Solid Enhancing Lesions Research Articles

Anesthetic Management of a Pediatric Patient with Midline Neck Mass Causing Significant Tracheal Compression in Stridor for Resection of Tumor

Abstract A 1-year-old female child weighing 10 kg, with a mass over the lower part of the neck presented with stridor. Computed tomography showed a solid enhancing lesion in the lower neck causing marked tracheal compression with complete apposition of the anterior and posterior walls of the trachea causing almost complete obliteration of the tracheal lumen. The child was posted for resection of the tumor under general anesthesia. She was induced with sevoflurane 8% in oxygen and intubated following a flexible bronchoscopic assessment with a 4.0 mm cuffed endotracheal tube using C-MAC videolaryngoscope. After positioning, she developed airway compression, and using a fiber-optic bronchoscope, ETT tip was repositioned distal to the area of tracheal compression. There were repeated episodes of airway compression with desaturation intraoperatively. Postoperatively, the child was ventilated. Due to tracheomalacia and bilateral vocal cord palsy, the extubation trials failed, and she was eventually tracheostomized on the 5th postoperative day to maintain airway.

Belzutifan treatment of Von Hippel-Lindau (VHL) related central nervous system (CNS) hemangioblastomas (HBs): A single institution experience.

2078 Background: Patients with inactivating germline mutations in the VHL gene develop CNS (brain and/or spine) HBs and/or renal cancers, pheochromocytomas and pancreatic neuroendocrine tumors. The oral HIF2a inhibitor belzutifan has been approved by FDA for the treatment of VHL-related HBs. We present here data on a cohort of VHL patients with CNS HBs treated with belzutifan in a single institution. Methods: Adult VHL patients, with radiologically documented CNS (brain and/or spine) HBs that displayed documented growth within the last 6 months prior to therapy, were treated with an initial dose of 120 mg belzutifan orally per day. Target lesions included HBs > 0.4cm long in one maximal cross-sectional diameter. Lesions were imaged by MRI at 1.5, 3, 6 months after initiation of treatment and at 6-month intervals thereafter. Solid enhancing lesions, associated cysts and peritumoral edema were recorded and quantified. Tumor sizes were evaluated by RECIST 1.1 criteria and volumetric analysis. All patients were evaluated and treated in the Hemangioblastoma Center and the VHL Clinic of the Massachusetts General Hospital Cancer Center. Results: At the time of analysis, 9 females and ten 10 male VHL patients (n=19) have been treated. Median age at treatment initiation was 36 yo (range 19-59). Median follow up is 12 months (range 1-19.5 months). Two patients were not yet evaluable for response. Of 17 evaluable patients, 8 had a PR (ORR 47%; 95% CI, 34-60), 8 had SD and 1 patient had progression (PD, 5.8%). Two patients had dose reduction to 80 mg/d because of anemia. No patient had grade 3 or greater toxicity and no patient experienced a CNS related toxicity during treatment. Volumetric analysis of solid and cystic components of the lesions, VHL germline mutations and other correlates of response to belzutifan will be presented. Conclusions: Real world data collected at a single institution confirm the high response rate of both solid and cystic components of CNS HBs to the FDA approved HIF2a inhibitor, belzutifan. Belzutifan was well tolerated. Further prospective controlled studies addressing the optimal dose, schedule and duration of treatment of HBs with belzutifan are required.

Regression and pseudoprogression of pediatric optic pathway glioma in patients treated with proton beam therapy.

We examined regression patterns in pediatric optic pathway gliomas (OPGs) after proton beam therapy (PBT) and evaluated local control and visual outcomes. A total of 42 brain magnetic resonance imaging (MRI) scans from seven consecutive sporadic OPGs that were initially treated with chemotherapy and received PBT between June 2007 and September 2016 at the National Cancer Center, Korea were analyzed. Patients underwent brain MRI regularly before and after PBT. Total tumor, cystic lesion, and solid enhancing lesion area delineation and volume calculations were performed on gadolinium-enhanced T1-weighted MRI using Eclipse version 13, Varian. The median follow-up period after PBT was 70months (range 47-88). The median age at the time of PBT was 7years (range 4-16) and the median duration of chemotherapy before referral to PBT center was 25months (range 3-70). The median time to the greatest increase in cystic volume was 32months (range 12-43) after PBT. Solid enhancing lesion volume gradually decreased throughout the follow-up period. On an individual basis, total volume change was varied. However, on average, it regressed, although at a slower rate than solid enhancing lesion volume did. The local control rate was 85.7% (5-year progression-free survival rate, 80%; 5-year overall survival rate, 100%) and the rate of vision preservation was 71.4% (five of seven patients). The regression patterns in pediatric OPGs after PBT involve significant cystic change. Therefore, total volume is not appropriate for evaluating response. Care by a multidisciplinary team is necessary to manage clinical symptoms related to radiologic changes.

MP61-09 INITIAL MANAGEMENT OF INDETERMINATE RENAL MASSES IN A STATEWIDE COLLABORATIVE:A MUSIC-KIDNEY ANALYSIS

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging/Surveillance III (MP61)1 Sep 2021MP61-09 INITIAL MANAGEMENT OF INDETERMINATE RENAL MASSES IN A STATEWIDE COLLABORATIVE:A MUSIC-KIDNEY ANALYSIS Mohit Butaney, Amit Patel, Brian Lane, Ji Qi, Anna Johnson, Craig Rogers, and for the Michigan Urological Surgery Improvement Collaborative Mohit ButaneyMohit Butaney More articles by this author , Amit PatelAmit Patel More articles by this author , Brian LaneBrian Lane More articles by this author , Ji QiJi Qi More articles by this author , Anna JohnsonAnna Johnson More articles by this author , Craig RogersCraig Rogers More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002101.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The widespread use of imaging has led to the increasing detection of incidental renal lesions. Although some may be accurately classified as suspicious (renal cell carcinoma) and others as benign (Bosniak I-IIF cysts or angiomyolipomas), other lesions are best initially characterized as ‘indeterminate’, for example when they cannot be determined to be enhancing without additional imaging sequences. Optimal management is not well understood. We assess the use of follow up imaging in the management of indeterminate renal lesions(IRL). METHODS: The Michigan Urological Surgery Improvement Collaborative—Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and follow-up data at 13 diverse practices. At initial evaluation, data was recorded regarding the radiologist interpretation of each imaging study (suspicious, indeterminate, benign) as well as the clinician’s assessment. Patients with complete data were assessed at 120 days after initial evaluation as to whether observation or treatment was performed. RESULTS: 19.6% (472/2413) patients(pts) were recorded as having an IRL at their initial imaging study, of which 36% had non-contrast imaging. 23.9% (113/472) of pts with IRL underwent subsequent imaging(SI), of which 59.3% (67/113) were re-classified as solid enhancing lesions, 20.4% as benign lesions, with only 20.4% IRL remaining. Of these 113 pts with repeat imaging, 17 underwent biopsy (15 malignant, 1 benign, 1 indeterminate) and 10 of 15 patients with cancer on biopsy underwent treatment, while the remaining selected surveillance. Pts with initial IRL reclassified to suspicious were less likely to have benign histology at pre-treatment biopsy (8.7% vs. 9.7%) or surgery (6.1% vs. 10.5%) compared with lesions initially characterized as suspicious, but these did not reach statistical significance. CONCLUSIONS: Until now, outcomes of indeterminate renal masses have been poorly understood. About 80% of patients with indeterminate renal lesions can be reclassified with subsequent dedicated imaging. Patients with benign renal lesions, including Bosniak I-IIF cysts, T1a AMLs, and other non-enhancing lesions or pseudotumors can be reassured and should not undergo intervention. Initial contrast axial imaging, the addition of further imaging and consideration of biopsy more fully characterizes an indeterminate renal lesion, often affecting subsequent management. Source of Funding: Funding from Blue Cross Blue Shield of Michigan © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1086-e1086 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohit Butaney More articles by this author Amit Patel More articles by this author Brian Lane More articles by this author Ji Qi More articles by this author Anna Johnson More articles by this author Craig Rogers More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement Loading ...

Female Adnexal Tumour of Wolffian Origin Masquerading as a Broad Ligament Fibroid: A Rare Case Report

Female adnexal tumour of Wolffian origin (FATWO), a rare neoplasm arising from the female adnexa, is typically benign in nature, although recurrences and metastasis have been reported infrequently. First identified and reported in the early 1970s, less than 100 cases have been reported thus far. We present a case of a 16-year-old girl with a left adnexal tumour of Wolffian origin who presented with excessive bleeding during mensuration. With no overt clinical signs, ultrasound revealed a left ovarian neoplasm which was confirmed by CT scan as a solid enhancing lesion in the left adnexa measuring 6.2 x 5 x 4.5 cm. A broad ligament mass was excised, and cytology of peritoneal fluid wash revealed no malignancy. Histomorphological examination and immunohistochemistry confirmed the diagnosis of FATWO. The postoperative course was uneventful; however, the patient was lost to follow-up. Due to the rarity of occurrence, asymptomatic presentation, its variable location, and its morphological diversity, the diagnosis of FATWO may present a challenge especially when the tumour arises in an ovarian location.

Unravelling chloroma: review of imaging findings.

Chloroma refers to the extramedullary proliferation of immature myeloid precursors occurring in a gamut of myeloproliferative and myelodysplastic conditions; acute myeloid leukaemia being the commonest. With non-specific clinical and imaging manifestations, it runs a high risk of misdiagnosis which may significantly affect the outcome of an otherwise treatable lesion. Also with these lesions heralding impending blast crises, awareness of the imaging findings becomes imperative. Imaging not only helps raise the suspicion but also guides further confirmation by demonstration of specific immunohistochemistry markers, ensuring timely institution of chemotherapy. In general, solid enhancing lesions in any haematological disorder could be chloromas, especially if multifocal with mass effect.

Giant Petrous Bone Osteoma Associated With Ipsilateral Clivus Meningioma in an Adult

Background and Importance: An association with multiple primary intracranial tumors of different histologic types not relating to radiotherapy or phacomatosis is a rare event. To the best of the authors’ knowledge, a giant osteoma originating from the inner surface of the petrous bone associated with an ipsilateral clivus meningioma has never been reported. Clinical Presentation: A 43-year-old patient with trigeminal neuralgia was found to have a posterior fossa bony lesion measuring 4 cm, with a solid enhancing lesion in juxtaposition and a separate bony lesion on the occipital bone on magnetic resonance and computed tomography imaging. A satisfactory resection of the coexisting tumors in the petroclival region was performed through a subtemporal transtentorial approach. The tumors were finally confirmed as an osteoma and a meningioma by pathologic evaluation. The patient demonstrated an improvement in her trigeminal neuralgia over a 3-month postoperative period of time. Conclusions: This case presents new clinical and radiographic findings associated with a rare lesion. Dependent tumors that one tumor may act as an irritating agent for the local proliferation of the other most likely accounted for this pattern of tumoral linkage. A satisfactory surgical result was achieved through a relatively minimal approach and different strategies. Trigeminal neuralgia, the initial presenting symptom, improved during the follow-up period.

Neurofibromatosis type 2 patient presenting with medulloblastoma

Background:Neurofibromatosis type 2 (NF2) is an autosomal dominant syndrome with a frequency of 1 in 25,000 live births and a penetrance of almost 100% by the sixth decade of life. The main tumors occurring in NF2 patients are bilateral vestibular schwannomas, other peripheral, cranial and spinal nerve schwannomas, intracranial and intraspinal meningiomas, ependymomas, and gliomas.Case Description:We report the case of a 6-year-old boy who presented with a 1-month history of nausea and recurrent vomiting. Physical examination was positive for ataxic gait and left-sided facial nerve palsy. Family history was positive for NF2 in the patient's father and paternal uncle. Magnetic resonance imaging brain revealed a solid enhancing lesion arising from the right cerebellar cortex, which was effacing the fourth ventricles and causing hydrocephalus. Craniotomy and excision of the lesion were performed. Histopathology report confirmed the diagnosis to be desmoplastic medulloblastoma. Based on the patients’ subsequent history and family history, he was diagnosed to be a case of NF2.Conclusion:This is the first case of medulloblastoma occurring in a patient with NF2 and raises the possibility of an association between medulloblastoma and NF2.

Renal

Cystic and small solid renal masses are frequently detected renal lesions with increasing incidence in the elderly population. Therefore, renal cell carcinomas are also increasingly detected as incidental findings on imaging. Nephron-sparing surgery has been the method of choice for the treatment of small solid renal masses. However, a large percentage of these solid renal lesions is benign and most of the incidentally detected malignant renal tumors such as renal cell carcinomas (RCCs) are smaller, with lower stage and are less aggressive than symptomatic RCCs. In addition, a corrleation with size of the solid lesion and growth rate has been described ranging from 0.13 – 0.31 cm per year. Therefore, active surveillance is now a more frequently applied approach to deal with these incidentally detected small solid renal lesions (< 3–4cm). Whereas in solid enhancing lesions < 1cm in diameter active surveillance is the treatment of choice at any age, in larger lesions management is mainly depending on clinical factors including the age and the performance state of the patient. The role of the radiologist is to exclude benign lesions such as Bosniak I and ll cysts and angiomyolipomas as well as non-neoplastic conditions mimicking a tumor (infection, infarct, vascular anomalies and aneurysms).

Revisiting the CNS Tuberculosis with Emphasis on Giant Tuberculomas and Introducing the “Outer Rim Excrescence Sign”

Central nervous system tuberculosis is a leading cause of morbidity and mortality in developing countries with Mycobacterium tuberculosis as the main etiological agent. Classical imaging findings pose no problem for diagnosis of CNS tuberculosis. Cases of giant or solitary ring enhancing lesions are increasing which mimic other infectious and noninfectious pathologies. This is a retrospective study of 40 patients (28 male and 12 female) of either surgically or clinically proven CNS tuberculosis. Solitary tuberculomas (ring or solid enhancing) were seen in 19 patients. Four patients showed presence of two to three lesions and the lesion more than one centimeter size was categorized as 'giant tuberculoma'. Multiple lesions with other associated findings were noted in 21 patients. Total 33 patients showed solitary or multiple ring enhancing lesions. Seven patients showed solid enhancing lesions (giant tuberculoma). The "Outer rim excrescence sign" was noted in a total of 16 patients. Both brain and spinal tuberculosis was noted in six patients. Seven patients presented with meningitis and hydrocephalous which is considered as the most common manifestation in the literature. Spinal leptomeningeal involvement was seen in five patients, whereas intramedullary cord tuberculomas were noted in four patients. Profound T2W hypointensity is a reliable predictor for giant tuberculomas with intense contrast enhancement, especially in deep locations. 'Outer rim excrescence' sign may contribute in cases of ring and solid enhancing lesions, however it requires further comprehensive study with MT Imaging and MR Spectroscopy to be recorded as a differentiating feature.

Detection of Renal Lesion Enhancement with Dual-Energy Multidetector CT

To determine whether dual-energy multidetector CT enables detection of renal lesion enhancement by using calculated nonenhanced images with spectral-based extraction in a non-body weight-restricted patient population. Between January 2008 and December 2009, 139 patients were enrolled in this prospective HIPAA-compliant, institutional review board-approved study. Written informed consent was obtained from all patients. After single-energy nonenhanced 120-kVp CT images were acquired, contrast material-enhanced dual-energy multidetector CT images were acquired at 80 and 140 kVp. Calculated nonenhanced images were generated by using spectral-based iodine extraction. Lesion attenuation was measured on the acquired nonenhanced, calculated nonenhanced, and 140-kVp contrast-enhanced nephrographic images. Enhancement, defined as a 15-HU or greater increase in attenuation on the nephrographic images, was assessed by using the baseline attenuation on the acquired and calculated nonenhanced images. Acquired nonenhanced versus calculated nonenhanced image attenuation, as well as enhancement values, were compared by using paired Student t tests and Bland-Altman plots. Hypoattenuating (n = 66) and hyperattenuating (n = 28) cysts, angiomyolipomas (n = 18), and solid enhancing lesions (n = 27) were detected. Mean attenuation values for hypoattenuating cysts on the acquired and calculated nonenhanced CT images were 6.5 HU ± 5.8 (standard deviation) and 8.1 HU ± 3.1 (P = .13), respectively, with corresponding enhancement values of 1.1 HU ± 5.2 and -0.5 HU ± 6.2 (P = .12), respectively. Mean values for hyperattenuating cysts were 29.4 HU ± 5.6 on acquired images and 31.7 HU ± 5.1 on calculated images (P = .39) (corresponding enhancement, 4.7 HU ± 3.3 and 2.3 HU ± 4.1, respectively; P = .09). Mean values for fat-containing enhancing lesions were -90.6 HU ± 24.7 on acquired images and -85.9 HU ± 23.7 on calculated images (P = .57) (corresponding enhancement, 18.2 HU ± 10.1 and 13.6 HU ± 10.7, respectively; P = .19). Mean attenuation values for solid enhancing lesions were 26.0 HU ± 15.0 on acquired images and 27.7 HU ± 14.9 on calculated images (P = .45) (corresponding enhancement, 60.3 HU ± 13.1 and 58.3 HU ± 15.5, respectively; P = .38). Dual-energy CT acquisitions with spectral-based postprocessing enabled accurate detection of renal lesion enhancement across the attenuation spectrum of frequently encountered renal lesions in a non-body habitus-restricted patient population.

Renal-Adrenal Fusion: Instance of an Adrenal Adenoma Mimicking a Solid Renal Mass at CT—Case Report1

The authors report an unusual case of unilateral renal-adrenal fusion with a concurrent adrenal adenoma. At computed tomography, this abnormality appeared as a solid enhancing lesion in the upper pole of the kidney, mimicking a renal mass. The ambiguous characteristics of this lesion at cross-sectional imaging, along with alternative diagnostic possibilities, are discussed.

Disseminated Cryptococcal Infection and Anti-Tumor Necrosis Factor-α Treatment for Refractory Sarcoidosis: An Expected Association?

The use of anti-tumor necrosis factor-α(anti-TNF-α) agents is validated in refractory rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, and ulcerative colitis. Although very effective in breaking down granulomatous inflammation typically involved in sarcoidosis, anti-TNF-α agents significantly reduce the host granulomatous defence mechanisms that normally contain pathogens such as mycobacteria and fungi. We describe a case of disseminated cryptococcosis in a patient with refractory systemic sarcoidosis, in whom complete resolution followed discontinuation of anti-TNF-α drug and antifungal therapy. A 42-year-old man was referred to our internal medicine department with a 2-year history of unexplained left-ear deafness and lymphocytic meningitis. Clinical examination was normal except for left-ear deafness. Gadolinium-enhanced magnetic resonance imaging (MRI) showed multiple solid enhancing lesions involving the left internal acoustic canal and the left frontal lobe. Cerebrospinal fluid (CSF) analysis revealed lymphocytosis (85/mm3), elevated CSF protein (1.24 g/l), and low glucose CSF concentrations (1.4 mmol/l). Viral, bacterial, and fungal cultures were negative. Thoracic computed tomography … Address reprint requests to Dr Sène; E-mail: damien.sene{at}psl.aphp.fr

Sickle cell trait and gross hematuria

CASE PRESENTATION A 35-year-old African-American woman with sickle cell trait presented to our medical center with severe gross hematuria. The patient reported having had dark urine for at least 2 months, but after a recent 2 h and 30 min air travel, her urine became bright red and she began passing dark clots. In addition, she started experiencing generalized fatigue, weakness, and mild dizziness. The patient had experienced several episodes of gross hematuria in the past. One such episode, 15 years ago, resulted in a prolonged hospitalization and transfusion of 5 U of blood. Another episode took place 11 years ago lasting for approximately 2 weeks, but symptoms resolved spontaneously. The etiology of her hematuria had never been established. Other medical problems included chronic right knee osteoarthritis and degenerative lumbar disk disease. She denied chronic use of non-steroidal anti-inflammatory agents, but admitted to frequent use of acetaminophen for arthritic pain. Upon presentation, the patient appeared comfortable. Her blood pressure was 130/60, and heart rate was 80/min. Head, neck, lung, and heart examinations were unremarkable. The abdomen was soft and non-tender and liver span was normal. The tip of the spleen was palpable. There was no pedal edema. Her laboratory values were significant for mild anemia with hematocrit of 33% (normal 34-44%). The platelet count was 313 x 10 9 /l (normal 165-415 x 10 9 /l) and white blood cell count was 6.5 x 10 9 /l (normal 3.5-9.0 × 10 9 /l). Her coagulation parameters were normal. The serum electrolytes were also within normal range. Her renal function was preserved with a creatinine of 0.9 mg/dl (normal 0.5-0.9 mg/dl) and a blood urea nitrogen of 7 mg/dl (normal 7-20 mg/dl). Urine analysis revealed 3+ hemoglobin and no protein. Urine microscopy showed 182 red blood cells per high powerfield. Urine cultures were negative. Renal ultrasound measured the right kidney length at 11.7 cm; the left kidney was 11.9 cm in length; there was no hydronephrosis or calculus in either kidney. The urinary bladder was unremarkable. Magnetic resonance imaging confirmed that both kidneys were of normal size and signal, and no solid enhancing lesion was identified. Diagnostic cystoscopy and ureteroscopy were performed. Blood was visualized effluxing from the right ureteral orifice. Upon inspection of the collecting system, the posterior middle pole calyx was found to have a stenotic infundibulum. Endoinfundibulotomy was performed to enter the calyx, where there appeared to be a sloughed ischemic papilla with an accompanying hemorrhage (Figure 1). The papilla was fully fulgurated in an attempt to stop the bleeding. The remaining calyces and the renal pelvis were also inspected and found to be free of disease. Although the bleeding ceased in the immediate post-procedure period, it reappeared later that day.

PROSPECTIVE PRETRANSPLANT ULTRASOUND SCREENING IN 206 PATIENTS FOR ACQUIRED RENAL CYSTS AND RENAL CELL CARCINOMA.

291 Objective: To assess the role of ultrasound screening in the detection of renal malignancies as part of the urologic evaluation of prospective renal transplant recipients. Materials and Methods: From January 1995-October 1997, 206 patients with end stage renal disease (ESRD) underwent a renal ultrasound as part of the urologic evaluation prior to renal transplantation. Acquired cystic kidney disease (ACKD) was defined as at least 3 cysts in each kidney in the absence of autosomal dominant polycystic kidney disease. When a solid lesion or complicated cyst was visualized on ultrasound, patients underwent a contrasted CT scan followed by a surgical excision of kidneys with solid enhancing lesions on CT scan. Results: 206 patients with a mean age of 37 years (range 22-65 years) underwent a urologic avaluation from January 1995-October 1997. 69/206 (33%) had ACKD on renal ultrasound, being dialysis dependant for a mean duration of 78.4 months (range 30198 months). 22/63 (34.9%) had a suspicious renal ultrasound for a solid mass of complicated cyst, 8/22 (36.3%) having a solid enhancing lesion on a contrasted CT scan (5 unilateral, 3 bilateral), being dialysis dependant for a mean duration of 71 months (range 6-192 months). 6/8 have undergone a radical nephrectomy (5 left, 1 bilateral) and had evidence of localized papillary renal cell carcinoma with no evidence of capsular invasion or lymph node involvement, while 2 patients are scheduled for a bilateral nephrectomy. Conclusion: Screening renal ultrasound had a sensitivity of 36.3% (8/22) in the detection of renal cancer associated with ACKD. Overall, the detection of renal cancer was 3.8% (8/206) in this group. Since post transplant immunosuppression has been speculated to accelerate the growth of malignancies, we recommend screening renal ultrasound as part of pretransplant urologic evaluation.