Flexible ureteroscope with ultrasound guidance for treatment of parapelvic renal cysts: A complementary approach to locate the cystic wall

Background The main treatment of parapelvic cysts is flexible ureteroscope currently. Considering the intraoperative localization of the cyst may fail with flexible ureteroscope, we tend to use an innovative method by ultrasound-guided for easily locating cystic wall during flexible ureteroscopic surgery Methods We retrospectively reviewed 17 consecutive cases of parapelvic renal cysts treated by ultrasound-guided flexible ureteroscope between March 2017 and May 2020. The differences of simple flexible ureteroscopic technique and ultrasound-guided flexible ureteroscopic technique were compared. The surgical procedures, postoperative complications, results and patients’ follow-ups were evaluated. Results The cysts wall were seen clearly in 10 patients with ureteroscopic vision. Another 7 patients changed to ultrasound-guided flexible ureteroscopic surgery since it was difficult to identify the cyst wall. Mean operative time were 25.9 ± 8.7 minutes and 37.1 ± 10.1 minutes for conventional and modified technique respectively (P =0.004), of which 17.6 ± 5.8 minutes and 26.5 ± 8.4 minutes to search the cysts, respectively (P = 0.002), and the mean time of the incising were 7.1 ± 4.9 minutes and 12.1 ± 5.6 minutes, respectively (P = 0.000). All of the patients were followed-up 12 months, there were no serious complications and recurrence observed. Conclusions We demonstrated that it is feasible and safe to treat parapelvic renal cyst by ultrasound-guided flexible ureteroscopic incision and drainage. The less sample size and further studies were the limitations of our study.

Diagnostic Yield of Transabdominal Ultrasonography for Evaluation of Pancreatic Cystic Lesions Compared with Endoscopic Ultrasonography

Detection rates of pancreatic cystic lesions (PCLs) have increased, resulting in greater requirements for regular monitoring using imaging modalities. We aimed to evaluate the capability of ultrasonography (US) for morphological characterization of PCLs as a reference standard using endoscopic ultrasonography (EUS). A retrospective analysis was conducted of 102 PCLs from 92 patients who underwent US immediately prior to EUS between January 2014 and May 2017. The intermodality reliability and agreement of the PCL morphologic findings of the two techniques were analyzed and compared using the intraclass correlation coefficient and κ values. The success rates of US for delineating PCLs in the head, body, and tail of the pancreas were 77.8%, 91.8%, and 70.6%, respectively. The intraclass correlation coefficient for US and the corresponding EUS lesion size showed very good reliability (0.978; p < 0.001). The κ value between modalities was 0.882 for pancreatic duct dilation, indicating good agreement. The κ values for solid components and cystic wall and septal thickening were 0.481 and 0.395, respectively, indicating moderate agreement. US may be useful for monitoring PCL growth and changes in pancreatic duct dilation, but it has limited use in the diagnosis and surveillance of mural nodules or cystic wall thickness changes.

Frontal Cystic Meningioma Removed by a Partial Transfrontal Craniotomy in a Cat

Background: Meningiomas are the most frequently reported intracranial tumors in cats. It is known to arise at the point of arachnoid cells project into the dural venous sinuses. Cats with intracranial meningiomas are treated by surgical management as the tumors are commonly delineated from normal brain tissue and are not likely to adhere to the cerebral parenchyma. Although meningioma is the most common intracranial tumor in cats, the incidence of cystic meningioma is low. The objective of the current study is to report a case of frontal cystic meningioma with peritumoral cystic structure removed by a partial transfrontal craniotomy. Case: A 10-year-old castrated British shorthair cat was referred to the Baeksan Feline Medical Center with a recent onset of seizures. On the physical examination, the patient was bright and alert. Neurological examinations were unremarkable at the time of presentation. Hematologic examinations were within normal limits. Thoracic and abdominal radiography, and abdominal ultrasonography revealed unremarkable findings. Magnetic resonance imaging revealed an extra-axial mass cranial to the frontal lobe. On the sagittal plane, a cystic structurewas identified in the frontal areaon post-contrast T1W images. No contrast enhancement of the cystic wall was identified after intravenous injection of contrast medium on T1W. On the transverse plane of T2W images, midline shift to the left due to peritumoral edema was observed. The mass was removed via partial transfrontal craniotomy. Postoperative radiography was performed to ensure appropriate placement of the mesh. The patient recovered uneventfully after anesthesia. After the surgery, the patient was closely monitored in an intensive care unit between 24 and 48 h. Based on the histologic findings, the final diagnosis was a fibroblastic meningioma. Nineteen months after the surgery, there was no seizure activity identified by the owner.Discussion: Depending on the location of the cyst, meningiomas can be classified into 4 types according to the human literature. In types 1 and 2, the whole cyst is located within the tumor, resulting in contrast enhancement of the cystic wall. In types 3 and 4, the cysts are located outside the tumor, and no contrast enhancement of the cystic wall is observed. In type 3, the cyst lies adjacent to the brain parenchyma rather than adjacent to the tumor and the meningioma is related to a cerebrospinal fluid cyst bordered by the arachnoid. It is important to classify the type of cystic meningioma prior to surgery in order to decide whether to remove the cystic wall. In type 2, the cystic wall is infiltrated by tumor cells, while the cystic wall of type 3 meningioma is composed of gliotic tissue without any tumor cells. Therefore, in type 2, the meningiomas with cystic walls should be removed for the prevention of recurrence, while in type 3 meningioma, the tumor can be managed by cyst decompression and excision of the solid component. Based on the Nauta classification, the cystic meningioma reported here was considered to be type 3. Therefore, the surgical procedure aimed to remove the solid component of the mass, leaving the cystic wall attached to the normal brain. As the solid part of the meningioma was located beneath the internal plate of the left frontal bone, the partial transfrontal craniotomy was sufficient to expose and remove the entire mass. To the author’s knowledge, this is first case report describing a patient with frontal meningioma with a peritumoral cyst removed by a partial transfrontal craniotomy based on the Nauta classification.

Abducens Nerve Paralysis Induced by a Primary Solitary Sphenoid Sinus Mucocele with Broad Osseous Thinning at the Cranial Base

Primary solitary sphenoid sinus mucocele is rare, generally presenting with headaches or eye symptoms at the anatomical site. We report the case of a 39-year-old woman incidentally diagnosed with sphenoid sinus mucocele during a complete medical checkup. Imaging revealed that the cystic wall had developed from the rear sphenoid sinus and had spread expansively to diminish the clivus; however, no symptoms were reported, and the patient was managed with close observation. During the follow-up period, diplopia developed suddenly due to isolated left-sided abducens nerve paralysis. An endoscopic endonasal approach was used to open the frontal cystic wall, and fascia lata and fat were used for cranial base reinforcement to avoid future cerebrospinal fluid leakage, resulting in improvement during the early stages of follow-up. Treatment options for sphenoid sinus mucoceles include close observation or surgery. In our case, we chose surgery because of an acute symptomatic manifestation during observation.

Intraductal papillary mucinous neoplasm complicated with intraductal bleeding in a young woman mimicked a cystic solid pseudo-papillary tumor: a case report

Background There are only 6 cases of intraductal papillary mucinous neoplasm (IPMN) complicated with intraductal hemorrhage have been reported in English literatures. All these 6 cases of IPMN occurred in the old people. The present rare case of IPMN complicated with intraductal hemorrhage occurred in a young woman, and mimicked a cystic solid pseudo-papillary neoplasm (SPN) on preoperative imaging findings. Case presentation A 29-year-old young woman complained of a sustained mild right upper quadrant abdominal pain. CT and MRI showed a lobulated, partly ill-defined cystic lesion located in the pancreatic head. Spotted calcification within cystic wall was seen on CT. The lesion was demonstrated as predominantly homogeneous hyperattenuation on CT and homogeneous high signal without decreased signal on fat suppression sequence on T1WI. After contrast administration, the cystic wall and septa of lesion was showed gradually mild to moderate degree of enhancement over time both on CT and MRI. No communication between lesion and the main duct was found on MRCP and the main pancreatic duct and common bile duct were not dilated. Considering patient’s age, gender and manifestations of lesion on CT and MRI (calcification, bleeding and gradually enhanced pattern), the present case mimicked as a cystic SPN. The lesion was pathologically confirmed a branch type IPMN after surgical resection. Conclusion We propose that IPMN may need to be taken into account in the differential diagnosis when pancreatic cystic lesions occur in young women with bleeding, calcification, progressive enhancement of cystic wall and no communication with the main pancreatic duct.

Distinguishing mummified thyroid nodules from malignant thyroid nodules

Aim: To study the ultrasonographic (US) differences between “mummified” thyroid nodules and malignant thyroid nodules in order to achieve a more accurate imaging-based diagnosis and to avoid unnecessary biopsy.Material and methods: We retrospectively reviewed the US features of mummified thyroid nodules, as confirmed by fine-needle aspiration cytology (FNAC), in 193 cases. The US features included content, echo, shape, margin, microcalcification, suspicious lymph nodes and some characteristic features, including the cystic wall shrinkage sign, the concentric configuration or finger sign, calcification and halo. All of these features were classified and compared with those of 109 malignant lesions. The changes of these mummified nodules during the follow-up period were also examined.Results: The cystic wall shrinkage sign and the concentric configuration or finger sign were highly specific indicators of mummified thyroid nodules and could be used to distinguish mummified nodules from thyroid cancer with a specificity of 91.7% and 99.9%, respectively. A continuous decrease in the cyst size was observed during follow-up.Conclusions: Mummified thyroid nodules are characterized by the cystic wall shrinkage sign and the concentric configuration or finger sign on US and a continuous decrease in size during follow-up. These features may be useful for the differential imaging-based diagnosis of mummified versus malignant thyroid nodules.

Low-grade appendiceal mucinous neoplasms confined to the appendix: clinical manifestations and CT findings

The clinical findings and CT images are investigated in order to fulfill an early preoperative diagnosis and increase awareness of low-grade appendiceal mucinous neoplasm (LAMN) confined to the appendix. 17 cases with histologically proven LAMNs confined to the appendix were included in this study. All patients had received multiphase CT examinations before the surgery. The imaging criteria included shape, size, margin, attenuation, secondary degeneration and internal mass enhancement pattern. In CT images, all cases appeared as oval or tubular cystic masses (average attenuation 20.4±3.6 Hounsfield units), with the longest dimensions ranging from approximately 38 to 106 mm (mean 66.3 mm), and the ratio of length against width was 1.83 in average. The cystic wall was unevenly thickened, with a mean maximal wall thickness of 5.7 mm (>10 mm in 3 cases). The inner capsule wall was rough, and calcification was observed in 3 cases. A few amounts of periappendiceal fat stranding were noted in 2 cases. Mild ring mural enhancement of the cystic wall was seen during the arterial phase, with progressive enhancement during the portal venous phase. In addition, mini enhancing mural nodules was observed in 5 cases. Although preoperative diagnosis of LAMNs confined to the appendix remains challenging, it should be considered when a focal well-defined cystic mass with slightly higher than water attenuation, thickened cystic wall with ring mural enhancement and a characteristic progressive contrast enhancement in CT imaging, especially in older females with non-specific symptoms similar to appendicitis.