Emergency Angioembolization for Life-Threatening Hemorrhage in Wilms Tumor.

Introduction: Renal artery embolization has been used in a palliative fashion for symptomatic relief of hematuria or flank pain in unresectable renal cell carcinoma in adults. There is limited data on the use of embolization for actively bleeding and unresectable tumors in the oncological pediatric population. Case Description: A previously healthy 5-year-old boy with no significant past medical or surgical history presented to the clinic with gradually worsening abdominal distension associated with occasional abdominal pain, gross hematuria, and lethargy for four months. Diagnostic investigations showed an 18-cm left-sided metastatic (pulmonary) renal tumor (Wilms), which was deemed unresectable on imaging. Treatment was planned according to the SIOP-RTSG protocol. However, he became hemodynamically and vitally unstable with acute, sudden distension of the abdomen on the left side after the first cycle of chemotherapy. Imaging showed active bleeding from an inferior branch of the left renal artery. Selective angioembolization was done, and chemotherapy was reinitiated with a patent left main renal artery. Following the fourth cycle of chemotherapy, he developed hemodynamic instability and abdominal pain; imaging revealed the resolution of pulmonary nodules and bleeding from the left renal artery (main); this was again embolized, and the patient was stabilized. The patient was operated on after optimization, and a complete resection of the mass was done with negative margins. On six months follow-up, he is well. Practical Implications: To the best of our knowledge, this is the first case where angioembolization has been done in conjunction with neoadjuvant chemotherapy to downsize a Wilms tumor to achieve favorable outcomes. Continued research efforts are necessary to optimize strategies and improve the prognosis for pediatric patients, and this case is one of the prime examples.

MRI Features of Synchronous Masses in Known Breast Cancer Patients in Predicting Benign Versus Malignant Lesions: A Case Based Review at Tertiary Care Cancer Hospital.

Sara RehmanObjectives The purpose of this study was to determine the diagnostic accuracy of breast magnetic resonance imaging (MRI) in classifying incidental satellite masses in biopsy-proven breast cancer patients as benign or malignant masses and assessing its impact on surgical management of these patients. We also analyzed the incidence of MRI-detected lesions, which were thereafter assessed with second look ultrasound (US). Materials and Methods A retrospective study was performed on breast cancer patients presenting from August 01, 2016 to July 31, 2019, with satellite masses seen on base line MRI. Satellite masses were classified as benign and malignant based on MRI features of shape, margin, T2-weighted imaging signals, internal enhancement pattern, enhancement kinetic curves, and diffusion restriction. This was compared with results of histopathological examination. The number of MRI-detected lesions, location of the satellite mass, and type of surgery were also documented. Results Out of 400 breast cancer patients undergoing MRI breast, 115 patients had multiple masses. Histopathological diagnosis was available for 73 patients; and a total of 93 satellite masses were evaluated. There was evidence of additional masses on second look ultrasound in 21 patients. Of 72 masses classified as malignant on MRI, 58 showed malignant pathological outcome; while out of 21 masses characterized as benign on MRI, 18 turned out to be benign on histopathology. A statistically significant association was found between MRI features and pathological outcome of satellite masses ( p = 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy were 95%, 56%, 80.56%, 85.7% and 81.7%, respectively. Based on these findings, modified radical mastectomy (MRM)/mastectomy was done for 42 patients, 5 patients underwent lumpectomy limited to a single tumor, extended resection done for 14 patients, 5 underwent bilateral breast conservation surgery (BCS), BCS for contralateral breast done for 4 patients undergoing ipsilateral MRM/mastectomy, and bilateral MRM/mastectomies were performed for 2 patients. One patient was lost to follow up. Conclusion Breast MRI is the most sensitive modality for the assessment of breast cancer and plays an essential role in the detection of additional tumor foci. These findings can modify the surgical approach in these patients. However, considering the low specificity, biopsy of satellite masses is imperative to determine the most appropriate surgical plan.

Fahr's disease: A rare neuropsychiatric disorder.

Fahr's disease is a rare clinical neurodegenerative entity, occurring mainly in 4th or 5th decade, showing gradually progressive bilateral symmetric calcifications in basal ganglia, subcortical white matter, thalami or cerebellum, which can lead to movement disorder and/or neuropsychiatric manifestations. We present two cases in the same family; a 68-year-old brother had involuntary jerky movements of hand and dysarthria for 10 years while the 44-year-old sister had right lower limb spasticity and decreased vision for 2 years. The serial MRI scans showed slow progression in the bilateral subcortical white matter and cerebellar dentate nuclei calcifications along with surrounding reactive gliosis.

Rare case image of retroperitoneal metastases from breast primary.

Breast cancer remains the leading cause of cancer related death in females worldwide. Metastatsis from breast primary are usually seen in lungs, bones and liver. Uncommon sites include adrenals, thyroid, spleen, pancreas and urinary bladder. Retroperitoneal metastasis are considered most unsual among breast cancer. We present the case of a treated breast cancer patient with a large reteroperitoneal lesion suggesting other aetiologies on imaging but proved to be metastasis on histopathology.

Vein of Labbe Thrombosis-A missed culprit.

Thrombosis of vein of Labbe is an uncommon finding and usually tends to occur along with extensive dural venous sinus thrombosis. Clinical presentation varies from headache to aphasia, dysarthria and upper motor neuron weakness symptoms. Recognized risk factors for thrombosis should be considered while diagnosis. MR venogram remains investigation of choice for detection and to look for the extent of thrombosis.

Intracranial Extra-axial Undifferentiated Pleomorphic Sarcoma; a Case Report.

Introduction: Head-and-neck sarcomas result in high mortality rates. A lot of new cases of sarcomas are diagnosed every year constituting about 1 % of all head-and-neck malignancies. Undifferentiated pleomorphic sarcomas (UPSs) are high-grade soft-tissue malignant tumours which occur primarily in limbs and retroperitoneal cavities. These tumours can often metastasize to the central nervous system. However, in rare instances, soft-tissue sarcomas may develop as a primary lesion within the intracranial compartments. Case Description: A young male presented to the clinic with occipital headache and blurring of vision. Initial workup included brain contrast-enhanced computed tomography (CECT) and magnetic resonance imaging (MRI). The CECT suggested that there was an extra-axial mass present which was pressing against the adjacent left frontal lobe. Overlying frontal bone of the left side showed remodelling effect and associated mild periosteal reaction. MRI scan showed intracranial extra-axial lobulated mass with T1 intermediate to low-signal intensity and intermediate to high signals on T2 sequences. Heterogeneous enhancement on post-contrast sequences was also seen. The lesion had a broad-based attachment with dura mater and was closely applied to the orbital roof without orbital invasion. Staging positron emission tomography-CT scan showed a solitary site of disease in an intracranial location. Final diagnosis was confirmed by histopathology following excision of mass as UPS. Post-surgery MRI brain showed satisfactory post-operative appearance without any residual disease. The patient remained asymptomatic for 2 years and 6 months following the resection of the tumour. Practical Implications: Most of the extra-axial intracranial soft-tissue tumours arise from the meninges with meningiomas making the substantial bulk; however, possibility of other relatively rare tumours of meningeal origin must not be ignored. Intracranial soft-tissue sarcomas mostly arise from meninges thus require a good understanding of clinical presentation as well as acquaintance with morphological features on radiological imaging to differentiate from other tumours. These can be treated with excision and radiotherapy along with sequential follow-ups to look for recurrence. Tissue sampling is mandatory followed by complete staging scan in case of sarcomas to rule out possible primary or secondary disease.

Tuberous Sclerosis.

Tuberous sclerosis is a rare genetic disorder inherited in an autosomal dominant fashion. It is a multisystem disorder involving brain, eye, skin, kidney and lungs which manifest in late childhood. We present a typical case of tuberous sclerosis in a young female patient.Extensive work-up including MRI brain, MRI abdomen and CT Thorax was performed. The clinical and radiological findingswere consistent with thediagnosis of tuberous sclerosis.

Renal Stent Crushed During Open Aneurysmorrhaphy for Endoleak After Fenestrated EVAR.

PURPOSE: To report a complication of renal stent crushing during open aneurysmorrhaphy performed 10 years after fenestrated endovascular aneurysm repair (FEVAR). CASE REPORT: A 67-year-old male patient underwent elective FEVAR of a juxtarenal aortic aneurysm. Uncovered balloon-expandable stents were placed through the fenestrations for the superior mesenteric and right renal arteries; the left renal artery received a Jostent covered balloon-expandable stent. The uncovered right renal stent was noted to be crushed on the first imaging after FEVAR, but was left untreated; the right kidney was thereafter significantly smaller than the left. Over several years, the aneurysm expanded, and type II endoleak involving the lumbar arteries was embolized with coils 7 years after FEVAR. Despite this, the aneurysm continued to enlarge and reached a diameter of 12.8 cm. Open aneurysmorrhaphy and selective ligation of lumbar arteries was performed 10 years after FEVAR. The first surveillance imaging after aneurysmorrhaphy demonstrated a new finding of a crushed left renal stent, which was presumed to be related to surgical instrumentation. The stent was successfully redilated percutaneously, and renal function remained stable. Computed tomography demonstrated a normal appearance of the left renal covered stent after re-expansion. Doppler ultrasound after 7.5 months showed normal renal perfusion. CONCLUSION: Balloon-expandable visceral artery stents are susceptible to crush injury during aortic surgery. Consideration should be given to early imaging after such surgery in FEVAR patients.