Angiomyolipoma with epithelial cysts (AMLEC): a distinct cystic variant of angiomyolipoma

Renal angiomyolipoma (AML) is typically a solid lesion, composed of varying amounts of adipose, vascular, and muscular tissue, lacking an epithelial component. Although it is known that entrapped renal tubules may be observed in AML, presentation as a cystic mass has not been previously reported. We report the clinicopathologic and immunohistochemical features of four cystic renal AML. The lesions were found in 2 male and 2 female patients, ranging in age from 37 to 76 years, none with a history of hormonal therapy. One of the four patients had known tuberous sclerosis, and this patient and 1 other presented with bilateral cystic renal lesions. Grossly, the lesions measured between 1.3 and 4.5 cm in greatest dimension. Histologically, the lesions were each composed of three components: 1) epithelial cysts lined by cuboidal to hobnail cells; 2) a compact subepithelial "cambium-like" layer of cellular, müllerian-like AML stroma with prominent admixed chronic inflammation; and 3) muscle-predominant AML with associated dysmorphic blood vessels exterior to the cellular subepithelial stroma. Immunohistochemically, the stromal components of all four lesions labeled with HMB-45 and Melan-A, most intensely in the cellular subepithelial stroma, whereas smooth muscle actin and desmin demonstrated the opposite pattern, with greatest intensity in the muscle-predominant AML areas. Immunoreactivity for estrogen and progesterone receptors (ER, PR) and CD10 was present in all cases, with strongest and most diffuse staining in the subepithelial AML cells. The cyst lining cells were positive for pancytokeratin and soy bean agglutinin (the latter characteristic of distal nephron epithelium) but did not label for ER, PR, or melanocytic markers. Although these distinctive lesions may be confused with mixed epithelial-stromal tumor, their lack of female predominance or association with hormone therapy, their distinctive dysplastic blood vessels and disorganized exterior muscular layer, along with their immunohistochemical profile, support their classification as AML with epithelial cysts. Whereas the cysts appear to arise primarily from entrapped collecting ducts, the peculiar subepithelial condensation of AML stromal cells, with morphologic and immunohistochemical features suggesting differentiation toward endometrial stroma, may represent epithelial-induced müllerian differentiation not previously reported in AML.     

Diffusion‐weighted magnetic resonance imaging in the differentiation of angiomyolipoma with minimal fat from clear cell renal cell carcinoma

The aim of the present study was to evaluate diffusion‐weighted (DW) magnetic resonance imaging (MRI) in differentiating between minimal fat angiomyolipoma (MFAML) and clear cell renal cell carcinoma (CCRCC). Forty‐one solid renal tumors without visible macroscopic fat on unenhanced computed tomography images were evaluated by MRI, including DW‐MRI, and were diagnosed pathologically as CCRCC (n = 36) or MFAML (n = 5). To evaluate the heterogeneity of diffusion in each tumor, the signals of the tumors on DW‐MRI were analyzed subjectively and the apparent diffusion coefficient (ADC) values and histograms assessed objectively. Thirty‐three of 36 CCRCC (92%) exhibited a heterogeneous signal on DW‐MRI and several peaks in the ADC value histogram, whereas four of five MFAML exhibited a homogeneous signal on DW‐MRI and a single prominent peak in the histogram. The standard deviations of the ADC values were significantly smaller for MFAML than for CCRCC (P = 0.0015). In conclusion, DW‐MRI can be considered a useful and noninvasive addition to the preoperative differentiation of CCRCC and MFAML.     

Intensity ratio curve analysis of small renal masses on T2‐weighted magnetic resonance imaging: Differentiation of fat‐poor angiomyolipoma from renal cell carcinoma

Objectives

To assess the diagnostic ability of a pixel intensity‐based analysis in evaluating the magnetic resonance imaging characteristics of small renal masses, especially in differentiating fat‐poor angiomyolipoma from renal cell carcinoma.

Methods

T2‐weighted images from 121 solid small renal masses (<4 cm) without visible fat (14 fat‐poor angiomyolipomas, 92 clear cell renal cell carcinomas, six chromophobe renal cell carcinomas and nine papillary renal cell carcinomas) were retrospectively evaluated. An intensity ratio curve was plotted using intensity ratios, which were ratios of signal intensities of tumor pixels (each pixel along a linear region of interest drawn across the renal tumor on T2‐weighted image) to the signal intensity of a normal renal cortex. The diagnostic ability of the intensity ratio curve analysis was evaluated.

Results

The tumors were classified into three types: intensity ratio fat‐poor angiomyolipoma (n = 19) with no pseudocapsule, iso‐low intensity and no heterogeneity; intensity ratio clear cell renal cell carcinoma (n = 76) with a pseudocapsule, iso‐high intensity and heterogeneity; and other type of intensity ratio (n = 26), including tumors that did not fall into the above two categories. The sensitivity/specificity/accuracy of the intensity ratio curve analysis in diagnosing fat‐poor angiomyolipoma was 93%/94%/94%, respectively. When the intensity ratio curve analysis was applied only to the tumor with undetermined radiological diagnosis, the sensitivity for diagnosing fat‐poor angiomyolipoma compared with subjective reading alone significantly improved (93% vs 50%; P = 0.014).

Conclusions

Our novel semiquantitative model for combined assessment of key features of fat‐poor angiomyolipoma, including low intensity, homogeneity and absence of a pseudocapsule on T2‐weighted image, might make diagnosis of fat‐poor angiomyolipoma more accurate.

     

A case report with review of literature of a rare variant of midfoot dislocations (mid-Chopart dislocation): Combined naviculo-cuneiform and calcaneo-cuboid dislocation

Closed midfoot and Chopart dislocations are uncommon injuries. Moreover, a combination of these dislocations is extremely rare. A 30-year-old male presented to our emergency department with mid-Chopart dislocation (combined naviculo-cuneiform and calcaneo-cuboid dislocation). Adequate open reduction with dual approach (dorsomedial and dorsolateral) and fixation with K-wires were achieved. Although the patient had satisfactory functional outcome postoperatively, he developed midfoot arthritis 12 months later. This type of dislocation is not yet classified, with only few cases reported in the literature.Level of clinical evidence4.     

Optimising the Diagnosis of Prostate Cancer in the Era of Multiparametric Magnetic Resonance Imaging: A Cost-effectiveness Analysis Based on the Prostate MR Imaging Study (PROMIS)

Background

The current recommendation of using transrectal ultrasound-guided biopsy (TRUSB) to diagnose prostate cancer misses clinically significant (CS) cancers. More sensitive biopsies (eg, template prostate mapping biopsy [TPMB]) are too resource intensive for routine use, and there is little evidence on multiparametric magnetic resonance imaging (MPMRI).

Effect of Mobilisation with Movement (MWM) on clinical outcomes in lateral ankle sprains: A systematic review and meta-analysis

PurposeTo investigate the evidence for the effectiveness of MWM’s in isolation for ankle sprains.Materials and methodsMedline, Embase, CINHAL and SPORTDiscuss were searched. Any RCT or cross-over trial assessing adolescents to adults with grade I/II lateral ankle sprains, and treated with any MWM technique was included. Any conservative intervention was chosen as the comparator, and any clinical outcome was eligible as the outcome. Methodological quality was determined using the Cochrane Handbook risk of bias assessment tool.ResultsEighty-two full-texts were included after screening 1707 of title and abstracts. Six full-texts were included and data were extracted based on the outcomes of range of movement, balance or pain from patients with sub-acute to chronic sprains.Pooled data from four studies with 201 participants with chronic recurrent sprains were grouped for analysis of the effects of weight-bearing MWM on dorsiflexion range and has shown significant immediate improvements after treatment (MD = 0.91, CI = 0.06–1.76, p = 0.04). There was insufficient data to permit analysis for evaluation of immediate or short-term benefits of MWM on other assessed outcomes.ConclusionWeight-bearing MWM appears to be beneficial for improving weight-bearing dorsiflexion immediately after application for chronic recurrent ankle sprains compared to no treatment or sham. Long-term benefits have not been adequately investigated.     

A rare case of multiple leiomyomas on rudimentary uterus in a woman with Mayer Rokitansky Kuster Hauser (MRKH) syndrome: A challenging diagnosis and laparoscopic approach

Mayer Rokitansky Kuster Hauser (MRKH) syndrome is a congenital disorder involving reproductive, genitourinary, bone, and cardiac malformation. The incidence is 1 in 4000–5000 females livebirths. The phenotype is female 46 XX karyotype, normal secondary sexual characteristics, and normal functional ovaries. The occurrence of leiomyoma in uterine remnant in MRKH syndrome is a very rare case, even though several cases have been reported. The diagnosis and management approach, in this case, is quite challenging. Here, we report a 38 years old female who represents multiple leiomyomas on the rudimentary uterus, then we did laparoscopic removal of the fibroids and adjacent rudimentary uterus.