Mild Contrast Enhancement Research Articles

Computed tomographic features of Morel-Lavallée lesions in 3 cats.

To describe the CT features of Morel-Lavallée lesions (MLLs) and their association with trauma in cats. This study aimed to investigate whether MLL fluid in cats accumulates between the dermis and deep fascia near superficial trauma, exhibits a vertical attenuation gradient, and shows no or only mild contrast enhancement on CT images. 3 young cats: a 1-year-old neutered male domestic shorthair cat, a 2-year-old neutered male domestic shorthair cat, and a 3-year-old neutered female British Shorthair cat. The clinical presentation of the 3 cats in the study involved recurrent swelling and fluid accumulation affecting at least 1 pelvic limb following trauma. In all cases, there was a fluid-filled space deep to the skin and superficial subcutaneous layer but superficial to the deep fascial plane overlying the muscular component of the pelvic limbs. The MLL fluid had a vertical attenuation gradient and no or only mild contrast enhancement. Morel-Lavallée lesions are often initially overlooked, likely due to distraction by concomitant significant bone injuries, and can be mistaken for hematomas, seromas, subcutaneous edema, contusions, or cellulitis, leading to less aggressive treatment. If left untreated, MLLs present a significant risk of extensive skin necrosis compared to other types of subcutaneous swelling.

Computed tomographic characteristics of testicular teratoma in a cat.

A 5-year-old intact male mixed-breed cat weighing 4.5kg was referred to our hospital with a left testicular mass. CT revealed mild heterogeneous contrast enhancement and calcification in the testicular mass. A well-defined, contrast-enhancing, multiloculated mass with fluid-filled areas was extended from the testicular mass in the scrotum to the caudal aspect of the left kidney. The abdominal mass extended to the right crus of the diaphragm, and the gastrointestinal tract was compressed dorsally. Histopathology was consistent with teratoma. Characteristic CT findings in a feline testicular teratoma may include calcification and cystic areas.

MODL-05. UNDERSTANDING THE METABOLIC VULNERABILITIES IN INFILTRATING GLIOMATOSIS CEREBRI CELLS

Abstract BACKGROUND Gliomatosis cerebri (GC), a rare form of high-grade glioma, is characterized by a particularly invasive phenotype within multiple lobes of the brain and a dismal prognosis. This entity was removed in 2016 of the WHO brain tumor classification because of an absence of specific GC driving molecular signature. Its diffusive aspect on MRI is defined by an absence of cohesive tumor mass, a mild contrast enhancement and a rare neoangiogenesis. Based on those observations, our objectives were to understand how these cells are adapting to their brain environment without a physiological nutritive efflux associated to a reduced oxygen concentration and determine a metabolic signature of GC. METHODS Preliminary results in a large cohort of HGGs bearing several drivers (H3.3 G34V, NMYC amplified, BCOR positive) or a more “wildtype” phenotype with new entities (pedRTK 1 and 2) were underlining glucose and glutamine as major nutrients in cell metabolic suppliance. Therefore, epigenetic assessments, bulk metabolomics, and Seahorse technology, as well as labeled glucose and glutamine metabolites study, helped us in pediatric GC-derived cell lines (BT97 and BT139, PEDIAMODECAN program) to understand the role of both nutrients and their central role in GC in hypoxic microenvironment. RESULTS Both glucose and glutamine are involved in carbon fueling biosynthesis in those cells. Glutamine is much more involved in supplying nitrogen to fuel several specific amino acids and mitochondrial metabolisms. Meanwhile, we developed drug testing using Matrigel invasion aspects. The tested drugs were able to reduce invasiveness of GC cells and modify the intratumoral metabolism. CONCLUSION All those observations seem to explain GC cell adaptation into the hypoxic microenvironment, their plasticity and resistance through metabolic reprogramming based on glutaminolysis and glycolysis.

Pediatric Pleomorphic Xanthoastrocytoma with Neoplastic Meningitis: A Case Report with Cytopathological Evidence with Literature Review

AbstractPleomorphic xanthoastrocytoma (PXA) was regarded as grade II tumor and considered to be associated with favorable outcome. The World Health Organization Central Nervous System 5 (WHO CNS5) has classified PXA under circumscribed astrocytic gliomas and graded 2 or 3 depending on histology. Cerebrospinal fluid (CSF) and leptomeningeal spread are observed rarely in these tumors. The present case report describes a PXA, grade 3 tumor in a young male with neoplastic meningitis. This 17-year-old male child presented with history of seizure, signs of raised intracranial pressure, and meningeal irritation. Well-defined, T2 heterogeneously hyperintense lesion (5.5*4.8 cm) was seen in right frontal lobe with mild heterogenous contrast enhancement and adjacent pachy-meningeal enhancement. Right frontal craniotomy and near total excision were done. Postoperative hydrocephalus was treated with CSF diversion. Histopathology showed epithelioid and rhabdoid morphology with significant cellular pleomorphism and atypical mitosis consistent with the PXA, grade 3. The CSF cytology showed numerous tumor cells with marked nuclear and cytoplasmic pleomorphism. PXA is a rare malignancy of children and young adults, commonly seen in the temporal lobes. BRAF point mutations of V600E type are most common in PXA, grade 2. Meningeal dissemination is uncommon in PXA and its presence marks poor outcome. PXA, grade 2 tumors could be followed with serial imaging following gross total resection. PXA, grade 3 tumors are managed with maximal-safe resection, radiotherapy, and/ or chemotherapy. PXA, grade 3 with CSF spread tends to have rapid decline in the clinical course and it is advisable to get routine baseline and follow-up craniospinal screening and needs aggressive management.

Pituitary Metastasis of Clear Cell Renal Carcinoma Mimicking Pituitary Macroadenoma – Case Report

Abstract Introduction Pituitary tumors account for 25% of all primary brain tumors and for 15% of overall intracranial expansive masses. Pituitary metastases, in contrast, are a rare condition, estimated as 1.8% of all resected sellar lesions. We present here a rare case of clear cell renal carcinoma metastasis to the pituitary gland. Case Report A 65-year-old patient with holocranial headache and diplopia, whose physical examination showed right eye abduction palsy and ipsilateral anisocoria. Magnetic resonance imaging (MRI) of the pituitary revealed a heterogeneous mass in T1 weighted imaging with mild peripheral contrast enhancement and considerable growth during follow-up. Prolactin levels were high and dropped to normal after use of cabergoline, but remained normal even after the medication was halted. Biopsy was compatible with clear cell renal carcinoma. After surgery, the patient underwent radiotherapy, which was effective in reducing the volume of the lesion. Discussion Only 25 cases of pituitary metastasis arising from the kidney were reported in the literature between the years of 1957 and 2018. Metastases can reach the pituitary through hematogenous spread, cerebrospinal fluid, and contiguous bony lesions. Clinical presentation varies from vague complaints such as fatigue or headache to more specific signs like polyuria and polydipsia, and ∼ 60% of cases have clinical manifestations. Conclusion Case reports of pituitary metastases are low worldwide, with only 25 case reports of kidney metastases in over a 60-year period. The rarity of the lesions and hormonal alterations due to pituitary stalk compression can mislead diagnosis, and some patients may even never be diagnosed regarding their lower life span. In this report, radiotherapy was effective postresection, and accounts for a treatment option. All these issues account for the relevance of these case reports.

SAT531 Thyroid Metastasis From Non-small Cell Lung Cancer: An Unusual Case Presentation

Abstract Disclosure: E.Y. Ibrahim: None. I. Guillen Alvarez: None. I. Hulinsky: None. D. Regelmann: None. C. Janowiecki: None. Background: Cases of thyroid tumors metastasizing from the lungs are rare, and their diagnosis is often challenging and can be mistaken for primary thyroid tumors or subacute thyroiditis. Thyroid function tests are typically normal and not helpful in establishing the diagnosis. Ultrasonography commonly shows focal or diffuse hypoechoic lesions. Correspondingly, heterogeneous hypodense areas with mild contrast enhancement are seen on CT scans. Clinical Case: Our patient is a 61-year-old male with a history of diabetes mellitus and 40 years tobacco use, who presented with a 1-week history of right-sided weakness and 3-weeks of dry cough. The weakness of his leg progressed to the point he could not ambulate. Initially, he was evaluated for a stroke and underwent CT imaging showing extensive lesions of the bilateral frontal, temporal, and parietal lobes. These findings were suspicious, and confirmed by MRI, to reflect multifocal metastatic lesions with vasogenic edema. Initial physical examination revealed a palpable thyroid nodule in the right lobe with bilateral cervical lymphadenopathy. CT of the neck demonstrated lymphadenopathy as well as multiple bilateral hypoechoic thyroid nodules, the largest of which measured 0.8 cm in the right thyroid lobe. TSH was 0.34 (0.48-4.17mU/L) with Free T4 at 1.39 (0.8-1.90ng/dL). The patient had denied symptoms of heat intolerance, tremor, or palpitations. A CT chest with contrast found a 3.5 cm cavitary lesion in the right upper lobe concerning for a primary lung neoplasm, as well as multiple bilateral lung nodules, mediastinal and hilar lymphadenopathy, and bilateral adrenal masses. Subsequent ultrasound-guided biopsy of the thyroid tumor revealed histologic features of a poorly differentiated non-small cell carcinoma, with features of a primary lung origin. These features were also present on a concurrent fine needle biopsy of an enlarged cervical lymph node. Immunohistochemistry staining showed the tumor was highly expressive for PDL1, focally positive for p40, pancytokeratin AE1/AE3, and negative for TTF-1 and thyroglobulinDue to the vasogenic cerebral edema, he was given dexamethasone with good response, and his weakness improved to the point that patient was able to ambulate. Treatment also included radiation therapy with subsequent pembrolizumab upon completion of radiotherapy. Conclusion: Several thyroid lesions representing metastases may go unnoticed because the physician’s attention toward lesions at other, more common sites, and detailed thyroid examination can be commonly overlooked. Patients with newly diagnosed malignancies should also be screened for thyroid involvement, including detailed physical, radiographic, and histologic examination of pathologic findings. Presentation Date: Saturday, June 17, 2023

342 Predicting Early Disease Progression in Tectal Plate Gliomas

INTRODUCTION: Tectal gliomas are slow-growing tumors of the midbrain. Due to their indolent nature, treatment mainly consists of observation and management of hydrocephalus. However, a subset of tectal gliomas may exhibit tumor enlargement and disease progression. Currently, there are no established guidelines for predicting future progression of tectal gliomas. Further, given the rarity of these tumors, studies in the literature are limited to <50 patients. METHODS: We performed a retrospective chart review of 172 patients diagnosed with tectal glioma. In addition to descriptive statistics, we performed univariate analysis using Student’s t-test and Chi-squared testing to determine if significant differences exist between patients with tumor progression versus those without progression. RESULTS: The median patient age was 24 years (range: 0-73 years); of these, 69 were pediatric (≤18 years). Hydrocephalus was present in 64% of cases. Lesions were incidentally detected in 37% of the cohort and were only present in the adult population. Of the patients that had > 1 year follow-up (n = 145), 26 experienced radiological progression (18%) with 19 requiring tumor-directed treatment (13%). Predictors of progression included younger age at diagnosis (p = 0.005), expansion of the lesion beyond the tectum on initial imaging (p < 0.001), moderate T1 signal (p < 0.001), and mild or moderate contrast enhancement (p = 0.011 and p < 0.001, respectively). At most recent follow-up, 92% had stable disease, 3% had progressive disease, 1% died from tumor progression, and 3% died of other causes. CONCLUSIONS: Certain characteristics of radiographic imaging may be predictive of future disease progression. In patients with progression, excellent survival can be achieved if progression is detected early and appropriate treatment is initiated.

A Woman With Kelch-like Protein-11 Encephalitis and Unmasked Metastatic Carcinoma

Objective To illustrate a case of a woman with rhombencephalitis with antibodies to Kelch-like protein-11 (KLHL11) and a metastatic carcinoma. Background KLHL11 encephalitis is an autoimmune paraneoplastic syndrome first described in 2019. The clinical presentation consists of a brainstem cerebellar syndrome with symptoms of hearing loss, diplopia, vertigo and ataxia. This entity has been mostly described in male patients with associated testicular seminomas. Few cases have been described in women. This is a case of a woman with a history of hysterectomy and oophorectomy with KLHL11 encephalitis and an associated aortocaval tumor. Design/Methods NA. Results The patient was a 62-year-old woman that presented to clinic with a 9-month history of vertigo, progressive bilateral sensorineural hearing loss, diplopia, oscillopsia, ataxia and bilateral tremor. Her MRI brain obtained 8 months after symptom onset showed T2 hyperintense lesions in the inferior cerebellar hemispheres and right medial hippocampus with mild contrast enhancement in these areas. Cerebral spinal fluid analysis showed a lymphocytic pleocytosis, elevated protein, and negative infectious work-up. She completed 5 days of intravenous methylprednisolone and continued a steroid taper. She noted mild to moderate improvement in tremors, gait, and diplopia after steroids. Her symptoms, however worsened as she tapered her steroid dose. Serum KLHL11 antibody levels were positive at a titer of 1:7680. Computed tomography of the chest, abdomen and pelvis did not reveal any evidence of malignancy. However, whole body proton emission tomography/computed tomography (PET CT) revealed a large hypermetabolic aortocaval mass soft tissue mass. A biopsy of the mass showed pathology consistent with a metastatic carcinoma of gynecologic origin for which the patient is undergoing chemotherapy with plans for possible tumor debulking. Conclusions This case highlights the importance of considering KLHL-11 encephalitis in female patients presenting with rhombencephalitis, and the need for adequate malignancy evaluation in this disorder.

Successful early diagnosis of monomorphic epitheliotropic intestinal T-cell lymphoma manifesting as chronic diarrhea and hypokalemia using video capsule endoscopy and double-balloon enteroscopy.

Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), formerly known as enteropathy-associated T-cell lymphoma (EATL) type II, is a rare disease with a poor prognosis that is often diagnosed when patients present with intestinal perforation or obstruction. Our patient, a man in his 60s, had a 5-month history of persistent watery diarrhea. Upper and lower gastrointestinal endoscopy, abdominal computed tomography (CT), and stool culture results were unremarkable. He was admitted to our hospital 8 months later with a weight loss of 20kg, general fatigue, and hypokalemia. Contrast-enhanced CT of the abdomen revealed mild thickening and contrast enhancement of the small intestinal wall. Video capsule endoscopy and double-balloon enteroscopy were performed to reveal a broad ulcer in the jejunum and multiple erosions throughout the small intestine. Examination of the biopsy specimens showed infiltration of atypical lymphocytes with pale cytoplasm in the glandular epithelium. The atypical lymphocytes were positive for CD3, CD8, CD56, granzyme B, and T-cell intracellular antigen-1 by immunostaining. Early diagnosis of MEITL was made, and the patient survived for 21months with continuous chemotherapy. Aggressive examination of the small intestine is effective for the early diagnosis of serious diseases, such as MEITL, in patients with chronic diarrhea of unknown origin.

Acute Disseminated Encephalomyelitis with Prefrontal Cortex Involvement in a 9-Year-Old Child after COVID-19 Infection: A Case Report

AbstractThe aim of the study was to present the rare co-occurring radiological findings of a child presenting with acute disseminated encephalomyelitis (ADEM) with a spinal cord and prefrontal cortex involvement after coronavirus disease 2019 (COVID-19) illness. The patient, who had COVID-19 a few weeks earlier, presented with progressive weakness in the right upper and lower extremities. Neurological examination of the patient was performed, and cranial magnetic resonance imaging (MRI) was taken on the same day. Serum severe acute respiratory syndrome coronavirus immunoglobulin M antibody testing was positive. MRI of the brain parenchyma and thoracic spine revealed fluid-attenuated inversion recovery and T2-weighted hyperintense lesions. Additionally, mild contrast enhancement was observed in both the prefrontal cortexes. The patient was discharged 10 days later with complete clinical recovery. Unlike other post-COVID-19 ADEM cases presenting in the literature, prefrontal cortex involvement makes our case rare.

Imaging features of laryngeal chondrosarcomas: A case series and systematic review.

To comprehensively summarize the characteristics of radiological findings of laryngeal conventional chondrosarcomas. We included patients with pathologically proven laryngeal conventional chondrosarcomas with CT and /or MRI, including 41 cases from 31 publications recruited after a systematic review and 14 cases from our institution. Two board-certified radiologists reviewed and evaluated all the radiological images. The relationship between pathological grade and radiological findings was analyzed. The median long diameter of the lesion was 3.1 cm (range, 1.5-8.5 cm). The most common location was the cricoid (74.5%), followed by the thyroid (12.7%), cricoid and thyroid (7.3%), and arytenoid (5.5%). All lesions showed well-defined margins. Cortical defect/expansion (98.0%), internal low density (89.6%), and calcification (95.8%) with homogeneous and scarce contrast enhancement on contrast-enhanced CT (85.3%) were frequently observed. All cases showed high signal on T2-weighted imaging, low signal on T1-weighted imaging (T1WI), and heterogeneous and mild contrast enhancement on postcontrast T1WI. No significant differences were found between the pathological grades and radiological findings. In our summary of comprehensive CT and MRI findings of laryngeal conventional chondrosarcomas, we found that the knowledge of these radiological features may facilitate prompt diagnosis and appropriate management.

Prevalence, distribution, and clinical associations of suspected postictal changes on brain magnetic resonance imaging in epileptic dogs.

To determine the prevalence of presumed postictal changes (PC) on brain MRI in epileptic dogs, describe their distribution, and recognize possible correlations with different epilepsy features. 540 client-owned dogs with epilepsy and a complete medical record that underwent brain MRI at 4 veterinary referral hospitals between 2016 and 2019. Data were collected regarding signalment, seizure type, seizure severity, time between last seizure and MRI, and etiological classification of epilepsy. Postictal changes were considered when solitary or multiple intraparenchymal hyperintense lesions were observed on T2-weighted and fluid-attenuated inversion recovery images and were hypointense or isointense on T1-weighted sequences, which were not confined to a vascular territory and showed no to mild mass effect and no to mild contrast enhancement. Sixty-seven dogs (12.4%) showed MRI features consistent with PC. The most common brain sites affected were the piriform lobe, hippocampus, temporal neocortex, and cingulate gyrus. Dogs having suffered cluster seizures or status epilepticus were associated with a higher probability of occurrence of PC, compared to dogs with self-limiting seizures (OR 2.39; 95% confidence interval, 1.33 to 4.30). Suspected PC were detected both in dogs with idiopathic epilepsy and in those with structural epilepsy. Dogs with unknown-origin epilepsy were more likely to have presumed PC than were dogs with structural (OR 0.15; 95% confidence interval, 0.06 to 0.33) or idiopathic epilepsy (OR 0.42; 95% confidence interval, 0.20 to 0.87). Time between last seizure and MRI was significantly shorter in dogs with PC. MRI lesions consistent with PC were common in epileptic dogs, and the brain distribution of these lesions varied. Occurrence of cluster seizures or status epilepticus, diagnosis of unknown origin epilepsy, and lower time from last seizure to MRI are predictors of suspected PC.

Case report of portal hepatic schwannoma: presentation of multimodality images

BackgroundPortal hepatic schwannoma is a rare benign tumor and difficult to diagnose preoperatively because of its rarity and imaging manifestations that mimic malignancy. We present a case of portal hepatic schwannoma that showed moderate contrast enhancement on computed tomography (CT), extension along the bile duct on T2-weighted imaging and magnetic resonance cholangiopancreatography (MRCP), and uptake of 18F-fluorodeoxyglucose (FDG) on positron emission tomography.Case presentationUltrasonography at an annual health checkup identified a hepatic mass in a 38-year-old woman. CT showed a well-defined portal hepatic tumor with mild contrast enhancement. T2-weighted imaging and MRCP showed a clavate tumor extending along the intrahepatic bile ducts but no dilatation of the ducts. The tumor exhibited increased FDG uptake, such as maximum standardized uptake values of 5.0 and 6.5 in the early and late phases, respectively. Neither dilatation of intrahepatic bile ducts nor lymphadenopathy was identified, and the multimodality imaging suggested hepatic portal lymphoma, gastrointestinal tumor, or IgG4-related disease rather than cholangiocarcinoma. A needle biopsy via endoscopic ultrasonography was performed, and immunohistology confirmed the tumor as a schwannoma.ConclusionsThe diagnosis of a portal hepatic schwannoma requires immunohistological examinations in addition to multimodality imaging studies to reflect fully the pathohistological characteristics of the tumor.

Clinical and CT features of ovarian torsion in infants, children and adolescents.

To investigate the clinical features and computed tomography (CT) findings of pediatric ovarian torsion. A retrospective analysis of the clinical and CT data of 61 newborns, infants, children, and adolescents with ovarian torsion confirmed by histopathology was performed. Clinical features included abdominal mass, abdominal pain, nausea and vomiting, and fever. The tumor marker α-fetoprotein was increased in five cases. Ovarian enlargement was found in 26 cases, and follicles were detected in the peripheral region of the ovary in 21 cases. Twenty-one cases presented as solid mixed-density masses on CT images. A total of 30 cases of ovarian torsion were associated with a benign ovarian mass. Among 27 cases of cystic or predominantly cystic masses, the mass had a thickened wall in 26 cases and showed an uneven density in 23 cases. Among all 61 patients, a torsed pedicle was detected in 47 cases. A torsed ovary or mass exhibited mild contrast enhancement in seven cases. Uterine deviation toward the involved side, blurred fat space around lesions, and pelvic free fluid were also found. Pediatric ovarian torsion presents a relatively characteristic CT appearance. Correct diagnosis can be established based on clinical and imaging features.

Progressive multifocal leukoencephalopathy: MRI findings in HIV-infected patients are closer to rituximab- than natalizumab-associated PML.

ObjectivesTo compare brain MRI findings in progressive multifocal leukoencephalopathy (PML) associated to rituximab and natalizumab treatments and HIV infection.Materials and methodsIn this retrospective, multicentric study, we analyzed brain MRI exams from 72 patients diagnosed with definite PML: 32 after natalizumab treatment, 20 after rituximab treatment, and 20 HIV patients. We compared T2- or FLAIR-weighted images, diffusion-weighted images, T2*-weighted images, and contrast enhancement features, as well as lesion distribution, especially gray matter involvement.ResultsThe three PML entities affect U-fibers associated with low signal intensities on T2*-weighted sequences. Natalizumab-associated PML showed a punctuate microcystic appearance in or in the vicinity of the main PML lesions, a potential involvement of the cortex, and contrast enhancement. HIV and rituximab-associated PML showed only mild contrast enhancement, punctuate appearance, and cortical involvement. The CD4/CD8 ratio showed a trend to be higher in the natalizumab group, possibly mirroring a more efficient immune response.ConclusionImaging features of rituximab-associated PML are different from those of natalizumab-associated PML and are closer to those observed in HIV-associated PML.Key Points • Nowadays, PML is emerging as a complication of new effective therapies based on monoclonal antibodies. • Natalizumab-associated PML shows more inflammatory signs, a perivascular distribution “the milky way,” and more cortex involvement than rituximab- and HIV-associated PML. • MRI differences are probably related to higher levels of immunosuppression in HIV patients and those under rituximab therapy.

SAT-252 A Rare Case of Crooke’s Adenoma

BACKGROUND: Crooke’s cell adenoma is a rare variant of ACTH-secreting corticotroph adenomas (<1%). These are aggressive macroadenomas and usually invade the cavernous sinus producing visual symptoms. Clinical Case: A 48-year old male presented with acute right eye and right temple pain, and diplopia that started 6 days prior. Past medical history included hypertension, type 2 diabetes, hyperlipidemia, traumatic brain injury, CSF leak with bacterial meningitis s/p sphenoid repair and palsy of the right III,V and VI cranial nerves. Head CT showed a 1.9 x 2.1 x 1.5 cm soft tissue-density mass medial to the right cavernous carotid artery extending into the sphenoid sinus. There was expansile bony change to the floor and right dorsum of the sella. The mass showed mild contrast enhancement and abutted the superior orbital fissure. A brain MRI was not obtained due to history of a left cochlear implant. He did not have any cushingoid features on exam. Neuro-ophthalmology exam revealed, severe sixth cranial nerve palsy, bilateral optic disc pallor and a mild right superotemporal visual field defect. Pre-operative pituitary function tests revealed ACTH 103 pg/ml (7–63), cortisol 14 ug/dl (6.0–18.4), FSH 2.7 mIU/ml (1.5–12.4), LH 3.8 mIU/ml (1.7–8.6), prolactin 17.6 ng/ml (4–15.2), total testosterone 175 ng/dl (249–836), TSH 1.10 uIU/ml (0.27–4.20), free T4 0.67ng/dl (0.8–1.8) and IGF-1 208 ng/ml (69–224). He underwent successful endoscopic trans-sphenoidal resection of a 4.2 x 2.5 x 0.5 cm mass. Pathology revealed hyaline deposits in the cytoplasm and perinuclear cytokeratin in more than 50% of the adrenocorticotroph cells consistent with Crooke’s cell adenoma. Post-operatively, his right eye pain and abduction deficit improved, and diplopia returned to baseline. He was placed on a short hydrocortisone taper. Due to high risk of recurrence, he received 54Gy in 30 fractions to the sella. Six and 12-month follow-up head CTs revealed stable residual enhancing tissue. Pituitary function tests done 9 months post-surgery were normal and no hormone replacement was needed. He was clinically stable 12 months after surgery. Conclusion: We described a rare case of invasive Crooke’s cell pituitary adenoma with visual disturbances that was managed with resection and radiotherapy. The patient remained free of recurrence 1 year later. However, lifetime surveillance is necessary due to high incidence of recurrence.Reference:1.Crooke’s Cell Tumors of the Pituitary. Neurosurgery, Volume 76, Issue 5, May 2015, Pages 616–22

1111 Atrial thrombi or cardiac tumors? The challenge of multimodality imaging of intracardiac masses

Abstract A 83-year-old man with hypertensive cardiomyopathy with left ventricular dysfunction diagnosed 5 years before (without coronary artery disease) in permanent atrial fibrillation since 8 years, was admitted to the ER for heart failure. He was not in anticoagulation therapy because contraindication for the presence of cerebral venous angiomas found several years before. An urgent ultrasound scan was performed that showed bilateral intra-atrial masses. UFH was started. The echocardiography(Fig. 1 panel A)show within the left atrium an isoechoic, not pedunculated mass, 8x5 cm, with lobulated margins, attached to the anterior wall and left atrial appendage, and expanding in the atrial cavity. Within the right atrium a smaller mass with the same characteristics was attached to the anterior wall, 4 x 3 cm (Fig. 1 panel B). TEE confirmed these characteristics and showed also vacuolated aspects inside the masses (Fig. 1 panel C). MDCT was then performed, the atrial masses appeared morphologically very similar to atrial myxomas, but they didn’t enhance iodine contrast agent resembling a typical thrombus behavior (Fig. 1 Panel D). No systemic emboli nor extracardiac tumors were found. CMR could not be performed due to patient claustrophobia. Considering intra-atrial thrombi as a main hypothesis, the treatment with UFH was continued and the masses were monitored by TTE. However, after more than one week the masses volume did not change. A contrast echocardiography with IV Sonovue was performed. A mild contrast enhancement of left atrial mass was seen, thus suggesting the diagnostic hypothesis of cardiac tumor (Fig. 1 Panel E). In this context we decided to perform transvenous biopsy of right atrial mass under intracardiac echocardiography guidance. The biopsy samples from the outer wall of the right atrial mass showed thrombotic features. After a long discussion in heart team, patient underwent to surgical resection of the masses through atrial approach and the surgical inspection was suggestive of neoplastic origin. The histological examination was performed showing thrombotic material with several phases of organization and mild aspects of neo-angiogenesis combined with mild lymphocyte infiltration and necrosis areas (Fig. 1 Panel F). We hypothesized that the histological features of the lesion, with the presence of vessel within the mass could explain the mild late contrast enhancement at Sonovue echocardiography simulating the features of cardiac tumor. In summary, in this case, despite a multimodal imaging approach, the nature of the bilateral intra-atrial masses could not be defined and the histological examination after surgical removal had a key diagnostic role showing organized thrombotic material. A proper differential diagnosis is extremely important in order to decide the appropriate treatment, but sometimes it is extremely challenging. Abstract 1111 Figure 1

Haemangioma of the Testis: A Review and Update of the Literature

Less than 60 cases of haemangiomas of the testis (HOTs) have been reported sporadically in different parts of the world in diverse age groups including in children and adults even though it has been more commonly reported in individuals who are younger than 20 years. HOTs may present with lump/mass in testis/scrotum, scrotal enlargement with or without associated pain/discomfort. The results of serum germ cell tumour marker levels tend to be normal always. The clinical examination does reveal a discrete lump/mass in the testis which may or may not be tender. Radiology imaging does illustrate a discrete mass which usually tends to be well-demarcated but at times the lesion could be abutting the tunica albuginea testis. Doppler scan would tend to show increased vascularity and blood flow within the lesion which may also contain calcifications and at times radiology imaging could illustrate some degree of mild contrast enhancement and these features at times may suggest the possibility of benign disease but malignancy cannot be excluded. An incidental lesion of HOT was identified incidentally in radiology imaging in the absence of a palpable mass/lump. The ideal treatment for HOT is testis-sparing partial orchidectomy which has been undertaken in about a third of cases of HOT reported and radical orchidectomy has been undertaken in two-thirds of cases of HOT under a provisional diagnosis of malignant testicular tumour and the final diagnosis has been based upon the post-operative pathology reports. Diagnosis of HOT tends to be based upon the histopathology examination findings of small tubules with red blood cells that are lined by mesothelial like cells that have uniform vesicular nuclei but they can have focally infiltrative growth pattern with entrapment of seminiferous tubules. Immunohistochemistry staining studies of HOTs do show positive staining for Factor VIII, CD31, CD34, and FLI1 but negative staining for Pancytokeratin AE1/AE3, Keratin 8 / 18, EMA, placental herpesvirus 8, human chorionic gonadotrophin, c-kit, and p53. No recurrence has been reported following either testis-sparing partial orchidectomy after frozen section pathology examination or after radical orchidectomy. If urologist and radiologists have a high index of suspicion for the disease, and intraoperative frozen section excision biopsies are undertaken in all cases of testicular tumours in all age groups with the knowledge of normal levels of germ cell tumour markers then testis-preserving surgery can be undertaken and unnecessary radical orchidectomy can be avoided.

Endoscopic Endonasal Odontoidectomy.

Odontoidectomy is a standard procedure employed in the treatment of irreducible, compressive ventral pathologies of the craniovertebral junction (CVJ). The traditionally used transoral route is often challenging due to the increased depth of the surgical corridor and risk of injuries to the soft tissues in the oral cavity. The emergence of endoscopic endonasal (EE) surgery has provided an attractive alternative route to the traditional treatment algorithm, and it has the advantages of avoiding complications related to tongue swelling, tracheal swelling, prolonged intubation, velopharyngeal insufficiency, dysphagia, and dysphonia.We present a case of a 66-year-old man with no pertinent past medical history, who presented with progressive quadriparesis and gait ataxia over last 6 months (Nurick's grade 2). Neurological exam revealed pattern suggestive of high-cervical myelopathy with no evidence of cranial nerve paresis. Magnetic resonance imaging (MRI) of his CVJ revealed a large pannus behind the dens with severe spinal cord compression, mild contrast enhancement was noted posterior to the pannus, likely from the ligamentous structures; pannus was hypointense on both T1- and T2-weighted images. Further, a computerized tomography (CT) scan did not reveal any obvious malalignment. He underwent an EE odontoidectomy, followed by posterior cervical fusion. He had an unremarkable postoperative period and recovered fully from his myelopathy over the next 6 months. The histopathological examination of the pannus revealed a degenerated disk. In this video, we have a step by step description of the EE approach to the odontoid and discuss the surgical nuances. The link to the video can be found at: https://youtu.be/pjg68_vK0C4 .

WITHDRAWN: Double primary carcinoid tumors of the kidney

Abstract Primary renal carcinoid tumor is extremely rare. Because of its similar presentation with other renal tumors, 14.5% were initially misdiagnosed. A 37-year-old female was referred to our department due to incidentally finding of left kidney tumor by sonography. She didn't present flank pain or gross hematuria, also absence of positive physical findings. The patient's general blood routine, urine routine, and renal function examination were all within normal limits. Abdomen computed tomography showed two soft tissue mass within left kidney. The larger renal tumor was about 3.8 cm in size, mild contrast enhancement and small cystic foci abutting renal sinus. The smaller renal mass was exophytic with same image characteristics. The subsequent kidney magnetic resonance imaging reported two lesions had persistent high diffusion-weighted imaging signal intensity, which strongly favor solid neoplasm. Differential diagnosis included renal cell carcinioma, benign adenoma and Wilm's tumor. Hence, frozen section of the smaller renal nodule was sent for pathologist, and it reported no evidence of obvious malignancy. We later performed open partial nephrectomy. The final pathology reported two well-differentiated grade 1 neuroendocrine (carcinoid) tumors. Immunohistochemistry showed these two lesions were strong positive for synaptophysin and neuron-specific enolase (NSE), but negative for WT-1 and vimentin, which were consistent with features of neuroendocrine tumor. Two weeks after operation, patient's serum creatinine was within normal limits. Abdomen computed tomography reported no specific lymph node involvement after 6 months. Primary renal carcinoid tumors are usually found incidentally, and nephron-sparing surgery whenever possible remains the standard treatment of choice.