Introduction: Mature cystic teratoma originating in the pancreas is very unusual, often observed as an incidental finding during routine examinations or recognized perioperatively as the patients present with very unspecific clinical symptoms. The confirmatory diagnosis of a pancreatic cystic teratoma is generally made by histopathology after surgical excision. So, the preoperative diagnosis is very challenging, especially differentiation from the other pancreatic pathologies. Patient concerns: A 23-year-old woman was admitted to our hospital with a complaint of mild grade periumbilical abdominal pain. A pancreatic mass was revealed on a preliminary abdominal ultrasound examination. Her medical history was unremarkable with no long-standing illness or malignancy. Diagnosis: Mature cystic teratoma in the head of the pancreas. Interventions: Roux-enY choledochojejunostomy with gastrojejunostomy was performed, excising the tumor from the pancreatic head. Outcomes: The postoperative course was uneventful; the patient was asymptomatic and has no evidence of recurrence on a 2-year follow up. Conclusions: Pancreatic cystic teratoma is a benign, well-differentiated, and extremely rare congenital tumor. MRI is the choice of imaging modality and phase-GRE or fat suppression is the best technique for pre-operative diagnosis.
Our case emphasizes the importance of recognizing IPAS radiological characteristics and typical variations in its presentation in an asymptomatic patient that could help the personnel to differentiate it from other mass lesions. Thus, recognizing imaging findings on Plain CT, Contrast CT and MRI plays a key role to form a conclusive diagnosis of an accessory spleen, which has to be clinically associated. So, surgeons should consider IPAS as a differential for which unnecessary resection and an unintended surgical procedure can be avoided.
Rationale:Left gastric artery aneurysms are very rare which progresses into hemorrhagic shock and diagnosis is very challenging particularly in patients with acute pancreatitis and cholecystitis whose vitals become unstable suddenly.Patient concerns:A 72-year-old female has presented with severe progressing abdominal pain was treated with total parenteral nutrition for acute pancreatitis based on preliminary work up, but suddenly became unstable with dropping vitals over the ensuing 48 hours. Physical examination has a positive Murphy sign and appeared lethargic. She has no past history of any chronic systemic illness or malignancy.Diagnoses:Ruptured left gastric artery aneurysm and left hepatic artery aneurysm with intraperitoneal hemorrhage associated with acute pancreatitis and cholecystitis.Interventions:Emergency interventional surgery was performed to embolize both the aneurysms and the giant aneurysmal sac of the left gastric artery was secured with a micrometallic occluding coil which eventually controlled the active hemorrhage.Outcomes:The patient became stable and was discharged after 15 days without any recurrence or complications during the 6-month follow-up.LessonsThis case is a peculiar example of a missed diagnosis of left gastric artery aneurysm associated with acute pancreatitis and cholecystitis with deteriorating clinical condition. Exhaustive radiological investigations are necessary for early diagnosis correlating with presenting clinical situations. Radiologists should be familiar with the challenges in diagnosis and management.
Purpose To clarify unique non-contrast CT (NCCT) characteristics for early recognition of Schistosomal associated appendicitis (SAA) differentiating from Non-schistosomal associated appendicitis (NSA). Material and methods Clinical and pathological data of 50 cases with SAA and 60 cases with NSA who underwent emergency appendectomy were retrospectively compared to pre-surgical NCCT features such as direct and indirect signs of acute appendicitis as well as appendicoliths, colon calcifications as diagnostic criteria. Statistical methods such as Chi-square (χ 2), t-tests, Principal component analysis (PCA), Binary Logistic regression (LR) and Factor Analysis (FA) were utilized to observe differences and isolate recognizable CT features of SAA. Pre and post hoc diagnostic performance of all criteria was calculated as sensitivity, specificity, and the Odds Ratio (OR). Results Age > 50 years, diameter > 13 mm, pneumatosis, peri appendiceal abscess, focal wall defect, perforation; Orbital, linear and point types of appendicular wall calcifications; sigmoid colon and cecal curvilinear calcifications were observed as unique characteristics with a sensitivity of 84-95% and specificity of 91-98% in predicting SAA by OR of 6.2 times. Pre and post hoc hypothetical analysis did not show any significance for all other factors. Conclusion Factors such as elderly age, CT features such as larger appendicular diameter, appendicular wall calcifications along with sigmoid colon, and cecal calcifications, signs of perforation or abscess are characteristic for early recognition of SAA. Keywords Schistosoma japonicum • Intestinal Schistosomiasis • Multislice computed tomography • curvilinear calcifications • Peri appendiceal abscess Abbreviations AIR score Appendicitis inflammatory response score SAA Schistosomal associated acute appendicitis Bimbadhar Valluru, Zhou Zhou contributed equally to this work.
Rationale:Clear cell sarcoma of tendon and aponeurosis (CCSTA) or soft parts is a rare malignant melanin producing tumor entity that is derived from the neural crest cells originating from soft tissues displaying melanocytic differentiation. Diagnosis of CCSTA is difficult as it is dependent on age, size, location, necrosis, calcifications, cystic degeneration, and local to distant metastatic deposits. These tumors have very poor prognosis with a survival rate of 5–10 years because of local recurrence, early to late metastasis to lymph nodes, lungs, bones, and liver.Patient concerns:A 30-year-old Asian male has presented with a painful mass in the posterior aspect of the right ankle. He recalled of noticing an increase in the size of the lump after a traumatic insult 3 months ago. Physical examination revealed a mass of size 9x4 cm in the posterior ankle with no cutaneous ulcerative lesions. There is no history of any longstanding illness or malignancy.Diagnoses:Clear cell Sarcoma of Tendon and Aponeurosis (CCSTA) or CCS of Soft parts.Interventions:Conventional radiography demonstrated merely a soft tissue mass in the posterior compartment of the right ankle and significant calcaneal bone erosion with the sparse trabecular pattern. Plain conventional tomography showed a well-defined soft tissue heterogeneous mass with a hypoattenuating osteo-destructive focal lesion in the calcaneus. Magnetic resonance imaging (MRI) - T1 weighted imaging (T1WI) revealed an iso-intense signal relative to adjacent muscle; heterogeneous high-signal intensity on fat saturated T2 weighted imaging (T2WI). On contrast examination, lesion on T1WI, showed a heterogeneous high signal intensity, central low signal intensity with peripheral and septal enhancement. The immune-histochemistry analysis was positive for HMB-45, S-100, myoD1 and Ki67 (30%). Correlating with imaging and immune-histochemistry, a confirmatory diagnosis of CCSTA was made.Outcomes:CCSTA is typically a slowly growing painless mass in the deep soft tissues of ear, pancreas, kidney, penis, abdomen, especially in the lower extremities- Achilles tendon and aponeurosis of the ankle or in foot of young adults. As, these tumors are highly malignant, difficult to diagnose, early recognition by imaging and surgical excision are the mainstay of management.Lessons:Our case emphasizes the importance of recognizing radiological characteristics of CCSTA, and its differentiation from other soft tissue tumors, when presenting atypically. MRI plays a significant role in the diagnosis supported by histopathology and immune-histochemistry. So, radiologists should be familiar about this presentation that could guide other personnel for early detection of soft tissue tumors while including CCSTA into differential diagnosis for evaluation.
Objective: To investigate the effects of NF-κB and the role of inflammatory response factors on the normal liver tissue around the tumors in rabbit VX2 hepatocellular carcinoma models after TAE.Methods: Seventy VX2 hepatoma rabbit models were prepared and success rate was 85.7%. Computed tomography (CT) and Magnetic resonance imaging (MRI) was performed after 21 days of modelling. Sixty rabbits were randomly chosen and divided into three groups, 20 in each group: TAE group, Contrast/Angiography group, and Control group respectively. TAE group was treated with Transarterial embolization (TAE) and the Contrast group was subjected to hepatic arteriography and DSA, while the Control group served as a control group. The immune-histochemistry analysis was used to detect the expression of NF-κB in normal liver tissue around the tumors of each group. The levels of inflammatory factors like TNF-α, IL-10 of each group were detected by Enzyme-linked immunosorbent assay (ELISA) in the normal liver tissue around the tumor. Using SPSS 22.0 statistical analysis software, measurement data was analyzed using t-test, count data were compared using the χ2-test; P <0.05 was considered as statistically significant.Results: The positive expression rates of NF-κB in the TAE group, contrast group, and control group were 75% (15/20), 35% (7/20) and 20% (4/20) respectively. The concentrations of TNF-α were 11.72 ± 0.65 (ng/L), 9.60 ± 0.31 (ng/L) and 8.82 ± 0.81 (ng/L); the concentrations of IL-10 were 2.18±0.13 (ng/L), 1.67 ± 0.12 (ng/L), 1.66 ± 0.10 (ng/L) respectively. Compared with the control group and contrast groups, TAE group showed a significant increase in the expression of NF-κB, and the levels of TNF-α and IL-10 were also increased. Conclusion:The hepatocytic injury, degrading function after TAE could be due to the interaction of NF-κB and inflammatory factors-TNF-α and IL-10.
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