Preoperative Radiological Investigations Research Articles

Successful surgical management of an aggressive IgG4-related sclerosing esophageal inflammatory pseudotumor: a case report and review of literature

BackgroundInflammatory pseudotumor (IPT) of the esophagus is a very rare benign lesions which clinical presentation is not clear and difficult to make a definitive diagnosis preoperatively.Case presentationIn this report, we presented a case of a 24-year-old female with signs of severe malnutrition state due to dysphagia increasing gradually and losing 10 kg in weight for 2 months. Comprehensive preoperative radiologic investigations were proceeded with a circumferential severe stricture caused smooth submucosal swelling in the esophagus under 23 cm from the upper dental arch and two times of negative biopsy. Due to the aggressive clinical symptoms and gross lesion characteristics, the patient underwent laparoscopic-thoracoscopic esophagectomy and reconstruction with a gastric tube. Histopathological examination showed that the squamous epithelium of the esophagus had a small, benign nucleus, the submucosal layer and the smooth muscle layer increased fibrous, with infiltrating many lymphocytes, plasma cells, and macrophages. Immunohistochemical staining was negative for CD68, CD34, Desmin and ALK markers, and there was an increase in the number of IgG4-positive plasma cells. The final diagnosis was an aggressive IgG4-related sclerosing esophageal inflammatory pseudotumor.ConclusionsInflammatory pseudotumor of the esophagus is an extremely rare benign lesion but could led to aggressive clinical presentation. The gold standard of diagnosis is histopathological examination of surgically removed specimens. Radical resection is still the most efficient treatment method.

Comparing Clinical Examination and Radiological Evaluation in the Preoperative Diagnosis and Location of Symptomatic Interdigital (Morton's) Neuroma

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected pre-operative clinical findings, radiological investigations and post-operative outcomes. Sensitivity and positive predictive value were calculated and Z-score for two populations proportions was performed. 114 consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common pre-operative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (P-value: <0.001 and P-value: <0.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (P-value: 0.005). Pre-operative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Pre-operative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound.

Azygous Venous System - Anatomical Variation and Its Clinical Significance

Introduction: Azygous venous system is the system of unpaired veins comprising of the azygous vein, the hemiazygous vein and accessory hemiazygous vein1. They are para vertebral in position, provided with valves and drain most of the blood from the thoracic and posterior abdominal walls. They communicate with the venacaval system infront and vertebral plexus behind. It connects the superior vena cava with the inferior vena cava. The azygous vein is inconstant in the mode of origin. Aim: To explore the anatomical variations in the course of azygous system of veins. Material and methods: The present study was done in the Department of Anatomy, Apollo institute of Medical sciences and Research, Hyderabad over a period of 2 years. The present study was conducted on 12 cadavers (irrespective of age and sex). The course of the azygos venous system in these 12 cadavers was carefully observed and documented. Results: Anatomical variation was found in two cadavers. Discussion: The azygous system of veins arises from a pair of longitudinal venous lines called right and left azygous venous lines on each side of the aorta1. On each side of the azygous venous lines lies two parallel primitive lines called right and left sub cardinal and posterior cardinal veins. It forms an important route for collateral circulation in venacaval occlusion such as in portal hypertension. It serves as the main collateral channel to shunt the blood from the upper half of the body to the inferior venacaval in case of superior vena caval obstruction. Conclusion: Identification and understanding of these variations are important during preoperative radiological investigations and surgical procedures especially spinal surgery between T7 and T12 to avoid injury which may lead to postoperative haematomas Keywords: Azygous venous system, azygous vein, venacaval system.

Rate of occult neck nodal metastasis in primary and salvage laryngectomy.

Rate of occult neck nodal metastasis in primary and salvage laryngectomy.

Treatment of dorsal wrist ganglion cyst by establishing midcarpal volar portal using the "Kiss-in" method.

IntroductionThis paper introduces the treatment and clinical outcome of the dorsal wrist ganglion cyst utilizing the Kiss-in method to establish a midcarpal volar portal.Materials and methodsPatients with dorsal ganglia of the wrist (n = 12, 6 females, 6 males) underwent arthroscopic surgery using the Kiss-in method at our hospital between September 2018 and January 2021. All patients underwent preoperative radiological investigations, such as magnetic resonance imaging (MRI; 12 cases) or ultrasonography (12 cases). The mean age of patients was 30.7 years (range: 19–46 years). The time lost from work, the wrist motion and strength, the presence of scarring, residual symptoms, complications, and recurrence were recorded at a mean follow-up of 24 months.ResultsEleven patients showed a good prognosis with active motion recovery. One patient showed the recurrence of ganglion, and the second arthroscopic resection was performed 5 months after the first surgery for this patient. After the surgery, the patient fully recovered.ConclusionsEstablishing the midcarpal volar portal by the Kiss-in method is safe. The dorsal ganglion cyst resection through the established midcarpal volar portal is a promising approach, allowing better visualization and a broader range motion of the arthroscope.

Endoscopic versus open surgical approaches for colloid cyst of the third ventricle

Colloid cysts are benign lesions of the anterior part of the third ventricle. Surgery is the main line of treatment. Endoscopic treatment gained wide acceptance among neurosurgeons. However, open microsurgical approaches still recommended by many surgeons. Each approach had its own advantages and drawbacks. The current study designed to explore the outcome of endoscopic versus open colloid cystectomy for the colloid cyst of the third ventricle. This is a retrospective study of patients who submitted to third ventricle colloid cystectomy during a duration of 10 years. A total number of 41 patients were included (20 managed by endoscopic approach and 21 by open surgery). Files were reviewed for preoperative (clinical examination and radiological investigations), operative (e.g, operative time, the size of the cyst and additional interventions) and postoperative outcome. Both approaches were comparable regarding demographics, preoperative, operative and postoperative data, except significant reduction of operative time and total duration of hospital stay among endoscopy than open group (127.95±18.32, 5.30±1.69 vs 178.33±20.51 and 8.95±1.62 respectively). The recurrence was reported among 3 patients (7.3%) (2 in the endoscopy and 1 in the open group). Among 90.0% of endoscopy group, their neurological condition was improved compared to 95.2% of open group.

Does a tailored magnetic resonance imaging technique affect the surgical planning and outcomes for different cystic urethral and periurethral swellings in females? Seven years tertiary center experience

PurposeTo evaluate the use of magnetic resonance imaging (MRI) in preoperative delineation and surgical planning for the management of female urethral and periurethral cystic vaginal swellings, with emphasis on postoperative surgical outcomes.Materials and methodsThis is a retrospective analysis of females complaining of periurethral and urethral cystic swellings referred to our tertiary center, who underwent MRI for preoperative planning in the period from January 2014 till January 2021, with a total number of 57 patients. Data retrieved from the medical records included: patients’ demographics, presenting symptoms and signs, preoperative radiological investigations, duration of symptoms, previous surgical intervention, detailed intraoperative data, postoperative complications, and postoperative follow-up.ResultsUrethral diverticulum was the commonest cystic lesion representing (64.9%) followed by Skene gland cysts in 14%, Mullerian cysts in 7%, Gartner cysts in 3.5%, and dermoid inclusion cysts in 10.5%. MRI precisely diagnosed the various pathological entities and anatomical complex lesions prior to surgery. This was confirmed after surgery and pathology analysis. All patients were followed up with a mean duration of 35 months, without any evidence of recurrence.ConclusionMRI as a standalone imaging technique is mandatory for diagnosis of all urethral and periurethral cystic lesions, as it offers the most accurate diagnostic modality for delineation of these lesions and hence aids in the preoperative surgical planning, aiming to avoid recurrence and improving surgical outcomes.

Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section Part II: Trigeminal and facial nerve schwannomas (CN V, VII).

Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogenous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations. A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the second of a three-part series describing non-vestibular schwannomas (V, VII). A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies, and follow-up management. This article represents the consensually derived opinion of the task force with respect to the treatment of trigeminal and facial schwannoma. The aim of treatment is maximal safe resection with preservation of function. Careful thought is required to select the appropriate surgical approach. Most middle fossa trigeminal schwannoma tumours can be safely accessed by a subtemporal extradural middle fossa approach. The treatment of facial nerve schwannoma remains controversial.

Utility of Three-Dimensional Printing for Preoperative Assessment of Children with Extra-Cranial Solid Tumors: A Systematic Review.

Background: In cases with solid tumors, preoperative radiological investigations provide valuable information on the anatomy of the tumor and the adjoining structures, thus helping in operative planning. However, due to a two-dimensional view in these investigations, a detailed spatial relationship is difficult to decipher. In contrast, three-dimensional (3D) printing technology provides a precise topographic view to perform safe surgical resections of these tumors. This systematic review aimed to summarize and analyze current evidence on the utility of 3D printing in pediatric extra-cranial solid tumors. Methods: The present study was registered on PROSPERO—international prospective register of systematic reviews (registration number: CRD42020206022). PubMed, Embase, SCOPUS, and Google Scholar databases were explored with appropriate search criteria to select the relevant studies. Data were extracted to study the bibliographic information of each article, the number of patients in each study, age of the patient(s), type of tumor, organ of involvement, application of 3D printing (surgical planning, training, and/or parental education). The details of 3D printing, such as type of imaging used, software details, printing technique, printing material, and cost were also synthesized. Results: Eight studies were finally included in the systematic review. Three-dimensional printing technology was used in thirty children with Wilms tumor (n = 13), neuroblastoma (n = 7), hepatic tumors (n = 8), retroperitoneal tumor (n = 1), and synovial sarcoma (n = 1). Among the included studies, the technology was utilized for preoperative surgical planning (five studies), improved understanding of the surgical anatomy of solid organs (two studies), and improving the parental understanding of the tumor and its management (one study). Computed tomography and magnetic resonance imaging were either performed alone or in combination for radiological evaluation in these children. Different types of printers and printing materials were used in the included studies. The cost of the 3D printed models and time involved (range 10 h to 4–5 days) were reported by two studies each. Conclusions: 3D printed models can be of great assistance to pediatric surgeons in understanding the spatial relationships of tumors with the adjacent anatomic structures. They also facilitate the understanding of families, improving doctor–patient communication.

Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section. Part I: oculomotor and other rare non-vestibular schwannomas (I, II, III, IV, VI).

Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogeneous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear, and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations. A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the first of a three-part series describing non-vestibular schwannomas (I, II, III, IV, VI). A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies and follow-up management. This article represents the consensually derived opinion of the task force with respect to the treatment of non-vestibular schwannomas. For each of these tumours, the management of these patients is complex, and for those which are symptomatic tumours, the paradigm is shifting towards the compromise between function preservation and progression-free survival.

TP9.2.22A six year retrospective study of appendicular neoplasms and review of literature

Abstract Aims The aim of this study was to evaluate the incidence of appendiceal neoplasm, identify possible association of pre and intra-operative factors associated with it, and to determine its clinical significance. Methods Using pathological reports from surgical specimens of appendix from January 2015 to September 2020, a single centre retrospective analysis was performed. Medical records of patients, pre-operative investigations, intra operative findings, histological reports and post operative management were evaluated. Results The incidence of appendiceal neoplasms was 2.33% (65/2791). They consisted of Neuroendocrine tumor (NET) in 35(53.85%), followed by Low grade mucinous neoplasm (LAMN) in 23(35.38%), Goblet cell carcinoid in three (4.62%), mucinous cystadenoma 2(3.08%), one (1.54%) adenocarcinoma and one (1.54%) metastasis. Appendicitis was the most common indication for surgery. 46(70.77%) patients had emergency surgery. 89.13% emergency surgeries was appendicectomy, NET being the most common tumor in 60.87%. 19(29.23%) patients had elective surgery, all had pre operative radiological investigation, LAMN being most common. Only five (7.69%) patients had intra operative suspicion of tumor. Ten patients required second procedure in the form of right hemicolectomy in nine, and cytoreducetive surgery in one. All patients were followed up as per national guidelines. Conclusions The incidence of appendiceal neoplasms though low, has been steadily rising. Its diagnosis is rarely evident on pre operative radiological investigations. Surgeons should be aware of these neoplasms and its frequent association with emergency appendicectomies done for suspected acute appendicitis.

Resection of fibrous bands, extraction of third molars, bilateral coronoidotomy, masticatory muscle myotomy and comparison of collagen membrane and buccal fat pad graft in surgical management of stage III, IV oral submucous fibrosis

Background: Oral submucous fibrosis is a treacherous, devastating state of the mouth bringing about critical wellbeing and social issues, which may meddle with the standard assessment of the oral depression for malignancy, satisfactory nourishing admission, dental cleanliness and discourse. Medicines proposed for OSMF have been palliative instead of remedial. They are pointed toward improving the patient’s capacity to open the mouth, which becomes confined when more scar tissue is shaped as the illness advances. Various unions are accessible today to cover the post fibrotic discharge deformity however none of them alone gave a drawn out victories. In our investigation we looked at two modalities as they were generally advantageous and convey less postoperative morbidity. Collagen sheet as a join to cover the careful deformity and the buccal cushion of fat turned onto the imperfection as a unite to cover it. Aims and Objectives: The current investigation was led to assess the clinical viability of collagen film and buccal cushion of fat join for careful administration of Oral Submucous fibrosis with extraction of third molars, two-sided coronoidotomy, masticatory muscle myotomy with arrival of fibrosis and remaking by collagen layer unite in five patients and buccal fat cushion join in five patients of clinically analyzed stage III, IV Oral Submucous fibrosis with a subsequent time of a half year from September 2010 to September 2012 at Department of Oral and maxillofacial Surgery in Al Badar Rural Dental College and Hospital. Materials and Methods: Ten patients with chief complaint of difficulty in mouth opening with no previous history of any medical or surgical line of treatment and clinically diagnosed as stage III, IV Oral submucous fibrosis were included in this study. Preoperative clinical findings, radiological investigations and maximum incisal distance were assessed for the need of surgical procedure for Oral submucous fibrosis. All the patients u

Petroclival meningiomas: update of current treatment and consensus by the EANS skull base section.

The optimal management of petroclival meningiomas (PCMs) continues to be debated along with several controversies that persist. A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the management of these tumors. To achieve this, the task force reviewed in detail the literature in this field and had formal discussions within the group. The constituted task force dealt with the existing definitions and classifications, pre-operative radiological investigations, management of small and asymptomatic PCMs, radiosurgery, optimal surgical strategies, multimodal treatment, decision-making, and patient's counselling. This article represents the consensually derived opinion of the task force with respect to the management of PCMs.

Pediatric E.N.T. emergencies during COVID-19 pandemic: our experience.

Our aim is to analyze effect of covid-19 pandemic in management of pediatric emergencies in E.N.T. and to provide recommendations for management of pediatric emergencies in E.N.T. during pandemic. In this retrospective study we included emergency pediatric cases required early intervention during covid-19 pandemic. Pre operative radiological investigation x-ray was done in all aero digestive foreign body patients. Pre operative HRCT neck and chest with virtual bronchoscopy in foreign body inhalation & compromised airway patients was done only in cases where patient’s clinical condition was stable. Similarly RT PCR for covid-19 screening done only in cases where patient’s clinical condition was stable. Adequate personal protective equipment was used during all the procedures. Total 29 Pediatric patients age ranging from 1 day to 13 years underwent procedures due to history of foreign body inhalation; ingestion, insertion and compromised airway in form of immediate endotracheal intubation were included. Comprehensively we recommend intervention only in emergency procedures during pandemic, use of personal protective equipment during all procedures, preoperative investigations for diagnosis and modifications in operation theatre, anesthesia and surgical techniques to reduce aerosols generation will minimize risk of infection transmission to health care workers.

Ovoid Foramen Magnum Shape is Associated with Increased Complications and Decreased Extent of Resection for Anterolateral Foramen Magnum Meningiomas.

Background Antero-laterally located meningiomas of the foramen magnum (FM) pose significant surgical resection challenges. The effect of FM shape on surgical resection of FM meningiomas has not been previously studied. The present study investigates how FM shape effects the extent of tumor resection and complication rates in antero-lateral FM meningiomas. Materials and Methods This retrospective study included 16 consecutive patients with antero-lateral FM meningiomas operated on by a single surgeon. FMs were classified as ovoid ( n = 8) and nonovoid ( n = 8) using radiographic evaluation. Results Sixteen patients were examined: seven males and nine females (mean age of 58.5, and range of 29 to 81 years). Gross total resection was achieved in 81% of patients, with tumor encased vertebral arteries in 44%. Patient characteristics were similar including age, sex, preoperative tumor volume, relationship of vertebral artery with tumor, preoperative Karnofsky performance score (KPS), symptom duration, and presence of lower cranial nerve symptoms. The ovoid FM group had lower volumetric extents of resection without statistical significance (93 ± 10 vs. 100 ± 0%, p = 0.069), more intraoperative blood loss (319 ± 75 vs. 219 ± 75 mL, p = 0.019), more complications per patient (1.9 ± 1.8 vs. 0.3 ± 0.4, p = 0.039), and poorer postoperative KPS (80 ± 21 vs. 96 ± 5, p = 0.007). Hypoglossal nerve palsy was more frequent in the ovoid FM group (38 vs. 13%). Conclusion This is the first study demonstrating that ovoid FMs may pose surgical challenges, poorer operative outcomes, and lower rates of extent of resection. Preoperative radiological investigation including morphometric FM measurement to determine if FMs are ovoid or nonovoid can improve surgical planning and complication avoidance.

Outcome of Semi-rigid Ureteroscopy with LASER Lithotripsy for Management of Upper Ureteric Calculi

Background: Proximal ureteral calculi are common with multi-modalities of treatment, with continuous invention of new modalities. Aim of the work: To present the early experience with LASER lithotripsy using semi-rigid ureteroscopy for treatment of upper ureteral calculi, regarding safety and efficacy. Patients and Methods:Eighty patients with upper ureteral stones managed by LASER lithotripsy using semi-rigid ureteroscopy were included [30 prospective and 50 retrospective]. Patient evaluation included medical history, clinical examination with preoperative laboratory and radiological investigations. The outcome measure was stone free rate, Intra operative and Postoperative complications, operative time, hospitalization time, and post-operative analgesia. Results: During the period from January 2018 through February 2020 in 30 prospective cases but retrospectively in 50 cases done in the last two years, 68.8% of patients were males and 31.2% of them were females, mean of age was 43.70 with range from 20 to 66 years, and mean of BMI was 19.75 with range from 18 to 23 with laterality of 60% of patients was right but of 40% was left and stone opacity of 96.25% of patients was radio opaque, while, 3.75% was radio lucent stones the mean operative time was 50.78 minutes and mean duration of hospital stay was 1.3 days. In addition, 66.2% of patient needed JJ, 32.5% required ureteric catheter and 15% failed ESWL. The mean ureteral stone diameter was 10.81. The clearance rate 97.5%; two cases had migrated stone. Conclusion: Semirigid ureteroscope with LASER lithotripsy is an effective and safe procedure for management of large proximal ureteral stones with a lesser rate of stone migration needs use of flexible ureterorenoscopy.

Surgical management of Tuberculum sellae Meningiomas: Myths, facts, and controversies.

The optimal management of tuberculum sellae (TS) meningiomas, especially the surgical strategy, continues to be debated along with several controversies that persist. A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumors on a European perspective. To achieve this, the task force also reviewed in detail the literature in this field and had formal discussions within the group. The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological and endocrinological assessments, optimal surgical strategies, and follow-up management. This article represents the consensually derived opinion of the task force with respect to the surgical treatment of tuberculum sellae meningiomas. Areas of uncertainty where further clinical research is required were identified.

Anterior Mediastinal Kitlelere Cerrahi Yaklaşım

Aim: The aim of this study was to evaluate the clinical progress, type of surgical approach and early results of resection of anterior mediastinal masses. Patients and Methods: We retrospectively reviewed the reports of 25 patients who underwent surgery for an anterior mediastinal mass between 2014 and 2019. Patients’ age, gender, presenting symptoms, preoperative radiological investigations and surgical techniques were recorded. There were eight male and 17 female patients, and their age ranged from 18-89 with a mean of 44.4± 16.9 years. Results: The most frequent presenting symptoms were chest pain (90%) and cough (50%). The most common pathological diagnoses were thymic tumors (n=14, 56%) and lymphoma (n=5, 20%). Surgical approaches applied were median sternotomy in 16 patients, partial sternotomy in five patients and VATS (Video Assisted Thoracic Surgery) in four patients. There were no postoperative deaths or major complications, but eight patients had minor complications. Postoperative stay was 5±5.2 days. Conclusion:Surgery is a safe technique for diagnosis and treatment of anterior mediastinal masses.

An exploration of goal-setting for Cognitive Remediation Therapy in patients with bipolar disorder

Tubulo-villous adenoma is a rare benign appendiceal neoplasm often asymptomatic with the most clinical manifestation that resembles acute appendicitis. Pre-operative diagnosis is difficult by its rarity and the absence of typical symptoms. Adequate treatment is surgical resection.A 69-year-old male was admitted to the Emergency Department with a two-day history of abdominal pain associated with constipation. Abdominal examination revealed abdominal pain localized, at deep palpation, in the right iliac fossa and in hypogastrium without obvious muscle guarding or rebound tenderness. Laboratory tests showed a normal white blood cell count with 82.3% neutrophils and high C-reactive protein level. After a negative abdominal ecography, the patient was evaluated by abdominal computed tomography, which revealed acute appendicitis. The patient was submitted to surgery and open appendectomy was performed. The post-operative course was uneventful and the patient was discharged on the 5th post-operative day.Acute appendicitis may be a clinical manifestation of a benign appendiceal neoplasm. Pre-operative radiological investigations not always are useful for an early diagnosis that is mandatory because of the potential risk of malignant degeneration. Appropriate treatment of acute appendicitis is debated: some surgeons suggest operative treatment, but others advocate for non-operative management. In our case the patient was submitted to surgery avoiding the risk of diagnostic delay of neoplasm.Appendiceal tubulo-villous adenoma is a rare neoplasm difficult to diagnose and suspect because of lack of pathognomonic symptoms and specific diagnostic signs. Acute appendicitis is the most common clinical presentation. Appendectomy is the appropriate treatment.

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

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