Metachronous pancreatic metastases from renal cell carcinoma: is there a place of Active-Surveillance before deferred deliberately Molecular Target Agent?

BACKGROUND: Metastatic renal cell cancer is a heterogeneous disease due to its diverse morphological features, the prognostic categories based on clinical criteria. Sometimes indolent course without any significant symptoms can be differentiated before the introduction of novel targeted agents. This observation led to interest in a strategy of deferring systemic therapy in the era of effective systemic therapies. CASE PRESENTATION: We report of a 78-year-old Moroccan man with pancreatic metastasis from renal cell carcinoma which occurred 14 years from right nephrectomy. Indolent disease based on body computed tomography imaging with 4 years follow-up was recognized. Active surveillance with deferred antiangiogenic multikinase inhibitor at disease progression was proposed. Nowadays, the patient is under oncological follow-up, he is in a good state of health, and he is disease-free for 48 months from the diagnosis of the tumor and for 20 months from the start of the treatment with Sunitinib CONCLUSIONS: Active surveillance before target therapy may be a suitable approach to ensure long progression-free survival with minimal side-effects and better quality of life in asymptomatic, low-volume, metastatic disease. Further prospective studies with biomarker validation are required to define the patients most likely to benefit from this approach.

Floating Thrombus in the Aortic Arch: Rare Images.

Aortic floating thrombus is a rare, life-threatening disease. Most cases of aortic thrombus are diagnosed after embolic events; however, on rare occasion we may diagnose this condition incidentally during routine examinations as in our case.

Hallucal sesamoiditis on a bipartite sesamoid bone: An uncommon cause of chronic great toe pain.

The pathologies and lesions affecting the sesamoid bones of the hallux are uncommon and can be easily overlooked. Among them, sesamoiditis is a relatively rare condition known to cause severe great toe pain; lack of awareness of this particular entity leads to misdiagnosis, delayed treatment, and contributes to significant morbidity. Herein, we present a chronic sesamoiditis case occurring on a medial bipartite sesamoid bone, presenting as chronic great toe pain. The main purpose of this work is to discuss the role of magnetic resonance imaging and X-rays in the diagnosis process. To the best of our knowledge, no cases of great toe sesamoiditis occurring on a bipartite bone in no-athletic patients have yet been reported.

Short Stature: Think About the Pituitary Stalk Interruption Syndrome.

Pituitary stalk interruption syndrome (PSIS) is an uncommon congenital defect of the pituitary gland. It is considered one of the rare endocrinal causes of abnormally short stature. Herein, we present a case of a four-year-old girl who consulted for short stature and delayed growth. The patient's history did not include any past medical or surgical pathology. Birth history revealed a full-term delivery with a breech presentation. Clinically, the patient had a small stature, beneath the third percentile. Magnetic resonance imaging findings, through a typical triad, were consistent with PSIS. We describe through this report, what we believe is a rare typical case of PSIS. This case was discovered in a young patient with pituitary dwarfism. We hope that the concise and synthesized structure of this case report will help physicians acquire the necessary reflexes to notice and diagnose the already underdiagnosed PSIS.

Hydatid cyst of the uterus: Very rare location.

The involvement of the genital tract of a hydatid cyst is rare and the occurrence in the uterus is an extreme rarity. The diagnosis of this localization is difficult because the clinical and radiological findings are often misleading and the diagnosis is often worn during surgery and after histopathological examination of the surgical specimen. We report the case of a patient who consulted for primary infertility, with a clinical finding as the only anomaly significantly large uterus, and imaging pointing strongly toward an ovarian multilocular cyst, and in which the discovery of hydatid cyst was accidental intraoperative with double localization uterine and omental. Radical treatment cannot be discussed in this young patient of 32 years and gravid 0. The removal of the cyst wall completely and excision of the mass epiploic seemed reasonable. The patient was placed under Mebendazol and is always under the supervision of a possible recurrence.

Exophytic hepatic hemangioma: a case report.

Hepatic hemangiomas may rarely arise outside the extra-hepatic capsule. It appears as a pedunculated mass. We report the case of a 58-year-old female presenting with abdominal chronic pain. Incidental diagnosis of a pedunculated hepatic hemangioma was suggested by ultrasonography confirmed by typical imaging features on computed tomography. Dynamic contrast- enhanced computed tomography and MR scan are relevant to approach the diagnosis of hemangioma, showing its origin from the liver edge and typical radiological features Surgical removal of the mass was performed to prevent volvulus along the pedicle. Pathological analysis confirmed the diagnosis of pedunculated benign hepatic hemangioma.

Cataclysmic Gastrointestinal Hemorrhage: Dreaded Complication of Metastatic Breast Cancer.

Upper gastrointestinal bleeding (UGIB) from variceal rupture is a serious condition that can be life-threatening in some cases. Usually, the main cause is portal hypertension in cirrhosis, but other etiologies like liver metastases can be also involved. We present the case of a 64-year-old woman, with a history of metastatic breast cancer, who was admitted for a massive UGIB due to ruptured esophageal varices related to portal hypertension.

Fortuitous Discovery of Nutcracker Syndrome During Acute Appendicitis: A Case Report.

Nutcracker syndrome (NCS) belongs to a group of rare vascular disorders. It refers to compression of the left renal vein (LRV) generally between the abdominal aorta (AA) and the superior mesenteric artery (SMA). It is one of the most unknown causes of chronic abdominal pain. Herein, we present the case of a young patient who came to the emergency department for acute abdominal pain. Patient's history revealed an uncharacterized chronic epigastric pain evolving for 13 years. The imaging showed acute appendicitis and NCS; the latter finding was the principal explanation for the patient's chronic pain. We hope that the concise and synthetized structure of this case report will help physicians acquire the necessary reflexes to notice and diagnose this already underdiagnosed syndrome.

Cerebral fat embolism syndrome after long bone fracture: A case report.

Cerebral fat embolism is a rare and potentially fatal condition that may occur following a long bone fracture. Its characterized by respiratory, neurological, and mucocutaneous signs. Isolated severe brain syndrome remains exceptional. We report a 21-year-old male patient admitted for the cerebral manifestation of a fat embolism syndrome due to a fracture of long bone after a traffic accident injury. Neurological deterioration after a free interval was seen with generalized tonic-clonic seizures. MRI of the brain was indicated which showed numerous multifocal hyperintensities involving the deep white matter of both hemispheres producing a "starfield" appearance. This pattern of cytotoxic cerebral edema, with lesions in the white matter rather than the grey matter, is indicative of the subacute stage of fat embolism. The patient was treated with comprehensive support in the intensive care unit, he returned to normal neurological function and was discharged after 3 weeks of hospitalization.

Metastatic rectal gastrointestinal stromal tumor with intestinal obstruction: A rare case report.

Gastrointestinal stromal tumors (GISTs) arising from the rectum are rare. We report the case of an aggressive rectal gastrointestinal stromal tumor (GIST) in a 60-year-old female that presented for symptoms of constipation and lower gastrointestinal bleeding. Upon rectal examination, a hard mass was found at 6cm from the anal marge. An MRI was indicated that shows a well-demarcated lesion originates from the distal rectum with exophytic growth and central necrosis. The diagnosis of rectal gist was confirmed by colonoscopy with biopsy and immunohistochemical analyses of bioptic material. Liver metastases were seen on computerized tomography (CT). She was referred for palliative chemotherapy. The patient had suffered from intestinal obstruction three weeks after his initial presentation and passed away shortly thereafter. We aimed to report this case as an aggressive and rare GIST localization.

Renal artery pseudoaneurysms post percutaneous nephrolithotomy: A case report.

Percutaneous Nephrolithotomy (PCNL) is a standard, safe and efficient method for removing large renal calculi. This pathology is associated with a risk of life-threatening Iatrogenic Renal Vascular Injuries, such as pseudoaneurysm (1%-3%). We report the case of a 49 old year male patient with Hematuria post PCNL for renal calculi. Computed tomography renal angiography was indicated which showed a pseudoaneurysm in the lower pole of the left kidney confirmed by digital subtraction angiography. Super selective endovascular embolization was successfully performed with conservation of the left-over vascularization of the kidney. No postoperative complications were seen. We aimed to report this case and to review the literature regarding endovascular management of kidney pseudoaneurysms after PCNL.

Gallstone ileus: An unusual cause of intestinal obstruction.

Gallstone ileus is an infrequent cause of intestinal obstruction. It is typically the result of cholecystoduodenal fistula, computed tomography scan is the best modality for the diagnosis. Surgical removal of the gallstone is the pillar of treatment to relieve intestinal obstruction. We report the case of a 77-year-old male with features of a small bowel obstruction. Computed tomography scan of the abdomen showed pneumobilia, a cholecystoduodenal fistula, and small bowel obstruction features suspicious for gallstone ileus. The patient had a laparotomy and removal of two gallstones via an enterotomy without postoperative complications.

Gastrointestinal stromal tumor of the small intestine with lung metastasis.

Gastrointestinal stromal tumours (GISTs) represent 1% of primary gastrointestinal cancers. These tumors most frequently metastasise to the liver and peritoneum and rarely to the lungs. We report the case of a 79-year-old woman with gastrointestinal stromal tumor of the small intestine and pulmonary metastases. Contrast-enhanced computed tomography (CT) revealed a focal mass centered around the last intestinal loop associated with pulmonary bilateral masses. The diagnosis of gist of the small bowel was confirmed by histopathological and immunohistochemical analyses of bioptic material obtained from CT guided biopsy of pulmonary lesions. To the best of our knowledge, only few cases had been reported in medical literature as This mode of presentation is unusual, with computed tomography (CT) playing a significant role in the diagnosis and management.

Is there any advantage to combined trastuzumab and chemotherapy in perioperative setting her 2neu positive localized gastric adenocarcinoma?

We report here a 44-year-old Moroccan man with resectable gastric adenocarcinoma with overexpression of human epidermal growth factor receptor 2 (HER2) by immunohistochemistry who was treated with trastuzumab in combination with chemotherapy in perioperative setting. He received 3 cycles of neoadjuvant chemotherapy consisting of trastuzumab, oxaliplatin, and capecitabine. Afterwards, he received total gastrectomy with extended D2 lymphadenectomy without spleno-pancreatectomy. A pathologic complete response was obtained with a combination of trastuzumab and oxaliplatin and capecitabine. He received 3 more cycles of trastuzumab containing regimen postoperatively.We conclude that resectable gastric carcinoma with overexpression of the c-erbB-2 protein should ideally be managed with perioperative combination of trastuzumab with chemotherapy. Further research to evaluate trastuzumab in combination with chemotherapy regimens in the perioperative and adjuvant setting is urgently needed.

Clinical and radiological resolution of vertebral sarcoidosis mimicking metastatic disease.

Sarcoidosis is a disease that exhibits extreme heterogeneous clinical manifestations. Bone involvement in sarcoidosis is rare (1%-13%), and involvement of the vertebrae is even rarer. Usually, it is a diagnosis of exclusion with nonspecific characteristics in imaging. A 35-year-old male, who has no significant medical history£. He came to clinical examination for lower back and associated bilateral lower extremity pain. Magnetic resonance imaging (MRI) was performed to exclude disc-related pathology. It demonstrates left paramedian lumbar disc herniation at L4-L5 level. Multiple small enhancing lesions throughout the lumbar vertebrae were discovered as an incidental finding. An 18F-labeled fluorodeoxyglucose was performed to evaluate for metastatic disease that shows hypermetabolic apical right nodule of the lung parenchyma with multiple mediastinal and right iliac external adenopathy. Increased uptake throughout the lumbar vertebral lesions was also seen. A CT-guided biopsy of the right apical lung nodule and one of the vertebral lesions (L3) revealed noncaseating granulomas consistent with sarcoidosis. We introduce steroid treatment with favorable evolution of vertebral lesions. Vertebral sarcoidosis cannot be certainly differentiated from metastatic disease based on imaging only. Accurate diagnosis is only attainable by histopathological verification of the lesions.

Anal Cancer with Atypical Brain and Cranial Bones Metastasis: About 2 Cases and Literature Review.

Canal anal cancer is a rare tumor that accounts for 2% of all colorectal neoplasms, with a low propensity for metastasis. The spread of anal squamous cell carcinoma to the brain is exceedingly rare and has been previously reported only 5 times in the medical literature. However, the first and only case of cranial bone metastasis from anal canal carcinoma was described in 2019. The purpose of this article is to add our cases to the limited literature for the management of metastatic anal cancer. The current study presents 2 cases of patients diagnosed with squamous cell carcinoma of the anal canal how underwent chemo and radiotherapy. Despite the treatment our patients developed neurological symptoms, cerebral magnetic resonance imaging showed brain lesions for the first case, and cranial bones metastasis for the second one, histopathology confirmed these lesions to be a poorly differentiated squamous cell carcinoma, consistent with the known primary tumor of the anal canal. Unfortunately, both patients succumbed quickly to systemic complications of the disease during these treatments. Despite its rarity, brain metastasis should be considered in any patient with a history of anal cancer presented neurological symptoms.

Renal angiomyolipoma with renal vein extension.

Renal angiomyolipomas are uncommon benign tumors containing fatty tissue. Only a few cases of infiltrating angiomyolipomas have been reported. We aimed to describe a case of a 65-year-old woman presenting a peripheral angiomyolipoma of the left kidney with CT evidence of involvement of the renal vein. The lesion has been found incidentally during abdominal CT for an unrelated reason. The patient underwent surgical treatment considering the vascular extension of the lesion and the risk of thromboembolic complications. The pathological analysis confirmed the diagnosis of renal AML in the upper pole of the left kidney invading the renal vein without malignancy.No post-operative complications and the evolution was favorable.

[Hydrocele of the canal of Nuck detected during infertility evaluation: an atypical case report]. / Une hydrocèle du canal de Nuck découverte au cours d´un bilan d´infertilité: à propos d'un cas atypique.

Hydrocele of the canal of Nuck is a rare woman condition often detected during childhood. We here report a rare case of hydrocele detected in adulthood during infertility evaluation. The patient presented with chronic non painful right inguinal swelling. Imaging test demonstrated typical image of hydrocele of the canal of Nuck. The ultrasound found cyst formation with few thin septa and MRI did not find any communication with the peritoneum. The same imaging tests were performed which showed non-partitioned bicornuate uterus that could fall under the framework of infertility evaluation. The main purpose of this study was to report the typical imaging features of hydrocele of the canal of Nuck, which is a little known diagnosis that should be integrated into differential diagnoses of inguinal swellings in women.

Curvilinear pericallosal lipomas diagnosed incidentally during evaluation following trauma with corpus callosum abnormalities in two patients.

Pericallosal lipomas are the most habitual location for an intracranial lipoma. They are fat-containing lesions arising from the interhemispheric fissure intimately related to the corpus callosum, which is often abnormal. They originate from aberrant differentiation of the persistent primitive meninx. Most Pericallosal lipomas are asymptomatic and come into clinical attention during neuroradiological investigations for other conditions. MRI is the modality of choice to characterize not only the extent of the lipoma but also the frequently associated agenesis/dysgenesis of the corpus callosum. Pericallosal lipomas can be divided into two groups: The Tubulonodular type and The curvilinear type. Curvilinear lipomas are less common than Tubulonodular. We report the clinical and radiological findings of curvilinear Pericallosal lipoma in two patients with corpus callosum abnormalities revealed incidentally during evaluation following trauma.

Acute pulmonary embolism mimicking COVID-19 pneumonia.

The case of 21-year-old man with an asthma history from childhood presenting severe respiratory distress associated with a right lower thoracic pain has been studied. The non-contrast Computed Tomography (CT)-chest scan showed a basal ground-glass opacity (GGO) of the right lung leading to suspicion of COVID-19 pneumonia. However, the molecular Reverse transcription polymerase chain reaction test and blood serology were negative while laboratory analyses revealed high levels of D-dimers (D-D). In addition, 2 repeated COVID-19 tests were negative. A thoracic CT angiography was disclosed due to the persistence of pain at the lower right thoracic side and hemoptysis that shows a bilateral distal pulmonary embolism with a right-sided basal subsegmental ischemia. We discuss a fortuitous discovery of pulmonary embolism associated with peripheral basal ground-glass opacities similar to radiological manifestations of SARS-CoV-2 pneumonia.