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Steka X, Martens F, Renzulli MM, Hauswirth F, Vrugt B, Renzulli P. Adrenal myelolipoma: Defining the role of surgery. A case report. Int J Surg Case Rep 2022; 98:107527. [PMID: 36030765 PMCID: PMC9434030 DOI: 10.1016/j.ijscr.2022.107527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/14/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance Adrenal myelolipomas (AMLs) are rare, non-functional, benign tumours mostly diagnosed incidentally. They present as small and unilateral masses that are histologically composed of mature adipose tissue with admixed haemopoietic elements. In a small percentage of patients, pressure symptoms, retroperitoneal haemorrhage or tumour rupture may occur. However, indications for surgery in the majority of asymptomatic patients are poorly defined. Case presentation A 44-year old male patient presented with signs of gastroenteritis. Computed tomography (CT) imaging revealed an encapsulated, sharply delineated mass measuring 87 × 76 × 87 mm displacing the right adrenal gland. Average attenuation was −30 Hounsfield units. Given the pathognomonic features, an AML was suspected. The patient underwent open tumour resection and the diagnosis was histologically confirmed. Clinical discussion Small (<4 cm), homogeneous, non-hormone secreting incidentalomas with an attenuation of <10 Hounsfield units on non-contrast CT are considered benign requiring neither treatment nor follow-up. Giant AMLs (>10 cm) may cause symptoms or complications and are therefore considered candidates for surgery. The treatment strategy of asymptomatic AMLs ranging from 4 cm to 10 cm, however, is controversial and poorly defined. The role of surgery in this specific subgroup of patients is studied. Conclusion Surgery is indicated in the presence of a tumour diameter above 6 cm, rapid tumour growth (RECIST 1.1 criteria for progressive disease at 6–12 months follow-up), imaging suspicious of malignancy, radiological signs of local invasion, functioning ipsilateral adrenocortical adenoma, pressure-related symptoms and signs of retroperitoneal bleeding or spontaneous tumour rupture. Adrenal myelolipoma are rare, non-functional, usually small, benign tumours. They are composed of mature adipose tissue and haemopoietic elements. 95 % of adrenal myelolipomas are asymptomatic and discovered as incidentalomas. The role of surgery in the treatment of mid-sized lesions (4–6 cm) is poorly defined. The present study states the indications for surgery of mid-sized lesions (4–6 cm).
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Mcnamara G, Abdelbaki A, Mccarver J, Owens D, Malik A, Pereira K, Mendez A. Transradial Embolization of Hemorrhagic Adrenal Myelolipoma. THE ARAB JOURNAL OF INTERVENTIONAL RADIOLOGY 2022. [DOI: 10.1055/s-0042-1749071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractAdrenal myelolipomas are largely benign, non-functioning, and asymptomatic adrenal tumors found incidentally on imaging. These tumors have an extremely low incidence and are exceedingly rare. We report a case of trans-radial embolization of hemorrhagic adrenal myelolipoma.
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Affiliation(s)
- Griffin Mcnamara
- Department of Interventional Radiology, Saint Louis University, Missouri, United States
| | - Ahmed Abdelbaki
- Department of Interventional Radiology, Saint Louis University, Missouri, United States
| | - Jeremy Mccarver
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States
| | - David Owens
- Department of Interventional Radiology, Saint Louis University, Missouri, United States
| | - Ali Malik
- Department of Interventional Radiology, Saint Louis University, Missouri, United States
| | - Keith Pereira
- Department of Interventional Radiology, Saint Louis University, Missouri, United States
| | - Alejandro Mendez
- Department of Interventional Radiology, Saint Louis University, Missouri, United States
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Badawy M, Gaballah AH, Ganeshan D, Abdelalziz A, Remer EM, Alsabbagh M, Westphalen A, Siddiqui MA, Taffel MT, Itani M, Shaaban AM, Elsayes KM. Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings. Br J Radiol 2021; 94:20210753. [PMID: 34464549 DOI: 10.1259/bjr.20210753] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.
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Affiliation(s)
- Mohamed Badawy
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ayman H Gaballah
- Department of Radiology, University of Missouri Health care, Columbia, MO, United States
| | | | - Amr Abdelalziz
- Department of Radiology, University of Missouri Health care, Columbia, MO, United States
| | - Erick M Remer
- Department of Radiology, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Mustafa Alsabbagh
- Department of Radiology, University of Missouri Health care, Columbia, MO, United States
| | - Antonio Westphalen
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Mohammed A Siddiqui
- Department of Radiology, University of Missouri Health care, Columbia, MO, United States
| | - Myles T Taffel
- Department of Radiology, NYU Langone Medical Center, New York, NY, United States
| | - Malak Itani
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Akram M Shaaban
- Department of Diagnostic Imaging, University of Utah, Salt Lake City, UT, United States
| | - Khaled M Elsayes
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Alexander A, Hunter K, Rubin M, Bhat AP. Extraosseous Ewing's Sarcoma: Pictorial Review of Imaging Findings, Differential Diagnosis, and Pathologic Correlation. Indian J Radiol Imaging 2021; 31:203-209. [PMID: 34316128 PMCID: PMC8299506 DOI: 10.1055/s-0041-1729770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Extraosseous Ewing's sarcoma (EES), first described in 1969, is a malignant mesenchymal tumor just like its intraosseous counterpart. Although Ewing's sarcomas are common bone tumors in young children, EESs are rarer and more commonly found in older children/adults, often carrying a poorer prognosis. We discuss the multimodality imaging features of EES and the differential diagnosis of an aggressive appearing mass in proximity to skeletal structures, with pathologic correlates. This review highlights the need to recognize the variability of radiologic findings in EES such as the presence of hemorrhage, rich vascularity, and cystic or necrotic regions and its imaging similarity to other neoplasms that are closely related pathologically.
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Affiliation(s)
- Alan Alexander
- Department of Radiolog, Imaging Medical Associates, Inc., Northridge, California, United States
| | - Kyle Hunter
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, United States
| | - Michael Rubin
- Department of Radiology, Akron Children's Hospital, Akron, Ohio, United States
| | - Ambarish P Bhat
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Missouri Columbia, Columbia, Missouri, United States
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Senne J, Nguyen V, Staner D, Stensby JD, Bhat AP. Demystifying Sacral Masses: A Pictorial Review. Indian J Radiol Imaging 2021; 31:185-192. [PMID: 34316126 PMCID: PMC8299490 DOI: 10.1055/s-0041-1729766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The sacrum is a triangular shaped bone made up of five fused vertebral bodies. It is composed of bone, cartilage, marrow elements as well as notochord remnants and is a common site for both benign and malignant (primary and secondary) tumors. Familiarity with the imaging features and clinical presentations of sacral bone tumors could be helpful in narrowing the differential diagnosis. Magnetic resonance imaging and computed tomography are the preferred imaging modalities for evaluating sacral masses. This pictorial review will highlight imaging features of common sacral tumors with pathologic correlation. Additionally, this article will review some critical principles and helpful tips to successfully biopsy these lesions.
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Affiliation(s)
- Julie Senne
- Department of Radiology, University of Missouri-Columbia, Columbia, Missouri, United States
| | - Van Nguyen
- Department of Pathology, University of Missouri-Columbia, Columbia, Missouri, United States
| | - Derek Staner
- Department of Radiology, University of Missouri-Columbia, Columbia, Missouri, United States
| | - James D. Stensby
- Department of Radiology, University of Missouri-Columbia, Columbia, Missouri, United States
| | - Ambarish P. Bhat
- Department of Radiology, University of Missouri-Columbia, Columbia, Missouri, United States
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Nance ME, Tarim AO, Nguyen V, Malhotra K, Davis RM, Bhat AP. Risk Factors for Major Hemorrhage Following Percutaneous Image-Guided Renal Biopsy: What is the "core" of the Problem? A Retrospective Case-control Study. J Clin Imaging Sci 2020; 10:54. [PMID: 33024609 PMCID: PMC7533095 DOI: 10.25259/jcis_87_2020] [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: 06/01/2020] [Accepted: 08/13/2020] [Indexed: 11/19/2022] Open
Abstract
Objectives: Percutaneous renal biopsy (PRB) plays a critical role in the work-up of renal parenchymal disease. Although it is considered a low-risk procedure, additional interventions may be required in about 7% of the cases following biopsy. The purpose of this study was to identify risk factors for major hemorrhage by microscopic analysis of the cores obtained following PRB, with an intent to enhance the sensitivity and specificity of the risk stratification process, especially in patients undergoing this procedure in an outpatient setting. Material and Methods: A retrospective review identified 17 of 179 patients (9.50%) with major hemorrhage following PRB between July 2014 and June 2019. Using propensity score matching, 26 controls (without major hemorrhage) were matched to 17 cases (with major hemorrhage). The biopsy cores obtained from the cases and controls were analyzed by a single pathologist for medullary, cortical, total (medullary + cortical) lengths, and the number of arcuate arteries (AAs). Medullary:cortical (M:C), cortical:total (C:T), and medullary:total (M:T) length ratios were then calculated. Results: A stratified version of logistic regression was used to test for an association between each of the variables identified on the cores and the probability of a major hemorrhage. The analysis revealed that there was a statistically significant association between the number of AAs per specimen with the risk of major hemorrhage (P = 0.0006). When 0, 1, or >2 AAs were identified, the frequency of major hemorrhage was 13.04%, 66.67%, and 75.00%, respectively. The odds of major hemorrhage were 6 times higher with one AA and (95% CI, 1.28–32.30) and 15 times higher with >2 AAs (95% CI, 1.41–169.57). No significant association was found between medullary length (P = 0.228), medulla:cortex (M:C) (P = 0.089), medulla:total (M:T) (P = 0.108), or cortex:total (C:T) (P = 0.112) length ratios and major hemorrhage. Conclusion: There was a strong and incremental correlation between major renal hemorrhage following PRB and the number of AAs per core specimen. Identification of AAs by the pathologist, while assessing for sample adequacy, in the US suite can help predict major hemorrhage in patients undergoing PRBs.
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Affiliation(s)
- Michael E Nance
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Andrew O Tarim
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Van Nguyen
- Departments of Pathology, University of Missouri, Columbia, Missouri, United States
| | - Kunal Malhotra
- Department of Medicine, Division of Nephrology, University of Missouri, Columbia, Missouri, United States
| | - Ryan M Davis
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, Missouri, United States
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, Missouri, United States
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Bhat R, Al-Samarraie M, Nada A, Leiva-Salinas C, Whitehead M, Mahdi E. Spotlight on the pediatric eye: a pictorial review of orbital anatomy and congenital orbital pathologies. Neuroradiol J 2020; 34:21-32. [PMID: 32865127 DOI: 10.1177/1971400920949232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Orbital lesions in the pediatric population vary from adults in terms of their presentation, unique pathology, and imaging characteristics. The prompt and accurate diagnosis of these lesions is imperative to prevent serious consequences in terms of visual impairment and disfigurement. Along with dedicated ophthalmologic examination, imaging is instrumental in characterizing these lesions, both for accurate diagnosis and subsequent management. In our pictorial essay, we provide a basic review of orbital embryology, anatomy, and congenital orbital pathologies, with emphasis on radiological findings.
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Affiliation(s)
- Roopa Bhat
- Department of Radiology, University of Missouri Health Care, USA
| | | | - Ayman Nada
- Department of Radiology, University of Missouri Health Care, USA
| | | | - Matthew Whitehead
- Diagnostic Imaging and Radiology, Children's National Health Systems, USA.,George Washington University Hospital, USA
| | - Eman Mahdi
- Department of Radiology, University of Missouri Health Care, USA
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Nance ME, Biedermann GB, Bhat AP, Davis RM. Chemorefractory liver metastasis from cervical cancer successfully treated with a combination of yttrium-90 and immunotherapy. Radiol Case Rep 2020; 15:1359-1365. [PMID: 32636973 PMCID: PMC7327429 DOI: 10.1016/j.radcr.2020.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/24/2022] Open
Abstract
Liver metastases in cervical cancer is rare and can be difficult-to-treat. The current guidelines established by the Gynecologic Oncology Group recommend platinum-based systemic chemotherapy in combination with an anti-angiogenic agent such as bevacizumab, however, overall survival remains poor following diagnosis and options for patients who fail chemotherapy are limited. Yttrium-90 (Y90) radioembolization (RE) has shown great promise in the treatment of chemo-refractory colorectal liver metastases. We describe a 30-year-old female with a history of stage IB endocervical adenocarcinoma who later developed metastases to the liver, that were unresponsive to multiple chemotherapeutics and chemoembolization, and was successfully treated with Y90 RE with concurrent systemic Pembrolizumab. The Y90 RE treatment resulted in positive clinical and imaging responses with improvement in her quality of life, all of which continue to persist at the time of writing this manuscript about 8-months into her RE treatment.
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Affiliation(s)
- Michael E. Nance
- School of Medicine, University of Missouri, Columbia, MO, USA
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, One Hospital drive, Columbia, MO 65212, USA
| | - Gregory B. Biedermann
- Department of Radiology, Section of Radiation Oncology, University of Missouri, Columbia, Columbia, MO, USA
| | - Ambarish P. Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, One Hospital drive, Columbia, MO 65212, USA
- Corresponding author.
| | - Ryan M. Davis
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, One Hospital drive, Columbia, MO 65212, USA
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Alexander A, Hunter K, Passerini S, Bhat R, Bhat AP. Appendiceal diverticulosis in a patient with family history of Birt-Hogg-Dubé syndrome--a case report. Radiol Case Rep 2020; 15:1317-1322. [PMID: 32612732 PMCID: PMC7322125 DOI: 10.1016/j.radcr.2020.05.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 12/12/2022] Open
Abstract
Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant disorder that predisposes patients to cutaneous tumors, pulmonary cysts with recurrent spontaneous pneumothoraces, and a variety of renal neoplasms including hybrid oncocytic and chromophobe renal cell carcinomas. There has been much debate regarding the genetic link with the occurrence of colorectal cancer and other colonic anomalies. Associations between BHD and intestinal adenomatous polyposis and sigmoid diverticulosis have been described in the literature, but there have been no prior reports of appendiceal diverticulosis in patients with BHD. Here, we present a 40-year-old female patient with a known family history of BHD, who was found to have diverticulosis of the appendix and pulmonary blebs on computed tomography upon routine screening for renal and pulmonary abnormalities, suggesting additional focus be given to the gastrointestinal tract (including the appendix) at the time of CT assessment.
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Affiliation(s)
- Alan Alexander
- Renaissance Imaging Medical Associates, Northridge, CA, USA
| | - Kyle Hunter
- Department of Radiology, Cleveland Clinic, OH, USA
| | | | - Roopa Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri- Columbia, One Hospital Drive, Columbia, MO, 65212, USA
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri- Columbia, One Hospital Drive, Columbia, MO, 65212, USA
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Marjara J, Hilli J, Davis RM, Bhat AP. Metastatic retro-crural lymph nodes from transitional cell carcinoma of bladder successfully treated with single session cryoablation. Radiol Case Rep 2020; 15:1197-1201. [PMID: 32550958 PMCID: PMC7292893 DOI: 10.1016/j.radcr.2020.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 01/09/2023] Open
Abstract
Bladder cancer (BC) is a relatively common tumor, with a male preponderance. High-grade muscle invasive bladder cancer (MIBC) has a very high incidence of pelvic lymph node metastasis at presentation. Involvement of the retro-crural lymph nodes, although has been described in other pelvic tumors, is very uncommon for BC. Cryoablation in the retro-crural region is extremely challenging due to the proximity to the critical structures like inferior venacava and aorta and has not been extensively reported. We describe a 56-year old male patient with MIBC who underwent extensive treatments including radical cystoprostatectomy, chemoradiation and immunotherapy, ultimately with localized disease in the retro-crural region. Single session cryoablation of these lymph nodes was performed with a curative intent yielding a positive response that has persisted for more than 2 years.
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Affiliation(s)
- Jasraj Marjara
- University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO, USA
| | - Jaffar Hilli
- Department of Medicine, Division of Hematology and Oncology, University of Missouri-Columbia, One Hospital Drive, Columbia, MO, USA
| | - Ryan M Davis
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri-Columbia, One Hospital Drive, Columbia, MO, 65212, USA
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri-Columbia, One Hospital Drive, Columbia, MO, 65212, USA
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