Multiloculated Cystic Lesion Research Articles

Primary Cutaneous Aspergillosis Presenting as a Multiloculated Cyst in the Hand

: Invasive aspergillosis typically occurs in immunocompromised patients and results in fatal complications. Musculoskeletal involvement of aspergillosis is extremely rare, therefore, when it occurs, its diagnosis and treatment could be delayed. In this paper, we report a rare case of primary invasive aspergillosis with radiologic findings in a patient with rheumatoid arthritis. A 57-year-old woman presented a palpable mass on the right hand with a previous medical history of long-term use of immunosuppressive agents due to rheumatoid arthritis. Magnetic resonance imaging showed a multilobulated and multiloculated cystic lesion with an enhancing wall. The wall of the cystic lesion showed low signal intensity on T2 weighted images and intermediate to high signal intensity on T1 weighted images. The mass was confirmed as chronic granulomatous inflammation with multiple acute branching and septated fungal hyphae, consistent with invasive aspergillosis. When a superficial multicystic mass in the hand of especially immunocompromised patients is encountered, invasive aspergillosis should be included in the differential diagnosis, although it is rare.

Cutaneous aneurysmal bone cyst—First report of a case and literature review

Aneurysmal bone cyst (ABC) is a benign, expansile, multiloculated and blood-filled cystic lesion most commonly involving bones. We report herein the case of a 78-year-old woman with a dermal ABC located in the skin of the right foot. Histologically, the lesion displayed characteristic features of ABC, including blood-filled cystic spaces lined by loose connective tissue, admixed with solid areas composed of spindle cells and osteoclast-like giant cells, associated with foci of woven bone formation and matrix calcification ("blue bone" formation). Fewer than 30 cases of extraosseous ABCs have been described in soft tissues and, to the best of our knowledge, ABC primarily occurring in the skin, not associated with an underlying lesion in the bone, has not so far been reported in the literature.

Biliary mucinous cystic neoplasm mimicking a hydatid cyst: a case report and literature review

BackgroundBiliary mucinous cystic neoplasms are rare cystic lesions of the liver which carry pre-malignant potential. Given the scarcity of reports in the literature, they pose a considerable challenge to clinical management, particularly with regards to accurate pre-operative diagnosis.Case presentationWe present the case of a 37-year-old Tunisian woman who presented with subacute right upper quadrant pain and a large multi-loculated cystic lesion, most consistent with a hydatid cyst. She underwent an open right hepatectomy, and pathology surprisingly revealed a biliary mucinous cystadenoma. Herein, we review the current literature on biliary mucinous cystic neoplasms, with a particular emphasis on diagnostic investigations, key radiological features and optimal treatment modalities.ConclusionBiliary mucinous cystic neoplasms require a high index of suspicion and should be managed with complete surgical resection, as conservative techniques are associated with high recurrence rates. Considering the potential for malignant transformation, periodical surveillance imaging is recommended in the post-operative period.

Preoperative contrast-enhanced computed tomographic characterisation of pancreatic cystic lesions: A prospective study.

BackgroundCharacterisation of pancreatic cystic lesions has a direct role in their management and computed tomography is the mainstay of investigation for diagnosing and characterising them.ObjectivesThe aim of this study was to prospectively assess the diagnostic accuracy of contrast-enhanced computed tomography (CECT) in preoperative characterisation of pancreatic cystic lesions with histopathology as the reference standard.MethodA total of 38 patients with cystic pancreatic lesions diagnosed after clinical, laboratory and sonographic evaluation, irrespective of age, were preoperatively evaluated with CECT. Images were reviewed for the general characteristics of the lesions on pre-contrast and portal venous phase images and overall diagnostic accuracy calculated. Imaging findings were compared with histopathology, or cytology and/or intra-operative findings.ResultsSerous cystadenoma (SCA) was the most common cystic pancreatic lesion found in 31.6% of patients followed by mucinous cystadenoma (MCA) (26.3%), solid pseudo-papillary tumour (SPT) (21.1%) and intra-ductal papillary mucinous neoplasm (IPMN) (10.5%). Three patients (7.9%) had simple cysts and one patient (2.6%) had a lymphangioma. The diagnostic accuracy of CECT for pancreatic cystic lesions was found to be 72.5%ConclusionThe diagnostic accuracy of computed tomography (CT) was high for SCA, IPMN and pancreatic cysts, and low for MCA and SPT. Combination of a multiloculated cystic lesion with locule size of less than 20 mm, septal enhancement with relative lack of wall enhancement, central scar and lobulated outline are highly specific for SCA. Unilocular or macro-cystic pattern with locule size of more than 20 mm, female gender and wall enhancement with smooth external contour are pointers towards MCA. Solid cystic pancreatic head lesions in young females may be suggestive of SPT. A dilated main pancreatic duct in a cystic lesion with internal septations may point towards IPMN. Fluid attenuation lesions with imperceptible non-enhancing wall indicate pancreatic cysts. Lastly, pseudocysts and neuroendocrine tumours with cystic components are great mimickers of pancreatic cystic lesions, and a history of pancreatitis and hormonal profile of patients should always be sought.

SUN-497 Atypical Parathyroid Adenoma- Is There More Than What Meets the Eye ?

Background: Parathyroid adenoma with severe hyperparathyroidism and parathyroid carcinoma can have similar clinical presentations. Atypical cases should prompt suspicion for parathyroid carcinoma. We report such a case of an atypical parathyroid adenoma in a young woman. Case: A 22 year old woman without any past medical history presented with an inability to bear weight on her left leg after ascending stairs. X-rays showed lytic lesions of the left femur and pubic ramus, and an intertrochanteric fracture of the left femur. Suspicion for a pathologic fracture prompted further imaging. CT imaging demonstrated an asymmetric enlarged mass originating from the inferior aspect of the right thyroid lobe and bilateral medullary nephrocalcinosis. MRI showed a pathologic fracture with multiloculated cystic lesions with multiple fluid levels in the left femur and multiple solid lesions in bilateral pubic rami. Labs: corrected calcium 14.9 mg/dL, phosphorus 1.8 mg/dL, ALP 208 U/L, PTH 1450.0 pg/mL, 25-hydroxy vitamin D 29 ng/mL, and creatinine 0.90 mg/dL. Endocrinology was consulted for management of hypercalcemia. Patient was managed with aggressive IV hydration, sq calcitonin, and a dose of IV pamidronate. The possibility of metastatic disease prompted a biopsy of the right pubic ramus, which demonstrated interstitial hemorrhage and numerous giant cells consistent with osteitis fibrosa cystica. A sestamibi scan revealed uptake suggestive of a large right parathyroid adenoma (measuring 3.0 x 2.7 x 5.7 cm) that corresponded to the mass found on CT. She underwent an ORIF of the left femur and right parathyroidectomy with resection of adjacent paratracheal lymph nodes after her calcium levels stabilized. The parathyroid mass was grossly described as being a well-circumscribed, well-encapsulated, yellow-tan, hemorrhagic lesion measuring 3.0 x 2.0 x 5.0 cm. Biopsy of the mass also indicated that the tumor was encapsulated and comprised of monotonous parathyroid cells without increase in mitosis. The final diagnosis was an atypical parathyroid adenoma. Post surgery, calcitriol and calcium supplements were initiated. Her PTH decreased to 19.3 pg/mL upon discharge from the hospital. Conclusion: This is an unusual presentation of severe hypercalcemia in a young woman due to primary hyperparathyroidism. Concerning features for possible parathyroid carcinoma included the patient’s young age, a corrected calcium level >14 mg/dL, a markedly elevated PTH, a parathyroid mass >3 cm, and the combination of renal and bone involvement.1 These factors prompted the resection of adjacent lymph nodes with the parathyroid mass. Pathology was suggestive of an atypical parathyroid adenoma. These aggressive clinical features warrant close Endocrine follow up. 1. Marcocci C, Cetani F, Rubin MR, Silverberg SJ, Pinchera A, Bilezikian JP. Parathyroid carcinoma. J Bone Miner Res. 2008;23(12):1869-80.

Intraductal papillary mucinous neoplasm developed on an ectopic gastric pancreas

In January 2014, a 69-year-old man with end-stage renal disease requiring dialysis was evaluated for kidney transplantation. During the work-up, abdominal ultrasound found an ill-defined intraabdominal cystic lesion. Abdominal magnetic resonance imaging revealed a 60 × 50 mm multiloculated cystic lesion developed over the lesser gastric curvature (Fig. 1). An endoscopic ultrasound (EUS) confirmed a subepithelial 60-mm a cystic gastric tumour. Fine needle aspiration was negative for malignancy. In order to rule out a primary gastric tumor, surgery was scheduled. A partial gastrectomy was performed with an uneventful postoperative course. Gross pathology found a 60-mm cystic tumor located into the gastric wall. Histology found heterotopic pancreatic tissue composed by ducts and acini (Fig. 2) into the gastric wall. Epithelial cells were mucin-secreting and columnar with extensive intestinal metaplasia and low degrees of atypia. Mucinous deposits were present over the lesser omentum. The diagnosis of intraductal papillary mucinous neoplasm (IPMN) with low grade dysplasia developed on heterotopic gastric pancreatic tissue was established. Six years later the patient was doing well under dialysis. The prevalence of heterotopic pancreatic tissues ranges from 0, 6 to15% and IPMN development has been rarely reported as a possible complication of a heterotopic pancreas [ [1] Patel N. Berzin T. Intraductal papillary mucinous neoplasm arising in a heterotopic pancreas: a case report. Am J Gastroenterol. 2010; 105: 2513-2514https://doi.org/10.1038/ajg.2010.298 Crossref Scopus (11) Google Scholar ]. Symptoms are unspecific and surgery should be advised based on the size and morphology of the lesion. Fig. 2Histological examination showing heterotopic pancreatic tissue into the gastric wall with acini and ducts. View Large Image Figure Viewer Download Hi-res image

Primary para-vertebral hydatid cyst in the sub-occipital area of the neck: an unusual case of echinococcosis

BackgroundHydatid disease is a parasitic infectious disease caused by Echinococcus granulosus. The parasite can form cysts in any part of the body with the liver and lung being the most commonly involved organs. It can rarely occur in other organs like the muscle, bone, pericardium, myocardium, spleen, spine, and neck. Para-vertebral hydatid cyst is very rare and can present with a variable clinical presentation. Surgical excision is the treatment modality of choice and accepted to be curative with a very low recurrence.Case presentationWe here present a case of primary hydatid cyst in the para-vertebral space in sub-occipital area of the neck who presented with complaints of pain and swelling in the right posterior-lateral side of the neck. X-ray cervical spine revealed suspicious lesion in the sub-occipital area. Magnetic resonance imaging (MRI) was suggestive of multi-loculated cystic lesion. There were no such cysts found in peritoneal viscera or any other organ. Patient was planned for surgery and the cyst was excised. Histopathological examination confirmed the hydatid disease. Post-operatively, the patient was put on albendazole and patient’s symptoms disappeared after surgery.ConclusionCysts in any part of the body should be evaluated for hydatid disease especially in the endemic areas. Radiological imaging and serology are important for diagnosis, and surgical excision is the best modality of treatment.

Mucinous cystic neoplasm of the liver with extrahepatic growth presenting with ascending cholangitis diagnosed by endoscopic ultrasound features: a case report

BackgroundMucinous cystic neoplasm of the liver with extrahepatic growth is a rare benign epithelial neoplasm of the biliary system that presents with a mass effect or is incidentally found on imaging. The tumor affects mostly the common hepatic duct, which is difficult to diagnose preoperatively by radiology, endoscopy, or cystic fluid analysis. Endoscopic ultrasound is a noninvasive tool for the evaluation of features of a cystic lesion and the extent of disease. Optimal treatment is complete tumor resection.Case presentationA 27-year-old Thai woman was referred to our hospital for investigation and treatment of clinical symptoms of obstructive jaundice and ascending cholangitis, as well as an unknown cause of obstruction. Multiple investigations were performed, including endoscopic retrograde cholangiography and magnetic resonance imaging. Endoscopic ultrasound showed a multiloculated cystic lesion with internal septations without communication to the bile duct, which helped to support a diagnosis of mucinous cystic neoplasm. Eventually, the pathological diagnosis made was mucinous cystic neoplasm of the bile duct. A follow-up clinical examination with imaging at 6 months revealed that the patient was asymptomatic and without recurrence.ConclusionsWe report a rare case of a patient with a large mucinous cystic neoplasm of the liver with extrahepatic growth causing biliary obstruction, which was diagnosed on the basis of endoscopic ultrasound features. Following definitive diagnosis, treatment with complete surgical resection using a multidisciplinary approach was successful.

Invasive mucinous adenocarcinoma of the lung presenting as a large, thin-walled cyst: A case report and literature review.

Invasive mucinous adenocarcinoma (IMA), formerly referred to as mucinous bronchioloalveolar carcinoma, is a rare variant form of invasive adenocarcinoma and is radiologically characterized by dense pneumonic consolidation, ground-glass opacity and nodules. By contrast, large, thin-walled cysts are rare. We herein report the case of a 75-year-old man with IMA presenting as a large, irregularly shaped cystic lesion. The histological diagnosis was based on specimens obtained during a bronchoscopy. The patient underwent lobectomy followed by anticancer chemotherapy for residual intrapulmonary metastases. Of note, the small metastatic nodules transformed into cystic lesions with thin walls and fused, forming a large, multiloculated cystic lesion. Typical pneumonic consolidation appeared in the pericystic parenchyma later during the clinical course. The available literature on this rare radiological manifestation was also reviewed and discussed. Clinicians should be aware of thin-walled cystic lesions as they may be an unusual radiological finding in IMA.

Serous Microcystic Adenoma of Pancreas: A Case Series from a Tertiary Care Centre in Southern India.

Serous microcystic adenoma is a rare exocrine tumour of the cystic neoplasm of pancreas seen predominantly in the elderly population. The first patient was a 56-year-old diabetic woman with abdominal pain, constipation and loss of weight since two months. The second patient was a 73-year-old female with complaints of abdominal pain and back pain since one year. The third patient was a 72-year-old diabetic man with complaints of burning sensation in the right lumbar region since two months. Clinical and laboratory examinations were normal. The radiological examinations of the first two patients showed multiloculated cystic lesion in the pancreas and of the third patient was suggestive of islet cell tumour. The histopathological examination of the three patients showed multiple cysts of varying sizes lined by cuboidal epithelium, showing no atypia. All the three patients were diagnosed as serous microcystic adenoma of pancreas. On follow up, all three patients had no recurrence. Serous epithelial neoplasms need to be differentiated from their non-neoplastic counterparts and other neoplastic lesions with cystic changes, in view of the differences in management. Serous microcystic adenomas have excellent prognosis.

Cervical giant pseudomeningocele presented with neck pain: conventional MRI and MR myelography findings

A 12-year-old boy with neck pain was admitted to our clinic. He had a history of head and neck trauma 3 years before presentation. Laboratory and neurologic examination was unremarkable. Conventional magnetic resonance imaging of cervical spine showed a giant multiloculated cystic lesion with the size of 7.5 cm×2.5 cm. The lesion was hypointense on T1weighted images and hyperintense on T2-weighted images such as cerebrospinal fluid (Fig. 1A, B). The cystic lesion was extending through neural foramens around the spinal nerve roots (Fig. 1C, D). Magnetic resonance myelography demonstrated the pseudomeningocele in detail anterior to spinal cord and thecal sac (Fig. 2). The spinal nerves of cervical and brachial plexus were intact. Conservative management of the lesion was decided because the patient showed no evidence of progressive neurologic deficit. Pseudomeningocele is defined as an extradural collection of cerebrospinal fluid that results from a tear in dura and arachnoid layer. It becomes encapsulated in a fibrous sac. Common etiologic factors are congenital, traumatic, and iatrogenic [1–3]. References

Congenital giant megaureter associated with ipsilateral multicystic dysplastic kidney in newborn

Congenital giant megaureter presents as abdominal mass and impose diagnostic difficulties. It can be associated with other upper urinary tract anomalies. A female newborn with antenatal diagnosis of polycystic kidneys was admitted at birth due to lower abdominal mass. Ultrasound and CT scans diagnosed a multiloculated cystic lesion in the mid and lower abdomen along with right side multicystic kidney. At laparotomy, an extaperitoneal, lobulated cystic swelling was found due to rightside giant megaureter. Its lower end was of normal caliber and orthotopic. End cutaneous ureterostomy was done. Intravenous urogram and isotope renograms showed nonfunctioning right kidney. She also had grade II vesicoureteral reflux on left side. Child suffered urinary infection twice. At 9m age, right nephroureterectomy was done. Histopathologic examination was consistent with cystic renal dysplasia and dilated ureter. This is the first case report of giant megaureter associated with ipsilateral multicystic dysplastic kidney in newborn.

Giant cardiac hydatid cyst: case presentation with radiologic survey and review of literature

Hydatid disease is mostly localised to liver and lungs. Cardiac involvement is a rare but potentially very serious complication of echinococcosis, constituting only 0.5–2% of all cases of hydatidosis. Cardiac hydatid cyst is a diagnostic and therapeutic challenge on account of highly variable clinical presentations and non-specifi c symptoms and often numerous unpredictable complications. We present a case report of 20-year-old man who was admitted to our hospital with chief complaint of palpitations and shortness of breath. Using baseline investigations like ECG, transthoracic echocardiography, ultrasonography, non-contrast computed tomography and magnetic resonance imaging, a giant multiloculated cystic lesion (58.4 mm × 43.3 mm) was diagnosed in the apex of left ventricle. Serologic tests (hydatid cyst antibody) confi rmed Echinococcus infection. Thoracic computed tomography with intravenous contrast was not performed because patient reported history of allergy to contrast. This case report is unusual as it is concerned with the description of a rare disease entity (large cardiac hydatid cyst). Its radiological appearances are discussed for early diagnosis and better understanding of the disease, together with a review of the literature.Journal of Kathmandu Medical CollegeVol. 3, No. 4, Oct.-Dec., 2014Page:

English

Renal hydatidosis represents only 2-3% of hydatid disease. Hydatid disease is a cyclozoonotic parasitic infestation caused by the cestode Echinococcus granulosus. Isolated renal involvement is extremely rare. We report a rare case of isolated left renal hydatid cyst in a 55-year- old female working as a farmer, who presented with vague abdominal pain and hydatiduria. Exploratory laparotomy was done, total excision of the cyst and pericystectomy was done. Diagnosis was confirmed by histopathology. Postoperative follow-up of the patient for six months showed the patient to be disease free. INTRODUCTION: Cystic echinococcosis (hydatidosis) is a parasitic disease caused by the larval form of Echinococcus granulosus. It is a common disease in specific regions. It is endemic in most sheep- raising countries in Asia, Europe, South America, New Zealand and Australia where sheep, dogs and humans live in close contact. (1,2) The guts of dogs and other carnivorous animals represent a definitive host for the adult worm. Humans become an accidental intermediate host by ingesting Echinococcus eggs. The liver is the most commonly involved organ, followed by the lungs. Renal involvement is very rare affecting up to 1.9% of patients.(3) However, a preoperative accurate diagnosis is important to provide appropriate antihelmentic treatment, take intraoperative precautions preventing parasite dissemination and possibly avoid unnecessary nephrectomy. (4) CASE REPORT: A 55-year-old female patient presented with vague abdominal pain of two year duration, insidious in onset, slowly progressive and dull aching in type. She had a history of intermittent passage of small, white, grape-sized, balloon-like structures in the urine (hydatiduria) for last two months. There were no other symptoms associated with the pain. General physical examination revealed no abnormality and systemic examination revealed a large ballotable mass in the left hypochondrium and lumbar region. Routine blood examinations were normal. The X-ray of the chest was normal. Ultrasonography of the abdomen picked up a cyst in the upper pole of the right kidney, measuring 25 cm in the largest dimension. Rest of the urinary system was normal. A computed tomography (CT) scan of the abdomen was done and displayed a large multiloculated cystic lesion at the upper pole of the left kidney (Figure 1). There were no other lesions in abdominal. A diagnosis of isolated left renal echinococcosis was made. The patient was started with albendazole. After four weeks, the patient underwent exploratory laparotomy under general anesthesia through midline incision, a large cyst involving the upper pole of the left kidney was noted (Figure 2), and fluid was aspirated and sent for analysis. Peritoneal cavity packed with hypertonic saline soaked mops. The hydatid cyst was laid open after

Isolated Hypoglossal Nerve Schwannoma: An Uncommon Presentation of Schwannoma.

Isolated Hypoglossal Nerve Schwannoma: An Uncommon Presentation of Schwannoma.

Cystic Nephroma of the Kidney

A 65-year-old female presented to the emergency room with shortness of breath. Chest computerized tomography revealed a pulmonary embolus as well as, a large, complex cystic lesion of the left kidney. Followup imaging confirmed a 16 cm Bosniak III cystic lesion. After reviewing management options, the patient elected laparoscopic radical nephrectomy. Gross examination revealed a 13 cm complex, multiloculated cystic lesion. Microscopic examination showed a well circumscribed lesion composed of cysts of variable size. The cysts were separated by septae with variegated appearance containing fibrous areas, calcified material, ovarian like stroma and histiocytes (fig. 1). Immunostain for estrogen receptor (ER) was diffusely and strongly positive in the areas of ovarian like stroma (fig. 2). No solid areas or clusters of clear cells in the septae were seen. The final diagnosis was cystic nephroma (CN). The World Health Organization defines cystic nephroma as a benign cystic neoplasm of the kidney with cysts lined by a single layer of flattened, low cuboidal or hobnail epithelium and separated by fibrous septa with scant cellularity or cells

Acute presentation of ruptured ovarian cyst secondary to torsion with ipsislateral concomitant ectopic pregnancy: A case report

Twenty-one year unmarried regularly menstruating lady without history of amenorrhea presented with acute abdomen in TU Teaching Hospital –Emergency Department. On evaluation urine pregnancy test was positive. Urgent ultrasound revealed multiloculated cystic lesion measuring 8.5 x 8 x 6.7 cms in the right adnexa anterolateral to the uterus with no intrauterine gestational sac. She underwent emergency laparotomy with right salpingo-oophorectomy. On laparotomy there was twisted and ruptured right ovarian cyst with unruptured ampullary pregnancy on the same side. There was coexistence of these two conditions which presented as acute abdomen. DOI: http://dx.doi.org/10.3126/njog.v3i2.10834 Nepal Journal of Obstetrics and Gynaecology Vol.3(2) 2008; 54-56

Pseudo-winging of the scapula caused by scapular osteochondroma: review of literature and case report.

A 20-year-old male was evaluated for winging of the scapula and an enlarging axillary mass of 4months' duration. Imaging demonstrated a multiloculated cystic lesion that extended into the axilla and superiorly displaced the brachial plexus and axillary vessels surrounding an exostotic mass arising from the scapula. Surgery confirmed the mass to be a benign osteochondroma with a reactive bursa. The long thoracic nerve was intact and the serratus anterior muscle contracted normally with nerve stimulation. The scapular winging resolved completely following resection of the osteochondroma, and shoulder and arm function remained normal. A literature review of causes of pseudo-winging of the scapula was performed. Scapular osteochondroma is a rarely reported cause of scapula winging.

Hydatid Cyst in the Uterus of Young Lady

Echinococcal disease remains a problem within some endemic areas. Echinococcal cysts usually involve the liver and lungs, but are extremely rare in the uterus. In this paper we report the rare case of a 27-year-old unmarried doctor presented with the complains of menorrhagia for 9 months and lump in lower abdomen for 6 months. Ultrasonography and MRI revealed a large multiloculated cystic lesion within the uterine cavity. Serological tests were positive for echinococcus. The patient was operated on; cysts were removed from uterine cavity. Antihelminthics were administered postoperatively and the patient was closely followed up for 9 months, without menorrhagia or recurrence of Echinococcal cyst. Although Echinococcal cysts are extremely rare in the uterus, it can be managed successfully. DOI: http://dx.doi.org/10.3329/bmj.v40i2.18513 Bangladesh Medical Journal 2011 Vol.40(2): 58-60

Complex Cystic Lesions in the Liver Causing Abdominal Pain

A 74-year-old woman was seen by her primary care physician for dull epigastric and right upper quadrant abdominal pain of 1-year duration. Routine laboratory values were within normal limits. The patient underwent ultrasonography of the abdomen, and 2 cystic lesions were discovered in the liver. Magnetic resonance imaging of the abdomen revealed 2 multiloculated cystic lesions in segments IV and V of the liver (Figure, A). Additional laboratory values included normal carcinoembryonic antigen and cancer antigen 19-9 levels. Percutaneous aspiration with a biopsy of one of the cystic lesions was performed that revealed atypical cells suspicious for malignancy. The patient was then referred for management to our institution, where she underwent an exploratory laparotomy and enucleation of these 2 complex multiloculated cystic lesions (Figure, B).