0:01

So here we have a 56 year old woman with a history of hypertension and

0:04

gastroesophageal reflux disease. She's referred.

0:08

In the outpatient Surgery Clinic as part

0:11

of a preoperative consultation for

0:14

ventral hernia repair.

0:16

She reports no symptoms beyond the modern discomfort that

0:19

she is felt due to what she feels

0:22

is an abdominal bulge physical examination is

0:25

performed and reveals a reducible hernia, because otherwise within

0:28

normal limits the vitals for this patient are

0:31

notable for a blood pressure of 143 over 92.

0:34

Top normal or slightly elevated rather. She's

0:37

referred for a preoperative CT scan as

0:40

part of a surgical planning.

0:42

So in the reading room, what do we see?

0:52

So what's the impression here? We have an anterior abdominal

0:55

wall. Hernia particularly large which we would have seen before.

0:59

Containing transverse colon with extensive herniation against

1:02

partly see it here, but no signs of

1:05

strangulation.

1:06

However, very carefully imaged here.

1:09

We have the right adrenal gland

1:12

which is thought to be displaced Superior immediately.

1:17

and Inseparable from

1:20

this Mass which is hypodens not

1:23

enhancing in nature measuring about 12

1:26

by 9.5 by 10.6 centimeters. So this

1:29

low density hypodens non-enhancing mass

1:33

occupying the Retro peritoneal space.

1:37

It doesn't seem to have any signs of liver or kidney invasion.

1:41

There are some fine septations if we had to clean a

1:44

little bit more.

1:46

Into this lesion it suggestive of mesenteric

1:49

fat within the mass.

1:52

The patient scheduled for CT guided biopsy of her right

1:55

adrenal mass. And here we see the needle

1:58

Progressively being Advanced and the CT guidance CT

2:01

fluoroscopy. In this case into the masking question the

2:04

IR performs an uncomplicated biopsy technically

2:07

successful. The tissue sample is

2:10

stored in formula and sent to the Pathology Department for analysis.

2:14

The path report comes back thin fragment

2:17

of adipose tissue with admix Desmond stain

2:20

cells concerning for an angiomyolipoma, which

2:23

as we know is a tumor of and you must

2:26

thinkable myomuscular and lipoma fatty

2:29

elements.

2:31

This for all intense purposes is benign tumor. So although

2:34

there was a limited amount of tissue. The thought

2:37

is that additional sampling was actually

2:40

required for definitive classification.

2:43

So the patients referred for general surgery consultation.

2:46

The surgeon is actually concerned for sarcominous Mass.

2:49

The patient is scheduled for Ratchet pensional tumor resection

2:52

on block adrenalectomy with concomitant

2:55

repair of eventual. Hernia.

2:57

Her surgical course is particularly uncomplicated thankfully

3:00

and she is discharged from the hospital the day after

3:03

her operation.

3:05

So what is a surgical pathology report read what we

3:08

see here is the Retro bedroom Mass contains ample

3:11

fatty tissue with intermix Desmond

3:14

staining cells again consistent with

3:17

Andrew. Myelypuma a benign tumor.

3:20

So the adjacent adrenal tissue also unremarkable no

3:23

evidence of malignant features.

3:26

In retrospect friends was open

3:29

surgery necessary to diagnose his patients regular Mass.

3:32

Yes. This was a suspicious mass

3:35

that needed direct sampling or no

3:38

radiographic features of this

3:41

Mass suggested that's benign C.

3:43

If you said no radiographic features

3:46

of this Mass suggested, it's been dignity. Then you

3:49

would have been spot on per the American College

3:52

of radiology criteria the diagnosis of

3:55

angiomyelopoma may be made radiator graphically.

3:58

This is a mass with gross fat

4:01

and it's particularly important for us

4:04

to be aware of that in the setting.

4:07

So per the ACR criteria, which features of

4:10

this Mass suggested Angie my life homo.

4:13

Is it the size greater than 5 centimeters?

4:16

Is it the shape?

4:18

Is it the presence of microscopic fat?

4:21

Or is it the attenuation pattern?

4:24

Well, if you heard me letting the cat of the

4:27

bag, the presence of ractoscopic fat should have told

4:30

this perspectively that this in the

4:33

setting of a non calcified solid renal

4:36

Mass indicates a benign angiomyelopoma

4:39

with virtual certainty.