Utility of anteroposterior diameter ratio of tumor and abdomen for laparoscopic approach for radical nephrectomy in large renal masses.

INTRODUCTION: Laparoscopic radical nephrectomy (LRN) is now increasingly done for tumors larger than 10 cm. Despite selection of favorable cases, LRN may not be successful due to lack of adequate working space with large tumors. We describe a new feature on Contrast Enhanced Computed Tomography (CECT) abdomen to predict feasibility of LRN for large renal masses between 10 and 15 cm. METHODS: From January 2005 to December 2015, renal tumors between 10 and 15 cm were selected retrospectively for LRN. Patients with retroperitoneal lymphadenopathy, Inferior vena cava (IVC) thrombus and involvement of adjacent organs were excluded. Anteroposterior (AP) diameter ratio of renal tumor and abdomen (APROTA) was calculated by dividing the maximum AP diameter of tumor along with normal renal parenchyma, by the AP diameter of abdomen on CECT. The patients were stratified into two groups: Group A (successful LRN) and Group B (conversion to open surgery) and outcomes were compared. The reasons for conversion were also noted. RESULTS: Of 29 patients, 16 (55.2%) had successful LRN (Group A), while 13 (44.8%) had conversion to open surgery (group B). The median tumor size in Group A was 11.3 ± 1.8 cm and in Group B was 13.6 ± 1.26 cm. Eleven of 13 patients had conversion due to large tumor size causing failure to progress. Two conversions were due to bleeding and injury to the colon each. There was a significant difference in the APROTA in group A and B [0.43 ± 0.09 in group A and 0.64 ± 0.14 in group B (p = 0.0001)]. CONCLUSIONS: Patients with APROTA of more than 0.65 are unlikely to have successful outcome with LRN.

Bicuspid aortic valve with severe stenosis and ruptured sinus of Valsalva aneurysm to left ventricle.

Bicuspid aortic valve (BAV) is a common congenital cardiac anomaly, and rarely, it is associated with sinus of Valsalva aneurysms (SOVAs). And very infrequently, these SOVAs rupture into left side of heart. We hereby report a case of 12-year-old male with BAV with severe aortic stenosis with a large SOVA that ruptured into the left side of the heart. The anatomy was delineated with multimodality imaging; initially with two-dimensional trans-thoracic echocardiography (TTE), and later on with three-dimensional TTE and with multi detector computed tomography. Operative interventions were planned for the patient.

Juvenile amyotrophic lateral sclerosis: Classical wine glass sign on magnetic resonance imaging.

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a chronic degenerative neurologic disease and is characterized by the selective involvement of the motor system. Usually, patients present with upper motor neuron (UMN) and lower motor neuron compromise. Degeneration of the UMN in the cerebral cortex is one of the main pathologic changes in ALS. These changes usually affect corticospinal tracts leading to degeneration of the fibers which show characteristic hyperintensities along the tracts leading to the "wine glass sign." Patients with ALS usually present in the sixth decade of life; presentation in pediatric age in the form of juvenile ALS being rare.

Huge Osteoclastoma of Hyoid Bone: A Case Report.

Giant cell tumors (GCT) of hyoid bone are very rare, and only few individual cases were reported in literature. We present such a case of GCT arising from left cornu of hyoid bone. The patient underwent trans-cervical complete excision of the tumour. Postoperatively, patient did well without recurrence or metastasis for 2 years follow up.

A new classification of inferior vena cava thrombus in renal cell carcinoma could define the need for cardiopulmonary or venovenous bypass.

INTRODUCTION: Although the level of inferior vena cava (IVC) thrombus governs the type of surgical approach, there is no consistency in reporting the levels of IVC thrombus in the literature. This prospective study illustrates a simple three-level classification based on the need for clamping hepatoduodenal ligament and venovenous or cardiopulmonary bypass. MATERIALS AND METHODS: Between January 2010 and June 2014, 30 patients of renal mass with renal vein and/or IVC thrombus were treated after classifying the IVC thrombus into three levels on the basis of need for clamping the hepatoduodenal ligament. After excluding renal vein thrombi, level I was described as thrombus located caudal to the hepatic vein. Level II included all retrohepatic, suprahepatic infradiaphragmatic or supradiaphragmatic thrombi reaching till the right atrium. Atrial thrombi were categorized as level III. Level I and II thrombi were managed without venovenous or cardiopulmonary bypass. Level III thrombus required cardiopulmonary bypass. RESULTS: Of 26 patients with thrombus, 13 had level I thrombus. Of eight cases with level II thrombus, three were retrohepatic, three were suprahepatic infradiaphragmatic and two were supradiaphragmatic. All were removed successfully. Of five patients with level III thrombus, three were operated with cardiopulmonary bypass while the remaining two patients were too sick to be taken up for surgery. The median hepatoduodenal ligament clamp time was 10 min. One patient with level II thrombus had transient liver enzyme elevation. CONCLUSION: Renal vein thrombus should not be categorized as level I thrombus. Level II thrombus, irrespective of its relation to the diaphragm, could be managed without venovenous or cardiopulmonary bypass.

Fracture of mandible during yawning in a patient with osteogenesis imperfecta.

Osteogenesis imperfecta is a genetic disorder characterised by fragility and multiple fractures of bones. Clinical signs and symptoms vary depending on the type of disease. Fractures of facial bones are rare compared with load-bearing long bones. We report a case of fracture of the mandible during yawning which was managed by open reduction and internal fixation.

Primary mesenteric lymphangioma in a young adult with intestinal malrotation and 'counter-clockwise barber pole sign'.

Mesenteric lymphangiomas are uncommon benign lesions that usually occur in isolation but rarely may be associated with gastrointestinal (GI) malrotation. Malrotation may cause chronic and recurrent volvulus leading to chronic venous congestion and lymphatic engorgement. Interference with lymphatic drainage may result in formation of a lymphangioma or a chylous mesenteric cyst. In our case, mesenteric lymphangioma was present with partial malrotation of small and large bowel. There was no radiological and surgical evidence of volvulus, favouring the hypothesis that lymphangioma may be a primary congenital association of GI malrotation. Another interesting finding was the counter-clockwise twisting of the superior mesenteric vein around the superior mesenteric artery which has been reported only seven times in the literature.

Non-compaction of the left ventricular myocardium with cor-triatriatum and associated anomalies.

Non-compaction of ventricular myocardium (NVM) is a rare clinical entity. It has been reported more frequently in recent years because of continuous improvements in imaging techniques and resolution. Although apical region of the left ventricle is the most commonly involved site, biventricular involvement has also been reported in the published literature. This abnormality is often associated with other congenital cardiac and extracardiac anomalies. We describe such a case, incidentally detected and documented by the combination of echocardiography and multidetector CT coronary angiography. In our case, NVM was associated with Cor-triatriutum, ventricular septal defect, persistent left superior vena cava and an anomalous extracardiac vessel. Synchronous association of all these anomalies in a child has never been reported in the literature.

Cardiac type of total anomalous pulmonary venous connection: diagnosis and demonstration by multidetector CT angiography.

Pulmonary venous developmental anomalies have been evaluated conventionally with echocardiography and catheter angiography, multidetector CT angiography (MDCTA) and MR angiography are playing increasing roles in their characterisation. Here, we report a rare case of a 15-year-old boy, who presented with cyanosis and dyspnoea which he had had since childhood. Cardiac type of total anomalous pulmonary venous connection (TAPVC) was diagnosed and demonstrated using MDCTA in this case. Only a few case reports describing the MDCTA findings in cardiac TAPVC are available in the published literature.

Clinicopathological spectrum and the outcome of treatment of upper tract transitional cell carcinoma.

INTRODUCTION: Disease spectrum of upper tract transitional cell carcinoma (TCC) in Indian patients is not known. Herein, we present data on clinical presentation, pathological characteristics, and the outcome of treatment of upper tract TCC. MATERIALS AND METHODS: Clinicopathological data of patients who were diagnosed for upper tract TCC between January 2000 and January 2010 were collected from the hospital information system and case records. Preoperative diagnosis was based on contrast-enhanced computerized tomography of the whole abdomen and urine cytology. Cross tab and logistic regression analysis was done on the effect of various clinicopathological characteristics on the outcome and cancer-specific and recurrence survival were derived. RESULTS: There were total 40 patients, 35 (87.5%) of them were male. The mean age was 62.7 ± 7.9 years. The most common symptom was gross hematuria present in 30 (75%). Mean tumor size was 2.8 ± 1.2 cm. Median duration of follow up was 36 (12 to 100) months. Laparoscopic nephroureterectomy was done in 27 patients along with bladder cuff excision and seven patients underwent open surgery. Thirty two (88.8%) patients had invasive T stage and high-grade lesions were seen in 24 (66.6%). Lymphovascular invasion was found only in one case and necrosis in 30 (83.3%). Necrosis was found to be the poor prognostic factor. Five-year recurrence-free and cancer-specific survivals were 36.33% and 26%, respectively. CONCLUSION: Patients with upper tract TCC present very late with a high-stage disease and a very low 5-year cancer-specific and recurrence-free survivals.

The stone man disease: fibrodysplasia ossificans progressiva: imaging revisited.

Fibrodysplasia ossificans progressiva (FOP) is a rare, disabling connective tissue disorder of unknown aetiology. Its occurrence is usually sporadic but may be an inherited autosomal-dominant condition with wide range of expression. FOP is characterised by congenital malformations of the great toes and abnormal progressive heterotopic ossification of striated muscles, tendons, ligaments, fascia and aponeuroses of the trunk and extremities leading to painful swellings. The ossifications typically appear within the first decade of life, resulting in progressive morbidity and severe disability. So far, there has been no effective treatment or prevention. In the early localised phase of disease it may be misdiagnosed, hence the role of correct diagnosis through imaging is essential. Herein, we report a case of a 10-year-old female who was evaluated radiologically and diagnosed as a case of FOP. The findings of plain radiography are described and the role of CT is highlighted.

Giant right atrial aneurysm presenting as right heart failure.

Idiopathic aneurysmal dilatations of the right atrium are rare anomalies. We report one such case of a young man presenting with fatigue, abdominal distension, pedal oedema, unremarkable cardiac examination except for raised jugular venous pressure, an electrocardiogram showing normal sinus rhythm with right bundle-branch block, and an radiograph of the chest showing cardiomegaly. The echocardiographic examination revealed a giant right atrium with low pressure tricuspid regurgitation. The computed tomography confirmed the findings of two-dimensional echocardiography. He was put on medical treatment and remained symptomatically controlled on follow-up.

Multiple neural tube defects in a child: A rare developmental anomaly.

BACKGROUND: The presence of multiple neural tube defects (NTDs) is a rare entity. Published literature shows not more than 10 case reports. Such cases contradict the well-established "zipper model" of neural tube closure and support "multi-site closure model." CASE DESCRIPTION: We are reporting a unique case of multiple NTDs in a 5-month-o ld female child. Occipital encephalocele, dorsal meningomyelocele, Split cord malformation (SCM), and tethered cord were present in this case. CONCLUSION: This case report further substantiate the "multisite closure model," however, more research work on human neuro-embryology is needed to overcome the controversies of neural tube closure.

Giant unilateral hydrocele "en-bisac" with right hydronephrosis in an adult: A rare entity.

Abdominoscrotal hydrocele consists of two large sacs; the abdominal and scrotal, both are connected via the inguinal canal. The diagnosis is made by clinical examination and can be confirmed with ultrasound scan. Surgical treatment is considered mandatory since spontaneous resolution is extremely rare. Herein, we report a case of giant unilateral hydrocele en-bisac who presented with spontaneous rupture of the sac.

Swyer-James-MacLeod syndrome with ipsilateral herniation of hyperinflated hyperlucent lung.

Swyer-James-MacLeod syndrome is characterised by unilateral hyperlucency on chest radiograph with small or normal-sized lung on the affected side and compensatory hyperinflation of opposite lung. Hyperinflation of the affected lung is a very rarely reported entity. An adult female patient, who presented with exertional breathlessness and diagnosed to have hypoplastic left pulmonary artery with hyperlucent, hyperinflated and herniated left lung is described.

Imaging spectrum in soft tissue sarcomas.

Imaging plays an important role in detection, diagnosis as well as pre and post operative management of patients with soft tissue sarcomas. Soft tissue sarcomas are generally a diagnostic dilemma needing the complimentary use of both radiology and pathology for their accurate diagnosis. In this review article, we have tried to highlight the important facts about the various imaging modalities available as well as the recent advances in the field of radiology.