Laparoscopic adrenalectomy for a giant adrenal teratoma: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Teratomas typically are benign gonadal neoplasms, arising from more than one embryonic germ layer. Extragonadal teratomas are rare and primary adrenal teratomas more so, with few documented cases. We present one such case, diagnosed via CT, resected via laparoscopic adrenalectomy, and confirmed on histology. To the best of our knowledge, this is the first case documented in the Caribbean. CASE PRESENTATION: A 38-year-old obese female with restrictive lung disease presented with right back/flank pain due to a non-functional 10.5 cm right adrenal mass on CT, likely a giant myelolipoma. Further radiologic review suggested this was instead a mature adrenal teratoma. She underwent a laparoscopic adrenalectomy and histology confirmed a mature adrenal teratoma. CLINICAL DISCUSSION: Most adrenal tumours are incidentalomas and are usually benign adenomas. Primary adrenal teratomas account for 1 % of teratomas and 0.13 % of adrenal tumours. They may be mature or immature; the latter carries a greater risk of malignancy. Benign adrenal teratomas are typically non-functional and commonly mistaken for myelolipomas on imaging. Adrenalectomy is required due to the risk of malignant transformation. The laparoscopic approach depends on size, localized tissue invasion and technical considerations, but offers advantages for the patient if possible. CONCLUSIONS: Though uncommon, preoperative radiologic diagnosis of an adrenal teratoma is possible and should be completely resected after a functional workup. A laparoscopic adrenalectomy is preferred once this can be done safely, even when very large, with surgical and oncologic outcomes equivalent to an open approach combined with the known advantages of laparoscopic surgery.

Surgical relevance of anatomic variations of the right hepatic vein.

BACKGROUND: Variations in the anatomy of hepatic veins are of interest to transplant surgeons, interventional radiologists, and other medical practitioners who treat liver diseases. The drainage patterns of the right hepatic veins (RHVs) are particularly relevant to transplantation services. AIM: The aim was to identify variations of the patterns of venous drainage from the right side of the liver. To the best of our knowledge, there have been no reports on RHV variations in in a Caribbean population. METHODS: Two radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral center. Venous outflow patterns were observed and RHV variants were described as: (1) Tributaries of the RHV; (2) Variations at the hepatocaval junction (HCJ); and (3) Accessory RHVs. RESULTS: A total of 118 scans met the inclusion criteria. Only 39% of the scans found conventional anatomy of the main hepatic veins. Accessory RHVs were present 49.2% and included a well-defined inferior RHV draining segment VI (45%) and a middle RHV (4%). At the HCJ, 83 of the 118 (70.3%) had a superior RHV that received no tributaries within 1 cm of the junction (Nakamura and Tsuzuki type I). In 35 individuals (29.7%) there was a short superior RHV with at least one variant tributary. According to the Nakamura and Tsuzuki classification, there were 24 type II variants (20.3%), six type III variants (5.1%) and, five type IV variants (4.2%). CONCLUSION: There was significant variation in RHV patterns in this population, each with important relevance to liver surgery. Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.

Complex abdominopelvic endometriosis: the radiologist's perspective.

Endometriosis is a multifocal gynecological disorder affecting approximately 6%-10% of women during their reproductive years (Giudice and Kao in: Lancet 364:1789-1799, 2004). Presenting symptomatology often relates to the anatomical structures involved. Given the complexity of both the management and pain control of patients with complex endometriosis, the British Society of Gynaecological Endoscopy has issued guidelines on the establishment of a multidisciplinary team approach to these cases (http://www.bsge.org.uk/ec-requirements-BSGE-accredited-endometriosis-centre.php). The ovaries are the most common site affected, but the gastrointestinal, genitourinary tract, chest and other soft tissues are not infrequently involved. Less well-recognized features of the disease include the deep infiltrative form of endometriosis, malignant transformation and decidualization of endometriomas under progesterone. In this pictorial essay, we will discuss the clinical presentation and review the imaging features of these complex and under appreciated forms of endometriotic disease.