Epithelial Cdc42 Deletion Induced Enamel Organ Defects and Cystogenesis

Cdc42, a Rho family small GTPase, regulates cytoskeleton organization, vesicle trafficking, and other cellular processes in development and homeostasis. However, Cdc42's roles in prenatal tooth development remain elusive. Here, we investigated Cdc42 functions in mouse enamel organ. Cdc42 showed highly dynamic temporospatial patterns in the developing enamel organ, with robust expression in the outer enamel epithelium, stellate reticulum (SR), and stratum intermedium layers. Strikingly, epithelium-specific Cdc42 deletion resulted in cystic lesions in the enamel organ. Cystic lesions were first noted at embryonic day 15.5 and progressively enlarged during gestation. At birth, cystic lesions occupied the bulk of the entire enamel organ, with intracystic erythrocyte accumulation. Ameloblast differentiation was retarded upon epithelial Cdc42 deletion. Apoptosis occurred in the Cdc42 mutant enamel organ prior to and synchronously with cystogenesis. Transmission electron microscopy examination showed disrupted actin assemblies, aberrant desmosomes, and significantly fewer cell junctions in the SR cells of Cdc42 mutants than littermate controls. Autophagosomes were present in the SR cells of Cdc42 mutants relative to the virtual absence of autophagosome in the SR cells of littermate controls. Epithelium-specific Cdc42 deletion attenuated Wnt/β-catenin and Shh signaling in dental epithelium and induced aberrant Sox2 expression in the secondary enamel knot. These findings suggest that excessive cell death and disrupted cell-cell connections may be among multiple factors responsible for the observed cystic lesions in Cdc42 mutant enamel organs. Taken together, Cdc42 exerts multidimensional and pivotal roles in enamel organ development and is particularly required for cell survival and tooth morphogenesis.

Adenocarcinoma arising in a rectal duplication cyst with distant metastasis A case report and a review of the recent literature

INTRODUCTION

Rectal duplication cysts are rare cystic lesions, arising from the hindgut and classified as congenital/developmental tumors of the presacral space. Their clinical presentation is nonspecific, the diagnosis remains difficult and their management is aided by a multidisciplinary evaluation.

CASE REPORT

We report the case of a 55-year-old woman with a cystic mass located in the retrorectal space and identified incidentally on a CT scan. Following imaging studies, surgical resection by a posterior approach (Kraske procedure) was carried out and an adenocarcinoma arising in a duplication cyst of the rectum was present an uncommon case of a rectal duplication cyst with malignant transformation and distant metastasis, describe the clinical, radiologic and pathologic findings and discuss tidentified by microscopy.

CONCLUSION

We phe embryological basis of rectal duplication cysts and the surgical anatomy of the presacral space. Key Words: Rectal adenocarcinoma, rectal duplication cyst, Retrorectal space.

Prenatal features of isolated subependymal pseudocysts associated with adverse pregnancy outcome

OBJECTIVES

To identify at prenatal ultrasound (US) the features of apparently isolated subependymal pseudocysts (SEPC) that may indicate underlying pathology and should lead to further investigations.

METHODS

This was a retrospective study of cases with SEPC detected on prenatal US and/or magnetic resonance imaging (MRI). Those with apparently isolated SEPC at US were classified into two groups as follows: Group 1 (n = 29): normal prenatal US and MRI (except for SEPC) and normal outcome; Group 2 (n = 12): normal prenatal cerebral US (except for SEPC) and abnormal prenatal cerebral MRI with or without abnormal outcome. A third group (n = 9) included cases with abnormal prenatal US and MRI. The latter cases with obvious cerebral abnormalities at US were excluded from the statistical analysis as they do not represent a diagnostic dilemma for clinicians. Groups 1 and 2 were analyzed, comparing them with respect to their SEPC characteristics (size, number, location in relation to the caudothalamic notch and the ventricular horns and morphology) and extracerebral abnormalities.

RESULTS

The mean ± SD SEPC great axis was longer in Group 2 (11.67 ± 5.82 mm) than it was in Group 1 (8.00 ± 5.64 mm) (P = 0.021), suggesting an optimal cut-off for size of SEPC of ≥ 9 mm (sensitivity = 75%, specificity = 62%) to maximize sensitivity for predicting pathological outcome. SEPC adjacent to the temporal horns and SEPC located posterior to the caudothalamic notch were observed more frequently in Group 2, indicating their association with poor outcome (P = 0.003 and P = 0.003, respectively). Atypical morphology and extracerebral abnormalities were observed more frequently in Group 2 (P = 0.013 and P = 0.044, respectively). There was no statistically significant difference between groups for either number or location of cysts along the inferior wall or adjacent to the lateral wall of the frontal horns (P = 0.591 and P = 0.156, respectively).

CONCLUSION

When apparently isolated SEPC are observed at prenatal US, further investigations should be performed under the following circumstances: (1) SEPC great axis ≥ 9 mm; (2) SEPC adjacent to the occipital and temporal horns; (3) SEPC located posterior to the caudothalamic notch; (4) SEPC with atypical morphology.

Expression of Nek1 during kidney development and cyst formation in multiple nephron segments in the Nek1-deficient kat2J mouse model of polycystic kidney disease

BACKGROUND

Neks, mammalian orthologs of the fungal protein kinase never-in-mitosis A, have been implicated in the pathogenesis of polycystic kidney disease. Among them, Nek1 is the primary protein inactivated in kat2J mouse models of PKD.

RESULT

We report the expression pattern of Nek1 and characterize the renal cysts that develop in kat2J mice. Nek1 is detectable in all murine tissues but its expression in wild type and kat2J heterozygous kidneys decrease as the kidneys mature, especially in tubular epithelial cells. In the embryonic kidney, Nek1 expression is most prominent in cells that will become podocytes and proximal tubules. Kidney development in kat2J homozygous mice is aberrant early, before the appearance of gross cysts: developing cortical zones are thin, populated by immature glomeruli, and characterized by excessive apoptosis of several cell types. Cysts in kat2J homozygous mice form postnatally in Bowman's space as well as different tubular subtypes. Late in life, kat2J heterozygous mice form renal cysts and the cells lining these cysts lack staining for Nek1. The primary cilia of cells lining cysts in kat2J homozygous mice are morphologically diverse: in some cells they are unusually long and in others there are multiple cilia of varying lengths.

CONCLUSION

Our studies indicate that Nek1 deficiency leads to disordered kidney maturation, and cysts throughout the nephron.

Imaging and differential diagnosis of suprarenal masses in the fetus

Prenatal sonography and magnetic resonance imaging of suprarenal fetal masses is presented, along with clinical information and follow-up. Imaging pearls and differential considerations for each diagnosis will be discussed. Fetal suprarenal mass diagnoses include neuroblastoma, extralobar pulmonary sequestration, congenital adrenal hyperplasia, partial multicystic dysplastic kidney, renal duplication, urinoma, gastric duplication cyst, and splenic cyst. Recognizing the range of malignant and benign suprarenal fetal masses that can present on prenatal imaging can help guide patient counseling and management.

Outcome of first-trimester fetal abdominal cysts: cohort study and review of the literature

OBJECTIVES

The aims of this study were to ascertain the outcome of fetuses with an abdominal cyst detected at 11-14 weeks' gestation in our unit and to undertake a review of cases reported in the literature.

METHODS

This was a retrospective study that included all fetuses found to have an abdominal cyst on ultrasound examination at 11-14 weeks, identified over a 14-year period. Pregnancy management and outcome were ascertained from maternal and neonatal records. We also performed a review of the literature using a systematic search strategy, to identify the outcome of similar cases and propose a management algorithm.

RESULTS

Fourteen cases were identified during the study period, of which four had associated abnormalities. Of the 10 isolated cases, the cyst had resolved at follow-up scan in eight (80.0%), one fetus died in utero at 15 weeks' gestation and the other case underwent surgery for a choledochal cyst 9 weeks after birth. An additional 19 cases were reported in the literature. In eight fetuses there were associated structural abnormalities, of which four had a diagnosis of anorectal malformation after birth. In two of these four, the cyst resolved in the second trimester. Of those cases with an isolated cyst (n = 11), the cyst resolved in seven (63.6%). The remainder were variably diagnosed as hepatic cyst, ileal duplication or choledochal cyst.

CONCLUSION

Fetal abdominal cysts at 11-14 weeks' gestation are rare. They constitute an isolated finding in the majority of cases and are usually associated with a good perinatal outcome. In view of the reported association with anorectal and other gastrointestinal malformations, perinatal assessment is recommended, even if the cyst resolves during pregnancy.

Prenatal magnetic resonance imaging (MRI) findings of a foregut duplication cyst of the tongue: value of real-time MRI evaluation of the fetal swallowing mechanism

Foregut duplication cysts of the oral cavity or lingual choristomas have a potential risk of airway obstruction. Two cases are reported that were initially detected by screening sonography. Further imaging with both static and real-time cine magnetic resonance imaging confirmed the lingual origin, relationship of the mass to fluid-filled spaces within the oral cavity, motion of the mass with the tongue during fetal swallowing, and airway patency. The additional information provided by magnetic resonance imaging aided in planning delivery and obviated the need for an ex utero intrapartum treatment procedure because airway patency was confirmed in both cases.

[Congenital cyst and fistula of the face and neck]

The authors propose an update on cervicofacial congenital cysts and fistulas' symptomatology. Embryological data, epidemiology and clinical manifestations are described. A reminder of the therapeutic principles is proposed as well as the evolution of these congenital pathologies, which may or may not involve the branchial system. branchial.

Significance of early prenatal diagnosis of fetal hepatic cyst

PURPOSE

: To summarize our experience of early prenatal diagnosis of fetal hepatic cysts.

METHOD

: We reviewed all cases of fetal hepatic cyst detected in our institution between 13 and 17 weeks' gestation over the last 20 years. All scans were initially performed transvaginally to improve image quality. Most of the scans were performed as a routine fetal anatomy scan in a low-risk population.

RESULTS

: Seven fetal hepatic cysts were detected out of 54,500 fetal anatomy scans performed between 13 and 17 weeks' gestation. Five peripheral cysts measuring 3-5 mm disappeared during the follow-up period, between 18 and 24 weeks' gestation. Two hilar cysts appeared on sonography as choledochal cysts; one disappeared at 22 weeks' gestation, and the other diminished in size during the postnatal follow-up.

CONCLUSION

: Based on our experience, when hepatic cysts are diagnosed during an early fetal anatomy scan, disappearance of these cysts can be expected, especially when the cysts are initially small and peripheral. (c) 2008 Wiley Periodicals, Inc. J Clin Ultrasound, 2009.

Fine-tuning the diagnosis of fetal scalp cysts: the value of high-frequency sonography

OBJECTIVE

The purpose of this series is to emphasize the importance of an exhaustive and appropriately conducted sonographic examination in the correct diagnosis of fetal cystic scalp lesions and the place of magnetic resonance imaging (MRI) in the diagnostic sequence.

METHODS

Transabdominal and transvaginal 2- and 3-dimensional sonography with color and power Doppler imaging as well as 3-dimensional rendering techniques such as inversion and Doppler angiography were used. In 1 case, an MRI study was performed.

RESULTS

In 1 case, the MRI missed and the different sonographic techniques correctly made the diagnosis of a meningocele. In the second case, sonography was sufficient to establish the diagnosis of an epidermal cyst.

CONCLUSIONS

These 2 cases show the value of going the distance with the newly available high-frequency sonography. Ultimately, the correct diagnoses were made with the tools offered by sonography without the need for any other imaging modality.

Foetal brain imaging: ultrasound or MRI. A comparison between magnetic resonance imaging and a dedicated multidisciplinary neurosonographic opinion

OBJECTIVES

(i) To compare original foetal brain ultrasound findings with a multidisciplinary expert opinion; (ii) to compare the multidisciplinary expert ultrasound opinion with foetal magnetic resonance imaging (MRI) findings and (iii) to determine in which circumstances foetal MRI gives additional information, and in how many cases management is changed by having information from MRI.

STUDY DESIGN

Ultrasound scans of 51 consecutive foetuses where foetal brain MR had been performed were retrospectively reviewed by a panel consisting of maternal-foetal-medicine (MFM) consultants, a geneticist, neonatologists and MFM subspecialty trainees. The original ultrasound opinion was compared with the multidisciplinary opinion, which was then compared with MRI findings. In the cases where MRI gave additional information, an assessment was made as to whether this changed management.

RESULTS

The multidisciplinary ultrasound opinion differed from the original opinion in 9 of 51 (17%) cases. In 19 patients (37%), the MRI gave additional information to the original ultrasound, in 7 (13%) cases, management, and in 7 (13%) cases, counselling was altered by additional information gained from MRI. The multidisciplinary ultrasound and MRI diagnoses were similar in 36 cases (71%).

CONCLUSION

Multidisciplinary review of an apparently abnormal foetal brain ultrasound can provide additional diagnostic information. When compared with this level of ultrasound expertise, MRI gave additional information in 29% of cases, but only resulted in change in management in about 13%.

Choroid plexus cyst, intracardiac echogenic focus, hyperechogenic bowel and hydronephrosis in screening for trisomy 21 at 11 + 0 to 13 + 6 weeks

OBJECTIVES

To investigate the potential value of choroid plexus cyst, intracardiac echogenic focus, hydronephrosis and hyperechogenic bowel as markers of trisomy 21 at 11 + 0 to 13 + 6 weeks.

METHODS

We examined three-dimensional volumes from 228 fetuses with trisomy 21 and 797 chromosomally normal fetuses at 11 + 0 to 13 + 6 weeks of gestation. We looked for choroid plexus cysts with a minimum diameter of 1.5 mm, intracardiac echogenic focus, hydronephrosis with a minimum anteroposterior diameter of the pelvis of 1.5 mm and hyperechogenic bowel.

RESULTS

The prevalence of intracardiac echogenic focus, hydronephrosis and hyperechogenic bowel was significantly higher in trisomy 21 than in normal fetuses (9.6% vs. 1.5%, 17.1% vs. 5.3% and 11.4% vs. 2.4%, respectively). There was no significant difference between the two groups in the prevalence of choroid plexus cysts (7.5% vs. 5.0%). There were no significant differences in crown-rump length or nuchal translucency thickness in either chromosomally normal or trisomy 21 fetuses between those with and those without any one of the markers.

CONCLUSIONS

At 11 + 0 to 13 + 6 weeks the prevalence of intracardiac echogenic focus, hydronephrosis and hyperechogenic bowel is higher in trisomy 21 than in chromosomally normal fetuses. As there is no significant association between the presence of these markers and nuchal translucency thickness, they could be included in the assessment of risk to improve accuracy of screening.

[Prenatal diagnosis and treatment of fetal choroid plexus cysts]

OBJECTIVE

To discuss the clinical management and significance of the prenatal diagnosis of Fetal Choroid Plexus Cysts (CPC).

METHODS

From May 2004 to March 2007, 55 cases of fetal CPC diagnosed by B-ultrasound during second trimester were prospectively studied. Each case was studied regarding fetal chromosome karyotype, disappearance weeks of the cyst, the clinical outcome and follow-up results respectively.

RESULT

The cases were diagnosed during 16 - 25 gestational weeks. The diameters of the cysts varied from 0.2 cm to 2.4 cm. There were 25 cases of bilateral cysts and 30 cases of unilateral or 50 cases of isolated CPC and 5 cases of complicated CPC. The cysts of all cases who continued pregnancy disappeared before 28 weeks. Fetal chromosome karyotypes were obtained in 50 cases. Among them, two cases were 18-trisomy, and one case was 21-trisomy. Five cases were terminated pregnancy because of abnormal chromosome karyotype or malformation during second trimester. One neonate was diagnosed as ventricular septal defect among 50 cases of follow up. Among these six cases, three were from advanced-age pregnant women, five cases were with abnormal fetal structure and five cases were with the diameter of bilateral or unilateral cysts more than 1.0 cm.

CONCLUSION

(1) Fetal CPC can be diagnosed during second trimester, and the majority disappear before 28 gestational weeks. (2) High risk factors for fetal abnormal chromosome karyotype may be: advanced-age pregnant women, abnormal structure of fetus, and the diameter of bilateral or unilateral cyst more than 1.0 cm. It is suggested that fetal CPC with the high risks should receive fetal chromosome karyotype test during pregnancy.

Prenatal diagnosis and outcome of congenital splenic cyst: report of two cases

Congenital splenic cyst (CSC) is a rare condition, and only a few cases with prenatal diagnosis and no associated malformation have been reported. Spontaneous regression is possible in case of mild CSC (under 40 mm), but enlargement or secondary complications may lead to surgical treatment. We report, herein, two cases of isolated mild CSC with complete spontaneous postnatal regression.

Bilateral hemorrhagic adrenal cysts in an incomplete form of Beckwith-Wiedemann syndrome: MRI and prenatal US findings

Benign hemorrhagic adrenal cysts are a cause of subdiaphragmatic mass in the fetus and neonate with Beckwith-Wiedemann syndrome. Characteristic imaging features on ultrasonography, color Doppler, and magnetic resonance imaging help differentiate adrenal hemorrhage from neonatal neuroblastoma and help avoid unnecessary surgery in these patients. Bilateral adrenal hemorrhage is self-limiting, and spontaneous resolution is the usual outcome. This report presents this rare condition with prenatal ultrasonographic and magnetic resonance imaging findings and reviews the differential diagnosis of neonatal adrenal masses.

Magnetic resonance imaging findings of a foregut duplication cyst of the floor of the mouth in a fetus

The MRI findings are described in a case of foregut duplication cyst arising from the floor of the mouth in a fetus.

Recurrent omphalitis in adults

Recurrent omphalitis is seen more frequently in children, but clinicians world-wide are occasionally challenged by cases of recurrent omphalitis in adults. Apart from folliculitis and infections associated with pilonidal cysts and piercing of the umbilical area, the clinician should consider the possibility of infected remnants of the allantois or the omphalomesenteric (vitelline) duct in adult patients with recurrent omphalitis. Imaging tests such as ultrasound and computed tomography scan frequently help to identify the exact cause of recurrent omphalitis. The combined surgical and medical management usually leads to cure of the problem.

Laparoscopic excision of a gastric duplication cyst detected on antenatal ultrasound scan

The authors report a gastric duplication cyst detected antenatally and its subsequent laparoscopic removal at 2 months of age. Before birth, a cystic mass was detected behind the stomach on fetal ultrasound scan (US). After birth, an US, barium meal, nuclide scan, and cervical and thoracic vertebral x-rays suggested that the most probably diagnosis was a gastric duplication cyst. At 2 months of age, laparoscopic removal of the cyst was performed with closure of the muscle defect in the stomach wall. The patient was discharged 4 days later, feeding normally. Histology findings confirmed the diagnosis of a gastric duplication cyst. After the antenatal detection of a cyst behind the stomach, the laparoscopic removal of this gastric duplication in a 2 month old was accomplished without complications. This appears to be the first reported case using this type of procedure in an infant.

Prenatal diagnosis of enteric duplication cyst of the tongue

Cysts located on the tongue are rare and usually diagnosed in childhood. Here we report on the prenatal diagnosis of an unusual cystic malformation of the tongue with heterotopic intestinal tissue explored by prenatal ultrasound, magnetic resonance imaging and on its surgical treatment and histological examination. The prenatal differential diagnoses as well as perinatal management of cystic lesions of the tongue are reviewed.

Foregut duplication cyst arising in the floor of mouth

Enteric duplications are uncommon. A rare foregut duplication cyst arising in the floor of mouth is reported. Diagnosis of cystic lesion within the oral cavity was made in utero. Enteric duplications have not yet been attributed to a single embryogenesis but are likely to represent an error in migration of normal cells that rest in an abnormal position. Immediately following delivery of the neonate via an ex-utero intrapartum treatment (EXIT) procedure, the cyst was marsupialised but required definitive surgical excision at 5 weeks of age.

Ciliated hepatic foregut cyst: report of first case in China and review of literature

OBJECTIVE

To report the first case of ciliated hepatic foregut cyst in China, and review of literature to introduce the characteristics of this disease for doctors to recognize this disease.

METHOD

Report the clinical procedure of diagnosis and treatment for the first case of ciliated hepatic foregut cyst in China, and to review the embryologic genesis, incidence, clinical manifestation, radiologic features and therapeutic principle of this disease.

RESULTS

We performed the resection for ciliated hepatic foregut cyst under laparoscopy; the patient recovered well after the procedure.

CONCLUSION

Ciliated hepatic foregut cyst is quite rare clinically, belongs to non-parasitic, solitary and unilocular cystic lesion, is always less than 4 cm in diameter, mostly seen in the left lobe, and has the tendency of malignant change. It should be removed as soon as diagnosed.

Fetal brain imaging: a comparison between magnetic resonance imaging and dedicated neurosonography

OBJECTIVES

To evaluate whether fetal brain magnetic resonance imaging (MRI) adds useful clinical information to that obtained by dedicated fetal neurosonography using a combined transabdominal and transvaginal approach in fetuses with suspected brain anomalies.

METHODS

In the 2-year period between January 2000 and January 2002, 42 fetuses underwent neurosonographic and MRI examinations of the brain. The referral indications were: asymmetric ventriculomegaly (13), ventriculomegaly (7), periventricular cysts (2), suspected midline findings (7), agenesis of the corpus callosum (3), infratentorial pathology (3), cytomegalovirus (CMV) infection (2) and miscellaneous indications (5).

RESULTS

Neurosonography and MRI produced similar diagnoses in 29 fetuses: normal examination (10), isolated asymmetric ventriculomegaly (11), isolated ventriculomegaly (3), periventricular cysts (2), agenesis of the corpus callosum (1), pericallosal lipoma (1) and cerebellar hemorrhage (1). The neurosonographic diagnoses were more accurate in seven patients: hemimegalencephaly, pericallosal lipoma, signs of CMV infection, brain anomalies associated with agenesis of the corpus callosum and three fetuses with a normal ultrasound scan in which MRI suggested a parenchymal abnormality. MRI provided a more accurate diagnosis in three patients: a third ventricular dilatation was ruled out, normal ventricles in a fetus with an ultrasonographic finding of asymmetric ventricles, and diagnosis of progression of asymmetric ventriculomegaly. In three patients the identified pathologies were differently interpreted, each examination provided another aspect of the anomaly or a definitive diagnosis was not possible.

CONCLUSIONS

Our study demonstrated that dedicated neurosonography is equal to MRI in the diagnosis of fetal brain anomalies. In most of the cases MRI confirmed the ultrasonographic diagnosis; in a minority of cases each modality provided additional/different information. The major role of MRI was in reassurance of the parents regarding the presence or absence of brain anomalies.

Bronchopulmonary foregut malformations: embryology, radiology and quandary

Bronchopulmonary foregut malformations (BPFM) are a heterogeneous group of pulmonary developmental anomalies that present at varying ages and with overlapping symptoms, signs and radiology. This article discusses the embryology of these lesions with reference to possible common origins and the link between aetiology and radiological appearance. The radiology of each lesion, both antenatally and postnatally, is described and illustrated. A number of quandaries exist in the prediction of prognosis and subsequent treatment of BPFM. We discuss the radiological features that may help to elucidate an individual prognosis and aid in the planning of treatment. The treatment options available for BPFM are briefly discussed. Finally, the link between BPFM, in particular cystic adenomatoid malformations and malignancy, is discussed. We aim to provide a comprehensive overview of the embryology, radiology, prognosis and treatment highlighting contentious issues of BPFM.

[Clinical and embryological approaches to nasal dermoid sinus cysts]

Nasal dermoid sinus cyst (NDSC) is an uncommon congenital lesion presenting as a large panel of midline craniofacial anomalies. Thirty children with nasal midline masses and/or sinus ostia were surgically treated in the pediatric ENT and cervicofacial surgery department of Trousseau's children's hospital (Paris-France) between 1995 and 2002. All our patients underwent radiological evaluation including CT scan (including axial and coronal planes) and/or MRI (in all three planes) in search of intracranial extension. Thirteen of our patients presented with a midline cyst only, ten had nasal pit only, and seven had combined anomalies. Preoperative radiology and surgery showed an intracranial extension in 3 patients, which exhibited contact of the cyst with the dura. Recurrence being expected if any dermal tissues were left in place, "one-time-excision management" was the rule. CT and MR imaging features were reviewed. The external rhinoplasty procedure resulted in a wide surgical approach, low recurrence and good esthetic results. The embryological and anatomical origins of NDSCs are reviewed. Development of NDSC during embryological development implicates two necessary and sufficient conditions: competence of the ectodermal and mesectodermal cells to form dermoid tissue with epithelial-mesenchymal interactions, and a topographical site of ectodermal inclusion, which fits well with the various clinical presentations of NDSCs. We propose to distinguish NDSCs of anterior topography, located at the anterior skull base level from the basal NDSCs, located at the middle skull base level. We reviewed the various localizations of NDSCs, revisiting a forgotten embryological theory, which unify the various clinical localizations of anterior NDSCs.

Adrenal Cytomegaly: Two Cases Detected by Prenatal Diagnosis

We report our experience with two cases of adrenal cytomegaly, both of which were detected as cystic adrenal masses during prenatal ultrasonographic examinations. In Case 1, a left suprarenal cystic mass was detected in the fetus at 25 weeks of gestation. The mass, measuring 7 cm in diameter, did not show any change in size and was resected 26 days after birth. In Case 2, a right suprarenal lesion was found at 30 weeks of gestation. The cystic lesion, measuring 2 cm x 1.5 cm, did not change in size and was resected 3 months after birth. Adrenal cytomegaly is still not well known. It is characterized by the presence of large polyhedral cells with eosinophilic granular cytoplasm and enlarged nuclei in the adrenal cortex. This condition is thought to be a degenerative process but not a malignancy. Adrenal cytomegaly rarely forms cysts. It seemed to be impossible to diagnose preoperatively in our cases. Because of the difficulty of differentiating between cystic adrenal cytomegaly and other cystic diseases such as neuroblastoma, operative intervention is required in cases where the cysts do not decrease in size. Further study of a larger number of cases is needed to establish an optimal treatment protocol for these tumours.

Single ectopic ureter inserting into a duplicated imperforate hemivagina: a rare cause of a fetal abdominal mass

We present a unique case of obstructed vaginal duplication with ectopic ureteral drainage of an ectopic dysplastic kidney presenting as an antenatal diagnosis of a pelvic mass.

Prenatal diagnosis of a prolapsed ureterocele with magnetic resonance imaging

Ectopic ureterocele with ureteral duplication is the most common type of ureterocele found in children. Early accurate diagnosis is desirable to decrease the risk of urosepsis and renal damage. Prenatal imaging with ultrasonography detects the vast majority of ureteroceles; however, in some cases, the diagnosis may remain in doubt. We report on the use of magnetic resonance imaging to clarify the prenatal diagnosis of a prolapsed ureterocele.

Foetal cystic abdominal masses

Foetal abdominal cysts are frequently found on routine antenatal ultrasound. Various sonographic features might help in their differential diagnosis. However, a definitive diagnosis is often not made until postnatal life, and detection of an intra-abdominal cyst antenatally rarely alters obstetric management. A review of possible causes of a foetal abdominal cyst is presented.

Experimental study of the embryogenesis of gastrointestinal duplication and enteric cyst

The theory of gastrointestinal duplication and enteric cyst embryogenesis was verified by examining the developmental process of this experimentally induced anomaly. In Cynopus pyrrhogaster (amphibian) embryos (stage 18), the dorsal midline structures (including the neural plate and notochord) were split regionally to induce partial separation of the notochord and gut anlage endoderm herniation between the split elements of the notochord. Following this procedure, the embryonic development was traced morphologically and histologically. Control embryos were cultured without the procedure. Following the incubation and breeding period, gastrointestinal duplication and enteric cysts were observed with vertebral anomaly, spina bifida, split cord malformation and subcutaneous manifestations in the mature animals. The combination of anomalies that was observed in these experimental animals is consistent with that found in "split notochord syndrome." No abnormal morphology or histology was observed in the control group. The embryogenetic theory of gastrointestinal duplication and enteric cysts was thus verified by simulating the partial separation of the notochord, which induced split notochord syndrome in laboratory animals. The results indicate that gastrointestinal duplication and enteric cysts may arise through a process of herniation of the gut anlage endoderm between split elements of the notochord.

Pathogenesis of dysplastic kidney associated with urinary tract obstruction in utero

Renal dysplasia is the major cause of chronic renal failure in children, and is commonly associated with urinary tract obstruction. There are two phenotypes of renal dysplasia associated with urinary tract abnormality, multicystic dysplastic kidney (MCDK) and obstructive dysplasia (ORD). Previous observations by Potter and co-workers suggested that cystic dilatation of the ureteric bud ampula was the cause of renal dysplasia. In this context, our recent investigation of human fetal dysplastic kidneys provided an alternative explanation for the evolution of renal dysplasia. We suggested that in utero urinary tract obstruction may cause urine retention in functioning nephrons and lead to glomerular cysts in the nephrogenic zone. The mechanism was common to MCDK and ORD, albeit at different sites of obstruction. Expansion of glomerular cysts with tubular dilatation (cysts) disturbs the subsequent nephron induction and may contribute to the abnormal development of fetal kidneys.

Fetal therapy for giant hepatic cysts

Cystic mesenchymal hamartoma is an extremely rare, benign tumor. Rapid growth to a giant size can pose a threat not only in early childhood but also during fetal life. The experience with 2 antenatally diagnosed giant hepatic cysts with widely disparate approaches to management, treatment, and outcome is presented. A giant hepatic cyst was diagnosed on routine screening ultrasound scan. Because of its extremely massive size, the cyst was treated in utero with repeated aspirations, primarily for obstetric considerations. The infant did well, and the lesion was excised laparoscopically during the neonatal period. A second fetus with a giant hepatic cyst was not treated in utero, and the pregnancy continued to term. Nonimmune hydrops fetalis developed, and the fetus was delivered prematurely at 34 weeks. At birth, the infant was noted to have diffuse neurologic injury and no urine output despite normal-appearing kidneys. The lesion was excised during the neonatal period by open laparotomy. Observations at the time of surgery and pathologic studies of the placenta showed aneurysmal dilatation of the placental veins suggesting in utero compression of the fetal intraabdominal umbilical vein. The infant died shortly after birth. The experience with these 2 cases suggests the possibility that giant mesenchymal hamartoma diagnosed in utero may cause umbilical venous obstruction leading to ischemia during fetal life. Decompression of giant hepatic cysts may reverse this phenomenon and allow normal fetal development.

Hydatid of morgagni with torsion diagnosed during cesarean delivery. A case report

BACKGROUND

Hydatids of Morgagni are benign, pedunculated, cystic structures arising from müllerian vestiges below the fallopian tube near the fimbria. They usually are of no clinical significance unless the pedicle becomes twisted and infarction occurs.

CASE

A 39-year-old primigravida at 41 weeks and 5 days' gestation underwent primary cesarean delivery for macrosomia and failure to descend during labor. A 4 x 3-cm hydatid of Morgagni with torsion of the pedicle was found on the left fallopian tube. Ligation of the pedicle and excision of the infarcted cyst were performed. Histology of the specimen demonstrated cuboidal epithelium with extensive hemorrhage and necrosis, consistent with an infarcted hydatid of Morgagni. All pain and symptoms experienced by the patient during the previous day were associated with the onset of labor. No specific left lower quadrant pain was reported.

CONCLUSION

Hydatids of Morgagni are common findings at pelvic surgery and usually of no clinical significance. Torsion of a hydatid of Morgagni is rarely reported and most likely is a rare occurrence. In this patient, torsion of the hydatid of Morgagni was possibly pregnancy related, and symptoms associated with torsion were probably masked by labor pain.

Thymopharyngeal duct cyst: an unusual variant of cervical thymic anomalies

BACKGROUND

The thymus develops from the third pharyngeal pouch and descends from the neck into the anterior-superior mediastinum. Thus, it is possible to have thymic remnants in the neck, which most often present as a cervical mass during childhood. One type of cystic thymic remnant is the thymopharyngeal duct cyst, a remnant of one of the paired tracts of embryological thymic descent. Thymopharyngeal duct cysts are rare lesions that can have a similar presentation to more commonly encountered childhood neck masses.

OBJECTIVES

To review the embryological development of cervical thymic remnants and to report our experience with the thymopharyngeal duct cyst.

DESIGN

Case series.

SETTING

Tertiary care center.

PATIENTS

Two children who presented with asymptomatic neck masses that were caused by cystic remnants of the thymopharyngeal duct.

RESULTS

Both patients underwent preoperative computed tomography, which revealed a multiloculated mass coursing adjacent to the carotid sheath. Surgical treatment was the definitive therapy for both patients, although neither patient had a definitive preoperative diagnosis. In both cases, the mass was approached through an incision anterior to the sternocleidomastoid muscle, and dissection proceeded along the length of the carotid sheath. A fibrous cord extending into the mediastinum was found in both patients. There were no postoperative complications. Histopathologic evaluation revealed the presence of mature thymic elements within the wall of a multiloculated cyst.

CONCLUSIONS

Thymopharyngeal duct cysts must be considered in the differential diagnosis of pediatric neck masses. Computed tomography is helpful to delineate the relationship to the carotid sheath. Complete surgical excision is the appropriate therapy in a majority of cases, with minimal morbidity when careful attention is paid to vital structures.

Imaging of cystic lesions

Cystic neck masses are varied in their histology and embryogenesis. Because neural, vascular, and lipomatous lesions may all appear cystic, a multimodality imaging approach can help identify these potential mimics. Developmental neck cysts include thyroglossal duct, thymic, and branchial cleft cysts, and teratomatous lesions or lymphangiomas. Although laryngoceles are acquired lesions, congenital anomalies (e.g., abnormally long saccules) may play a role in their formation. Lesion location is at least as important a determinant as morphology in formulating the differential diagnosis of a cystic neck mass. Midline cystic lesions are most commonly thyroglossal duct cysts, although dermoid tumors are also frequently midline. Squamous cell carcinoma metastatic to anterior triangle lymph nodes (Fig. 17), and cystic, necrotic schwanommas, can mimic the typical appearance of an infected second branchial cleft cyst. Posterior triangle lymphadenopathy and lipomatous lesions may resemble cystic hygromas. Cystic-appearing masses in the carotid space include neurogenic tumors, vascular thromboses, and carotid chain lymphadenopathy. Neural-based lesions typically occur posterolateral to the carotid artery. Necrotic lymphadenopathy may be suggested by lesion multiplicity, or by the presence of ancillary features, such as systemic symptoms, or the existence of a primary tumor. It must be emphasized that the primary role of the radiologist in head and neck imaging is to help stage disease and guide surgery. Despite clinical and radiographic analysis, the diagnosis of many lesions ultimately depends on image-guided or excisional biopsy.

Coexistent neurenteric cyst and enterogenous cyst. Further support for a common embryologic error

The authors describe common embryological pathways responsible for coexistent neurenteric and enterogenous cysts in a patient with spinal dysraphism.

Ciliated hepatic foregut cyst: a study of six cases and review of the literature

Ciliated hepatic foregut cyst (CHFC) is a rare, benign, solitary cyst consisting of ciliated pseudostratified columnar epithelium, subepithelial connective tissue, a smooth muscle layer, and an outer fibrous capsule. We studied six previously unreported cases of CHFC and 50 cases from the literature. The literature search revealed that Friedreich first described the lesion in 1857 and hypothesized its congenital origin. The cyst generally is found incidentally on radiologic imaging or during surgical exploration, although one case presented with portal vein compression. It occurs more frequently in men and is found most commonly in the medial segment of the left hepatic lobe, unlike most other solitary cysts that show a female predominance and greater occurrence in the right hepatic lobe. Two of the 56 cases were multilocular. There has been an increase in the number of reports of CHFC during the past 15 years. This may reflect the increased availability and use of various radiologic imaging modalities. A large number of cases have been reported in the Japanese population, but the significance of this is unclear. CHFC should be considered in the differential diagnosis of other solitary liver cysts, including simple cysts, hepatobiliary cystadenomas, and parasitic cysts.

The second-trimester fetus with isolated choroid plexus cysts: a meta-analysis of risk of trisomies 18 and 21

OBJECTIVE

To assess the risk of trisomy 18 and trisomy 21 associated with isolated choroid plexus cysts diagnosed by ultrasound in the second trimester.

METHODS OF STUDY SELECTION

We reviewed the unabridged PREMEDLINE and MEDLINE databases for articles written in the English language regarding second-trimester fetal isolated choroid plexus cysts and trisomies 18 and 21, published in the period 1987-1997. Selection criteria included only second-trimester, prospective studies in which the rate of fetal isolated choroid plexus cysts could be calculated, the number of fetuses with trisomy 18 and 21 was reported clearly, and pregnant women of all ages were included, rather than only those at high risk for aneuploidy due to advanced maternal age. TABULATION AND RESULTS: Thirteen prospective studies, comprising 246,545 second-trimester scans, were selected. Among 1346 fetuses with isolated choroid plexus cysts, seven had trisomy 18, and five had trisomy 21. For each study, a 2 x 2 table was constructed and the likelihood ratio of a positive test was computed. The likelihood ratios for trisomies 18 and 21 were found to be homogeneous (P = .08 for trisomy 18, and P = .16 for trisomy 21). The summary likelihood ratio and 95% confidence interval (CI) for each chromosomal abnormality were calculated using the Mantel-Haenszel fixed effects model of meta-analysis. The summary likelihood ratio for trisomy 18 was 13.8 (CI 7.72, 25.14, P < .001) and for trisomy 21 was 1.87 (CI 0.78, 4.46, P = .16).

CONCLUSION

The likelihood of trisomy 18 was 13.8 times greater than the a priori risk in fetuses with isolated choroid plexus cysts diagnosed in the second trimester. However, the likelihood of trisomy 21 was not significantly greater than the a priori risk with isolated choroid plexus cysts. The data supported offering pregnant women karyotyping to rule out trisomy 18 when maternal age at delivery is 36 years or older, or when the risk for trisomy 18 detected by serum multiple-marker screen is more than one in 3000.

Prevalence and significance of isolated fetal choroid plexus cysts detected in early pregnancy by transvaginal sonography in women of advanced maternal age

This study examines the prevalence of isolated fetal choroid plexus cysts (CPCs) detected in early pregnancy by transvaginal sonography in an increased genetic risk population and their association with abnormal fetal karyotype. A prospective study was performed on 1692 pregnant women (>37 years) who underwent transvaginal scan at 11-16 weeks' gestation before genetic amniocentesis. The prevalence of isolated CPCs in our population was 1.48 per cent. An abnormal fetal karyotype was found in one case (4 per cent). It was concluded that if fetal CPCs are apparently isolated, genetic amniocentesis is not mandatory and additional risk factors such as advanced maternal age should be the main indication for fetal karyotyping.

Congenital cystic masses of the neck: radiologic-pathologic correlation

Cervical congenital cystic masses constitute an uncommon group of lesions usually diagnosed in infancy and childhood. The most common congenital neck mass is the thyroglossal duct cyst. The diagnosis is easily established from the presence of a cystic lesion in the anterior midline portion of the neck. The vast majority of branchial cleft cysts arise from the second branchial cleft. They can occur anywhere from the oropharyngeal tonsillar fossa to the supraclavicular region of the neck. Cystic hygroma is the most common form of lymphangioma. In the neck, cystic hygromas are most commonly found in the posterior cervical space. They typically extend into adjacent structures without respecting the fascial planes. Dermoid and epidermoid cysts result from sequestration of ectodermal tissue. The floor of the mouth is the most common location in the neck. Cervical thymic cysts are very uncommon lesions and are found anywhere from the angle of the mandible down to the sternum. Laryngoceles are classified into internal, external, and mixed types and have a frequent association with laryngeal carcinoma.

[Naso-alveolar cysts. A report of 10 new cases and a review of the literature]

Nasoalveolar cysts, also known as Klestadt's or nasolabial cysts, are uncommon midfacial lesions. Ten cases treated at the 12 de Octubre University Hospital are reported, describing the most relevant clinical and pathological findings are reported. The main theories of the origin of these developmental, non-odontogenic cysts are discussed. A review of the literature is included.

Factor V Leiden and genetic defects of thrombophilia in childhood porencephaly

AIMS

To determine to what extent the Arg506 to Gln point mutation in the factor V gene and further genetic factors of thrombophilia affect the risk of porencephaly in neonates and infants.

METHODS

The Arg506 to Gln mutation, factor V, protein C, protein S, antithrombin, antiphospholipid antibodies and lipoprotein (a) (Lp(a)) were retrospectively measured in neonates and children with porencephaly (n = 24).

RESULTS

Genetic risk factors for thrombophilia were diagnosed in 16 of these 24 patients: heterozygous factor V Leiden (n = 3); protein C deficiency type I (n = 6); increased Lp (a) (n = 3); and protein S type I deficiency (n = 1). Three of the 16 infants had two genetic risk factors of thrombophilia: factor V Leiden mutation combined with increased familial Lp (a) was found in two, and factor V Leiden mutation with protein S deficiency type I in one.

CONCLUSIONS

The findings indicate that deficiencies in the protein C anticoagulant pathway have an important role in the aetiology of congenital porencephaly.

[Vaginal atresia as a rare cause of a cyst in the fetal lower abdomen. Pre- and postnatal diagnosis/therapy]

This is a report on the course of a cystic mass in the lower abdomen of a female fetus, which could bei seen by prenatal ultrasound. We are describing differential diagnosis, pre- and postnatal therapy and the origin, as well as the risks of vaginal atresia.

Isolated fetal choroid plexus cysts: not an indication for genetic diagnosis?

Offering invasive prenatal cytogenetic testing in cases of isolated choroid plexus cysts is controversial. To give a contribution to this discussion we recorded prospectively the course of 41 fetuses with cysts of the choroid plexus diagnosed in 4,326 pregnancies sonographically scanned in our center between January 1994 and August 1995. The fetuses were all in the 13th to 24th week of gestation, with an average of 19.3 weeks. Only 1 of these fetuses (with large bilateral choroid plexus cysts) had further sonographically visible malformations (renal and cardiac anomalies, malposition of the hands). 34 fetuses had bilateral and 7 one-sided plexus cysts. 38 of the 41 patients decided on invasive diagnosis; karyotyping was successful in all these cases. The complete follow-up until 5 days after birth is known in 38 fetuses, including 3 without genetic diagnosis. A chromosomal aberration was detectable only in 1 fetus (trisomy 18, this fetus had the additional malformations described above), the other fetuses all displaying neither chromosomal nor morphological abnormalities. All fetuses, excluding 1 (the pregnancy was terminated due to trisomy 18) were re-examined before the 25th week of gestation, plexus cysts only still being visible in 3 fetuses. By the 30th week of gestation in these 3 fetuses the cysts had also disappeared. Furthermore, 20 pregnancies with confirmed trisomy 18 diagnosed between 1990 and 1996 were analyzed retrospectively. In 19 cases heart defects had been detected by prenatal ultrasound, cervical hygroma being less common (6 cases) and other malformations still rarer. Choroid plexus cysts had, however, been seen only in the 1 case described above. There was no case of isolated choroid plexus cysts in this group. From our data and current literature we conclude that isolated choroid plexus cysts are not an absolute indication for fetal karyotyping. In our opinion a detailed ultrasound assessment to seek for further malformations in a specialized center would be necessary if fetal choroid plexus cysts have been diagnosed, and only if additional fetal malformations are indeed detectable a fetal karyotype should be recommended.