Benign hemorrhagic renal cyst: a case report

A case of benign hemorrhagic renal cyst in a 64-year-old man is reported. The patient was admitted to our hospital for further evaluation of left upper abdominal mass. CT scan and ultrasonic sonography showed a left giant renal cystic mass. The characteristic findings were thick and irregular wall and heterogeneous contents of the cystic mass. Selective renal arteriography showed a hypervascular area in a part of the cyst wall and hemorrhagic cyst was suspected by MR imaging. The presence of a malignant tumor in the cyst wall was suspected, and radical nephrectomy was performed. The specimen measured 18 x 12 x 8 cm and weighed 1,170 g. The cyst contained bloody fluid and a hemorrhagic degenerating mass. Pathohistological examination showed no evidence of malignant tumor at any site of the cyst wall.     

Computed tomography for the diagnosis of a renal mass

The accuracy of differential diagnosis of renal mass lesions by computed tomography (CT) was evaluated. A retrospective study was done on 23 patients with renal mass lesion suspected by conventional IVP. Cases studied included 6 renal cell carcinomas, 1 nephroblastoma, 2 transitional cell carcinomas of renal pelvis, 3 parapelvic cysts, 2 polycystic kidneys and 9 other benign renal lesions. CT, especially with enhancement, is advantageous for evaluation of the extent of the tumor and also for the differentiation between cystic and solid masses by their attenuation. However, angiography and venography could provide valuable information for surgery of malignancy; and, retrograde pyelography also would help in assessing the extent of tumor spread in the renal pelvis. Two of our cases of parapelvic cyst and a case of renal bleeding could not be distinguished accurately by CT. Sonography or other diagnostic procedures might be helpful in such cases.     

An evaluation of Bosniak's radiological classification of cystic renal masses

OBJECTIVE: To determine the clinical usefulness of Bosniak's classification of cystic renal masses, the differentiation of which remains difficult despite significant advances in diagnostic imaging. PATIENTS AND METHODS: The computed tomography (CT) findings of all histopathologically examined cystic renal masses diagnosed at our institution were analysed retrospectively; 35 patients with cystic renal masses were treated between 1986 and 1998. Tissues surgically removed were examined pathologically and the final diagnosis compared with the preoperative CT category of Bosniak's classification. RESULTS: The histopathological examined showed cystic renal cell carcinoma in 21 patients, a benign renal cyst in 12, haemangiosarcoma in one and transitional cell carcinoma in one. Most of the 35 masses (26, 74%) were found incidentally during evaluation for an unrelated disease or a routine health check. All 11 masses of Bosniak category I were benign and one category II mass was malignant. All 10 masses of category III and 12 of category IV were malignant. CONCLUSIONS: Bosniak's classification is useful for differentiating category I, III and IV cystic renal masses. There were too few samples to allow meaningful conclusions to be drawn for category II renal masses. It is critical to differentiate between complicated cysts of category II and III because of the major implications for prognosis and clinical management.     

Complex renal cyst. A new case

Approximately 15% of cases of renal cell carcinoma present cystic configuration on radiologic and pathologic examination. These lesions are often difficult to differentiate from the multiloculated renal cyst or other benign cystic lesions such as hemorrhagic cyst and so on. We report a case of multilocular cyst of the right kidney complicated with clear cell type renal cell carcinoma in which MRI suggested benign cyst. The diagnosis of complicated benign cyst must be proposed very cautiously and the persistence of doubtful images justifies surgical exploration.     

Renal cell carcinoma- diagnosis by computed tomography

In approximately 10% of cases, renal cell carcinoma (RCC) could present as a fluid- filled cystic mass. There are three mechanisms by which RCC may become cystic: extensive cystic necrosis, intrinsic cystic growth and origin from the epithelium lining a simple renal cyst. Simple renal cysts are very common. Uncommonly these cysts are complicated by hemorrhage, infection and possibly ischemia. The goal of the radiologist in evaluating these cystic lesions is to distinguish malignant neoplastic cystic masses from non-neoplastic complicated cysts so that appropriate management can be undertaken: RCC is best treated by surgical excision while non-neoplastic complicated cysts do not require surgery. The radiologic findings in these cystic masses which must be carefully evaluated include calcification, abnormal density, septations, nodularity, wall thickening and enhancement.     

Non-neoplastic Epithelial Cysts of the Pancreas: A Rare,Benign Entity

Objectives

With the increased use of cross-sectional radiologic imaging in recent years, cystic lesions of the pancreas are being diagnosed with greater frequency. While pseuodocysts have historically accounted for the majority of benign pancreatic cysts, there are a number of rare, benign cystic lesions of the pancreas that can mimic neoplastic cysts. The objective of this study was to review a single institution’s experience with these benign cystic lesions of the pancreas.

Methods

We conducted a retrospective analysis of all patients who underwent surgical resection for pancreatic disease from 2005 to 2012 at our institution. Out of a total of 947 pancreatic resections, we identified those cases performed for cystic disease, and focused upon the clinicopathologic data of patients with non-neoplastic pancreatic cysts.

Results

Of the 947 pancreatic resections, 256 (27 %) were performed for cystic disease. Sixteen cases (6.3 %) out of the total of 256 pancreatic operations performed for cystic disease were found to have non-neoplastic cystic lesions of the pancreas. Preoperative imaging revealed primary lesions in all patients, eight of which were found incidentally. Of these lesions, 14 were suspected preoperatively to be mucinous neoplasms and two to harbor pancreatic adenocarcinoma. However, postoperative pathology revealed eight patients with ductal retention cysts, three squamoid cysts, one mucinous non-neoplastic cyst, one congenital ciliated foregut cyst, one lymphoepithelial cyst, and two endometrial cysts. Two patients had complications postoperatively, one pancreatic fistula and one SMV thrombosis. Both complications resolved with conservative management.

Conclusions

Non-neoplastic epithelial pancreatic cysts are rare, benign lesions. In our institutional experience, these lesions are often indistinguishable from cystic neoplasms of the pancreas preoperatively. As such, many of these lesions are resected unknowingly. It is important for the clinician to be well informed of the nature of these lesions, in the hopes to avoid unnecessary resection whenever possible.     

Expression of matrix metalloproteinase in the fluids of renal cystic lesions

PURPOSE: Cystic lesions of the kidney are common conditions usually diagnosed by imaging. Although simple cysts are easy to diagnose, preoperative diagnosis of a complicated cystic lesion can be difficult. There is little information available on the biological activity of cystic fluid and associations with clinicopathological findings. We analyzed the expression of matrix metalloproteinase (MMP) in the fluids of benign and malignant renal cystic lesions to clarify matriolytic activities in the cyst. MATERIALS AND METHODS: Included in this study were 22 samples of cystic fluids from renal cystic lesions, including 14 benign cysts and 8 cystic renal cell carcinomas. MMP-2 and 9 was determined in fluids using gelatin zymography and enzyme-linked immunosorbent assay. RESULTS: MMP-2 expression was ubiquitously observed on zymography except for 2 benign cysts associated with acquired cystic disease of the kidney. MMP-9 was detected in 7 of 8 carcinomas but in only 2 of 14 benign cysts (p <0.01). The concentration of MMP-2 and 9 was significantly higher in cystic carcinomas than in benign cysts (p <0.01). CONCLUSIONS: Our data show that MMPs were detectable in cystic fluids in the presence of renal cystic changes. MMP-2 and 9 are more abundant in cystic carcinoma fluids than in benign cystic fluids. These observations suggest that matriolytic enzymes in renal cystic fluid reflect biological aggressiveness and in part explain the pathogenesis of renal cystic lesions.     

囊性肾肿物超声造影诊断分析

目的 探讨超声造影对囊性肾肿物诊断价值. 方法 按照影像诊断标准,对29例囊性肾肿物的常规超声、超声造影、增强CT诊断结果进行分级,与最终诊断结果比较,应用受试者工作特征(ROC)曲线进行分析.男15例,女14例,年龄18～63岁.肿瘤位于左肾13例,右肾16例.29例均行常规超声检查后1～3 d行超声造影及增强CT检查. 结果 29例中20例有病理结果,其中恶性18例、良性2例.其余9例中失访1例,8例随访6～12个月,经超声或增强CT检查,病灶无明显变化.常规超声、超声造影与增强CT对囊性肾肿物分级的ROC曲线下面积分别为0.721、0.997、0.997,超声造影与常规超声比较差异有统计学意义(P=0.003),与增强CT比较差异无统计学意义(P=1.000).结论 超声造影对于囊性肾肿物诊断效果优于常规超声,与增强CT相似,可以应用Bosniak诊断系统对囊性肾肿物进行评价.     

Non-neoplastic cystic and cystic-like lesions of the pancreas: may mimic pancreatic cystic neoplasms

BACKGROUND: Cystic lesions of the pancreas consist of a broad range of pathological entities. With the exception of the pancreatic pseudocyst, these are usually caused by pancreatic cystic neoplasms. Non-neoplastic pancreatic cystic and cystic-like lesions are extremely rare. In the present article, the surgical experience with these unusual entities over a 14-year period is reported. METHODS: Between 1991 and 2004, all patients who underwent surgical exploration for a cystic lesion of the pancreas were retrospectively reviewed. Patients with a pancreatic pseudocyst were excluded. There were 106 patients of whom 8 (7.5%) had a final pathological diagnosis consistent with a non-neoplastic pancreatic cystic or cystic-like lesion, including 3 patients with a benign epithelial cyst, 2 with a pancreatic abscess (one tuberculous and one foreign body), 2 with mucous retention cysts and 1 with a mucinous non-neoplastic cyst. These eight patients are the focus of this study. RESULTS: There were six female and two male patients with a median age of 61.5 years (range, 41-71 years). All the patients were of Asian origin including seven Chinese and one Indian. Four of the patients were asymptomatic and their pancreatic cysts were discovered incidentally on radiological imaging for other indications. All the patients underwent preoperative radiological investigations, including ultrasonography, computed tomography or magnetic resonance imaging, which showed a cystic lesion of the pancreas. Three patients, all of whom were symptomatic, were diagnosed preoperatively with a malignant cystic neoplasm on the basis of radiological imaging. Two patients were eventually found to have a pancreatic abscess, one tuberculous and the other, secondary to foreign body perforation. The third patient was found on final histology to have chronic pancreatitis with retention cysts. The remaining five patients had a preoperative diagnosis of an indeterminate cyst; on pathological examination, they were found to have a benign epithelial (congenital) cyst (n = 3), retention cyst (n = 1) and mucinous non-neoplastic cyst (n = 1). At a median follow up of 20 months (range, 3-34 months), none of the patients had any evidence of recurrent disease. CONCLUSION: Non-neoplastic cystic and cystic-like lesions of the pancreas are rare causes of pancreatic cystic lesions that are generally benign and do not require surgery when asymptomatic. However, despite advances in diagnostic investigations such as endoscopic ultrasound with fluid aspirate and magnetic resonance imaging, the preoperative diagnosis remains unreliable. Hence, the challenge for all clinicians is to recognize these lesions preoperatively and to avoid 'unnecessary' surgery.     

胰腺黏液性囊性肿瘤的CT、MR诊断

目的分析胰腺黏液性囊性肿瘤（MCN）的CT及MR影像特点。方法18例胰腺黏液性囊性肿瘤均经病理证实,其中囊腺瘤11例,交界性肿瘤4例,囊腺癌3例。患者均进行了CT和（或）MR检查,回顾性分析肿瘤的CT及MR影像表现。结果胰腺黏液性囊性肿瘤平均大小为6．7cm,11例位于胰体、尾：除2例囊腺瘤为单房性无间隔外,其余16例均为多房性。3例囊腺癌囊壁及间隔明显增厚或囊壁上见壁结节,其中2例的囊腔直径大于2．0cm;13例非恶性肿瘤的囊壁及小房间隔较薄且均匀,无壁结节,小房直径大于2．0cm。1例囊壁钙化,4例合并胰腺炎改变,1例合并有胆总管扩张,1例周围血管包绕。结论胰腺黏液性囊性肿瘤的CT及MR表现具有一定的特点,有助于黏液性囊性肿瘤的诊断及鉴别诊断。     

Intra-abdominal bronchogenic cyst with gastric attachment: Report of a case

We report a rare case of an intra-abdominal bronchogenic cyst. An abnormal lesion was detected on an ultrasonogram, done as part of a physical checkup, in an 81-year-old woman. Computed tomography and magnetic resonance imaging showed a cystic mass attached to the lesser curvature of the stomach. Initially, we suspected a congenital cyst without malignant components; however, as the patient wished to have the lesion removed, we performed a minilaparotomy. The cystic lesion was firmly attached to the lesser curvature by fibrous tissue. Microscopic examination subsequently revealed the 26-mm mass to be a benign bronchogenic cyst with a bronchial element. We compared our findings with those of 50 previously reported cases of intraabdominal bronchogenic cysts. None of these patients was older than ours, and lesions attached to the esophagus or stomach were extremely unusual. Bronchogenic cysts are difficult to diagnose preoperatively based on imaging findings, but surgery may be indicated if malignant components are suspected, or if the lesion is enlarging or causing symptoms.     

BosniakⅡ~Ⅳ级肾囊性占位临床与病理学特点分析简

目的 探讨Bosniak Ⅱ-Ⅳ级肾囊性占位临床与病理学特点。方法 回顾性分析上海交通大学医学院附属仁济医院从2008年1月至2012年12月CT诊断为囊性肾脏占位（BosniakⅡ、ⅡF、Ⅲ、Ⅳ）的170例患者的病例资料,其中Ⅱ级囊肿73例,ⅡF级囊肿34例、Ⅲ级囊肿38例、Ⅳ级囊肿25例。男105例,女65例;年龄20-85岁,平均（56±14.2）岁;病灶位于左侧87例,右侧66例,双侧17例。80例接受手术治疗的患者中,Ⅱ级囊肿18例,ⅡF级囊肿8例,Ⅲ级囊肿30例,Ⅳ级囊肿24例;行腹腔镜肾囊肿去顶减压术25例,腹腔镜肾部分切除术15例,腹腔镜根治性肾切除术7例,开放肾癌根治术6例,开放肾部分切除术27例。其余90例进行了影像学的随访。分析不同分型囊性肾脏占位的良恶性比例、病理学特点、随访结果。结果 手术病例中Ⅱ级囊肿恶性病例为1例（5.6%）,ⅡF级1例（12.5%）,Ⅲ级16例（53.3%）,Ⅳ级21例（87.5%）,组间比较有明显统计学差异（P＜001）。术后病理结果：恶性肿瘤共39例（透明细胞癌31例,乳头状癌8例）,Fuhrman分级均为Ⅰ级。良性病例共41例（单纯囊肿26例,囊肿伴出血3例,囊肿伴感染5例,囊性肾瘤4例,错构瘤3例）。术后患者随访时间为6-65月,平均随访25月,恶性病例均无发生局部复发或远处转移。影像学随访病例中BosniakⅡ级为55例,ⅡF级26例, Ⅲ级为8例,Ⅳ级为1例,随访时间为6-64月,其中1例Ⅱ级（1.8%）进展至ⅡF级,其余病例均未进展。结论 Ⅱ、ⅡF级囊肿恶性率较低、进展缓慢建议定期随访,而Ⅲ、Ⅳ级恶性率较高应积极手术处理。但由于囊性肾癌组织学分级往往较低,其术后复发、进展及远处转移率较低,保肾手术是首选的治疗方案。     

良性占位性病变误诊为肾癌的原因分析

目的　提高肾脏良恶性占位的诊断水平 ,降低误诊率。　方法　肾占位性病变患者 12例 ,年龄 35～ 6 9岁 ,平均 5 2岁。腰部胀痛不适 9例 ,其中 2例伴全程血尿 ;体检超声偶然发现肾脏占位 3例。术前均行超声、CT等影像学检查诊断为肾癌。　结果　 12例患者均手术治疗。术中行冰冻病理检查 7例 ,提示为肾脏良性占位 ,行肿块剜除或单纯肾切除术 ;按肾癌行根治术 5例 ,术后病理均为肾脏良性病变。随访 1～ 3年 ,无复发。　结论　临床医师不应过高评价CT及超声等影像检查的诊断学意义 ,对无法确诊病例可行手术探查 ,术中行冰冻病理检查提高确诊率。多数误诊的良性肾占位与肾癌的影像学表现不同。     

Radiation-induced bilateral cystic frontal lobe necroses demonstrating a fluid-blood level--case report.

A 41-year-old male developed radiation-induced bilateral cystic frontal lobe necroses after irradiation for an olfactory neuroblastoma. Computed tomography (CT) and magnetic resonance (MR) imaging revealed the lesions, one containing a fluid-blood level on CT scans and niveau formation on MR images. It was proved to be a coagulated hematoma within the cyst at surgery. Such a fluid-blood level in a radiation-induced cyst has never been reported, although hemorrhage frequently accompanies delayed radiation necrosis. Positron emission tomography with multiple tracers may be useful in differentiating cerebral radiation necrosis from tumor recurrence, because of absence of abnormal tracer accumulation.     

Surgical exploration for renal cyst: two-case report]

A 59-year-old male was admitted to our clinic for further examination of the calcified renal cyst discovered incidentally on medical workup elsewhere. CT showed a left renal cyst associated with calcification. Ultrasound-guided puncture of the renal cyst was not successful because of thickness of the cystic wall. Renal angiography showed hypervascularity of the cystic wall. Association of renal cell carcinoma could not be ruled out, therefore the exploration was performed. Histological examination revealed benign renal cyst with calcification. A 27-year-old male presented with the chief complaint of left flank pain. Following examinations by US, CT and MRI, a renal cyst associated with renal cell carcinoma was highly suspected. Subsequent exploration revealed cluster of cysts with a yellowish lesion a few mm in diameter. Frozen section revealed no malignancy, and cystic fluid was not hemorrhagic. Therefore as many cystic walls as possible were removed without nephrectomy. Histological examination of the permanent specimen revealed renal cell carcinoma. Renal cyst associated with renal cell carcinoma was regarded as rare clinical entity, but such cases are reported in increasing number in recent years. We report such cases and review the pertinent literature in this paper.     

Incidental renal mass

Fifty-five patients with 64 incidentally discovered renal masses were evaluated with sonography and/or computerized tomography (CT scanning). Cyst puncture or surgical exploration confirmed the nature of the mass in all cases. We demonstrate that ultrasound is accurate in evaluating renal mass lesions 3 cm. in size or greater, but cannot distinguish between simple or hemorrhagic cysts. CT scanning can characterize lesions 1.5 cm. or greater in size, and those masses that are clearly cystic by CT scanning do not require further evaluation. Masses found to be indeterminate or solid by CT scanning require a more traditional approach. A 9.1-per cent incidence of malignant tumors in this series emphasizes the need for a complete and meticulous evaluation of all renal masses.     

肝胆管囊腺瘤及囊腺癌的CT、MRI诊断

目的总结肝胆管囊腺瘤和囊腺癌的CT、MRI表现,探讨CT、MRI诊断该肿瘤的价值。方法回顾性分析经手术病理证实为肝胆管囊腺瘤(3例)和囊腺癌(5例)的CT和(或)MRI表现、术前诊断,并与病理所见进行对照分析。结果3例囊腺瘤均为单房或多房的囊性肿物,无壁结节,术前均误诊为肝包虫或肝囊肿;5例恶性者中囊腺癌3例,囊腺瘤伴局部癌变2例。5例均为单房或多房的囊实性肿物,有壁结节。CT扫描囊性部分呈均匀液性密度,囊壁、分隔厚薄不均,壁结节大小不一,增强扫描囊壁、分隔及壁结节强化。MR示囊性部分呈均匀液性信号,增强扫描囊壁、分隔及壁结节强化。5例恶性者术前4例诊断为囊腺瘤或囊腺癌,1例诊为胆管癌。CT、MRI表现与病理所见对应良好。结论胆管囊腺癌在CT、MRI上具有特征性表现,可以做到术前正确诊断;但胆管囊腺瘤如果无壁结节则缺乏特征性表现,需要和肝复杂性囊肿或肝包虫病等鉴别。     

Radiologic characteristics and results of surgical management of Rathke's cysts in 43 patients.

Although Rathke's cysts are a relatively common autopsy finding, rarely have they been reported as a clinical entity. Because of recent improvements in neuroradiological imaging, cystic intrasellar and suprasellar lesions are discovered often, leading to questions about proper management. Against this background, we reviewed the data from 43 patients with Rathke's cysts treated by one neurosurgeon over a 13-year period, and present the results here. The 43 patients had a mean age of 34 years, and 77% were female. Headache was the most common symptom, followed by galactorrhea, visual field loss, and hypopituitarism. Computed tomographic (CT) scans were reviewed in 20 cases, magnetic resonance (MR) images were reviewed in 15, and both CT and MR studies were reviewed in 5 cases. Although all Rathke's cysts were discrete and well-defined by both CT and MR imaging, the diversity of locations, CT attenuations, and MR signal intensity make it difficult to establish the diagnosis by radiological criteria. Forty patients underwent transsphenoidal surgery and three underwent craniotomy. There was one recurrence at 25 months requiring a second operation, and the mean follow-up period was 62 months. Seven patients had persistent headaches. For symptomatic lesions suspected to be Rathke's cysts, the recommended treatment is simple drainage of the cyst with biopsy of the wall, when this can be done safely. Follow-up imaging should be minimal for asymptomatic patients, and radiation therapy is not indicated.     

Long-term surgical outcome in patients with intracranial hydatid cyst

Summary Background. Cerebral hydatid cysts account for up to 3.6% of all intracranial space-occupying lesions, in endemic countries. The vast majority of patients affected are children. Computed tomography (CT) and magnetic resonance imaging (MRI) have greatly contributed to a more accurate diagnosis of hydatids. However, correct pre-operative diagnosis still remains quite puzzling. Extirpation of the intact cyst is the treatment of choice, resulting in most cases to a complete recovery. Method. In our retrospective study, we have reviewed 76 cases of intra-cranial hydatid disease operated on in our hospital over a 22 year period. Presenting clinical symptoms and signs and the radiological findings on CT and MRI were documented. Albendazole was given preoperatively to patients with giant (>5 cm) or multiple cysts and postoperatively to all patients. The follow-up period ranged from 12 months to 22 years and the outcome was assessed using the Glasgow Outcome Scale (GOS). Findings. Sixty seven (95.7%) of our patients were children. Increased intracranial pressure and papilledema were the predominant findings in this group, whereas focal neurological deficits were most prevalent in adults. CT and MRI revealed round cystic lesions, isodense and iso-intense respectively to cerebrospinal fluid (CSF), with no rim enhancement or perifocal edema. Multiple cysts were identified in 3 cases. Extirpation of the cyst without rupture was accomplished in 56 patients (73.7%). Recurrences occurred in 19 patients (25%). 4 patients (5.3%) died within 6 months after surgery; 3 of these patients had multiple cysts and one died shortly after the operation due to anaphylactic shock following intra-operative rupture of the cyst. Conclusion. Long-term follow-up confirms that intracranial hydatid cysts should always be surgically removed without rupture; the outcome remains excellent in these cases. Correct preoperative diagnosis is vital for the successful outcome of surgery. A high index of suspicion is therefore required in endemic areas despite the availability of advanced neuro-imaging. Medical treatment with albendazole seems to be beneficial both pre- and post-operatively. Newer diagnostic methodologies, such as MR spectroscopy and MR diffusion weighted imaging, might lend themselves to the diagnosis of intracranial hydatid cysts.     

Sonography of popliteal masses

Sonography of the popliteal space was performed in 28 patients with a history of a popliteal mass, verified by physical examination in all but 7 patients. The final diagnosis was established by needle biopsy or surgery. Three main types of lesions were found sonographically. A thin-walled echo-free cyst was present in 16 patients. The diagnosis in all of these cases was Baker's cyst. Two patients had a mixed cystic and solid lesion, which was found to be a Baker's cyst, with a loose body in 1 case and a soft-tissue sarcoma with hematoma in the other. Three patients showed solid lesions subsequently diagnosed as an old rupture of the semimembranosus muscle, lipoma, and soft tissue sarcoma. Sonography was normal in the 7 patients without clinical evidence of a popliteal mass.

Sonography of popliteal masses is useful to distinguish benign cysts from other lesions.