Intramural Nodules Research Articles

Fluorescence guidance during robotic resection of bladder wall endometriosis: case report and technique.

The application of indocyanine green (ICG) has recently been reported to aid in the resection of endometriosis in the bladder wall and/or involving the ureters. A symptomatic 41-year-old patient with dysmenorrhea and pollakisuria was referred to our tertiary center. Imaging revealed a 1.5-2cm intramural endometriotic nodule in the posterior bladder wall. She was planned for robotic resection of the endometriotic nodule, under ICG guidance, together with a hysterectomy. After placement of double-J ureteral stents and clamping the bladder, perforation of the bladder mucosa could be avoided whilst performing a circumferential resection of the nodule. By clamping the bladder catheter after instillation of ICG, both the bladder wall thickness and ureters could be visualized with near-infrared imaging during robotic resection of the endometriotic nodule and hysterectomy. With the surgical approach described here, endometriotic nodules/tissue can be removed precisely with enlarged vision at the robot console, safely, and completely without damaging adjacent tissues.

Xanthogranulomatous Cholecystitis: A Rare form of Chronic Cholecystitis

Xanthogranulomatous cholecystitis (XGC) is a rare form of cholecystitis distinguished by the presence of numerous yellow-brown intramural nodules with severe fibrosis and foam cells within the gallbladder wall, which may be misdiagnosed as a Gall Bladder Carcinoma. It is typically diagnosed between the sixth and seventh decades of life, predominantly in females. Clinical signs and symptoms are comparable to those of acute and chronic cholecystitis, making it challenging to distinguish XGC prior to surgery. The case of a 52-year-old man who presented to the emergency department with right upper quadrant abdominal pain for 4 months, radiating into the right shoulder is discussed. Patient was diagnosed to have Chronic Calcular Cholecystitis on Ultrasound. Laparoscopic Cholecystectomy was performed and XGC was diagnosed post-operatively through definitive histopathological examination. Preoperatively and intraoperatively, Xanthogranulomatous Cholecystitis is difficult to diagnose and pathological examination is required for a definitive diagnosis. XGC, which exhibits clinical and radiological signs similar to those of gallbladder tumors, must be included in the differential diagnosis in order to avoid an extensive surgical procedure.

Xanthogranulomatous Cholecystitis: A Distinctive Subtype of Importance.

A 53-year-old female with a history of hiatal hernia repair presented with right upper quadrant pain and jaundice. Physical examination revealed tenderness of the right upper quadrant. Laboratory tests showed elevated C-reactive protein of 109 mg/L (normal <10) and total bilirubin of 181 μmol/L (normal 0–21). Abdominal computed tomography highlighted a gallstone within the main bile duct and an enlarged gallbladder with heterogenous enhancement and intramural hypoattenuating nodules (Figure A). These radiological features established the diagnosis of xanthogranulomatous cholecystitis (XC).

Evaluation of the effectiveness of a proposed approach to treat infertility against the background of uterine leiomyoma, which includes treatment with a releasing hormone agonist, hysteroresectoscopy or conservative myomectomy, and pre-pregnancy treatment

There is much discussion about the effect of uterine leiomyomas on the outcomes of assisted reproductive technologies (ART). This study aimed to analyze the effectiveness of in vitro fertilization following the use of a therapy scheme we propose to treat infertility with the background of uterine leiomyoma. The therapy scheme includes the use of a releasing hormone agonist, hysteroresectoscopy or conservative myomectomy and pre-pregnancy pre-treatment. The clinical study involved 175 women of reproductive age who had been diagnosed with uterine leiomyoma, and were divided into the groups as follows. The treatment group A included 137 women with uterine leiomyoma, and was further divided into subgroups. Subgroup A1 included 55 women with uterine leiomyoma after conservative myomectomy who underwent the proposed treatment scheme (TS); A2 included 45 women with uterine leiomyoma after hysteroresectoscopy who underwent the TS; A3 included 37 women with uterine leiomyoma who underwent the TS but not the surgical removal of uterine leiomyoma. Control group B included 38 women with uterine leiomyoma after conservative myomectomy. All patients with intramural and submucosal myoma nodules underwent a hormonal preparatory treatment with a gonadotropin-releasing hormone (GnRH) agonist (Diphereline 3.75 mg intramuscularly once every 28 days for 3 months) prior to the myomectomy. After the surgery, patients were prescribed a combination therapy with a vitamin complex FT 500 plus, vitamin D3 and Pelvidol for three months before and during controlled ovarian stimulation (COS) protocol up to the follicle puncture. We determined that the incidence of pregnancy was the lowest (37.8 %) in women with infertility against the background of uterine leiomyoma, who surgically treated for the myomas, but underwent pre-pregnancy pre-treatment. The frequency of pregnancy did not differ between the A1 and A2 treatment groups, and was on average 7.0 % higher than in the control group, and 11.0 % higher than in the A3 group. The relative incidence of clinical pregnancies was the highest in A1 (45.5 %) and A2 (44.4 %) treatment groups. The frequency of live births in the A1 group was significantly higher than in A3 group (by 14.0 %), while the relative number of term live births in the A1 group exceeded that of A3 group by 26.0 %. Thus, both proposed therapy schemes to treat infertility against the background of uterine leiomyoma, which include the use of a releasing hormone agonist, either a conservative myomectomy or hysteroresectoscopy and pre-pregnancy pre-treatment in addition to the ART protocol with a multi-vitamin complex with inositol, vitamin D3, alpha-lipoic acid and magnesium, had the equivalent effects on the incidence of clinical pregnancy, however the frequency of live births was highest after conservative myomectomy (84.0 %).

Outcomes in Sonographically Categorized Complex Cystic Breast Lesions.

To investigate outcomes of patients with complex cystic breast lesions and to determine malignancy rates for each sonographic category. A total of 124 women with a mean age of 45 were enrolled in this retrospective study. Complex cysts were classified into four categories according to sonographic findings (thick septa/wall, intramural nodule, solid/cystic ratio) by two radiologists. Size, margin, short-to-long axis ratio, and vascularity were also noted. The relationship between sonographic features and histopathological/follow-up results was evaluated. Of 124 complex cysts, 11 were malignant and 113 were benign. There were 31 with thick septa/wall (category 1), 14 with intramural nodule (category 2), 60 with solid/cystic ratio < 1 (category 3), and 19 with solid/cystic ratio > 1 (category 4). Among 11 malignant tumors, six intraductal papillary carcinomas and three invasive ductal carcinomas were in category 3, whereas one invasive ductal carcinoma was in category 1 and one was in category 4. Most of malignant lesions (9/11, 82%) were in category 3. Most of benign lesions (96/113, 85%) were fibroadenomatoid/fibrocystic changes. The presence of vascularity (96%), irregular margin (94%), and short-to-long axis ratio ≥ 1 (94%) had higher accuracy rates for diagnosis of malignancy. The malignancy rate was 8.8% in our study. Besides internal morphological features, other sonographic features should be considered in the evaluation of complex cystic breast lesions. Due to substantial risk of malignancy and the overlapping sonographic features of benign and malignant lesions, tissue sampling of all complex cysts should be performed.

Laparoscopic Myomectomy Assisted by Hysteroscopy: A Case Report

Study Objective To demonstrate the benefits of laparoscopic myomectomy assisted by hysteroscopy to minimize endometrium damage, therefore providing a better fertility outcome. Design Case report for surgical technique and description of the procedure using video. Setting Tertiary hospital. Patients or Participants A 30-year-old nulliparous woman presents with abnormal uterine bleeding and pelvic pain for a year and a half. She previously tried clinical treatment with Tranexamic Acid and Oral Progesterone without symptoms remission. In the physical examination there weren't any irregular findings. The MRI evidenced multiple nodular formations: a 2 cm submucous fibroid on the fundus with cavity distortion and 8mm of myometrial free margin and others intramural and subserous fibroids measuring up to 1.7cm. Interventions We performed a diagnostic hysteroscopy to locate the submucous fibroid and used the hysteroscope's pressure and light to guide de surgeon on the laparoscopy towards that fibroid. We did a vertical incision and proceeded to enucleate the fibroid. We also excised other subserous and intramural nodules along the surgery. Uterine suture was done with a 2-0 barbed suture in two layers. We finished the procedure with another diagnostic hysteroscopy to evaluate endometrium damage. Measurements and Main Results In the final hysteroscopy we could see little endometrium damage. The patient was discharged on the first postoperative day without significant pain. Conclusion We were able to achieve minimal endometrium damage in a Type 2 FIGO staging fibroid, which would not be possible if we had performed a hysteroscopic myomectomy. On the other hand, if we had done only a laparoscopic procedure, we would have had a significant higher degree of difficulty at finding the fibroid due to its deep placement. Therefore, we reached a favorable outcome regarding the surgical approach in resecting a submucous fibroid in a patient with intention of childbearing. To demonstrate the benefits of laparoscopic myomectomy assisted by hysteroscopy to minimize endometrium damage, therefore providing a better fertility outcome. Case report for surgical technique and description of the procedure using video. Tertiary hospital. A 30-year-old nulliparous woman presents with abnormal uterine bleeding and pelvic pain for a year and a half. She previously tried clinical treatment with Tranexamic Acid and Oral Progesterone without symptoms remission. In the physical examination there weren't any irregular findings. The MRI evidenced multiple nodular formations: a 2 cm submucous fibroid on the fundus with cavity distortion and 8mm of myometrial free margin and others intramural and subserous fibroids measuring up to 1.7cm. We performed a diagnostic hysteroscopy to locate the submucous fibroid and used the hysteroscope's pressure and light to guide de surgeon on the laparoscopy towards that fibroid. We did a vertical incision and proceeded to enucleate the fibroid. We also excised other subserous and intramural nodules along the surgery. Uterine suture was done with a 2-0 barbed suture in two layers. We finished the procedure with another diagnostic hysteroscopy to evaluate endometrium damage. In the final hysteroscopy we could see little endometrium damage. The patient was discharged on the first postoperative day without significant pain. We were able to achieve minimal endometrium damage in a Type 2 FIGO staging fibroid, which would not be possible if we had performed a hysteroscopic myomectomy. On the other hand, if we had done only a laparoscopic procedure, we would have had a significant higher degree of difficulty at finding the fibroid due to its deep placement. Therefore, we reached a favorable outcome regarding the surgical approach in resecting a submucous fibroid in a patient with intention of childbearing.

Disseminated Peritoneal Leiomyomatosis: A Case Report of an Incidental Finding During an Emergency Caesarean Section and a Review of the Literature

Aim: To present the case report of an incidental finding of disseminated peritoneal leiomyomatosis (DPL) found during an emergency caesarean section in a young Nigerian woman who presented with slow progress in labour and maternal exhaustion.&#x0D; Presentation of Case: We present the case of a 35-year-old unbooked primigravida with previous myomectomy who presented with maternal exhaustion and slow progress in labour and subsequently had an emergency lower segment caesarean section. At surgery, multiple firm to hard nodules of varying sizes were seen scattered throughout the peritoneum. Histological examination and immunohistochemical analysis of the nodules showed features consistent with disseminated peritoneal leiomyomatosis. Clinical and radiological follow-up for 1 year was uneventful.&#x0D; Discussion: DPL is a rare benign smooth muscle tumour that clinically and macroscopically simulates disseminated intra-abdominal or pelvic malignancy. It occurs predominantly in women of child bearing age and is mostly discovered incidentally. The occurrence of DPL in association with pregnancy and uterine leiomyomas was also corroborated in this index case as pedunculated and intramural uterine nodules were also seen during surgery.&#x0D; Conclusion: Disseminated peritoneal leiomyomatosis is a rare benign disease which may be misdiagnosed as disseminated or metastatic intra-abdominal malignancy. Therefore, a high index of suspicion is required for accurate diagnosis and proper management.

A Case Report on Chronic Xanthogranulomatous Cholecystitis

Xanthogranulomatous cholecystitis is an uncommon form of cholecystitis often being misdiagnosed as gallbladder carcinoma, hence poses as a diagnostic challenge for physicians. The proposed mechanism of the formation of this lesion is through mucosal ulceration or the rupture of Rokitansky-Aschoff sinuses due to increased intraluminal pressure. This causes granulomatous changes that lead to the formation of intramural nodules. Due to its nature of presenting as a gallbladder mass, certain surgical interventions can become unwarranted, which may diminish the patient’s quality of life. This paper presents a case of a 59-year-old male who presented with epigastric pain, initially treated as reflux disease, relieved by antacids, antispasmodics and opioid analgesics. The imaging studies revealed a mass in the gallbladder with signs of cholecystitis. The patient underwent intra-operative ultrasound, extended cholecystectomy and lymph node dissection with an unremarkable postoperative course. The final histopathology revealed chronic xanthogranulomatous cholecystitis and was negative for malignancy. This paper further reviews the presentation of the lesion under different imaging modalities. On ultrasound, it appears as a hypoechoic focus and marked or focal thickening of the gallbladder wall, while on computed tomography, it presents with hypoattenuating nodules in thickened walls, luminal surface enhancement with continuous mucosal lines. While on magnetic resonance imaging, it may appear as either a reduced signal intensity on out of phase images or slightly high signal intensity and slight enhancement on early phase and strong enhancement on the late phase. In general, the recommended treatment approach is through open cholecystectomy.

A scoring system based on computed tomography for the correct diagnosis of xanthogranulomatous cholecystitis.

BackgroundXanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The differential diagnoses of XGC include gallbladder cancer (GBC), adenomyomatosis, and actinomycosis of the gallbladder.PurposeTo assess the usefulness of computed tomography (CT) findings in the diagnosis of XGC and differentiation from GBC.Material and MethodsWe retrospectively assessed the pathological and radiological records of 13 patients with pathologically proven XGC and 33 patients with GBC.ResultsSignificant differences were observed for the following five CT findings: diffuse wall thickening (XGC = 85%, GBC = 15%, P < 0.01); absence of polypoid lesions (XGC = 100%, GBC = 48%, P < 0.01); intramural nodules or bands (XGC = 54%, GBC = 9%, P < 0.01); pericholecystic infiltration (XGC = 69%, GBC = 9%, P < 0.01); and pericholecystic abscess (XGC = 23%, GBC = 0%, P = 0.018). We defined the scoring system based on how many of the five CT findings were observed. Our scoring system, which included these findings, revealed that patients with three or more findings had sensitivity of 77% (95% confidence interval [CI] = 57–87) and specificity of 94% (95% CI = 86–98).ConclusionOur scoring system can assist in the differentiation of XGC from GBC.

25. Strumal carcinoid – When two become one

Background: Strumal carcinoid is the rare coexistence of both struma ovarii and carcinoid. Recognition of this essentially benign entity avoids misdiagnosis and over-treatment. Aims: To present the macroscopic, microscopic, immunohistochemical, and ultrastructural findings of a case of strumal carcinoid. Methods: A 51-year-old female presented with a 4 cm left adnexal mass that was resected and received by the Anatomical Pathology Department at Concord Repatriation General Hospital. Macroscopic examination, light microscopy, immunohistochemistry, and electron microscopy were performed. Results and conclusions: Macroscopically, the specimen consisted of a 40 mm cystic lesion lined by dark-brown granular material, with a 14 mm brown-and-spongy intramural nodule including a colloid-like area. By light microscopy, the cyst was a haemorrhagic corpus luteum and the nodule was a biphasic tumour composed of thyroid tissue and rosette-forming/trabecular areas. By immunohistochemistry, the rosette-forming/trabecular areas were positive for CD56 and NSE—though negative for chromogranin and synaptophysin. By electron microscopy, the rosette-forming/trabecular areas contained ‘salt-and-pepper’ nuclear chromatin and cytoplasmic single-membrane bound dense core granules. Therefore, the biphasic tumour was concluded to be composed of both thyroid and neuroendocrine tissue and a diagnosis of strumal carcinoid was made. Strumal carcinoid is the intimate association of thyroid and carcinoid tissue, seen in 25% of primary ovarian carcinoid. It is a unilateral lesion, 1–20 cm, beefy-red to yellow, and can be near-pure or part of a cystic teratoma. The morphologic and immunohistochemical features are predictable. The prognosis is almost invariably benign and local disease is treated by salpingo-oopherectomy, however a study of 50 cases reported one incident of peritoneal metastasis and death. In this same study, strumal carcinoid had been misdiagnosed as malignant transformation of struma ovarii in 4 of 50 cases. The diagnostic pitfall today is to over-interpret the frequently present mucinous epithelium of strumal carcinoid as representing mucinous (goblet cell) carcinoid.

RATIONAL DELIVERY FOR WOMEN WITH UTERAL FIBROID AND BREECH PRESENTATION AND DECREASING THE INDEXES OF MATERNAL MORBIDIY

Introduction. Breech presentation and uterine fibroids in women are clinical cases which occur more and more frequently in modern obstetric practice. Regarding this issue, scientists’ attention is drawn to the aspect of surgical delivery for such patients, which unavoidably requires taking into account both unplanned necessity of expanding the volume of caesarian section (myomectomy, uterine removal) and increased intraoperative blood loss. Aim. Decreasing the indexes of maternal morbidity in women with uterine fibroid and breech presentation by developing the optimal approach to their delivery.Materials and methods. An analysis of primiparae and secundiparae with uterine fibroid and with single full-term pregnancy with breech presentation has taken place and constituted the main group (MG) (n=40). The control group (CG) (n=40) consisted of primiparae and secundiparae with single full-term pregnancy with breech presentation without uterine fibroid. All the women had their deliveries at Odesa Regional Perinatal Centre. The data has been processed with Microsoft Office Excel 2017. Research results. The analysis of the data received has shown that gynecological anamnesis of women from the CG was reliably more frequently complicated by: late menarche 12 (30%), abnormal uterine bleeding 9 (22.5%) and dysmenorrhea 18 (45%) (p<0,05). It has been determined that the women from the CG had deliveries through natural birth canal almost twice as frequently 32 (80 %). In the MG 17 (42,5 %) conservative deliveries occurred under the condition of patients having subserous or intramural myoma nodules with the size not larger than 5 cm localized in the uterus body (p<0,05). It has been determined that pregnancies of the CG women ended with surgical delivery three times as frequently 23 (57,5 %) as in the MG 8 (20 %) (p<0,05). All cases of the cesarean section in the MG were planned in advance with regard to such variations of fibrosis as: multiple nodules, single nodules with centripetal growth, localization in the lower uterine segment or large size (5 - 16 см). It has been shown that advanced planning of the surgical deliveries with uterine fibroid and breech presentation in the MG 23 (57,5 %) does not prevent from urgent situations н 7 (30,4 %), which is complicated by the necessity of extending the volume of the surgery 3 (13 %). Issues of elective cesarean section among women from the MG did not require volume extension in any case. В свою чергу, advanced planning of conservative delivery with breech presentation in the CG 40 (100%) also does not prevent from cases of urgent surgical deliveries 8 (20 %), where the leading indication for it was deviation of labour activity 4 (50 %). Conclusions. Balanced obstetrical approach to the issue of uterine fibroid with breech presentation considering the variation of fibroids in each particular case favours preliminary determination of the optimal method of delivery for each woman, which might be effective in the cases of decreasing the indexes of maternal morbidity among such patients due to decreasing both the number of surgical deliveries and the cases of volume extension for cesarian sections.

Is Final Histopathological Examination the Only Diagnostic Criteria for Xanthogranulomatous Cholecystitis?

Background:Xanthogranulomatous cholecystitis (XGC) is an uncommon inflammatory disease of gallbladder (GB) and can mimic GB cancer in extensive form. This study aims to assess the predictability of XGC on the basis of clinical presentation, laboratory tests, and radiological or intraoperative findings on frozen section analysis.Materials and Methods:This is a retrospective study, conducted over a period of 4 years from October 2013 to November 2017. In this study, all patients with histopathological reports of XGC, who underwent cholecystectomy or a radical cholecystectomy, were included. Clinical records of these patients were reviewed for clinical features, laboratory tests, and findings on radiological imaging.Results:Out of 700 consecutive cholecystectomies reviewed, 34 had histologically proven XGC (4.85%). Two patients had simultaneous presence of GB carcinoma with XGC. The most common presenting symptoms were right upper quadrant pain in 32 (94%) patients, jaundice in 9 (36%) patients, and fever in 5 (14%) patients. The most common radiological finding was cholelithiasis in 85.2% of cases. Thick-walled GB was present in 79.4% of patients; irregular wall thickening was present in 20.5% of patients. Intramural nodule was present in two patients, whereas hepatic invasion was observed in 11% and pericholecystic infiltration was present in 8.8% of patients. Regional lymphadenopathy was present in 9 (26.4%) patients.Conclusion:Clinical presentation and laboratory parameters were unequivocal due to considerable overlap. Despite recent advances in radiology, none have significant sensitivity and specificity to accurately diagnose XGC preoperatively. Intraoperative frozen section can add to the diagnosis with limited accuracy. The diagnosis of XGC can be confirmed only on histopathological examination.

Diagnostic accuracy of MDCT in differentiating gallbladder cancer from acute and xanthogranulomatous cholecystitis

ObjectiveTo determine the diagnostic accuracy of multi-detector CT (MDCT) for differentiating gallbladder cancer from acute and xanthogranulomatous cholecystitis using previously described imaging features. MethodsIn this IRB approved HIPAA-compliant retrospective cohort study, contrast-enhanced MDCT of histologically confirmed acute cholecystitis (n = 17), xanthogranulomatous cholecystitis (n = 25), and gallbladder cancer (n = 18) were reviewed independently by three abdominal radiologists blinded to outcome. The primary outcome was the diagnostic accuracy of MDCT for the differentiation of gallbladder cancer from cholecystitis (acute and xanthogranulomatous) using various imaging parameters. Kappa (κ) statistics and two-way mixed-model single-measure intra-class correlation statistics (ICC) were calculated for each imaging feature and the final radiologic diagnosis. ResultsInter-rater agreement was moderate to substantial (κ = 0.43–0.70), sensitivity 0.67–0.78, specificity 0.22–0.33 and the positive likelihood ratio was 4.28–8.56 for the differentiation of gallbladder cancer from benign gallbladder pathology. Only three imaging findings: disrupted gallbladder mucosa (κ = 0.68), intraluminal gallstones (κ = 0.66), and gallbladder wall thickness (ICC = 0.63) had substantial inter-rater agreement. The following had slight or no agreement: intramural hypoattenuating nodules (κ = 0.17), transient hepatic attenuation differences (κ = 0.14), gallbladder wall calcification (κ = −0.01), gallbladder wall enhancement (κ = 0.18), and omental or mesenteric invasion (κ = 0.08). In the final multivariate model, the following were significant predictors useful in making or excluding diagnosis of gallbladder cancer: focal gallbladder wall thickening (p = 0.003, OR: 13.09 [95% CI: 2.40–71.48]), pericholecystic “fat stranding” (p = 0.018, OR: 0.10 [95% CI: 0.01–0.66]), and maximum short axis lymph node diameter (p = 0.043, OR: 1.18 [95% CI: 1.00–1.38]). ConclusionMDCT has moderate sensitivity, poor specificity, and moderate-to-substantial inter-rater repeatability for the differentiation of gallbladder cancer from acute and xanthogranulomatous cholecystitis.

Computed Tomography (CT) and Magnetic Resonance (MR) Findings in Xanthogranulomatous Cholecystitis: Retrospective Analysis of Pathologically Proven 30 Cases – Tertiary Care Experience

SummaryBackgroundTo study CT and MR findings in xanthogranulomatous cholecystitis (XGC).Material/MethodsRetrospective analysis of 30 histopathologically confirmed cases of XGC. Seventeen patients underwent CECT and 13 underwent MRI. The following features were studied – wall thickness, intramural nodules, pericholecystic stranding, wall thickness, THAD, fat in gallbladder wall, cholelithiasis, infiltration, biliary dilatation, lymph nodes, complications.ResultsThe majority of cases (22/30) showed discontinuous mucosal lining. Discontinuous mucosal lining was seen in all cases with wall thickness >10 mm, 75% of cases with wall thickness between 3–10 mm and none in normal wall thickness (p=0.03). Diffuse wall thickening was seen in 23 cases, focal thickening in 3 and polypoidal wall thickening in 2 cases. Polypoidal thickening was seen in gallbladder carcinoma. Intramural nodules were present in 87.5% of cases with discontinuous mucosal lining. Pericholecystic stranding was seen in 19, biliary dilatation in 12, liver infiltration in 13 and fat in 7 cases. Lymphadenopathy was seen in 1 case with gallbladder carcinoma. Four cases showed a signal drop in the intramural nodules on chemical shift MRI.ConclusionsDiscontinuous mucosal lining is evident in xanthogranulomatous cholecystitis. Diffuse wall thickening, intramural nodules, continuous or discontinuous mucosal lining and cholelithiasis may indicate XGC rather than gallbladder carcinoma. Based on correlation with pathophysiological findings, we conclude that discontinuous mucosal lining is not an unusual finding in cases of XGC. Advances in knowledge: Being aware of the radiological findings described in this article may be helpful in making preoperative radiological diagnosis of XGC. Mucosal lining may be continuous or discontinuous in XGC.

Symptomatic orbital cysticercosis: Patterns of positive imaging findings on CT

BackgroundOrbital cysticercosis is a common disease in the developing world. Although previous studies reported the spectrum of imaging findings of orbital cysticercosis and variable involvement of the extraocular muscles, the relationship between the lesion and the extraocular muscle (within the muscle or on the surface), as well as its distribution within the muscle (muscle belly or the tendinous insertion) was uncertain. PurposeTo characterize the predominant imaging findings of orbital cysticercosis on computed tomography (CT) and assess the relationship between orbital infection and extraocular muscles. Methods and MethodsA cohort of 35 patients with orbital cysticercosis was included in the analysis. All patients underwent CT examination, whereas 6 underwent magnetic resonance imaging. Results52 lesions were visualized on CT. The nodular calcified stage was rather common, followed by the colloidal vesicular or granular nodular stage and vesicular stage. Approximately, two-thirds of the lesions were presented as a cyst with/without an intramural nodule and the remaining as calcification. The extraocular muscle involvement consisted of a single, two, and three lesions, respectively; these were predominantly located within the extraocular muscles, whereas 12 lesions were attached to the extraocular muscles. The lesions were frequently within or adjacent to the muscle belly and less frequently associated with the tendinous insertion. The lateral rectus was frequently involved. The intracranial or extra-orbital involvement was found in 12 patients. ConclusionOrbital cysticercosis mainly presented as a cyst containing an intramural nodule and frequently residing within an extraocular muscle, with a predilection for the muscle belly.

Value of ultrasonography in diagnosis of xanthogranulomatous cholecystitis

To assess the value of ultrasonography in differential diagnosis of xanthogranulomatous cholecystitis (XGC) and wall-thickening type of gallbladder cancer (GBC). The clinical features and sonographic finding of 31 patients with XGC and 36 patients with wall-thickening type of GBC were retrospectively reviewed. The diagnosis of all cases was confirmed by pathological examination, and the ultrasonographic manifestations of the thickening of the gallbladder wall, intramural hypoechoic nodules, gallbladder mucosa line, gallbladder stones, biliary dilatation and gallbladder-liver boundary were compared between two groups. There were significant differences in the intramural hypoechoic nodules, the continuous gallbladder wall mucosal line and dilatation of bile duct between XGC and GBC groups (all P<0.05), while no statistically significant differences in the other sonographic features(all P>0.05). In the six positive sonographic features of the XGC patients, the intramural hypoechoic nodules and the continuous mucosa line of the gallbladder wall had highest accuracy in the diagnosis of XGC(64.2% and 65.7%). Intramural hypoechoic nodule and the continuous mucosal line are characteristic sonographic features of XGC, which can be used for the diagnosis of XGC.

English

Objective: The presentation of cystic meningioma in the inter-hemispheric near the falx cerebri is uncommon. It is difficult to differentiate it from intra-axial tumors, such as gliomas. Therefore, it is likely that it is misdiagnosed as other types of brain tumors. Methods: In this study, we reported a cystic meningioma case in the inter-hemispheric location, showing an intramural nodule on magnetic resonance imaging scans. Results: Patient underwent surgical treatment and pathological section confirmation revealing meningioma. The patient was a middle-age woman and had been misdiagnosed as suffering from glioma followed by slight hemipharesis on the right extremities. Conclusions: Although this is a rare case, it will be good if we always consider cystic meningioma in inter-hemispheric space when diagnosing this type of cystic lesion if the magnetic resonance imaging (MRI) shows a cystic lesion mimicking glioma image presentation. Keywords: Cystic meningioma, interhemispheric space, magnetic resonance imaging, diagnosis DOI: 10.15850/ijihs.v4n1.686

Xanthogranulomatous cholecystitis: What every radiologist should know.

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis characterized by xanthogranulomatous inflammation of the gallbladder. Intramural accumulation of lipid-laden macrophages and acute and chronic inflammatory cells is the hallmark of the disease. The xanthogranulomatous inflammation of the gallbladder can be very severe and can spill over to the neighbouring structures like liver, bowel and stomach resulting in dense adhesions, perforation, abscess formation, fistulous communication with adjacent bowel. Striking gallbladder wall thickening and dense local adhesions can be easily mistaken for carcinoma of the gallbladder, both intraoperatively as well as on preoperative imaging. Besides, cases of concomitant gallbladder carcinoma complicating XGC have also been reported in literature. So, we have done a review of the imaging features of XGC in order to better understand the entity as well as to increase the diagnostic yield of the disease summarizing the characteristic imaging findings and associations of XGC. Among other findings, presence of intramural hypodense nodules is considered diagnostic of this entity. However, in some cases, an imaging diagnosis of XGC is virtually impossible. Fine needle aspiration cytology might be handy in such patients. A preoperative counselling should include possibility of differential diagnosis of gallbladder cancer in not so characteristic cases.

Xanthogranulomatous cholecystitis: diagnostic performance of US, CT, and MRI for differentiation from gallbladder carcinoma.

The purpose of this study is to evaluate the diagnostic performance of HRUS, CT, and MRI for differentiating xanthogranulomatous cholecystitis (XGC) from gallbladder (GB) cancer. Patients with surgically proven XGC (n=40) and GB cancer (n=44), who had undergone at least one HRUS (n=43), CT (n=82), or MRI (n=34) examination between 2000 and 2012, were included. Two radiologists retrospectively graded the likelihood of XGC or GB cancer using a 5-point confidence scale; they also assessed the imaging features. Statistical analyses were performed using ROC, ANOVA, and Fisher's exact test. Diagnostic performance of MRI was better than HRUS for differentiating XGC from GB cancer (AUCs=0.867 and 0.911 vs. AUCs=0.818 and 0.86). However, HRUS showed a better performance than CT (AUCs=0.818 and 0.86 vs. AUCs=0.806 and 0.84) with moderate to excellent agreement (κ=0.48-0.83). Statistically common findings for XGC included non-focal thickening, smooth GB wall, presence of intramural nodules, type I enhancement of wall, transient hepatic attenuation difference, and continuity of mucosa (p<0.05). Co-existence of gallstones (OR=16.5), non-focal thickening (OR=14.7), and collapsed lumen (OR=13.0) on HRUS, and type I enhancement on CT (OR=3.52) were independently associated with XGC (p<0.05). Although MRI showed a better performance than both HRUS and CT, HRUS showed a better performance than CT. The co-existence of gallstones, non-focal thickening, and collapsed lumen on HRUS was independently associated with XGC.

Tracheal varices caused by mediastinal compression of a large intrathoracic goiter: report of a case

Tracheal varices are a rare condition but they can be an important source of massive or recurrent haemoptysis. Usually they are related to increased pressure in the pulmonary veins. Mediastinal goiter is often associated to compressive effects on the surrounding structures, including mediastinal vessels with potential superior vena cava syndrome.We describe a case, not previously reported in literature, of mediastinal goiter with hemoptysis as first clinical manifestation. Bleeding was attributed to a superior vena cava syndrome associated to a tracheal fragile mucosa with an easily bleeding intramural nodule which was diagnosed as tracheal varices after total thyroidectomy. The nodule in fact disappeared together with the venous hypertensive signs after venous decompression of the mediastinum.Compressive symptoms including tracheal varices, related to mediastinal goiter, can be treated surgically by total thyroidectomy via cervicotomy and when required with associated median sternotomy.