Scrotal Wall Metastasis from Adenocarcinoma of Unknown Origin, with Concurrent Extramammary Paget's Disease - a Case Report.

INTRODUCTION: Scrotal cancer is a very rare disease, with the most common subtype being squamous cell carcinoma. Metastatic carcinoma to the scrotal wall is very rare. A histological finding of adenocarcinoma in a scrotal malignancy invariably suggests a metastasis from another primary cancer. We describe an enigmatic case of metastatic adenocarcinoma to the scrotum managed as metastatic adenocarcinoma of unknown origin. Attempts to identify a primary cancer were complicated by ambiguous diagnostic results. This is the first case in literature of metastatic cancer to the scrotum from an adenocarcinoma of unknown origin, and this was complicated by concurrent extramammary Paget's disease. CASE PRESENTATION: A 70-year-old male presented with painless progressive scrotal skin swelling, which was shown on histology to be adenocarcinoma. Immunohistochemistry showed prostatic lineage markers. However, the argument for a prostatic primary was weakened by negative prostate transrectal ultrasound biopsy findings and negative radiological findings. The scrotal metastatic adenocarcinoma was managed as metastatic adenocarcinoma of unknown origin. A differential of occult poorly differentiated prostatic primary was considered in view of the clinical phenotype of an elderly male patient with extensive sclerotic bony metastases, immunohistochemistry results and relatively low PSA level in relation to systemic burden of disease. The patient was managed with palliative systemic chemotherapy (carboplatin/paclitaxel) with initial disease response, but eventually developed progressive disease. DISCUSSION AND CONCLUSION: Finding of adenocarcinoma in scrotal skin malignancy indicates a metastasis and should prompt further work-up to identify a primary cancer, particularly of other genitourinary or lower gastrointestinal origin, so that treatment can be targeted at the underlying primary malignancy. However, attempts to identify a primary cancer might be complicated by ambiguous diagnostic results.

The Utility of Ultrasound Guidance to Improve the Safety of Closure of Antegrade Common Femoral Artery Access after Lower Limb Revascularization.

This study aimed to investigate the feasibility of ultrasound (US)-guidance in reducing adverse event (AE) rates when using Angioseal device during antegrade lower limb angioplasty via common femoral artery access. From December 2016 to November 2022, 1,322 patients were identified, including 1,131 (85.6%) patients who underwent US-guided closure and 191 (14.4%) who underwent non-US-guided closure. Moderate AEs were encountered in 10 (5.2%) patients in the non-US-guided closure group compared to 38 (3.4%) patients in the US-guided closure group (P = .208). Severe AEs were encountered in 4 (2.1%) patients in the non-US-guided closure group compared to 3 (0.3%) patients in the US-guided closure group (P = .010). Overall AEs occurred in 14 (7.3%) patients in the non-US-guided closure group compared to 41 (3.6%) patients in the US-guided closure group (P = .029). Binary logistic regression showed that only non-US guidance was an independent risk factor for the occurrence of severe AEs (P = .008).

Intracranial "white" epidermoid tumours - An imaging approach and systematic review.

INTRODUCTION: Intracranial epidermoid cysts are rare congenital inclusion cysts that can be divided into the classical "black epidermoid" and the exceedingly rare "white epidermoid". White epidermoids are often misdiagnosed because they have different imaging features compared to black epidermoids. There is a paucity of imaging review on white epidermoids. We hereby derive an explanation for the variable imaging features of white epidermoids and propose an imaging approach to distinguish white epidermoids from black epidermoids. METHODS: We conducted a review of white epidermoids in PubMed and Cochrane databases based on PRISMA principles. Qualitative analysis was carried out on the selected cases of white epidermoids, focusing on pathogenesis, imaging features, treatment and prognosis. RESULTS: Out of 1281 studies, we identified 26 full-text articles, comprising 68 patients with white epidermoid cysts, including an illustrative case example from our institution. White epidermoids have completely different MRI signals compared to the classical black epidermoids. Owing to tumour adhesions to the surrounding structures, there is a higher risk of leakage of white epidermoid content during surgery, causing severe aseptic meningitis. We demonstrate an approach to explain the variable imaging features of white epidermoids based on their cyst content - white epidermoids with low T2 signals content often contain high protein levels and viscosity, while those with high T2 signals contain blood products. CONCLUSION: During preoperative planning, it is important to identify white epidermoids. Extensive neurovascular damage should be avoided during surgery given the favourable prognosis of the epidermoids regardless of the extent of tumour resection.

Variant Hepatocellular Carcinoma Subtypes According to the 2019 WHO Classification: An Imaging-Focused Review.

The 2019 5th edition of the WHO classification of digestive system tumors estimates that up to 35% of hepatocellular carcinomas (HCCs) can be classified as one of eight subtypes defined by molecular characteristics: steatohepatitic, clear cell, macrotrabecular-massive, scirrhous, chromophobe, fibrolamellar, neutrophil-rich, and lymphocyte-rich HCCs. Due to their distinct cellular and architectural characteristics, these subtypes may not display arterial phase hyperenhancement and washout appearance, which are the classic MRI features of HCC, creating challenges in noninvasively diagnosing such lesions as HCC. Moreover, certain subtypes with atypical imaging features have a worse prognosis than other HCCs. A range of distinguishing imaging features may help raise suspicion that a liver lesion represents one of these HCC subtypes. In this review, we describe the MRI features that have been reported in association with various HCC subtypes according to the 2019 WHO classification, with attention given to the current understanding of these subtypes' pathologic and molecular bases and relevance to clinical practice. Imaging findings that differentiate the subtypes from benign liver lesions and non-HCC malignancies are highlighted. Familiarity with these sub-types and their imaging features may allow the radiologist to suggest their presence, though histologic analysis remains needed to establish the diagnosis.

A systematic review and meta-analysis of magnetic resonance imaging and ultrasound guided fusion biopsy of prostate for cancer detection-Comparing transrectal with transperineal approaches.

Targeted biopsy using multiparametric magnetic resonance imaging increases the detection rate of clinically significant prostate cancer (csCaP). In this meta-analysis, we compare the diagnostic accuracy of transrectal (TR) vs transperineal (TP) approaches for MRI-guided software fusion biopsy (FB) in the detection of csCaP. A literature search was performed in PubMed, Cochrane and Embase electronic databases up until July 2019 following the preferred reporting items for systematic review and meta-analysis system. The pooled sensitivity and specificity of either approach was evaluated using radical prostatectomy or systematic biopsies with ≥24 biopsy cores to be the reference standard. Fourteen papers with a total of 2002 patients were selected. Seven hundred and sixty-five patients underwent TR FB, while 1,387 underwent TP FB. One hundred and fifty of the patients underwent both TR and TP approaches. Both approaches were similar in terms of sensitivity (TR vs. TP: 0.81 vs 0.80) and specificity (TR vs. TP: 0.99 vs 0.95). In terms of likelihood ratios and diagnostic odds ratio, TR performed better than TP approach. The area under the receiving operator curve for both approaches was similar (0.91 vs 0.88 respectively). However, there was substantial heterogeneity across the studies for both approaches. TP and TR approaches to software-based FB yield similar diagnostic performance for the detection of csCaP. When deciding on the approach, physicians should consider other inherent features of either technique that suit their practice.

Type 2 Endoleaks: Common and Hard to Eradicate yet Benign?

PURPOSE: The exact significance of type 2 endoleaks (T2ELs) and the indication and efficacy of treatment are widely debated. We report our experience with managing T2ELs in a tertiary Asian centre. MATERIALS AND METHODS: This was a retrospective study of patients who underwent endovascular abdominal aortic aneurysm repair (EVAR) between February 2006 and December 2016. Patients with T2ELs were identified, and their data were analysed. RESULTS: A total of 156 patients underwent EVAR, of which 67 (42.9%) developed T2ELs. Seven were lost to follow-up. The remaining 60 patients had a mean follow-up period of 50.3 ± 33.9 months-34 (56.7%) experienced T2ELs early and the rest (43.3%) had late T2ELs. Forty-one patients had isolated T2EL, whilst 19 had concomitant T1EL and/or T3EL. Spontaneous resolution occurred in 25 patients (41.7%). All T2ELs with stable sac size were on continued surveillance. Amongst those with persistent T2ELs associated with sac growth (n = 17), 14 underwent intervention, of which 7 (50%) received > 1 embolisation procedure. A total of 16 transarterial embolisation and 8 translumbar embolisation procedures were performed. Technical success rate was 75%. In the intervention group, 5 (35.7%) had complete and sustained resolution, 7 had persistent/recurrent T2ELs but stable sac size, and 2 had progressive sac expansion. Overall mortality due to sac rupture occurred in 2 patients with concomitant T2EL and T1EL/T3EL. CONCLUSION: T2ELs are common, albeit mostly benign if occurring in isolation and not in association with sac growth. Achieving complete T2EL resolution with embolisation is difficult even with reinterventions. LEVEL OF EVIDENCE: Level 2B, retrospective study.