Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study.

BACKGROUND: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

Immune checkpoint inhibitor treatment of a first cancer is associated with a decreased incidence of second primary cancer.

BACKGROUND: Second primary cancers (SPCs) are diagnosed in over 5% of patients after a first primary cancer (FPC). We explore here the impact of immune checkpoint inhibitors (ICIs) given for an FPC on the risk of SPC in different age groups, cancer types and treatments. PATIENTS AND METHODS: The files of the 46 829 patients diagnosed with an FPC in the Centre Léon Bérard from 2013 to 2018 were analyzed. Structured data were extracted and electronic patient records were screened using a natural language processing tool, with validation using manual screening of 2818 files of patients. Univariate and multivariate analyses of the incidence of SPC according to patient characteristics and treatment were conducted. RESULTS: Among the 46 829 patients, 1830 (3.9%) had a diagnosis of SPC with a median interval of 11.1 months (range 0-78 months); 18 128 (38.7%) received cytotoxic chemotherapy (CC) and 1163 (2.5%) received ICIs for the treatment of the FPC in this period. SPCs were observed in 7/1163 (0.6%) patients who had received ICIs for their FPC versus 437/16 997 (2.6%) patients receiving CC and no ICIs for the FPC versus 1386/28 669 (4.8%) for patients receiving neither CC nor ICIs for the FPC. This reduction was observed at all ages and for all histotypes analyzed. Treatment with ICIs and/or CC for the FPC are associated with a reduced risk of SPC in multivariate analysis. CONCLUSION: Immunotherapy with ICIs alone and in combination with CC was found to be associated with a reduced incidence of SPC for all ages and cancer types.

Validation of transcutaneous bilirubinometry during phototherapy for detection and monitoring of neonatal jaundice in a low-income setting.

Background: Severe neonatal jaundice (SNJ) and the associated long-term health sequelae are a significant problem in low-income countries (LIC) where measurement of total serum bilirubin (TSB) is often unavailable. Transcutaneous bilirubinometry (TcB) provides the opportunity for non-invasive, point-of-care monitoring. Few studies have evaluated its agreement with TSB levels during phototherapy in LIC.Aim: To determine agreement between TcB and TSB during phototherapy in a Haitian newborn population and to establish whether TcB can be safely used to guide treatment during phototherapy when TSB is unavailable.Methods: A single-centre prospective study (February to May 2017) in Cap Haïtien, northern Haiti was undertaken. Newborns <7 days of age with clinically detected jaundice were eligible for inclusion. A TcB device (JM-103) was used to screen for newborn jaundice along with a parallel TSB. A strip of black tape was placed across the sternum during phototherapy and uncovered for subsequent TcB measurements. Decisions about phototherapy treatment were based upon UK National Institute of Clinical Excellence (NICE) threshold criteria. Paired TSB and TcB measurements were compared using Bland-Altman methods.Results: The final analysis included 70 parallel TSB/TcB measurements from 35 infants within the first 5 days of life. Nineteen (54.3%) were male and 12 (34.3%) were <35 weeks. Thirty-two (91.4%) were receiving phototherapy. There was good agreement between TSB and TcB. Compared with TSB, TcB tended to over-estimate bilirubin (mean difference 11.1 µmol/L, 95% CI -10.2-32.5 µmol/L). However, at higher bilirubin levels (>250 µmol/L), TcB tended to under-estimate bilirubin compared with TSB and the difference increased.Conclusion: In an LIC setting in which serum bilirubin testing is not commonly available, TcB demonstrates good agreement with TSB and can be safely used to guide jaundice treatment during phototherapy but can lead to over-treatment at lower bilirubin levels and are more inaccurate at higher levels. For TcB levels >250 µmol, confirmation with serum bilirubin should be performed, if available, to avoid under-estimation.Abbreviations: LIC: low income countries; LMIC: low and middle income countries; TcB: transcutaneous bilirubinometry; TSB: transcutaneous serum biliubin.

Early role of vascular dysregulation on late-onset Alzheimer's disease based on multifactorial data-driven analysis.

Multifactorial mechanisms underlying late-onset Alzheimer's disease (LOAD) are poorly characterized from an integrative perspective. Here spatiotemporal alterations in brain amyloid-ß deposition, metabolism, vascular, functional activity at rest, structural properties, cognitive integrity and peripheral proteins levels are characterized in relation to LOAD progression. We analyse over 7,700 brain images and tens of plasma and cerebrospinal fluid biomarkers from the Alzheimer's Disease Neuroimaging Initiative (ADNI). Through a multifactorial data-driven analysis, we obtain dynamic LOAD-abnormality indices for all biomarkers, and a tentative temporal ordering of disease progression. Imaging results suggest that intra-brain vascular dysregulation is an early pathological event during disease development. Cognitive decline is noticeable from initial LOAD stages, suggesting early memory deficit associated with the primary disease factors. High abnormality levels are also observed for specific proteins associated with the vascular system's integrity. Although still subjected to the sensitivity of the algorithms and biomarkers employed, our results might contribute to the development of preventive therapeutic interventions.

Metabolic comorbidities and hypertension in psoriasis patients in France. Comparisons with French national databases.

INTRODUCTION: Several studies have shown a high prevalence of cardiovascular and metabolic comorbidities in psoriasis. Our study aimed to evaluate the association of psoriasis with key comorbidities such as smoking, obesity, hypertension, dyslipidaemia and diabetes comparatively with French national data. MATERIAL AND METHODS: This multicentre noninterventional observational study of adults with psoriasis was conducted in 29 dermatology centres in France. A total of 2210 patients were included. The prevalence of comorbidities in psoriatic patients was compared to data from the French national databanks "ObEpi 2012" (obesity, hypertension, dyslipidaemia and diabetes) and "Baromètre Santé 2010" (smoking). RESULTS: We reported a higher prevalence of all metabolic comorbidities and high blood pressure in psoriatic patients. Smoking: 32.5% were active smokers; the age of onset and the prevalence of familial psoriasis were significantly lower in the smoking group but the severity of psoriasis was significantly higher. The frequency of smoking was higher than in the general population, particularly among young female patients. Obesity: 24% of patients with psoriasis were obese. Multivariate analysis showed obesity to be significantly associated with other comorbidities, severity of psoriasis and psoriatic arthritis. The incidence of obesity was higher than in general population, occurring chiefly in subjects aged over 45 years. HYPERTENSION: 26% of patients with psoriasis had hypertension. The age of onset of psoriasis and the prevalence of psoriatic arthritis were significantly higher in the hypertension group, although there was less familial psoriasis. The incidence of hypertension was higher than in general population. Dyslipidaemia: 27.5% of patients with psoriasis had dyslipidaemia. The age of onset in the dyslipidaemia group was higher although there was less familial psoriasis. The incidence of dyslipidaemia was higher than in general population. Diabetes: 11.0% of patients with psoriasis had diabetes. The age of onset of psoriasis was significantly higher in the diabetes group although there was less familial psoriasis. The incidence of diabetes was higher than in general population particularly after the age of 35 years. CONCLUSION: These results confirmed that psoriasis is associated with significant metabolic comorbidities and hypertension compared to the general population in France, with certain epidemiological differences for each.

Should we fear cement leakage during kyphoplasty in percutaneous traumatic spine surgery? A single experience with 76 consecutive cases.

OBJECTIVE: Although kyphoplasty is widely used to repair osteoporotic and pathologic vertebral fractures, balloon kyphoplasty and vertebral body stenting are new treatment options in cases of traumatic spinal injury. To our knowledge, there are no literature data on the incidence of cement leakage whereas these two percutaneous techniques are commonly used to repair non-pathologic fractures. The aim of this study was to evaluate and compare the clinical characteristics and the incidence of cement leakage associated with balloon kyphoplasty and vertebral body stenting in the percutaneous treatment of traumatic spinal injury. METHODS: A series of 76 consecutive kyphoplasties (50 with vertebral body stenting and 26 balloon kyphoplasties) were retrospectively reviewed. Preoperative and postoperative computed tomography scans were analyzed in order to detect cement leakage and grade it as minor, moderate or major. RESULTS: The overall leakage rate was 50%. None of the leakages gave rise to clinical symptoms. Although balloon kyphoplasty and vertebral body stenting did not differ in terms of the leakage rate, the latter technique was associated with a lower leakage volume. The Magerl type, fracture level and use of concomitant osteosynthesis did not appear to significantly influence the leakage rate. CONCLUSION: Vertebral body stenting can reduce the amount of cement leakage due to a better cohesion of the bone fragments after kyphosis correction and maintenance.

Perfusion MRI as a neurosurgical tool for improved targeting in stereotactic tumor biopsies.

OBJECTIVE: Stereotactic biopsies are subject to sampling errors (essentially due to target selection). The presence of contrast enhancement is not a reliable marker of malignancy. The goal of the present study was to determine whether perfusion-weighted imaging can improve target selection in stereotactic biopsies. METHODS: We studied 21 consecutive stereotactic biopsies between June 2009 and March 2010. Perfusion-weighted magnetic resonance imaging (MRI) was integrated into our neuronavigator. Perfusion-weighted imaging was used as an adjunct to conventional MRI data for target determination. Conventional MRI alone was used to determine the trajectory. RESULTS: We found a linear correlation between regional cerebral blood volume (rCBV) and vessel density (number of vessels per mm(2); R = 0.64; p < 0.001). Perfusion-weighted imaging facilitated target determination in 11 cases (52.4%), all of which were histopathologically diagnosed as glial tumors. For glial tumors, which presented with contrast enhancement, perfusion-weighted imaging identified a more precisely delimited target in 9 cases, a different target in 1 case, and exactly the same target in 1 other case. In all cases, perfusion-selected sampling provided information on cellular features and tumor grading. rCBV was significantly associated with grading (p < 0.01), endothelial proliferation (p < 0.01), and vessel density (p < 0.01). For lesions with rCBV values ≤1, perfusion-weighted MRI did not help to determine the target but was useful for surgical management. CONCLUSIONS: For stereotactic biopsies, targeting based on perfusion-weighted imaging is a feasible method for reducing the sampling error and improving target selection in the histopathological diagnosis of tumors with high rCBVs.

[Brown-Sequard syndrom complicating a C6 teardrop fracture associate with an occult vertebral artery dissection: case report]. / Syndrome de Brown-Séquard compliquant une fracture teardrop de C6 associée à une dissection d'une artère vertébrale asymptomatique : à propos d'un cas.

CASE REPORT: We report the case of a 27-year-old man, presenting a C6 tear-drop fracture associated to medullar contusion with a Brown-Sequard syndrome. An asymptomatic right vertebral artery dissection in its V2 portion was also discovered by the radiologic investigations. A surgical treatment and antiplatelet therapy were performed. The patient outcome was quite satisfactory.

[Subependymomas of lateral ventricle. Analysis of our series and review of literature]. / Les subépendymomes (astrocytomes subépendymaires) du ventricule latéral. Analyse de notre série et revue de la littérature.

Subependymoma is a benign lesion, slow-growing neoplasm, representing 0.2 to 0.7 % of intracranial tumors. They are often clinically silent, incidentally discovered at autopsy. These symptoms are related to big volume. They are attached to the septum pellucidum, leading to hydrocephalus by Monro foramen obstruction. Overall mean age at diagnosis is 39 years with more males than females. At CT-scan, subependymoma shows a slightly low attenuation compared to gray matter. There is no or mild enhancement following contrast injection. On MR T1-weighted imaging, subependymoma is isointense and hyperintense on MR T2-weighted imaging. Intramural calcifications and cystic components are noted in 20 to 30 % of patients. Peritumoral oedema is absent. Immunohistochemicals studies show intense positivity for S-100 and GFAP. The treatment is surgical with an excellent prognosis.

[Rare tumors of the lateral ventricle. Review of the literature]. / Les tumeurs rares du ventricule latéral. Revue de la littérature.

Metastases of lateral ventricle (LV) are attached to choroidal plexus. Primary source is cancer of kidney. Two thirds of patients are male. Oligodendrogliomas occur in young females. Signs of increased intracranial pressure are a constant feature. These tumors are found in anterior portion of the LV with severe enhancement and clumped calcifications. Treatment is surgical. Cavernomas have a preponderance of rapid growth with a bleeding revelation. Seizures are rare. Rebleeding is frequent and justifies a surgical treatment. Schwannomas are a rare entity in which the majority of patients are very young. MRI shows calcifications, cystic components and a strong enhancement. They are limited to sporadic cases, never associated with neurofibromatosis. Arachnoid cysts are located in the atrium and/or in the occipital horn. Patients are young (mean age < 40 years). MRI demonstrates an intracystic lesion with signal intensity similar to the CSF. Best treatment is an endoscopic fenestration. Epidermoid cysts occur in third decade. These pearly tumors appear isointense or a little hyperintense on T1-weighted imaging, very characteristic. They are enhanced after gadolinium injection and appear strongly hyperintense on T2-weighted imaging. An incomplete removal with a thorough long-term follow-up is necessary. Cavernomas of LV are hyperintense on T1- and T2-weighted imaging. They have a bleeding risk of 25 to 45%. Therefore, they must be operated.

[Bilateral failure of fusion between pedicles and body of C7]. / Défaut de fusion corporéo-pédiculaire bilatéral de C7.

We expose the case of a 48-year-old woman suffering of a chronic bilateral C7 radiculalgy and bilateral C7 failure of fusion between pedicles and body. According to spine embryogenesis we bring three hypothesis to explain this failure of fusion. Then we show that bilateral C6-C7 foraminal compression can arise from local cervical spine instability due to C7 and disk development abnormalities. The treatment proposed is dissectomy bone graft and anterior osteosynthesis leading to clinical and radiological good results. The patient went back to work after three months.

[Giant thoracolumbar synovial cyst: case report]. / Synovialome géant thoracolombaire: un cas.

METHODS: A case report of a giant thoracolumbar synovial cyst is presented. RESULTS: A 74-year-old woman presented with a chronic lumbar pain associated with pain in the left leg. MR imaging showed a voluminous extradural cyst extending from T12 to L2. The cyst was surgically removed entirely. Microscopic examination revealed a synovial cyst. CONCLUSIONS: In spite of a careful review of the literature, no other description of a giant thoracolumbar synovial cyst developed on three metameric levels was found. The diagnosis was made with a MRI scan combined with microscopic examination. The pathogenesis and therapeutic strategy are discussed.

Non-traumatic pseudocyst of Glisson capsule complicating a ventriculoperitoneal shunt.

BACKGROUND: Cerebrospinal fluid pseudocysts in the peritoneal cavity following ventriculoperitoneal shunt are relatively uncommon. In these complications, perforation of solid organs is unusual. CASE DESCRIPTION: A case of subcapsular hepatic pseudocyst is described. A 48-year-old man treated by ventriculoperitoneal shunt presented with abdominal pain. Laboratory examinations revealed hepatic cytolysis. The CT-scan of the abdomen demonstrated a small ovoid non-enhanced cystic collection in the subcapsular area of hepatic segment V. Percutaneous hepatic fine-needle aspiration of the cyst guided by abdominal ultrasonography showed no abnormal findings. Peritoneal reimplantation at a different site was performed. The clinicopathological features of this entity are described and treatments are discussed. CONCLUSION: Reinsertion of the catheter at a different abdominal site is effective in non-infections cases. In contrast, a temporary external drainage with adequate antibiotic treatment followed by shunt reinsertion is necessary to treat a documented infection of CSF collections.

Dual, minimally invasive fixation in acute, double, thoracic spine fracture.

BACKGROUND: We report on a dual percutaneous fixation in 2 patients with a double thoracic spine fracture. The advantages and limitations of this new approach for treating traumatic spinal fractures are reviewed. CLINICAL PRESENTATION: A 67-year-old male was admitted following a fall from a height of 3 m. A neurological examination revealed sub-T11 motor and sensory paraparesis. There were a T6 vertical body and bi-articular fracture and a T11 vertebral burst fracture with > 75% posterior wall damage. A 40-year-old male was admitted after a suicide attempt. A neurological examination revealed sub-T11 paraplegia. There were a T7 vertebral body fracture with intact posterior wall and a T11 burst fracture with > 75% posterior wall damage. SURGICAL TECHNIQUE: The same technique was used in both cases. 2 minimally invasive percutaneous fixations of the 2 fractures were performed. In a third step, we performed a T10-T12 open laminectomy. This technique helped to limit blood loss and avoid an over-long fixation. Pedicle screw targeting was optimal. 16 months later, the neurological status was normal in patient 1 and there was neurological improvement in patient 2. No secondary segmental kyphotic deformities appeared.Percutaneous fixation enables the treatment of an acute thoracic spine fracture. With appropriate presurgical planning, this technique can be applied to all thoracic vertebrae. Spinal cord injuries justify the use of laminectomy together with percutaneous fixation, in order to limit erector muscle injury and blood loss.

[Odontoid process fracture in elderly patients over 70 years: morbidity, handicap, and role of surgical treatment in a retrospective series of 27 cases]. / Fracture de l'odontoïde chez le sujet de plus de 70 ans: morbidité, handicap et place du traitement chirurgical. A propos d'une série de 27 patients.

BACKGROUND AND PURPOSE: Odontoid process fractures of the axis are frequent in elderly patients. However, the impact in terms of handicap and morbidity in this particular population are unknown. The role of surgical treatment remains controversial. METHODS: We present a retrospective series of patients aged 70 years or older with odontoid fractures treated in our department between 1998 and 2006. Two cohorts were defined (surgery versus conservative) and compared. Morbidity, handicap, and radiographic fusion were analyzed. RESULTS: Twenty-seven patients were treated. The mean age was 80.67 years. Five patients died early during hospitalization. Fractures were type II in 66.7% of the cases and type III in 33.3%. Orthopedic treatment was chosen in 44.4% of the cases. A non-union at the fracture site was found in 33% of the cases and morbidity in 41.7% of the cases was found after a 1-year follow-up. Surgery was performed in 40.7% of the cases. There was 18% non-union and no morbidity after 1-year of follow-up. Morbidity was statistically lower in the surgery group (p=0.037), particularly in cases of type II fracture (p=0.0063); no statistically significant difference was found for non-union at the fracture site (p=0.64) except for type II fractures (p=0.028). CONCLUSIONS: Odontoid fractures in the elderly are a very frequent problem. Immediate mortality is still high but appears correlated to associated lesions. Today's treatments must preserve autonomy for these patients. For elderly patients, the treatment must be chosen in relation to the fracture analysis. In our opinion, surgical management is the treatment of choice for unstable fractures (type II). Conservative management is indicated for stable fractures.

[Pituitary apoplexy and severe bilateral visual loss: a case report]. / Apoplexie hypophysaire et baisse d'acuité visuelle bilatérale sévère : à propos d'un cas.

UNLABELLED: Pituitary apoplexy is caused by an infarction or a hemorrhage in a pituitary adenoma manifesting in acute headaches, consciousness impairment, endocrine features, and moderate to severe visual loss, with chiasmal syndrome or oculomotor palsies. We present a case report and a review of the literature. CASE-REPORT: We report the case of a 31-year-old man who neglected bitemporal visual loss (less than 1/10 OD and 2/10 OS). Emergency cerebral tomodensitometry found a pituitary apoplexy. Visual field loss was nearly complete at OD and temporal hemianopia was present at OS. These ocular complications led to a neurosurgical transsphenoidal resection of the necrotic adenoma. Follow-up was satisfactory with complete recovery of visual acuity and visual field. DISCUSSION: In the literature, headaches are present in 76% of the patients, visual loss in 62%, and ocular motor nerve palsy in 40%. Third cranial nerve palsies are predominant. CONCLUSION: The clinical picture of pituitary apoplexy is characterized by the sudden onset of oculomotor palsy or blindness with acute headaches and even consciousness impairment. A functional and vital risk is present because of acute hypopituitarism. This emergency diagnosis is confirmed by tomodensitometry or magnetic resonance imaging. The association of hormone substitution and tumor transsphenoidal resection commonly leads to a positive outcome and visual improvement.

[Follicular dural lymphoma. Case report]. / Lymphome folliculaire méningé. A propos d'un cas.

A case of a meningeal B-cell lymphoma is described. A 48-year-old man presented with an episode of grand mal seizure following a brain injury. An initial diagnosis of extradural hematoma was made based on the results of the cerebral computerized tomography scan. Magnetic resonance images demonstrated an enhanced mass with a dural tail attached to the meningeal layer of the temporal bone, suggesting a meningioma "en plaque". The mass was surgically excised. Tumoral removal was subcomplete (Simpson 2). Operative inspection also suggested a meningioma, but histological analysis and electron microscopy revealed a grade IV follicular B-cell lymphoma. Biological studies were normal. An extensive workup found an external iliac adenopathy with several osseous locations on PET. The patient underwent chemotherapy and radiotherapy. Three years after the first symptoms appeared, the patient is alive and free of symptoms. The clinicopathological features and treatments were discussed.

Tension pneumocephalus and rhinorrhea revealing spontaneous cerebrospinal fluid fistula of the anterior cranial base.

Spontaneous cerebrospinal fluid fistulas (CSFFs) of the anterior skull base are extremely rare. We report a case of spontaneous CSFF of the ethmoid cribriform plate presenting with rhinorrhea and tension pneumocephalus. We discuss the physiopathology, the radiological management, and the treatment of spontaneous CSF fistulas related to the anterior skull base. A 58-year-old woman was admitted to our institution for headaches with clear rhinorrhea persisting over several days. Antecedents were unremarkable. An episode of epistaxis three days before was reported. Clinical examination showed clear rhinorrhea, headaches, and anosmia. The CT scan showed voluminous epidural and subdural pneumocephalus with mass effect on both frontal and temporal lobes. A high-resolution CT scan with bone reconstruction showed a 2-mm bony defect of the cribriform plate. Surgery consisted of epidural frontal anterior skull base repair. Postsurgery follow-up was uneventful. At one year, the patient was asymptomatic apart from the persistence of anosmia. Spontaneous CSF fistulas are uncommon and can be associated with tension pneumocephalus. The physiopathology remains unclear. Their treatment by complete exclusion of the fistula is necessary because of the lethal risk of pneumococcus meningitis.

[Giant cystic widening of Virchow-Robin spaces, case report]. / Dilatations géantes des espaces de Virchow-Robin.

INTRODUCTION: Virchow-Robin spaces are very well-known anatomical and radiological entities. However, the observation of giant cystic widening of Virchow-Robin spaces is anecdotic. We report herein the case of a patient presenting with giant cystic widening of Virchow-Robin spaces located in both cerebral hemispheres. OBSERVATION: A 26-year-old female presented with numbness of left arm and then, of both arms. CT scan showed many hypodensities located in the two hemispheres. Neurologic examination was normal. MR imaging allowed the diagnosis of giant cystic widening Virchow-Robin spaces in T2, T2*, T1 gadolinium and Flair weighted images. Neuropsychological investigations were normal. CONCLUSION: Giant cystic widening of Virchow-Robin spaces are extremely rare entities. MR imaging helps the diagnosis. Only extreme dilatation of Virchow-Robin perivascular spaces close to ventricular system must be watched and treated in case of an obstructive hydrocephalus risk. When located in cerebral hemispheres, these dilatations are mostly asymptomatic and must not be confused with a cystic tumoral disease.