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Rwomurushaka ES, Lodhia J. Diagnosis and management of a sacrococcygeal teratoma at a tertiary hospital in northern Tanzania: A case report. Int J Surg Case Rep 2024; 120:109895. [PMID: 38852569 PMCID: PMC11193032 DOI: 10.1016/j.ijscr.2024.109895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 06/11/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Sacrococcygeal teratoma is a rare extragonadal germ cell tumor occurring at the lower end of the back. It is congenital, and can be diagnosed in utero or just after birth. These tumors are sporadic in nature, more common in females than in males. They can be solid, cystic or a mixture of the two in consistency. Authors present this case to share their experience because these congenital tumors are rare and a lapse in appropriate management can be devastating because of chances of recurrence and the possibility of a malignant nature of the disease. CASE PRESENTATION Authors in this case present a baby that was referred to their center 5 days post vaginal delivery with a huge mass on the sacrococcygeal region. MRI revealed sacrococcygeal teratoma type II. Wide local excision was done. Tumor margins were microscopically negative. The patient recovered well and was discharged. The patient did not require adjuvant treatment. CLINICAL DISCUSSION Routine obstetric ultrasound can diagnose sacrococcygeal teratoma with 100 % sensitivity. Fetuses with tumors <5 cm in size can be delivered vaginally. Tumors larger than that should be delivered at term through cesarean section. High risk sacrococcygeal teratomas can be delivered at 28 weeks of gestation by cesarean section followed by ex-utero intrapartum therapy. MRI is useful to assess the intrapelvic extent of the tumor and to plan management. Surgical intervention should be done after delivery. CONCLUSION Intrauterine diagnosis is not an indication for termination of pregnancy. Surgical resection with negative margins provides a cure. Histological examination of the tumor is mandatory. For malignant sacrococcygeal teratomas, adjuvant chemotherapy is necessary for positive tumor margin after surgical resection. Positive margins may require chemotherapy. Neoadjuvant chemotherapy may be used for tumor debulking prior to surgery if the tumor infiltrates neighboring structures or is metastatic.
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Affiliation(s)
- Evance Salvatory Rwomurushaka
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P O Box 3010, Moshi, Tanzania; Department of Anatomy and Neuroscience, Kilimanjaro Christian Medical University College, P O Box 2240, Moshi, Tanzania
| | - Jay Lodhia
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P O Box 3010, Moshi, Tanzania; Faculty of Medicine, Kilimanjaro Christian Medical University College, P O Box 2240, Moshi, Tanzania.
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2
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Ozdemir OMA, Turgut M, Demir GS, Uzunlu O, Ergin H. Holt-Oram Syndrome with Sacrococcygeal Teratoma - A Rare Association. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:563-566. [PMID: 38268646 PMCID: PMC10805053 DOI: 10.14744/semb.2022.02359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/14/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022]
Abstract
Holt-Oram syndrome (HOS) is characterized by upper-limb defects and congenital heart malformation, and its prevalence is very rarely. Mature cystic teratoma is the most common tumor seen in neonates and its most common location is sacrococcygeal region. Diagnosis of a sacrococcygealteratoma should be confirmed by pathology. Surgical resection is the mainstay therapeutic approach of this tumor. Some malformations such as genitourinary system, musculoskeletal anomalies, neural defects, cardiovascular anomalies, and pulmonary disorders associated with this tumor have been reported. Herein, we reported a male neonate diagnosed with HOS associated with sacrococcygealteratoma. To our knowledge, it has been not reported a case with HOS associated with sacrococcygealteratoma. Patients with sacrococcygealteratomas (SCTs) may have multiple and extreme congenital abnormalities; therefore, patients with SCTs should be carefully evaluated clinically, laboratory, and radiologically and it should be also considered that HOS may accompany them.
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Affiliation(s)
- Ozmert Muhammet Ali Ozdemir
- Department of Pediatrics, Division of Neonatology, Pamukkale University Faculty of Medicine, Denizli, Türkiye
| | - Musa Turgut
- Department of Pediatrics, Division of Neonatology, Pamukkale University Faculty of Medicine, Denizli, Türkiye
| | - Gulay Sonmez Demir
- Department of Pediatrics, Division of Neonatology, Pamukkale University Faculty of Medicine, Denizli, Türkiye
| | - Osman Uzunlu
- Department of Pediatric Surgery, Pamukkale University Faculty of Medicine, Denizli, Türkiye
| | - Hacer Ergin
- Department of Pediatrics, Division of Neonatology, Pamukkale University Faculty of Medicine, Denizli, Türkiye
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3
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Bista A, Ghimire S, Gaire NS, Bataju P, Mishra D. Giant Sacrococcygeal Teratoma in a Neonate: A Case Report. JNMA J Nepal Med Assoc 2023; 61:675-679. [PMID: 38289807 PMCID: PMC10566610 DOI: 10.31729/jnma.8251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Indexed: 02/01/2024] Open
Abstract
Sacrococcygeal teratomas are common tumours in neonates and infants, primarily affecting females. A 35-year-old primigravida presented with a large sacrococcygeal teratoma that was detected during the 30th week of gestation in the fetus. The baby was delivered via elective caesarean section at 36+3 weeks, and surgical excision of the 10x10x5 cm³ mass was performed successfully on the third day of life. Despite a surgical site infection, the patient had a favourable outcome with normal vital signs, bowel, bladder, and lower extremity functions upon discharge. Early diagnosis and prompt management of sacrococcygeal teratoma in newborns is vital for optimal outcomes, providing valuable insights and guidance to medical practitioners. Keywords anaesthesia; case reports; neonate; teratoma.
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Affiliation(s)
- Anup Bista
- Department of Anaesthesia and Critical Care,
Patan Academy of Health Sciences, Lagankhel, Lalitpur,
Nepal
| | - Suson Ghimire
- Department of Anaesthesia and Critical Care,
Patan Academy of Health Sciences, Lagankhel, Lalitpur,
Nepal
| | - Niharika Sharma Gaire
- Department of Anaesthesia and Critical Care,
Patan Academy of Health Sciences, Lagankhel, Lalitpur,
Nepal
| | - Pujan Bataju
- Department of Intensive Care Unit and
Neurosurgery, Metrocity Hospital, Srijana Cnowk, Pokhara,
Nepal
| | - Dipesh Mishra
- Department of Intensive Care Unit, Chirayu
National Hospital and Medical Institute, Basundhara, Kathmandu,
Nepal
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4
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Surgical management of neonatal Sacrococcygeal teratoma in a tertiary care center of Eastern Nepal: An observational cross-sectional study in a resource-limited setting. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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5
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AbouZeid AA, Radwan AB, Elghandour MM, Guirguis NN, Bersy MA. Vertical wound closure following sacrococcygeal teratoma excision: an approachable aesthetic solution. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-022-00223-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Sacrococcygeal teratoma is a rare tumour, usually presenting in the neonatal period. The benign nature of most tumours and the high survival rates would emphasise on the importance of both cosmetic and functional outcomes.
We report on our extended experience with more cases concentrating on the aesthetic outcome of vertical wound closure following excision of large irregular sacrococcygeal tumours.
The study included primary cases of sacrococcygeal teratoma who were referred to our surgical team for excision. Cases of presacral tumours associated with anorectal anomalies and sacral bony defects (Currarino triad) were excluded. In all cases, we planned for a vertical midline wound closure after tumour excision. The aesthetic outcomes are evaluated concerning the vertical midline scar, buttock’s contour, and position of the anus.
Results
In addition to twelve previously reported cases (during the period 2011 through 2016), we included another ten new consecutive cases operated during the period 2017 through 2021. Collectively, the study included 22 cases of sacrococcygeal teratoma that underwent vertical perineal wound closure after excision of the tumour. In 13 cases (those with relatively small or medium-sized tumours), the perineal wound was perfectly closed in the midline (well-hidden vertical scar in the natal cleft). For the rest of the cases (9 cases with large and/or irregular sacrococcygeal tumours), some modification was applied on the vertical linear mid-line skin closure to accommodate for skin redundancy and irregularity at the lower end of the wound, usually ending with an ‘inverted-Y’ skin closure
Conclusion
Vertical wound closure was always feasible after excision of sacrococcygeal teratomas. Even with large and irregular tumours, the vertical scar was perfectly or partially hidden within the natal cleft. Usually, there was adequate buttock development with minimal disturbance to the normal anal location within the perineum.
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6
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Serratrice N, Faure A, de Paula AM, Girard N, André N, Scavarda D. Description of a giant hypothalamic hamartoma associated with an immature ruptured giant sacrococcygeal teratoma: a case report. Childs Nerv Syst 2021; 37:2363-2367. [PMID: 32978641 DOI: 10.1007/s00381-020-04894-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
Giant hypothalamic hamartomas (GHH) are rare neonatal intracerebral congenital malformations responsible for gelastic epilepsy and/or endocrine disturbances. Sacrococcygeal teratomas (SCT) are fetal neoplasms associated with perinatal morbidity and mortality, especially hemorrhagic complications in giant examples (GSCT). Here, we describe an immature ruptured GSCT complicated by hemorrhagic shock at 32-week gestation boy requiring an emergency delivery, followed immediately by urgent surgical removal. A brain lesion resembling a GHH was also present on the antenatal MRI. In order to exclude metastatic immature teratoma or glioma, a biopsy was performed by a retro-sigmoidal approach, which confirmed the nature of the hamartoma. Here, we describe for the first time the association of a ruptured immature GSCT associated with a GHH.
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Affiliation(s)
- Nicolas Serratrice
- Department of Pediatric Neurosurgery, La Timone Children Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, Provence-Alpes-Côte d'Azur, France.
| | - Alice Faure
- Department of Pediatric Surgery, La Timone Children Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, Provence-Alpes-Côte d'Azur, France
| | - Andre Maues de Paula
- Department of Pathology, La Timone Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, Provence-Alpes-Côte d'Azur, France
| | - Nadine Girard
- Department of Neuroradiology, La Timone Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, Provence-Alpes-Côte d'Azur, France
| | - Nicolas André
- Department of Pediatric oncology, La Timone Children Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, Provence-Alpes-Côte d'Azur, France
| | - Didier Scavarda
- Department of Pediatric Neurosurgery, La Timone Children Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, Provence-Alpes-Côte d'Azur, France.,Institut de Neurosciences des Systèmes, Aix-Marseille Université, Marseille, France
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Mitani K, Uebayashi EY, Fujino H, Sumimoto S. A rare case of retroperitoneal teratoma with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome. BMJ Case Rep 2021; 14:14/5/e243302. [PMID: 34011651 DOI: 10.1136/bcr-2021-243302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 9-month-old girl presented with progressive abdominal distension. Imaging revealed a huge cystic mass in the left retroperitoneum with solid components. The right kidney was absent and hydrometrocolpos was found. Tumour drainage and complete surgical excision were performed. A bulge in the right side of the uterus, suggestive of a uterine anomaly, was seen on laparoscopic observation. Pathology was consistent with teratoma with a small portion of immature neural tissue. The patient was discharged in good condition and was advised regular follow-up.
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Affiliation(s)
- Kazuki Mitani
- Department of Pediatrics, Osaka Red Cross Hospital, Osaka, Japan
| | | | - Hisanori Fujino
- Department of Pediatrics, Osaka Red Cross Hospital, Osaka, Japan
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8
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Phi JH. Sacrococcygeal Teratoma : A Tumor at the Center of Embryogenesis. J Korean Neurosurg Soc 2021; 64:406-413. [PMID: 33906346 PMCID: PMC8128526 DOI: 10.3340/jkns.2021.0015] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/10/2021] [Indexed: 02/02/2023] Open
Abstract
Sacrococcygeal teratoma (SCT) is an extragonadal germ cell tumor (GCT) that develops in the fetal and neonatal periods. SCT is a type I GCT in which only teratoma and yolk sac tumors arise from extragonadal sites. SCT is the most common type I GCT and is believed to originate through epigenetic reprogramming of early primordial germ cells migrating from the yolk sac to the gonadal ridges. Fetal SCT diagnosed in utero presents many obstetrical problems. For high-risk fetuses, fetal interventions (devascularization and debulking) are under development. Most patients with SCT are operated on after birth. Complete surgical resection is the key for tumor control, and the anatomical location of the tumor determines the surgical approaches. Incomplete resection and malignant histology are risk factors for recurrence. Approximately 10-15% of patients have a tumor recurrence, which is frequently of malignant histology. Long-term surveillance with monitoring of serum alpha fetoprotein and magnetic resonance imaging is required. Survivors of SCT may suffer anorectal, urological, and sexual sequelae later in their life, and comprehensive evaluation and care are required.
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Affiliation(s)
- Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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9
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Maneira‐Sousa P, Rocha G, Soares P, Arnet V, Guimarães S, Fragoso AC, Ramalho C, Costa E, Guimarães H. Massive sacrococcygeal teratoma in a preterm infant. Clin Case Rep 2021; 9:1183-1186. [PMID: 33768807 PMCID: PMC7981706 DOI: 10.1002/ccr3.3722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 09/26/2020] [Accepted: 11/16/2020] [Indexed: 11/20/2022] Open
Abstract
In extreme preterm infants, massive congenital sacrococcygeal teratomas with great hemodynamic commitment may be a situation for limitation of care.
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Affiliation(s)
- Pedro Maneira‐Sousa
- Department of NeonatologyCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Gustavo Rocha
- Department of NeonatologyCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Paulo Soares
- Department of NeonatologyCentro Hospitalar Universitário de São JoãoPortoPortugal
- Faculty of MedicineUniversity of PortoPortoPortugal
| | - Vanessa Arnet
- Department of NeonatologyCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Susana Guimarães
- Faculty of MedicineUniversity of PortoPortoPortugal
- Pathology DepartmentCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Ana Catarina Fragoso
- Faculty of MedicineUniversity of PortoPortoPortugal
- Department of Pediatric SurgeryCentro Hospitalar de São JoãoPortoPortugal
- Center of Prenatal DiagnosisDepartment of ObstetricsCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Carla Ramalho
- Faculty of MedicineUniversity of PortoPortoPortugal
- Center of Prenatal DiagnosisDepartment of ObstetricsCentro Hospitalar Universitário de São JoãoPortoPortugal
- i3S ‐ Instituto de Investigação e Inovação em SaúdeUniversity of PortoPortoPortugal
| | - Estevão Costa
- Faculty of MedicineUniversity of PortoPortoPortugal
- Department of Pediatric SurgeryCentro Hospitalar de São JoãoPortoPortugal
| | - Hercília Guimarães
- Department of NeonatologyCentro Hospitalar Universitário de São JoãoPortoPortugal
- Faculty of MedicineUniversity of PortoPortoPortugal
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10
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Rattan KN, Singh J. Neonatal sacrococcygeal teratoma: Our 20-year experience from a tertiary care centre in North India. Trop Doct 2020; 51:209-212. [PMID: 33356941 DOI: 10.1177/0049475520973616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Advances in diagnostic and therapeutic interventions have improved the survival of neonates with sacrococcygeal teratoma in richer countries. These changes have not yet taken place in resource-limited settings. A retrospective analysis of neonates with sacrococcygeal teratoma operated at our centre during 1997-2016 was performed. Among 44 neonates enrolled, prenatal diagnosis of sacrococcygeal teratoma was available in 25% of pregnancies. All babies except one were born vaginally. Associated congenital malformations were seen in 20% (9/44). Types of sacrococcygeal teratoma were classified as Altman type I in 12 (27.3%), 24 (54.5%) as type II, 6 (13.6%) as type III and 2 (4.5%) as type IV. Morphologically, 77% (34/44) neonates had cystic lesions. All patients were managed successfully by total excision. Histopathology confirmed mature teratoma in 43 (97.7%). After a 12-month follow-up, no recurrence was observed. An uneventful pregnancy, absence of associated congenital anomalies, cystic morphology and a mature histology are good prognostic factors.
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Affiliation(s)
- Kamal N Rattan
- Senior Professor & Head, Department of Pediatric Surgery, PGIMS, Rohtak, Haryana, India
| | - Jasbir Singh
- Senior Resident, Department of Pediatrics, PGIMS, Rohtak, India; Assistant Professor, Department of Pediatrics, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
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Abstract
BACKGROUND Intramedullary cervical spinal cord teratomas (ICTs) are extremely rare, and diagnosis and treatment are challenging. We conducted a systematic review of the literature on the diagnosis and treatment of ICT. METHOD The presentation, imaging manifestations, diagnosis, management, surgery findings, prognosis and histology were reviewed following Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. English-language studies and case reports published from inception to 2018 were retrieved. Data on presentation, imaging characteristics, diagnosis, management, surgery findings, outcomes, and histopathology were extracted. RESULTS Ten articles involving 10 patients were selected. The lesions were located in the upper cervical vertebrae in 4 cases, whereas in the lower cervical vertebrae in the remaining 6 cases. In 5 cases, the lesions were located on the dorsal side of the spinal cord, and in the center of the spinal cord in the remaining 5 cases. Quadriparesis (60%), paraplegia (30%), monoplegia (10%), and neck pain (50%) were the main presentations. The lesion appeared as a intramedullary heterogeneous signal during an MRI scan, and the lesion signal would be partially enhanced after the contrast medium was applied. All patients underwent surgical intervention through a posterior approach. Neurological function improved postoperatively in all patients. Two patients with pathology confirmed to be immature teratomas experienced recurrence. CONCLUSION ICTs are extremely rare entities that are mainly located in the center or dorsal part of the spinal cord which mainly manifest as quadriplegia and neck pain. MRI is a useful modality that provides diagnostic clues. Surgery from a posterior approach is the primary treatment, and the effect of adjuvant therapy remains uncertain. The prognosis is mainly related to the pathological nature of the tumor and not the method of resection.
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Affiliation(s)
- Lishuai Wang
- Department of Oncology, The Second People's Hospital of Yibin
| | - Tongxiang Li
- Department of Orthopedics, The First People's Hospital of Yibin, Yibin City
| | - Min Gong
- Department of Orthopedics, Chengdu
| | - Fei Xing
- Department of Orthopedics, Chengdu
| | - Lang Li
- Department of Pediatric surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, PR China
| | - Rui Xiao
- Department of Orthopedics, The First People's Hospital of Yibin, Yibin City
| | - Qing Guan
- Department of Orthopedics, The First People's Hospital of Yibin, Yibin City
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12
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Hanafy AK, Mujtaba B, Yedururi S, Jensen CT, Sanchez R, Austin MT, Morani AC. Imaging in pediatric ovarian tumors. Abdom Radiol (NY) 2020; 45:520-536. [PMID: 31745573 DOI: 10.1007/s00261-019-02316-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The spectrum of ovarian tumors in the pediatric population differs significantly from that in adults. Germ cell tumors are the predominant class of ovarian tumors in children, whereas epithelial tumors are the most common in adults. Ultrasonography is the modality of choice for the initial evaluation of pediatric ovarian tumors. Determining the diagnosis based on imaging may prove difficult, and combining the imaging findings with the clinical scenario is very helpful in reaching a differential diagnosis during clinical practice. We will discuss the spectrum of ovarian neoplasms in the pediatric population and describe their clinical, pathologic, and imaging characteristics. A few unique entities related to ovarian tumors, such as growing teratoma syndrome, anti-N-methyl-D-aspartate receptor encephalitis, and hereditary ovarian tumor syndromes, are also discussed. In addition, we will review several entities that may mimic ovarian neoplasms as well as their distinct imaging features.
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Affiliation(s)
- Abdelrahman K Hanafy
- Diagnostic Radiology, The University of Texas Health Science Centre at San Antonio, San Antonio, TX, 78229, USA
| | - Bilal Mujtaba
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Sireesha Yedururi
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Corey T Jensen
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Ramon Sanchez
- Radiology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Mary T Austin
- Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Ajaykumar C Morani
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA.
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