Imaging features of adrenal masses

Feasibility and Safety of Laparoscopic Complete Mesocolic Excision (CME) for Right-sided Colon Cancer: Short-term Outcomes. A Randomized Clinical Study

OBJECTIVE

The aim of this prospective clinical study is to compare short-term outcome of laparoscopic right hemicolectomy using the Complete Mesocolic Excision (CME group) with patients who underwent conventional right-sided colonic resection (NCME group).

SUMMARY BACKGROUND DATA

Although CME with central vascular ligation in laparoscopic right hemicolectomy is associated with a significant decrease in local recurrence rates and improvements in cancer-related 5-year survival, there may be additional risks associated with this technique because of increased surgical complications. As a result, there is controversy surrounding its use.

METHODS

In this randomized controlled trial, several primary endpoints (operative time, intraoperative blood loss, other complications, conversion rate, and anastomotic leak) and secondary endpoints (overall postoperative complications) were evaluated. In addition, we evaluated histopathologic data, including specimen length and the number of lymph nodes harvested, as objective signs of the quality of CME, related to oncological outcomes.

RESULTS

The CME group had a significantly longer mean operative time than the NCME group (216.3 minutes vs 191.5 minutes, P = 0.005). However, the CME group had a higher number of lymph nodes (23.8 vs 16.6; P < 0.001) and larger surgical specimens (34.3 cm vs 29.3 cm; P = 0.002). No differences were reported with respect to intraoperative blood loss, conversion rate, leakage, or other postoperative complications.

CONCLUSIONS

In this study laparoscopic CME were a safe and feasible technique with improvement in lymph nodes harvesting and length of surgical specimens with no increase of surgical intraoperative and postoperative complications.

Bilateral adrenal metastasis of renal cell carcinoma 4 years after radical nephrectomy: A case report and review of literature

RATIONALE

Renal cell carcinoma (RCC) almost metastasizes to every organ, the possibility of adrenal metastasis is relatively low in patients that have undergone radical nephrectomy, only a few cases of bilateral adrenal metastasis are reported on literature. Although surgical treatment of metastases from RCC is preferred and contributes to the rate of survival, it is considered challenging to manage such cases due to the rarity of bilateral metastasis to the adrenal glands.

PATIENT CONCERNS

A 64-year-old Manchus female presented with an incidental ultrasonic finding of a left adrenal mass 4 years after radical nephrectomy for left renal cell carcinoma.

DIAGNOSIS

Abdominal contrast enhanced CT scan revealed bilateral adrenal masses, suggesting metastatic lesion. Examinations indicated neither local recurrence nor distant metastasis anywhere have been detected by whole body Positron Emission Tomography/Computed Tomography (PET/CT) scan except high radioactive uptake in bilateral adrenal glands.

INTERVENTIONS

Metachronous bilateral adrenalectomy was taken and laparoscopic right adrenalectomy was first performed. She was discharged home on third postoperative day. Pathological examination revealed metastatic renal cell carcinoma. Two months later she was performed laparoscopic left adrenalectomy.

OUTCOMES

The patient healed without obvious complications and no tumor recurrence.

LESSONS

Bilateral metastatic adrenal recurrence from RCC is very rare. Early diagnosis of adrenal metastasis is challenging because they are usually silent both anatomically and functionally. Surgical intervention is a wise option for these patients that may improve survival, and metachronous bilateral adrenalectomy is proved to be safe and effective.

Cross-sectional imaging features of unusual adrenal lesions: a radiopathological correlation

The detection rates of adrenal masses are increasing with the common and widespread use of cross-sectional imaging. Adrenal adenomas, myelolipomas, metastases, pheochromocytomas, and adrenocortical tumors are well-known and relatively common adrenal tumors. However, there are many less-known neoplastic and nonneoplastic adrenal diseases that might affect the adrenal glands in addition to these common lesions. These rare entities include, but are not limited to, hydatid cysts, congenital adrenal hyperplasia, Wolman disease, adrenal tuberculosis, primary adrenal lymphoma. This article aims to present imaging findings of these unusual lesions in accordance with their pathologic characteristics. We think that the simultaneous presentation of the pathological findings with the imaging features may facilitate the learning process and may potentially enhance the recognition of these entities.

Adrenal Leiomyoma: A case report

Introduction and importance

Adrenal Leiomyomas are infrequent tumors with only a few cases reported to date. They are difficult to differentiate from malignant adrenal tumors due to non-specific findings on clinical examination and imaging studies.

Case presentation

We discuss the case of a 49-year old male who had been experiencing generalized abdominal pain for 14 months and was found to have a mass on ultrasonography. Further evaluation with Contrast-enhanced Computerized Tomography (CECT) revealed an uneven soft tissue density mass in the retroperitoneal region of the left side. The histopathological examination of the excised mass was suggestive of a mesenchymal tumor, which was further confirmed as leiomyoma by immunohistochemistry.

Clinical discussion

Adrenal Leiomyomas are rare smooth muscle tumors that present with heterogeneously enhancing mass on radiologic imaging. On histopathological examination, spindle cells arranged in lobules and fascicles can be appreciated. Positive staining for desmin and smooth muscle actin in immunohistochemistry confirms the diagnosis.

Conclusion

Identification of the type of tumor in any adrenal mass is challenging pertaining to the non-specific findings on imaging studies. So, prompt surgical resection is the mainstay of the treatment.

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Adrenal leiomyomas are rare tumors.

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These tumors are usually identified incidentally on USG and CT scans of the abdomen & pelvis.

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Histopathological and immunohistochemical studies of the resected tumor mass aid in reaching a definitive diagnosis.

Imaging side effects and complications of chemotherapy and radiation therapy: a pictorial review from head to toe

Newer biologic drugs and immunomodulatory agents, as well as more tolerated and effective radiation therapy schemes, have reduced treatment toxicity in oncology patients. However, although imaging assessment of tumor response is adapting to atypical responses like tumor flare, expected changes and complications of chemo/radiotherapy are still routinely encountered in post-treatment imaging examinations. Radiologists must be aware of old and newer therapeutic options and related side effects or complications to avoid a misinterpretation of imaging findings. Further, advancements in oncology research have increased life expectancy of patients as well as the frequency of long-term therapy-related side effects that once could not be observed. This pictorial will help radiologists tasked to detect therapy-related complications and to differentiate expected changes of normal tissues from tumor relapse.

[Adrenal imaging: anatomy and pathology (literature review)]

This literature review focuses on the normal adrenal gland anatomy and typical imaging features necessary to evaluate benign and malignant lesions. In particular, adenoma, pheochromocytoma, metastases and adrenocortical carcinoma were discussed as some of the most common lesions. For this purpose, a review of relevant local and international literature sources up to January 2021 was conducted.In many cases, adrenal incidentalomas have distinctive features allowing characterization using noninvasive methods. It is possible to suspect a malignant nature and promptly refer the patient for the necessary invasive examinations in some cases. -Computed tomography, especially with intravenous contrast enhancement, is the primary imaging modality because it enables differential diagnosis. Magnetic resonance tomography remains a sensitive method in lesion detection and follow-up but is not very specific for determining the malignant potential. Positron emission computed tomography also remains an additional method and is used mainly for differential diagnosis of malignant tumors, detecting metastases and recurrences after surgical treatment. Ultrasound has a limited role but is nevertheless of great importance in the pediatric population, especially newborns. Promising techniques such as radiomics and dual-energy CT can expand imaging capabilities and improve diagnostic accuracy.Because adrenal lesions are often incidentally detected by imaging performed for other reasons, it is vital to interpret such findings correctly. This review should give the reader a broad overview of how different imaging modalities can evaluate adrenal pathology and guide radiologists and clinicians.

A collision between vascular adrenal cyst and adrenocortical adenoma

We report a patient with sigmoid colon cancer who revealed a unique collision of hemorrhagic vascular adrenal cyst and adrenocortical adenoma with myelolipomatous changes. Two months before referral to our hospital, anticoagulant therapy was started for acute myocardial infarction. The components of the adrenocortical adenoma demonstrated a typical signal drop in opposed-phase magnetic resonance (MR) images although macroscopic fat was also depicted both on CT and MR images. The components of the vascular adrenal cyst demonstrated peripheral nodular enhancement with progressive enhancement on dynamic contrast-enhanced CT and a hemorrhagic change in the central region, which showed hyper intensity on T1-weighted images (T1WI) and hypo intensity on T2-weighted images (T2WI). Microscopically, the cyst was filled with foci of hemorrhage, fibrin, fibrosis, and hemosiderin. Furthermore, a white thrombus was found that corresponded to the central low signal intensity depicted on T2WI. Dilated vascular channels that were immunohistochemically positive for CD31 and CD34 were identified within the cyst. They were consistent with the pathological findings of hemorrhagic vascular adrenal cyst. Radiologists should be aware that the diagnosis of adrenal vascular cyst could be challenging since image findings may resemble hemangiomas, pheochromocytomas, and malignancy.

Handcrafted MRI radiomics and machine learning: Classification of indeterminate solid adrenal lesions

PURPOSE

To assess a radiomic machine learning (ML) model in classifying solid adrenal lesions (ALs) without fat signal drop on chemical shift (CS) as benign or malignant.

METHOD

55 indeterminate ALs (21 lipid poor adenomas, 15 benign pheocromocytomas, 1 oncocytoma, 12 metastases, 6 primary tumors) showing no fat signal drop on CS were retrospectively included. Manual 3D segmentation on T2-weighted and CS images was performed for subsequent radiomic feature extraction. After feature stability testing and an 80-20% train-test split, the train set was balanced via oversampling. Following a multi-step feature selection, an Extra Trees model was tuned with 5-fold stratified cross-validation in the train set and then tested on the hold-out test set.

RESULTS

A total of 3396 features were extracted from each AL, of which 133 resulted unstable while none had low variance (< 0.01). Highly correlated (r > 0.8) features were also excluded, leaving 440 parameters. Among these, Support Vector Machine 5-fold stratified cross-validated recursive feature elimination selected a subset of 6 features. ML obtained a cross-validation accuracy of 0.94 on the train and 0.91 on the test sets. Precision, recall and F1 score were respectively 0.92, 0.91 and 0.91.

CONCLUSIONS

Our MRI handcrafted radiomics and ML pipeline proved useful to characterize benign and malignant solid indeterminate adrenal lesions.

Prostatic tissue in 46XX congenital adrenal hyperplasia: Case report and literature review

The presence of prostatic tissue, in addition to uterus and adrenal tumors, is possible in 46XX patients with CAH. Lesions of these organs are usually benign. However, complications including prostate and adrenal cancer were also reported.

Can we differentiate neoplastic and non-neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation

Spontaneous adrenal bleeding is a rare clinical event with non-specific clinical features. Life-threatening bleeding in the adrenal glands may be promptly diagnosed with imaging. Computed tomography (CT) is generally the first imaging modality to be used in these patients. However, in the acute phase of bleeding, it may be difficult to detect the underlying mass from the large hematoma. In these patients, additional imaging studies such as magnetic resonance imaging or positron emission tomography/CT may be utilized to rule out a neoplastic mass as the source of bleeding. In patients where an underlying neoplastic mass could not be identified at the time of initial diagnosis, follow-up imaging may be helpful after the acute phase subsides.

Classic adrenal adenoma undergoing necrosis secondary to chemotherapy for pancreatic adenocarcinoma

Our patient was a 53-year-old male with borderline resectable pancreatic adenocarcinoma who on his initial staging CT and subsequent MRI was found to have an incidental adrenal adenoma. Following completion of six cycles of neoadjuvant chemotherapy over a three-month period, the patient returned for restaging. The adrenal nodule had increased in size and had undergone necrosis with just a fine cuff of residual viable lesion at the margins. It is thought that chemotherapeutic agents should not lead to significant cell death of an adrenal adenoma, and this produced diagnostic uncertainty. Interestingly, the lesion was subsequently biopsied under CT with histology confirming a classic adrenal adenoma. This rare case challenges our understanding of chemotherapeutic effects on adrenal adenomas, and offers another differential when assessing necrotic adrenal lesions.

Association of Adrenal Venous Sampling With Outcomes in Primary Aldosteronism for Unilateral Adenomas

Importance

Adrenal venous sampling is recommended prior to adrenalectomy for all patients with hyperaldosteronism; however, cross-sectional imaging resolution continues to improve, while the procedure remains invasive and technically difficult. Therefore, certain patients may benefit from advancing straight to surgery.

Objective

To determine whether clinical and biochemical resolution varied for patients with primary aldosteronism with unilateral adenomas who underwent adrenal venous sampling vs those who proceeded to surgery based on imaging alone.

Design, Setting, and Participants

Retrospective, international cohort study of patients treated at 3 tertiary medical centers from 2004 to 2019, with a median follow-up of approximately 6 months. A total of 217 patients were consecutively enrolled. Exclusion criteria consisted of unknown postoperative serum aldosterone level and imaging inconsistent with unilateral adenoma with a normal contralateral gland. A total of 125 patients were included in the analysis. Data were analyzed between October 2019 and July 2020.

Exposures

Adrenal venous sampling performed preoperatively.

Main Outcomes and Measures

The primary outcome measurements were the clinical and biochemical success rates of surgery for the cure of hyperaldosteronism secondary to aldosterone-producing adenoma.

Results

A total of 125 patients were included (45 cross-sectional imaging with adrenal venous sampling and 80 imaging only). The mean (SD) age of the study participants was 50.2 (10.6) years and the cohort was 42.4% female (n = 53). Of those patients for whom race or ethnicity were reported (n = 80), most were White (72.5%). Adrenal venous sampling failure rate was 16.7%, and the imaging concordance rate was 100%. Relevant preoperative variables were similar between groups, except ambulatory systolic blood pressure, which was higher in the imaging-only group (150 mm Hg; interquartile range [IQR], 140-172 mm Hg vs 143 mm Hg, IQR, 130-158 mm Hg; P = .03). Resolution of autonomous aldosterone secretion was attained in 98.8% of imaging-only patients and 95.6% of adrenal venous sampling patients (P = .26). There was no difference in complete clinical success (43.6% [n = 34] vs 42.2% [n = 19]) or partial clinical success (47.4% [n = 37] vs 51.1% [n = 23]; P = .87) between groups. Complete biochemical resolution was similar as well (75.9% [n = 41] vs 84.4% [n = 27]; P = .35). There was no difference in clinical or biochemical cure rates when stratified by age, although complete clinical success rates downtrended in the older cohorts, and sample sizes were small.

Conclusions and Relevance

Given the improved sensitivity of cross-sectional imaging in detection of adrenal tumors, adrenal venous sampling may be selectively performed in appropriate patients with clearly visualized unilateral adenomas without affecting outcomes. This may facilitate increased access to surgical cure for aldosterone-producing adenomas and will decrease the incidence of morbidities associated with the procedure.

Difficult laparoscopic cholecystectomy and preoperative predictive factors

Laparoscopic cholecystectomy (LC) is the standard technique for treatment of gallbladder disease. In case of acute cholecystitis we can identify preoperative factors associated with an increased risk of conversion and intraoperative complications. The aim of our study was to detect preoperative laboratory and radiological findings predictive of difficult LC with potential advantages for both the surgeons and patients in terms of options for management. We designed a retrospective case-control study to compare preoperative predictive factors of difficult LC in patients treated in emergency setting between January 2015 and December 2019. We included in the difficult LC group the surgeries with operative time > 2 h, need for conversion to open, significant bleeding and/or use of synthetic hemostats, vascular and/or biliary injuries and additional operative procedures. We collected 86 patients with inclusion criteria and difficult LC. In the control group, we selected 86 patients with inclusion criteria, but with no operative signs of difficult LC. The analysis of the collected data showed that there was a statistically significant association between WBC count and fibrinogen level and difficult LC. No association were seen with ALP, ALT and bilirubin values. Regarding radiological findings significant differences were noted among the two groups for irregular or absent wall, pericholecystic fluid, fat hyperdensity, thickening of wall > 4 mm and hydrops. The preoperative identification of difficult laparoscopic cholecystectomy provides an important advantage not only for the surgeon who has to perform the surgery, but also for the organization of the operating block and technical resources. In patients with clinical and laboratory parameters of acute cholecystitis, therefore, it would be advisable to carry out a preoperative abdominal CT scan with evaluation of features that can be easily assessed also by the surgeon.

Pitfalls and differential diagnosis on adrenal lesions: current concepts in CT/MR imaging: a narrative review

The purpose of this pictorial essay is to review the imaging findings of adrenal lesions. Adrenal lesions could be divided into functioning or non-functioning masses, primary or metastatic, and benign or malignant. Imaging techniques have undergone significant advances in recent years. The most significant objective of adrenal imaging is represented by the detection and, when possible, characterization of adrenal lesions in order to direct patient management correctly. The detection and management of adrenal lesions is based on cross-sectional imaging obtained with non-contrast CT (tumour density), contrast-enhanced CT including delayed washout (either absolute percentage washout or relative percentage one) and finally with MR chemical shift analysis (loss of signal intensity between in-phase and out-of-phase images including both qualitative and quantitative estimates of signal loss). The small incidental adrenal nodules are benign, in most of cases; some tumors such as lipid-rich adenoma and myelolipoma have characteristic features that can be diagnosed accurately in CT. On contrary, if the presenting contrast-enhanced CT shows an adrenal mass with uncertain or malignant morphologic features, particularly in patients with a known history of malignancy, further evaluations should be considered. The most significative implications for radiologists are represented by how to assess risk of malignancy on imaging and what follow-up to indicate if an adrenal incidentaloma is not surgically removed.

11C-metomidate PET in the diagnosis of adrenal masses and primary aldosteronism: a review of the literature

BACKGROUND

Adrenal masses are commonly encountered in clinical practice, many of whom are incidental. Identifying malignancy, and excess hormone production is essential for appropriate management. Biochemical workup and imaging tests (dedicated adrenal CT and/or MRI) are used to determine the likelihood of excessive hormone function and malignancy, respectively. However, imaging cannot provide information about function and biochemical workup cannot localize the source. Furthermore, in primary aldosteronism, adrenal vein sampling, the gold standard for lateralization, has important limitations such as the technical expertise required, the elevated costs, and potential complications. Over the last decades, there has been a renewed interest in alternative noninvasive imaging techniques that provide information about adrenal function without the need for invasive procedures. In this review, we will evaluate the evidence and the potential role of ¹¹C-metomidate as a promising positron emission tomography (PET) tracer in clinical practice.

METHODS

A review of the English literature for articles describing the use of the tracer ¹¹C-metomidate in adrenal disorders.

RESULTS

A total of 12 studies were included in the systematic review, which altogether addressed the use of ¹¹C-metomidate in adrenal masses and the application of this tracer in primary aldosteronism.

CONCLUSIONS

¹¹C-metomidate, a selective inhibitor of 11-β-hydroxylase, demonstrated a high specificity for adrenocortical tissue. In addition, ¹¹C-metomidate is correlated with this enzyme activity making it a potentially useful PET tracer for the identification primary aldosteronism, in addition to detection of adrenocortical masses.

Splenic lymphoma with complex gastro-spleno-diaphragmatic fistula: 3D laparoscopic multivisceral resection. The first literature case report

INTRODUCTION

Gastrosplenic fistula is a rare disease involving stomach and spleen that can lead to dangerous complications like massive gastrointestinal bleeding. Diffuse large B-cell lymphoma (DLBC) is the principal pathological cause of gastrosplenic fistula.

CASE REPORT

We report a case of A 76-year-old caucasian woman came to the emergency room with fever for two week and gravative pain in left upper quadrant of the abdomen. CT scan of thorax and abdomen demonstrated an inhomogeneous hypodense large lymphomatous mass (10 × 6 cm) of upper pole of the spleen deformating medial profile and infiltrating gastric fundus and left diaphragm. with the diagnosis of complex gastro-splenic-diaphragmatic fistula we performed an en-block resection using a 3D laparoscopic vision system.

DISCUSSION

Gastrosplenic fistula is a rare complication of several clinical conditions. Among the different causes diffuse large B-cell lymphoma is the most frequent although diffuse histiocytic lymphoma, Hodgkin's lymphoma and extranodal NK/T-cell lymphoma are also described. After a literature review we found less then 30 cases of gastrosplenic fistula secondary to lymphoma. In our case report we do the first description of three-organs fistula envolvement, stomach, spleen and diaphragmatic dome, managed with 3D laparoscopic approach.

CONCLUSION

Gastrosplenic fistula can represent a fatal evolution of splenic or gastric lymphoma independently from chemotherapy treatment. The diagnosis of this condition is very difficult and related to its rarity. To our opinion, laparoscopy represents a valid and safe alternative to open surgery in management of these patients.

Unusual giant chromophobe renal cancer totally managed with laparoscopic technique: Report of a case

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We describe a case report of giant renal cell chromophobe carcinoma totally treated by laparoscopic surgery.

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The size of renal lesion represents a critical point in surgical approach because to perform a laparoscopic radical nephrectomy can be challenging even for skilled surgeons in giant renal tumors.

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A brief review of literature was performed to identify outcomes and potentially surgical advantages of laparoscopic approach for retroperitoenal liposarcoma.

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The possibility of the laparoscopic approach derives from from the preoperative identification of adipose cleavage, from the absence of invasion of major vascular axes, from the absence of distant metastatic lesions.

Introduction

Chromophobe carcinoma of the kidney is a rare pathological entity generally smaller and asymptomatic than other renal cell carcinomas and with a lower risk of metastatic disease. We describe a case of a giant renal chromophobe carcinoma successfully treated by laparoscopy.

Case report

A 37-years-old Caucasian man presented at physical examination a rigid elastic mass in right upper abdominal quadrant. CT abdominal scan revealed an enhancing well-defined heterogeneous large mass measuring 17 × 15 cm and originating from the upper pole of the right kidney, with necrotic and solid areas within the lesion. Considering the young age of the patient and the absence of local invasiveness, despite the large size of the lesion, we decided to perform a laparoscopic transperitoneal right nephrectomy. The morphological and immunophenotypic characteristics (CK7+, CD10+, CD117+) confirmed the diagnosis of chromophobe renal cell carcinoma.

Results

Chromophobe renal cell cancer is an unusual hystological entity. The pathological diagnosis of chromophobe tumor is based on atypia with nuclear irregularities, binucleation, and nucleolar prominence. In our case reports the pathological examination showed no tumor necrosis, mitosis or sarcomatoid differentiation and perirenal tissues were free from tumor infiltration with low risk of tumor progression after surgery.

Conclusion

Laparoscopic approach is today considered the standard treatment for localized renal cancer. Nevertheless, the size of renal lesion represents a critical point in surgical approach because to perform a laparoscopic radical nephrectomy can be challenging even for skilled surgeons in giant renal tumors.

Acute appendicitis in a patient with situs viscerum inversus totalis: Role of laparoscopic approach. A case report and brief literature review

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Abdominal pain due to acute appendicitis in one of the most causes of access to Emergency Room requiring surgical consult and treatment.

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The occurrence of anatomical anomalies should be considered especially when clinical and imaging features are misleading. In these cases laparoscopic surgery can be a safe tool in order to confirm uncertain diagnosis.

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We report a case of acute appendicitis in a 23-year-old Caucasian men with situs viscerum inversus detected on radiological investigation.

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Laparoscopic approach was used to confirm the diagnosis and to perform appendectomy. Trocars placement was tailored for this peculiar case.

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Situs viscerum inversus and midgut malrotation should be taken into consideration in patients with findings of the physical examination suspicious for left-sided acute appendicitis.

Introduction

Abdominal pain due to acute appendicitis in one of the most causes of access to Emergency Room requiring surgical consult and treatment. The occurrence of anatomical anomalies should be considered especially when clinical and imaging features are misleading. In these cases laparoscopic surgery can be a safe tool in order to confirm uncertain diagnosis.

Case report

We report a case of acute appendicitis in a 23-year-old Caucasian men with situs viscerum inversus detected on radiological investigation. Laparoscopic approach was used to confirm the diagnosis and to perform appendectomy. Trocars placement was tailored for this peculiar case.

Discussion

One third of patient with acute appendicitis complains abdominal pain in an unexpected location due to various anatomical position of appendix. Left-sided acute appendicitis is a cause of misdiagnosis and it can occur in association with anatomical anomalies such as situs viscerum inversus and midgut malrotation. Laparoscopic surgery may represent a valuable approach in terms of differential diagnosis and treatment in these patients.

Conclusion

Left-sided acute appendicitis should always be considered in young male patients with left lower quadrant pain. Laparoscopic approach is useful and safe procedure both for diagnosis and treatment of these unclear clinical pictures.

Laparoscopic treatment of mesenteric avulsion and intestinal perforation after blunt abdominal trauma: A report of a case

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Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen.

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The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

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We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion treated with laparoscopic approach.

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Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment.

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The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Introduction

Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen. The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

Case report

We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion. Since the patient was hemodynamically stable, a laparoscopic approach was carried on.

Discussion

Blunt abdominal trauma are responsible of 6–14.9% of all traumatic injuries (Galia et al., 2017). The frequency of small bowel lesions ranges from 5% to 15%, while small bowel mesenteric injuries are approximately found in 5% of patients after blunt abdominal trauma. There are different biomechanical reasons explaining how a blunt trauma can cause damages to small bowel and its mesentery. Clinical diagnosis of small bowel perforation after blunt abdominal trauma is often challenging for non-specific objective clinical signs and because peritoneal irritation symptoms are present only in collaborative patients.

Conclusion

Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment. The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Duodenal perforation as presentation of gastric neuroendocrine tumour: A case report

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Gastric neuroendocrine neoplasms (g-NENs) represent the most frequent digestive NENs and are increasingly recognized thanks to diffusion of upper gastrointestinal endoscopy.

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g-NENs can be sporadic or associated with multiple endocrine neoplasia type 1 (MEN-1) and present with a functional Zollinger-Ellison syndrome.

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We described a case of a 60 years old Caucasian male came to emergency room with diffuse abdominal pain and leukocytosis on blood tests.

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At the level of the pyloric portion we found irregularly thickened walls associated with a small fluid collection and bubbles of free air. On exploratory laparoscopy we found a large perforation (about 5 cm of size) in the first duodenum portion.

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Histological examination revealed a gastric NET perforation as a consequence of hypergastrinemia secondary to gastrinoma.

Introduction

Neuroendocrine tumors (NETs) represent uncommon neoplasms with different characteristics. They can be asymptomatic and benign or they can also proliferate and manifest themselves with neoplastic mass symptoms such as intestinal occlusion or with carcinoid syndrome. Gastric neuroendocrine neoplasms (g-NENs) are the most frequent digestive NENs while duodenal neuroendocrine neoplasms (d-NENs) may be sporadic or associated with multiple endocrine neoplasia type 1 (MEN-1) and present a functional syndrome (e.g. gastrinoma with Zollinger-Ellison syndrome).

Presentation of case

We report a case of duodenal perforation due to a unknown gastrinoma responsible of Zollinger-Ellison Syndrome. He underwent an emergency contrast enhanced CT abdominal scan that showed a perforation. We performed a distal gastrectomy. The histopathological examination revealed a g-NET configuring a possible picture of Zollinger-Ellison Syndrome.

Discussion

The management of NETs is diffulcult and controversial because of their rarity. It is useful to know the pathologic assessment of tumor differentiation and/or grade, evaluate surgical resectability and control the carcinoid syndrome symptoms.

Conclusion

This case report shows that gastric NETs can be found in cases of duodenal perforation. Our future goal is to evaluate the possibilities to diagnose the Zollinger Ellison Syndrome as early as possible and to treat it with targeted therapy in order to prevent its related complications.

Small bowel volvulus due to a large intestinal lipoma: A rare case report

INTRODUCTION

A lipoma of the small bowel mesentery is a uncommon clinical entity. It rarely causes obstruction and volvulus of the small bowel.

CASE REPORT

A 63 year old man was admitted to the emergency department with acute abdominal pain. Contrast-enhanced CT abdominal scan revealed small bowel obstruction due to a large fat density lesion suspected to be a lipoma. We performed a laparotomy in urgent setting that confirmed a small bowel volvulus secondary to a large antimesenteric lipoma. En-bloc resection with antiperistaltic side-to-side ileal anastomosis was done.

DISCUSSION

Mesenteric lipoma is rare. They are usually asymptomatic but when have large sizes can cause several symptoms related to small bowel obstruction or volvulus. The diagnosis is difficult and is rarely made prior to exploratory laparoscopy or laparotomy. CT scan is the gold-standard imaging technique. It can shows the typical characteristics of tumor and may demonstrate the typical "vortex" pattern of a volvulus. In patients with acute clinical presentation en-bloc resection of the lipoma with the affected small bowel loops is often necessary. This treatment may also be reserved in asymptomatic patients with large mesenteric lipomas to avoid future complications.

CONCLUSION

Volvulus of the small bowel caused by an antimesenteric lipoma is a very rare entity. It is diagnosed by CT scan and surgery represents the standard treatment.

May an adrenal incidentaloma change its nature?

BACKGROUND

Up to 70% of adrenal masses detected in patients affected by extra-adrenal malignancy are metastatic lesions. Therefore, detection of an adrenal mass in patients with active or previous malignancy requires a careful differential diagnostic workup. ¹⁸F-Fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG-PET/CT) is increasingly being used to determine the malignant potential of adrenal lesions.

CLINICAL CASE

We report the case of a 64-year-old man who had a single adrenal metastasis due to non-small-cell lung carcinoma developing on a pre-existing benign adrenal lesion. This metastasis occurred in a phase of perceived oncological remission and was detected thanks to ¹⁸F-FDG-PET/CT showing a focal adrenal uptake. Contrast-enhanced computed tomography (CT), performed as part of oncological follow-up, and MRI with chemical shift sequences did not lead to the correct diagnosis. The patient underwent laparoscopic adrenalectomy and the pathological evaluation confirmed a lung carcinoma metastasis.

CONCLUSION

The present case highlights the peculiarity of the follow-up of adrenal masses in cancer patients and the primary role of ¹⁸F-FDG-PET/CT in the management of such patients.

Surgical outcomes of a randomized controlled trial compared robotic versus laparoscopic adrenalectomy for pheochromocytoma

BACKGROUND

Robotic adrenalectomy for pheochromocytoma is increasingly popular because of the advantage that have been proved by some researchers recently. However, prospective randomized clinical trials comparing robotic assisted laparoscopic adrenalectomy (RA) with traditional laparoscopic adrenalectomy (LA) for pheochromocytoma are rare. The aim of this study is to compare perioperative outcomes of RA versus LA for pheochromocytoma prospectively.

METHODS

From March 2016 to April 2019, all patients with pheochromocytoma suitable for laparoscopic adrenalectomy were assigned randomly to RA or LA. The primary endpoint was the operative (exclude docking time) time. Secondary endpoints were estimated blood loss and postoperative recovery. Demographics and perioperative data were prospectively collected.

RESULTS

A total of 140 (RA 70, LA 70) patients were enrolled in this prospective research. The following significant differences were identified in favor of RA: shorter median operative (exclude docking time) time (92.5 vs 122.5 min, P = 0.007), however, RA group has higher total hospitalization cost (8869.9 vs 4721.8 $, P < 0.001). Demographics and other perioperative outcomes were similar in both groups. The RA group showed a significant lower blood loss and operative (exclude docking time) time compared with LA group (P < 0.05) for patients with high Nor-Metanephrine (NMN).

CONCLUSIONS

Both RA and LA for pheochromocytoma are safe and effective. Patients with high NMN can benefit from less blood loss and operative time when a robotic surgery system was used, but RA has a significant higher cost.

Non-neoplastic conditions mimicking peritoneal carcinomatosis at CT imaging

The general appearance of peritoneal carcinomatosis at abdominal CT and other cross-sectional imaging modalities consists of varying amounts of peritoneal-based soft tissue implants (mass-forming or infiltrative), peritoneal fluid, and occasionally calcification. However, a wide variety of common and uncommon neoplastic and non-neoplastic conditions can closely mimic peritoneal carcinomatosis at imaging. Neoplastic mimics of peritoneal carcinomatosis include primary peritoneal and sub peritoneal tumors, as well as peritoneal lymphomatosis and sarcomatosis.Broad categories of non-neoplastic mimics of peritoneal carcinomatosis include tumor-like conditions, systemic processes, atypical infections, and fat-based conditions. For many entities, suggestive or specific patient information and/or CT imaging findings exist that may allow the radiologist to narrow the differential diagnosis. In this article, we review the salient clinical and cross-sectional imaging features of non-neoplastic mimics of peritoneal carcinomatosis and malignancy, with emphasis on the CT findings and the additional clues that may suggest the correct benign diagnosis.

Diffusion-Weighted Imaging in Oncology: An Update

To date, diffusion weighted imaging (DWI) is included in routine magnetic resonance imaging (MRI) protocols for several cancers. The real additive role of DWI lies in the "functional" information obtained by probing the free diffusivity of water molecules into intra and inter-cellular spaces that in tumors mainly depend on cellularity. Although DWI has not gained much space in some oncologic scenarios, this non-invasive tool is routinely used in clinical practice and still remains a hot research topic: it has been tested in almost all cancers to differentiate malignant from benign lesions, to distinguish different malignant histotypes or tumor grades, to predict and/or assess treatment responses, and to identify residual or recurrent tumors in follow-up examinations. In this review, we provide an up-to-date overview on the application of DWI in oncology.

Surgery for adrenocortical carcinoma: When and how?

Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.

Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management

Adrenocortical carcinoma (ACC) is a rare tumor with a poor prognosis. Most tumors are either metastatic or locally invasive at the time of diagnosis. Differentiation between ACC and other adrenal masses depends on clinical, biochemical, and imaging factors. This review will discuss the genetics, pathological, and imaging feature of ACC.

Systemic schistosomiasis and large bowel perforation: An unexpected surgical urgency. Report of a case and literature review

In the presence of suggestive clinical picture (high eosinophil count and multiple CT scan granuloma-like lesions), schistosomiasis should be taken into account in case of suspected bowel perforation even if common risk factors are not identified through anamnesis.

Dedifferentiated retroperitoneal large liposarcoma and laparoscopic treatment: Is it possible and safe? The first literature case report

INTRODUCTION

Soft tissue sarcomas are rare neoplasms often characterized by local invasiveness and distant metastasis with poor prognosis for affected patients. Among the most frequent sarcomas we find well-differentiated and dedifferentiated liposarcomas characterized by a better survival compared to the other histological types. When it is possible the only curative treatment for these neoplasms is surgical resection.

CASE REPORT

We report a case of a 62-year-old caucasian woman with CT abdominal scan that demonstrated a voluminous solid oval mass in the left perirenal space with dislocation of the kidney and in continuity with the anterior renal fascia. After a percutaneous CT-guided biopsy of the mass the histopathological diagnosis was a dedifferentiated retroperitoneal liposarcoma. We performed a laparoscopic surgical resection of the retroperitoneal mass in block with kidney and left adrenal gland.

DISCUSSION

When possible, surgical resection with adequate margins represents the only curative therapeutic option for this pathology. Only a few papers are available in literature which take into consideration the possibility of laparoscopic approach for retroperitoneal masses with better vision of surgical field, reduction of post-operative pain and better cosmesis.

CONCLUSION

A retroperitoneal mass represents a serious diagnostic challenge. The choice of the best surgical procedure can benefit to the patient prognosis. To our opinion laparoscopy can be a safe and successful treatment and it can represent a valid alternative to open surgery. However, we have no randomized controlled trials that compare laparoscopic versus open resection for retroperitoneal liposarcomas.