and Neuroanatomy (DGNN), and tumors were diagnosed according to the 2016 WHO classification. Molecular characterization identified 47RELA-fused tumors. We analyzed the preoperative MRI according to standardized criteria, and comparison was performed between CDKN2A altered (n = 21) and CDKN2A wild type (n = 26) tumors. The RELA-fused ST-EPN showed aspectrum of predominantly hemispheric tumors with cysts and necrosis. Statistical analysis on CDKN2A status revealed significant differences in terms of younger manifestation age (p =0.002) and more intratumoral hemorrhage in T2-weighted imaging (T2WI) (p =0.010) in wild type tumors; however, the location was not aparameter for differentiation. This study first provides comprehensive MRI data for RELA-fused ST-EPN as adistinct entity, with further interest on CDKN2A genomic status. Patient stratification by morphological MRI alone seems difficult at present. The results may support ongoing research in ST-EPN within the framework of the radiogenomics concept.

Gamma Knife Radiosurgery for Metastatic Brain Tumors from Malignant Melanomas: A Japanese Multi-Institutional Cooperative and Retrospective Cohort Study (JLGK1501)

Background: The incidences of metastatic brain tumors from malignant melanomas have increased and survival has been prolonged by novel molecular targeted agents and immunotherapy. However, malignant melanomas are uncommon in Asian populations. Objectives: We retrospectively analyzed treatment efficacy and identified prognostic factors impacting tumor control and survival in Japanese melanoma patients with brain metastases treated with gamma knife radiosurgery (GKRS). Methods: We retrospectively reviewed the medical records of 177 patients with 1,500 tumors who underwent GKRS for brain metastases from malignant melanomas. This study was conducted by the Japanese Leksell Gamma Knife Society (JLGK1501). Results: Six and 12 months after GKRS, the cumulative incidences of local tumor recurrence were 9.2 and 13.8%. Intratumoral hemorrhage (p < 0.0001) and larger tumor volume (p = 0.001) in GKRS were associated with significantly poorer local control outcomes. The use of immune checkpoint inhibitors before GKRS was significantly associated with symptomatic adverse events (p = 0.037). The median overall survival time after the initial GKRS was 7.3 months. Lower Karnofsky performance status scores (p = 0.016), uncontrolled primary cancer (p < 0.0001), and multiple brain metastases (p = 0.014) significantly influenced unfavorable overall survival outcomes. The cumulative incidences of neurological death 6 and 12 months after GKRS were 9.7 and 17.4%, those of neurological deterioration were 14.2 and 19.6%, and those of new tumor appearance were 34.5 and 40.5%. Conclusions: The results of the present multicenter study suggest that GKRS is a relatively effective and safe modality for control of tumor progression in Japanese patients with brain metastases from malignant melanomas.

Spontaneous Fatal Rupture of a Large Pseudoaneurysm within a Renal Angiomyolipoma following Incomplete Embolization in a Patient with Bilateral Renal Angiomyolipomas

Angiomyolipoma (AML)—a frequently seen solid renal tumor—is the most common benign tumor of the kidney. It was considered to be hamartomatous in origin and is now considered to be a member of the family of perivascular epithelioid cell (PEComa).[1] Classically thought to be associated with tuberous sclerosis that is an autosomal dominant disease with TSC1 or TSC2 gene mutation, around 80% AMLs may present sporadically.[1] They are also seen in patients with lymphangiomyomatosis and included in its diagnostic criteria.[2] Clinically, the tumor has myriad of presentations ranging from being completely asymptomatic at the time of diagnosis to abdominal pain, hematuria, recurrent urinary tract infection, and intratumoral bleed that can be occasionally massive requiring urgent embolization or nephrectomy.[3] On ultrasound AMLs appear as markedly hyperechoic to hypoechoic depending on the fat content. Though they are more frequently echogenic compared with renal cell carcinoma, overlap in imaging features can occur.[4] On color Doppler, pseudoaneurysms are seen as anechoic structure showing internal turbulent to-and-fro motion.[5] On computed tomographic (CT) scan, the diagnosis of renal AML depends on the detection of intralesional fat.[6]

Chances of Improvement in Cases of Vestibular Schwannoma Presenting with Facial Nerve Weakness: Presentation of Two Cases and Literature Review

Background and Study Aim Facial nerve (FN) weakness as a presenting feature in vestibular schwannoma (VS) is extremely rare. We are presenting two different cases of VS with significant facial weakness and reviewed the literature for similar cases. Methods and Results We are presenting two cases of VS with significant facial weakness. The first case was a 63-year-old male patient presented with 3 weeks' history of severe left-sided facial weakness (House-Brackmann [HB] grade V) and hearing loss. Magnetic resonance imaging (MRI) of the brain showed a tumor in the left internal auditory canal. Gross total removal with anatomical and physiological FN preservation was performed through a retrosigmoid approach under neurophysiological monitoring. FN function improved postoperatively to HB grade II after 16 months. The other case was 83-year-old male patient presented with sudden left-sided hearing loss and severe facial weakness (HB grade V). MRI of the brain 2.5 years before showed a left-sided (Class-T3A) cystic VS. The tumor was asymptomatic; wait-and-scan strategy was advised by the treating neurologist. Recent MRI of the brain showed approximately three times enlargement of the tumor with brain stem compression, extensive cystic changes, and suspected intratumoral hemorrhage. Surgery was performed; the tumor was subtotally removed through a retrosigmoid approach with intraoperative FN monitoring. The FN was anatomically preserved; however, physiological preservation was not possible. Severe facial weakness with incomplete lid closure persisted postoperatively. Conclusion Surgical treatment could be offered to cases of suspected VS presenting with facial weakness, as these cases may still have a chance for improvement especially in laterally located tumors.

Tumor-associated hemorrhage in patients with vestibular schwannoma.

Intratumoral hemorrhage (ITH) associated with vestibular schwannomas (VS) is very rare. We retrospectively analyzed VS patients presenting with ITH in our department to further gain a better understanding of this uncommon clinical presentation. We treated seven patients who had VS presenting with ITH between January 2012 and June 2017. All the patients had preoperative computed tomography (CT), computed tomography angiography (CTA), and magnetic resonance imaging(MRI) done which aided in the radiological diagnosis as well as postoperative MRI to confirm the resection extent of the VS. Continuous electrophysiological monitoring of cranial nerves was carried out during surgery. Of the seven patients, three were male and four were female. Their ages ranged from 42 to 71years (average age, 57.4years). Two patients reported a history of hypertension. Sudden onset or rapid worsening of clinical symptoms occurred in five patients at time of hemorrhage. The mean diameter of the lesions was 4.1cm (range, 3.0-5.0cm). No patient had a pretreatment of stereotactic radiosurgery. Gross total resection was achieved in four cases and subtotal resection in three cases. There were no surgery-related neurological deficits but one patient died 18days after surgery. Follow-up visits were scheduled at 6months postoperatively and two patients had tumor recurrence and received stereotactic radiosurgery again. The incidence of ITH in VS is relatively rare and hypertension may highly correlate with ITH in VS. In comparison with peritumoral adhesion caused by chronic inflammation in multicystic VS with microhemorrhage,ITH caused by acute massive hemorrhage will not increase the extent of peritumoral adhesion immediately. The prognosis of surgery for patients with acute hemorrhagic VS may be better than that for microhemorrhage in multicystic VS. Besides, timely microsurgical treatment is also important to relieve symptoms.

A rare case of a spontaneously ruptured secondary hepatic malignant lymphoma

BackgroundAlthough secondary liver involvement of the lymphoma is common and occurs in 50% of patients with non-Hodgkin’s lymphoma, liver tumor rupture in malignant lymphoma is extremely rare. We report a case of a spontaneously ruptured secondary liver involvement of non-Hodgkin’s lymphoma that was successfully treated with transcatheter arterial embolization (TAE) to obtain hemostasis, and subsequent hepatectomy and systemic chemotherapy. To the best of our knowledge, this is only the second reported case of a ruptured hepatic lymphoma.Case presentationA 74-year-old man with sudden-onset right shoulder and upper quadrant pain was transferred to our hospital via an ambulance. His vital signs were stable. Contrast-enhanced computed tomography showed a large hypo-enhancing tumor (94 × 81 mm) in the posterior segment of the liver, with intratumoral extravasation and a 12 × 10 mm daughter tumor in segment 5 of the liver. Hemoperitoneum due to rupture of hepatocellular carcinoma with intratumoral hemorrhage was suspected, although the serum alpha-fetoprotein and protein induced by vitamin K absence-II levels were within normal range. TAE was used for hemostasis. Extended posterior segmentectomy including tumor resection in segment 5 was performed on day 23 after embolization. The postoperative course was uneventful. Pathological examination of the resected specimens revealed that the ruptured tumor was diffuse large B-cell lymphoma. Postoperative fluorodeoxyglucose positron emission tomography-computed tomography showed uptake in the left parotid gland, pancreas, and thoracic vertebra. Based on these findings, the final diagnosis was a ruptured secondary hepatic malignant lymphoma. Complete remission was achieved with chemotherapy. He remains alive 30 months after hepatectomy without evidence of relapse.ConclusionsWe report the first case describing a hepatic tumor rupture as the first presentation of a primary or secondary hepatic malignant lymphoma. The patient was successfully treated with TAE, hepatectomy, and subsequent systemic chemotherapy for non-Hodgkin’s lymphoma.

Predictors of postoperative motor function in rolandic meningiomas.

Resection of supratentorial meningiomas is generally considered a low-risk procedure, but tumors involving the rolandic cortex present a unique challenge. The rate of motor function deterioration associated with resecting such tumors is not well described in the literature. Thus, the authors sought to report the rates and predictors of postoperative motor deficit following the resection of rolandic meningiomas to assist with patient counseling and surgical decision-making. An institution's pathology database was screened for meningiomas removed between 2000 and 2017, and patients with neuroradiological evidence of rolandic involvement were identified. Parameters screened as potential predictors included patient age, sex, preoperative motor severity, tumor location, tumor origin (falx vs convexity), histological grade, FLAIR signal (T2-weighted MRI), venous involvement (T1-weighted MRI with contrast), intratumoral hemorrhage, embolization, and degree of resection (Simpson grade). Variables of interest included preoperative weakness and postoperative motor decline (novel or worsened permanent deficit). The SPSS univariate and bivariate analysis functions were used, and statistical significance was determined with alpha < 0.05. In 89 patients who had undergone resection of convexity (80.9%) or parasagittal (19.1%) rolandic meningiomas, a postoperative motor decline occurred in 24.7%. Of 53 patients (59.6%) with preoperative motor deficits, 60.3% improved, 13.2% were unchanged, and 26.4% worsened following surgery. Among the 36 patients without preoperative deficits, 22.2% developed new weakness. Predictors of preoperative motor deficit included tumor size (41.6 vs 33.2 cm3, p = 0.040) and presence of FLAIR signal (69.8% vs 50.0%, p = 0.046). Predictors of postoperative motor decline were preoperative motor deficit (47.2% vs 22.2%, p = 0.017), minor (compared with severe) preoperative weakness (25.6% vs 21.4%, p < 0.001), and preoperative embolization (54.5% vs 20.5%, p = 0.014). Factors that trended toward significance included parafalcine tumor origin (41.2% vs 20.8% convexity, p = 0.08), significant venous involvement (44.4% vs 23.5% none, p = 0.09), and Simpson grade II+ (34.2% vs 17.6% grade I, p = 0.07). Resection of rolandic area meningiomas carries a high rate of postoperative morbidity and deserves special preoperative planning. Large tumor size, peritumoral edema, preoperative embolization, parafalcine origin, and venous involvement may further increase the risk. Alternative surgical strategies, such as aggressive internal debulking, may prevent motor decline in a subset of high-risk patients.

Clinical Parameters to Distinguish Silent Corticotroph Adenomas from Other Nonfunctioning Pituitary Adenomas

It is difficult to distinguish silent corticotroph adenomas (SCAs) from other nonfunctioning pituitary adenomas (NFPAs) preoperatively. This study aimed to determine the preoperative clinical parameters associated with SCAs. This was a retrospective single-center study of patients who underwent surgery for NFPAs during 2011-2016 in our tertiary hospital and who had preoperative combined pituitary function test (CPFT) and immunohistochemical staining results available. After we excluded patients with increased 24-hour urinary free cortisol to preclude overt Cushing's disease, 341 patients were finally enrolled. The medical records, including the CPFT and immunohistochemistry results, of the patients were reviewed. The age and tumor size were similar between patients with SCAs and other NFPAs. The SCA group had a greater proportion of women (89.2% vs. 57.6%, P < 0.001), cavernous sinus invasion (35.1% vs. 20.7%, P= 0.047), and intratumoral hemorrhage on preoperative sella magnetic resonance imaging (32.4% vs. 9.2%, P < 0.001) compared with the NFPA group. In the preoperative CPFT, the cortisol response was not significantly different between groups. However, the peak adrenocorticotropic hormone (ACTH) (67.80 ± 49.83 vs. 85.67 ± 78.97 pg/mL, P= 0.061) tended to be lower, and the ΔACTH (53.71 ± 50.14 vs. 72.67 ± 75.82 pg/mL, P= 0.046) was significantly lower in SCAs. After we excluded patients with preoperative hypopituitarism caused by mass effects, the peak ACTH (69.39 ± 39.45 vs. 119.75 ± 89.84 pg/mL, P= 0.001) and ΔACTH (58.58 ± 36.51 vs. 107.66 ± 86.05 pg/mL, P= 0.001) were significantly lower in SCAs than in other NFPAs. Female sex, cavernous sinus invasion, intratumoral hemorrhage on sella magnetic resonance imaging, and decreased ACTH response in the CPFT are independent indicators of SCAs.