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Cysts Cysts Presentation Transcript

  • Intracranial Bone Jaw Ovarian Neck Srotal Mesiastinal Cysts Retro-rectal Pulmonary Dr/ Hytham Nafady Retroperitoneal Hepatic Renal Biliary
  • Intracranial cysts
  • Intracranial cysts Non neoplastic cysts Normal variants Developmental cysts Postinfectious Neoplastic cysts Posttraumatic
  • Normal variant cysts Normal variants Cavum septum pellucidum Cavum vergae Cavum villum interpositum Mega cisterna magna Dilated PVR spaces
  • Developmental cysts Intra-axial Extra-axial cyst Intra-ventricular Posterior fossa • Neuro-glial cysts • Arachnoid cyst. • Epidermoid cyst. • Dermoid. • Choroid plexus cyst. • Ependymal cyst • Colloid cyst •Dandy Walker spectrum Pineal region • Pineal cyst Sellar region • Rathke’s cleft cyst Premedullary • Neuroenteric cyst.
  • Post-infectious Neurocysticercosis Hydatid cyst
  • Post-traumatic Porencephalic cysts Leptomeningeal cysts
  • Neoplastic cysts Extra-axial cyst • Glioblastoma multiforme. • Ganglioglioma. • Pleomorphic xanthoastrocytoma. • DNET. • Cystic metastasis. • Cystic meningoma. • Cystic schwannoma. Posterior fossa •Pilocytic astrocytoma. Hemangioblastoma. Pineal region • Cystic pineocytoma. Sellar region • Craniopharyngioma. • Cystic pituitary macroadenoma. Intra-axial
  • Cystic schwannoma • Extra-axial (CP angle) Cystic meningioma • Extra-axial (convexity, paraflacine or CP angle) Cystic macroadenoma • Sellar & supra-sellar Craniopharyngioma • Sellar & supra-sellar Pineocytoma • Pineal gland Hemangioblastoma • Intra-axial, Posterior fossa Pilocytic astrocytoma • Intra-axial, Posterior fossa Glioblastoma multiforme • Intra-axial, Supra-tentorial Cystic oligodendroglioma • Intra-axial, Supra-tentorial (frontal lobe) Pleomorphic xanthoastrocytoma • Intra-axial, Supra-tentorial (cortical) Ganglioglioma Cystic metastases • Intra-axial, Temporal lobe • Intra-axial, Cortical / white matter interface
  • Cavum septum pellucidum • Lack of fusion of the 2 leaflets of the septum pellucidum. Cavum vergae • Lack of fusion of the 2 leaflets of the septum pellucidum Cavum vellum interpositum Dilated VR spaces • Cystic dilatation of the vellum interpositum cistern. • Atrophy, or CSF trapping. Mega cisterna magna Dandy Walker spectrum Arachnoid cyst Epidermoid cyst Choroid plexus cyst Ependymal cyst Colloid cyst • Congenital splitting of the arachnoid layer, with entrapment of CSF. •Congenital inclusion of ectodermal epithelial elements. • Entrapment of CSF within an in-folding of neuroepithelium. • Sequestration of developing neuroectoderm during embryogenesis. • Cyst of endodermal origion (similar to Rathke’s cleft cyst) Neuroglial cyst Pineal cyst Rathke’s cleft cyst •Cyst of endodermal origin (due to peristent Rathke’s cleft). Neuroenteric cyst • Cyst of endodermal origin (due to persistent neuroenteric canal). Hydatid cyst Cysticercosis Porencephalic cyst Leptomeningeal cyst • Cystic encephalomalacia communicating with CSF. • Calvarial fracture, with dural tear.
  • Intracranial cysts of endodermal origin Colloid cyst Rathke’s cleft cyst Neuroenteric cyst
  • Intracranial cysts of endodermal origin Colloid cyst Rathke’s cleft cyst Neuroenteric cyst
  • Cavum septum pellucidum Cavum vergae Cavum vellum interpositum Dilated VR spaces Mega cisterna magna Dandy Walker spectrum Arachnoid cyst Epidermoid cyst Choroid plexus cyst Ependymal cyst Colloid cyst Neuroglial cyst Pineal cyst • Between the frontal horns anterior to the foramen of Monro • Between the lateral ventricles posterior to the foramen of Monro • Superior to the roof of the 3rd ventricle & inferior to the fornix. • Centrum semi-ovale, basal ganglia & midbrain, • Midline (posterior fossa) •Posterior fossa • Middle cranial fossa •CP angle • Choroid plexus • Periventricular or intraventricular. • Thrid ventricle • Intra-axial • Pineal gland Rathke’s cleft cyst •Sellar & suprasellar Neuroenteric cyst • Premedullary cistern. Hydatid cyst • Intra-axial, usually hemispheric (middle cerebral territory). Cysticercosis • CSF cisterns > parenchyma > ventricular system. Porencephalic cyst Leptomeningeal cyst • Intra-axial • Intra-axial, below clavrial fracture.
  • Cavum septum pellucidum • No Cavum vergae • No Cavum vellum interpositum • No Dilated VR spaces • No Mega cisterna magna • No Dandy Walker spectrum Arachnoid cyst Epidermoid cyst Choroid plexus cyst Ependymal cyst Colloid cyst •Hydrocephalus. • Subdural hemorrhage •CP angle • May be associated with trisomy 18. • Obstructive hydrocephalus (large cysts in vulnerable locations). • hydrocephalus Neuroglial cyst • No Pineal cyst • No Rathke’s cleft cyst Hydatid cyst Cysticercosis Porencephalic cyst Leptomeningeal cyst •Compression of the optic chiasm if large • Compression.
  • Cavum septum pellucidum • CSF like Cavum vergae • CSF like Cavum vellum interpositum • CSF like Dilated VR spaces • CSF like Mega cisterna magna Dandy Walker spectrum Arachnoid cyst Epidermoid cyst • CSF like (septations) •CSF like (+ vermian hypoplasia & elevated torcular herophilli) • CSF like signal on all pulse sequences • CSF like( lobulated margin, bright on FLAIR, restricted diffusion) Choroid plexus cyst • CSF like, with marginal calcification & restricted diffusion. Ependymal cyst • CSF like, with well defined wall & no surrounding gliosis. Colloid cyst Neuroglial cyst Pineal cyst • Hyperdense on CT, may be bright on T1 & low signal on T2 • CSF like • CSF like with thick enhancing margin Rathke’s cleft cyst •, Variable signal, may be bright on T1, with intracystic non enhancing nodule. Neuroenteric cyst • Variable signal, may be bright on T1. Hydatid cyst • CSF like, no enhancement, rarely calcification. Cysticercosis • According to stage (vesicular, colloidal, granular or involution). Porencephalic cyst Leptomeningeal cyst • CSF like (communicating with the subarachnoid space or ventricular system) • CSF like protruding through the scalloped calvarial defect.
  • Dandy Walker spectrum Dandy Walker malformation Dandy Walker variant Persistent Balke’s pouch Mega cisterna magna
  • DWM DWV Anterior membranous area anomaly Persistent Blake’s pouch Mega cisterna magna Posteriror membranous area anomaly Retro-cerebellar cyst Vermis Hypoplastic Rotated upwards hypoplastic No or mild hypoplasia No or mild hypoplasia 4th ventricle Markedly dilated Dilated Dilated Normal Posterior fossa Expanded Normal size Normal size Normal size hydrocephalus 80 % of cases No Present No
  • Vellum interpositum cistern • Vellum interpositum is the double layered tela choroidea. Location: • Superior to the roof of the third ventricle. • Inferior to the body of fornix. • The anterior end of the vellum interpositum is closed posterior to the interventricular foramen. • The posterior end of the vellum interpositum is open & continuous with the quadrigeminal cistern. Contents: • Internal cerebral veins .
  • Cavum vili interpositi
  • Vellum interpositum cistern
  • Embryologic Basis for the Development and Anatomy of the Cavum Veli Interpositi
  • Choroid plexus cyst
  • Ependymal cyst
  • Colloid cyst
  • Pineal cyst
  • Arachnoid cyst
  • Hydatid cyst
  • Neurocysticercosis
  • Leptomeningeal cyst (growing skull fracture)
  • Leptomeningeal cyst (growing skull fracture)
  • Leptomeningeal cyst (growing skull fracture) Pathology: • It is not cyst (misnomer). • Calvarial fracture, with dural tear. Radiology: • Lytic calvarial lesion, with scallped edges, in which encephalomalacia invaginates.
  • Porencephalic cyst Pathology: • Cystic encephalomalacia that communicates with the subarachnoid space or ventricular system. Types: • Developmental (simple porencephaly). • Congenital encephaloclastic porencephaly (acquired porencephaly). • Radiology: • CSF like signal on all pulse sequence. • Usually no mass effect. • Occasionally, associated with mass effect, if large. • Communication with SAC or ventricular system. • Lined by gliotic white matter.
  • Porencephalic cyst Internal External Communicates with the ventricular system Communicates with the subarachnoid space
  • Porencephalic cyst
  • DD of porencephalic cyst Arachnoid cyst lined by grey matter Neuroglial cyst no communication with the SAC or ventricular system
  • Cystic meningioma
  • Cystic schwannoma
  • Pilocytic astrocytoma
  • Glioblastoma multiforme
  • Ganglioglioma
  • Ganglioglioma
  • Pleomorphic xanthoastrocytoma
  • DNET
  • Suprasellar cysts Arachnoid cyst CSF Epidermoid cyst CSF Diffusion restriction Dermoid cyst Fat signal Rathke’s cleft cyst Variable signal Non enhancing intracystic nodule (pathogonomonic) Craniopharyngioma Multilocular Calcification Cystic macroadenoma Enhancing solid component
  • Jaw cysts
  • Jaw cysts Non neoplastic Epithelial Developmental Odontogenic Dentigerous cyst Odontogenic keratocyst Non odontogenic Cyst of the incisive papilla Neoplastic Non epithelial inflammatory Stafne cyst Radicular (periapical) Simple bone cyst Residual cyst Aneurysmal bone cyst Ameloblastoma
  • Residual radicular cyst
  • Globulo-maxillary cyst
  • Stafne cyst remodelling of the mandibular cortex around salivary tissue
  • Dentigerous cyst
  • Simple bone cyst
  • Fibrous dysplasia
  • Dentigerous cyst
  • Incisive canal cyst
  • Incisive canal cyst • Heart shaped (superimposed anterior nasal spine).
  • Ameloblastoma
  • Ameloblastoma
  • Cystic neck masses
  • Neck spaces Supra-hyoid neck Infra-hyoid neck Pharyngeal mucosal space Visceral space Retropharyngeal space Retropharyngeal space Perivertebral space Perivertebral space Carotid space Carotid space Paraphrayngeal space Posterior cervical space Masticator space Parotid space
  • Suprahyoid neck
  • Supra-hyoid neck spaces 1. 2. 3. 4. 5. 6. 7. Parapharyngeal space. Masticator space. Carotid space. Parotid space. Pharyngeal mucosal space. Perivertebral space. Retropharyngeal space.
  • Pharyngeal mucosal space cyst • Torn Waldt cyst. • Retention cyst.
  • Torn Waldt cyst Pathology: • Developmental cyst. Location: • Midline nasopharyngeal cyst. Radiology: • Midline nasopharyngeal unilocular cyst with thin wall & no enhancement.
  • Torn Waldt cyst
  • Mucus retention cyst Pathology: • Obstruction of the duct of mucus gland. Location: • Vallecula (vallecular cyst). • Aryepiglottic folds. • Piriform sinuses. • Tonsils (tonsillar cyst). Radiology: • Off midline unilocular cyst with thin wall & no enhancement.
  • Vallecular retension cyst
  • Vallecular retension cyst
  • Retro-pharyngeal cyst • Foregut cyst.
  • Retro-pharyngeal foregut cyst
  • Perivertebral space cysts
  • Para-pharyngeal space • 2nd branchial cleft cyst. • Cystic lymphangioma.
  • 2nd branchial cyst
  • Cystic lymphangioma
  • Carotid space • Branchial cleft cyst.
  • Parotid cyst
  • Parotid cysts Non neoplastic Developmental Inflammatory 1st branchial cleft cyst Sarcoidosis Dermoid cyst Sjogern’ syndrome Neoplastic Obstructive Sialocele Benign Wartin’s tumor Lymphoepithelal cyst (HIV) Neoplastic Necrotic neoplasm or LN
  • Benign lympho-epithelial cysts Pathology: • HIV +ve patients. • Obstruction of intra-glandular ducts due to lymphoid hypertrophy. C.P: • Painless parotid swelling. • Bilateral in 20% of cases. Radiology:
  • Benigh lymphoepithelial cyst
  • Masticator space • Mandibular cysts
  • Mandibular cysts Non neoplastic Epithelial Developlmental (Odontogenic) Neoplastic Non epithelial inflammatory Stafne cyst Dentigerous cyst Radicular (periapical) Simple bone cyst Odontogenic keratocyst Residual cyst Aneurysmal bone cyst Ameloblastoma
  • Infra-hyoid neck
  • Deep spaces of infra-hyoid neck
  • Infra-hydoid deep space Cyst Visceral space Thyroglossal cyst. 4th branchial cleft cyst. Laryngocele. Retropharyngeal space Retension cyst Posterior cervical space 3rd branchial celft cyst.
  • Nasopharyngeal cysts • Thorn Waldt cyst. • Retension cyst
  • Cyst Age Thyroglossal duct cyst <10 y Branchial cleft cyst Middle 1st age Sex Location Equal Hyoid level or below (80%), within 2 cm of midline F > M Parotid, external auditory canal Submandibular space, lateral to carotid vessels 2nd 10–40 y Equal 3rd 10–30 y … 4th Cystic hygroma Any age … <2 y Equal Left posterior cervical space Sinus tract arising from left pyriform sinus Posterior cervical triangle, oral cavity Dermoid cyst 10–30 y Epidermoid cyst Infancy Equal Floor of mouth Equal Floor of mouth Thymic cyst M > F Low anterolateral neck (L > R) 2–13 y Ranula Floor of the mouth Laryngocele Visceral space.
  • Thyroglossal cyst • The most common congenital neck cyst. • C.P: • Midline cyst mass moves with tongue protrusion • Complications: • Infection • Malignancy (very rare).
  • Thyroglossal cyst 1. 2. 3. 4. Infra-hyoid. Juxta-hyoid. Supra-hyoid. Intra-lingual. 4 3 2 1
  • Branchial cysts • Branchial = gills • Responsible for the development of gills in fish.
  • Branchial cleft cyst Branchial cyst 1st branchial cleft cyst Location Parotid space. 2nd branchial cleft cyst 1. 2. 3. 4. 5. 6. Anterior to the sternomastoid & deep to the paltysma muscle. Anterior to the sternomastoid & superficial to the carotid sheath. Carotid bifurcation. Submandibular space. Parapharyngeal space. Pharyngeal mucosal space medial to the carotid sheath. 3rd branchial cleft cyst Posterior cervical space, posterior to the sternomastoid muscle. 4th branchial cleft cyst Visceral space, adjacent to the left thyroid lobe.
  • 3rd branchial cleft cyst
  • 4th branchial cleft cyst
  • 4th branchial cleft cyst
  • Laryngocele Pathology: • Dilated laryngeal ventricle. Types: • Internal or external. • Primary or secondary. Radiology: • May be air filled or fluid filled.
  • Laryngocele External Internal
  • Laryngocele Secondary Primary neoplastic Idiopathic
  • Sub-mandibular cyst
  • Submandibular cysts Non neoplastic Developmental Inflammatory 2nd branchial cleft cyst Sarcoidosis Dermoid cyst Sjogern’ syndrome Neoplastic Obstructive Sialocele Benign Wartin’s tumor Neoplastic Necrotic neoplasm
  • Floor of the mouth cysts • Dermoid / epidermoid. • Ranula.
  • Dermoid / epidermoid
  • Dermoid cyst • Sac of marbles appearance.
  • Epidermoid cyst
  • Ranula Pathology: • Mucous retension cyst of the sublingual salivary gland. • It is a pseudocyst (not lined by epithelium). Ranula Simple Plunging Confined to the sublingual space Extend to the submandibular space (through or around the myelohyoid muscle)
  • Ranula Radiology: • Sublingual space cystic lesion.
  • Ranula C.P: • Mass at the floor of the mouth with bluish discoloration. • Neck mass.
  • Cystic mediastinal masses
  • Mediastinal cystic masses Anterior mediastinal Thymic cyst. Middle mediastinal Bronchogenic cyst Posterior mediastinal Meningocele Cystic thymoma Cystic schwannoma Cystic teratoma Esophageal duplication cyst Cystic hygroma Neuroenteric cyst Pericardial cyst Pseudopancreatic cyst
  • Thymic cyst • Congenital (unilocular). • Acquired (multilocular): post-chemotherapy, post-thoracotomy, post-inflammtory. Cystic thymoma Cystic teratoma Cystic hygroma Pericardial cyst • Aberration in the formation of the coelomic cavities. Bronchogenic cyst • Abnormal ventral budding of the primitive foregut Esophageal duplication cyst • Abnormal dorsal budding of the primitive foregut. Neuroenteric cyst • Persistent neuroenteric canal. Cystic schwannoma Meningocele Pseudo-pancreatic cyst • Neural tube defect (NF, Marfan) • Pancreatitis.
  • Foregut cysts Bronchogenic cyst Esophageal duplication cyst Neuro-enteric cyst Abnormal ventral budding of the primitive foregut Abnormal dorsal budding of the primitive foregut Persistent neuroenteric canal
  • Cyst Location Thymic cyst Prevascular Cystic thymoma Prevascular cystic teratoma Prevascular Cystic hygroma (lymphangioma) Prevascular Pericardial cyst Right cardiophrenic angle Bronchogenic cyst Subcarinal or right paratracheal. Meningocele Paraspinal Cystic schwnnoma Paraspinal Foregut cyst Paraesophageal Pseudopancreatic cyst Tracking up into the posterior mediastinum.
  • Anterior mediastinal cysts
  • Thymic cyst
  • Cystic thymoma
  • Lymphangioma
  • Dermoid cyst
  • Pericardial cyst
  • Middle mediastinal cysts
  • Bronchogenic cyst
  • Posterior mediastinal cysts
  • Duplication cyst
  • Cystic schwannoma
  • Meningocele
  • Pseudopancreatic cyst
  • Cystic lung disease
  • DD of air filled spaces Thick walled > 1 mm Cavity Thin walled < 1 mm Bulla Bleb Sub-pleural Sub-pleural > 1cm < 1cm Cyst Intrapulmonary with epithelialized wall Pneumatocele Intrapulmonary without epithelialized wall
  • Cystic lung diseases Pediatrics Adults Multifocal Focal (1 lobe or multiple lobes in 1lung) Pneumatocele Congenital lobar emphysema (staph, PCC) Uni-locular Intrapulmonary bronchogenic cyst Pulmonary sequestation Type I CCAM Pneumatocele Diffuse (all lobes of both lungs) Cystic bronchiectasis Emphysema Cysts associated with PA hypoplasia Multi-locular Large Focal or multifocal Small Type II CCAM Intrapulmonary bronchogenic cyst PLCH Cysts associated with PV hypoplasia Cystic metastases LAM Lymphoid interstitial pneumonia Honeycombing IPF
  • Diffuse cystic lung disease & its mimics Findings C.P Distribution Associated findings Subpleural & basilar predominance Reticular opacities. GGO IPF Honeycombing LIP Thin walled cysts AIDs Sjogren syndrome Basilar predominance Peri-vascular GGO PLCH Bizzare shaped cysts Male smoker Random Spares the bases. Nodules LAM Thin walled cysts Female TS Random Diffuse Chylous effusion. TS Cystic bronchiectasis Cysts communicating with the bronchial tree Focal Diffuse (central, upper, middle & lower) Air fluid levels. Emphysema Cystic air spaces without discernable wall Upper (cetrilobular) Hyperinflation Lower (panlobular) Subpleural (paraseptal)
  • Lymphoid interstitial pneumonia • Diffuse ground glass opacification. • Perivascular cysts.
  • UIP • Honeycombing. • Reticular opacities.
  • Congenital cysts
  • Intrapulmonary bronchogenic cyst
  • Infected bronchogenic cyst
  • Renal cysts
  • Simple cysts ARPKD ADPKD TS MCDK Medullary sponge kidney Medullary uremic Dialysis cysts
  • Cysts versus hydronephrosis
  • Etiology Developmental Genetic Cysts associated with systemic disease • MCDK • ADPKD • ARPKD • Medullary cystic disease (nephronophthisis). • TS • VHL Acquired cysts • Simple cyst. • Medullary sponge kidney. • Acquired cystic disease of uremia. Malignant cysts • Multilocular cystic nephroma. • Cystic renal cell carcinoma
  • Renal cysts Large cysts > 2 cm Small cysts < 1cm MCDK ARPKD ADPKD Medullary cystic disease Simple cysts Medullary sponge kidney Cystic neoplasms Acquired cystic disease of uremia
  • Large renal cysts Simple cysts ADPKD MCDK Cystic neoplasms
  • Renal cysts Children Adult MCDK ADPKD ARPKD Medullary cystic disease TS / VHL Medullary sponge kidney Cystic neoplasms Acquired cystic disease of uremia TS / VHL Cystic neoplasm
  • Large renal cysts MCDK ARPK TS Medullary cystic disease
  • MCDK • Atresia of the proximal ureter during intrauterine development, with replacement of the kidney by multiple cysts & un-differentiated mesenchymal tissue. ARPKD • Cystic dilatation of distal convoluted tubules & collecting ducts. ADPKD • Cystic dilatation of Bowman's capsule, loop of Henle & proximal convoluted tubules Medullary cystic disease (nephronophthisis) • Ciliary dysfunction of renal tubules. TS • Mutation of tuberin & hamartin suppressor gene  proliferation of renal tubular epithelium. VHL • Mutation of VHL suppressor gene  proliferation of renal tubular epithelium. Medullary sponge kidney Simple cortical cysts Acquired cystic disease of uremia • Renal tubular duct ectasia. • Unknown. • Hypertrophy of functioning nephrons, hyperplasia of tubular epithelium  obstruction & expansion of renal tubules.
  • MCDK • Neonate, with abdominal mass. ARPKD • Infant, with bilateral flank masses, renal failure, hypertension or portal hypertension. ADPKD • Adult, with bilateral flank pain, hematuria, renal failure, hypertension, SAH or family history. Medullary cystic disease (nephronophthisis) TS VHL Medullary sponge kidney Simple cortical cysts Acquired cystic disease of uremia • Renal failure • Triad: Adenoma sebaceum, Fits & Mental retardation. • Renal, pancreatic or epididymal cysts. • Cerebellar, spinal or retinal hemanigoblastoma. • Asymptomatic • Complications (stones or sepsis) • Asymptomatic. • Complications (rupture or infection) • Chronic renal dialysis.
  • MCDK • Multiple non communicating cysts with dysplastic echogenic renal tissue. ARPKD • Nephromegaly, with echogenic parenchyma & striated nephrogram. ADPKD • Multiple non communicating cysts with spider leg deformity of the pelvicalyceal system. Medullary cystic disease (nephronophthisis) TS VHL • Medullary multiple cysts. • • • • • Cysts. AML Oncocytoma. Renal, pancreatic or epididymal cysts. Cerebellar, spinal or retinal hemanigoblastoma. Medullary sponge kidney • Medullary nephrocalcinosis, paint brush appearance or bouquet of flowers appearance. Simple cortical cysts • Clear contents, thin regular wall, with no mural vegetations, internal septations or calcification. Acquired cystic disease of uremia • Small atrophic kidney, with multiple cysts.
  • MCDK ARPKD ADPKD Medullary cystic disease (nephronophthisis) • Bilateral MCDK is incompatible with life. • Renal falilure, • hypertension or • portal hypertension. • Hemorrhage, rupture, infection. • Subarachnoid hemorrhage. • Aortic dissection. • Renal failure TS • The incidence of RCC in TS is similar to the general population. VHL • Cystic renal cell carcinoma. Medullary sponge kidney Simple cortical cysts Acquired cystic disease of uremia • Stones or • Sepsis. • Hemorrhage, • Rupture, • Infection. • Hemorrhage. • Infection. • Malignancy.
  • MCDK • Contralateral PUJ obstruction or VUR ARPKD • Hepatic periportal fibrosis ADPKD • Liver cysts & cerebral aneurysms. Medullary cystic disease (nephronophthisis) TS VHL Medullary sponge kidney Simple cortical cysts Acquired cystic disease of uremia • Cortical tubers, subependymal calcified nodules, white matter lesions, subependymal giant cell astrocytoma, LAM, renal angiomyolipoma, cardiac rhabdomyoma. • CNS hemangioblastoma, pancreatic cysts • Caroli disease.
  • Multicystic dysplastic kidney
  • Bilateral ureteric atresia with bilateral MCDK
  • ARPKD with hepatic fibrosis
  • Acquired uremic cystic disease
  • Medullary sponge kidney
  • Tuberous sclerosis
  • Multilocular cystic nephroma
  • Bosniak classification: Grade I Simple cyst Grade II Minimally complicated cyst Grade III Grade IV Moderately Malignant cyst complicated cyst Wall: Thin walled. Thin walled. Thick walled. Contents: Clear contents: Turbid contents U/S: U/S: -anechoic. Internal echoes. -back enhancement. U/S: Internal echoes. Septations: CT: < 20 HU. No CT: > 20HU. Thick septations. Calcification: No CT: < 20 HU. Paper thin septations. Minimal calcification. Has solid and cystic components. Heavy calcification. Enhancement: No Wall enhancement. Wall enhancement. Workup: Follow up by U/S or CT. No further workup. -biopsy. Nephrectomy. -aspiration of cyst.
  • Management of renal cysts Simple cysts Cystic masses (Bosniak I) (Bosniak II, III or IV) Ignore Ignore Follow Excise
  • • A fluid-filled lesion is considered a cystic mass (ie not a simple cyst) when it has any of the following features: 1 - Calcification 2 - High attenuation ( > 20 HU ) at NECT 3 - Septation 4 - Multiple locules 5 - Enhancement 6 - Wall thickening 7 - Nodularity
  • Management Consequences in calcification Ignore Follow Excise Small amounts Smooth, septal Milk of Ca No enhancement Thick or nodular Nodularity or thickening of the wall No enhancement enhamncement
  • Management Consequences in hyperdense cysts Ignore Sharp margins < 3 cm Not completely intrarenal Homogenous Cystic on US No enhancement Follow Excise Poorly defined > 3 cm Totally intrarenal Cystic on US No enhancement Heterogenous Solid on US Enhamncement
  • Management Consequences in septations Ignore Follow Excise Thin Smooth No enhancement Slightly > hairline Thick , Irregular or nodular Enhancement No enhancement
  • Management Consequences in enhancement Ignore Follow Excise < 10 HU 10 – 15 HU 15 HU *unless Infection
  • • NECT : 16 HU • Cortical phase 17 HU • Nephrographic phase 19 HU Ignore
  • • NECT : 44 HU • Enhanced scan:61 HU ------ Excise
  • Management Consequences in multiloculated lesions Ignore --------- Follow ---------- Excise All *unless Infection
  • Management Consequences in nodular cysts Ignore --------- Follow Excise Very small Non enhancing All others
  • Renal sinus cysts
  • Renal sinus cysts
  • Renal sinus cysts Parapelvic cyst Peripelvic cysts Renal cortical cyst Lymphatic cyst (lymphangiectasia) Single Multiple Unilateral Bilateral
  • Hepatic cysts
  • Etiology Developmental Traumatic Inflammatory Neoplastic • Simple cysts. • Bile duct hamartomas. • Caroli disease. • Biloma. • Hematoma. • Hydatid cyst. • Hepatic abscess. • Extrapancreatic pseudocyst • • • • Biliary cystadenoma & cystadenocarcinoma. Embryonal sarcoma. Cystic HCC. Cystic metastasis.
  • C.P Associations Simple cysts Asymptomatic Homogeneous, rounded, regular, no wall, no enhancment. Bile duct hamartoma Asymptomatic Homogeneous, rounded, regular, mural enhancment, all lesions are < 1.5 cm in diameter Caroli diease Asymptomatic, Cummunicating with the biliary unless complicated. tree. Central dot sign. Embyronal sarcoma Young adults Complex cyst with enhancing solid component Cystadenoma & cystadenocarcinoma Asymptomatic Middle aged females Multilocular, mural nodules. Cystic metastasis Abscess Multiplicity. Mural enhancement. Not equal to fluid on heavy T2 Constitutional symptoms Double target sign History of trauma Surrounding pseudocapsule Hydatid cyst biloma ADPKD VHL Medullary sponge kidney
  • Hepatic cyst
  • Biloma
  • Multiple biliary hamartomas
  • Multiple biliary hamartomas
  • Double target sign with transient segmental enhancement Inner enhancing rim • Abscess capsule. Outer hypodense rim • Edematous liver parenchyma. Transient segemental enhancement • Hyperemia.
  • Retroperitoneal cysts
  • Retroperitoneal cysts Non neoplastic Neoplastic Hematoma Cystic lymphangioma Urinoma Mucinous cystadenoma Lymphocele Cystic teratoma Pseudopancreatic cyst
  • Cyst History Radiology Non neoplastic Hematoma Trauma Urinoma Trauma Lymphocele Lymphadenectomy Pseudopancreatic cyst Retroperitoneal fluid collection. Pancreatitis Neoplastic: Cystic Lymphangioma Mucinous cystadenoma Multilocular Cystic teratoma Calcification. Fat density.
  • Lymphocele
  • Retroperitoneal urinoma
  • Retroperitoneal hematoma
  • Pseudopancreatic cyst
  • Retroperitoneal serous cystadenoma
  • Retroperitoneal mucinous cystadenoma
  • Retroperitoneal cystic teratoma
  • Retro-rectal cysts Epidermoid cyst • Unilocular. • Thin wall. • Clear contents. Dermoid cyst • Fat contents. • Sacral defects Tail gut cyst Sacro-coccygeal teratoma Anterior sacral meningocele • Multilocular cyst (thin internal septations). • Mucinous content (may be bright on T1). • Mural calcification • Pediatrics. • Solid & cystic components. • Sacral defect. • Communicating with the thecal sac.
  • Epidermoid cyst
  • Anterior sacral meningocele
  • Rectal duplication cyst
  • Tailgut cyst
  • Pancreatic cysts
  • Pancreatic cysts
  • Serous cystadenoma
  • Mucinous cystadenoma
  • IPMN Intraductal papillary & mucinous neoplasm Main duct Segmental Side branch Diffuse Microcystic Macrocystic
  • IPMN main duct diffuse
  • IPMN main duct segmental
  • Side branch IPMN
  • Ovarian cysts
  • Ovarian cysts Functional cysts Non functional (can produce hormones) Follicular cyst Corpus luteum cyst Non neoplastic Single Endometrioid cyst Serous inclusion cyst Neoplastic multiple PCO Theca lutein cysts (ovarian hyperstimulation syndrome) Benign malignant Mature cystic teratoma Immature cystic teratoma Serous cystadenoma Serous cystadenocarcinoma Mucinous cyst adenoma Mucinous cystadenocarcinoma Endometerioid carcinoma Cystic metastases
  • Functional cysts
  • Follicular cyst Epidemiology • Reproductive age. C.P: • asymptomatic Pathology • Un-ruptured Graafian follicle. Natural course • Spontaneous resolution in 2 or 3 cycles Radiographic features Ultrasound • Simple cyst • Unilocular. • Thin wall, with no mural vegetations, internal septations or solid components. • Clear contents, with acoustic enhancement & no internal echoes. Duplex: • No color flow.
  • Corpus luteum cyst Epidemiology • 1st trimester of pregnancy. • Post-menopasual female. C.P: • asymptomatic Pathology • Failure of regression of corpus luteum. Natural course • Spontaneous regression by the end of 2nd trimester. Radiographic features • Ultrasound • Simple cyst • Hemorrhagic cyst • Duplex: • Ring of fire (DD with tubal pregnancy).
  • PCO
  • Ovarain cysts Simple Hemorrhagic Functional cyst Hemorrhagic functional cyst Cystic neoplasm Chocolate cyst Cystic neoplasm Complex Cystic neoplasm
  • Management of ovarian cysts
  • Ultrasound pattern recognition
  • Criteria of malignancy Size • Large size. Wall • Thick irregular wall. • Mural vascularity. • Mural vegetations. • Mural papillary projections. • Mural solid components. Septations Secondary signs •Thick septations (> 3 mm). •Vascularized septations • Ascites. • Peritoneal deposits. • lymphadenopathy
  • MR signal of ovarian cysts
  • Breast cysts Breast cyst Simple Complicated Complex cyst cyst cyst
  • Breast cyst Breast cyst Micro-cyst Marco-cyst < 3 mm > 3 mm
  • Simple cyst Complicated cyst Complex cyst BIRADS 2 BIRADS 3 BIRADS 4 U/S An-echoic Smooth wall. Circumscribed in shaped. Posterior acoustic enhancement. Reverberation artefact. Internal echo or layering debris Thick wall. Thick septations (> 5 mm). Solid mural nodules. Solid & cystic compnents MRI Hypointense on T1. Hyperintense on T2. Variable signal depending on cyst contents Thick wall Thick septations Solid mural nodule Enhancement No enhancement Thin marginal enhancement.
  • Complex breast cyst Type 1 Thick wall or thick septa Type 2 Solid mural nodule Type 3 Type 4 Solid & cystic component Solid & cystic component (> 50 % cystic) (> 50% solid)
  • Simple cyst
  • Simple cyst
  • Simple cyst
  • Complicated cyst
  • Complicated cyst
  • Breast cysts Simple Fibrocystic disease Complicated Galactocele Complex Benign Malignant Oil cyst Galactocele Necrotic breast mass Hematoma Oil cyst Intracystic breast carcinoma Abscess Hematoma Abscess
  • Galactocele • Pathology: retension cyst due to obstruction of lactiferous duct. • C.P: lactating female. • Mamography: radiolucent lesion, with eggshell calcification. • U/S: complicated cyst or complex cyst. • Colour doppler: no flow. • Complications: 2ry infection  breast abscess.
  • Galactocele
  • Oil cyst • Pathology: traumatic fat necrosis. • C.P: history of trauma or operation. • Mamography: well circumscribed radiolucent mass with or without eggshell calcification. • U/S: complicated cyst or complex cyst, with no acoustic shadowing or enhancement. • Fat fluid level. • Color doppler: no flow.
  • Oil cyst
  • Oil cyst
  • Breast abscess • Pathology: staph aureus • C.P: constitutional symptoms, local hotness, redness and tenderness. • Lactating female. • Mamography: non specific. • U/S: complicated or complex cyst. • Hypoechoic rim. • Adjacent interstitial fluid.
  • Breast abscess
  • Scrotal cysts Intra-testicular cysts Paratesticular cysts Simple cyst Epididymal cyst Tunica albuginea cyst Spermatocele Cystic transformation of the rete testis Cystadenoma of the rete testis Testicular epidermoid cyst Testicular neoplasm with cystic component
  • Simple testicular cysts • • • • C.P: not palpable & not firm (even if large). U/S: Anechoic, thin imperceptible wall, through transmission.
  • Simple testicular cyst
  • Tunica albuginea cyst C.P: • small palpable mass. Radiology (U/S): • Similar to simple cyst (anechoic cyst with thin imperceptible wall). • But small in size and located at the upper anterior or lateral aspect to the testis.
  • Tunica albuginea cyst
  • Epidermoid cyst • • • • C.P: painless palpable testicular mass. Radiology (U/S): onion peel appearance.
  • Epidermoid cyst
  • Cystic transformation of the rete testis Pathology: • partial or complete obliteration of the efferent ducts. Radiology (U/S): • Multiple cyst or tubular anechoic structures that replace the mediastinum testis. • No mass effect. • No internal flow.
  • Cystic transformation of the rete testis
  • Cystadenoma of the rete testis
  • Epididymal cyst
  • Cystic transformation of the rete testis associated with spermatocele
  • Epididymal cyst Spermatocele Any where in the epididymis Epididymal head Anechoic Low level internal echos. Unilocular Unilocular or multilocuar
  • Choledochal cysts
  • Definition • Congenital cystic dilatation of the biliary tree.
  • PATHOPHYSIOLOGY Anomalous junction of the CBD, with pancreatic duct (90%). Reflux of the pancreatic secretions & enzymes into the CBD. Inflammation & weakening of the bile duct wall. Formation of choledochal cyst.
  • Demographics Age: • it can be discovered at any age. • 60 % below 10 ys. Sex: • F > M, 4 : 1
  • C.P Choledochal cyst Abdominal pain Jaundice Abdominal mass
  • Complications Pancreatitis. Cholangitis. Cholangiocarcinoma.
  • Cholangiocarcinoma within a choledochal cyst
  • Types Todani classification Type I: dilatation of the CBD. Type II: true diverticulum. Type III: Choledochocele. Type IV: dilatation of the extrahepatic & intrhepatic biliary system. Type V: Caroli disease.
  • Type I • Fusiform dilatation of a segment or the entire CBD. • True choledochal cyst. • Most common type 80%.
  • Portal vein Splenic vein
  • Type II • True diverticulum. • Saccular outpouching of the supra-pancreatic portion of the CBD. • 3%.
  • Type III • Choledochocele (dilatation of the ampullary portion of the CBD). • 5 %.
  • Type IV • 2nd most common type 10%
  • Type V • Caroli disease
  • Central dot sign
  • Caroli disease • Autosomal recessive disorder 2ry to ductal plate malformation.
  • Normal development of ductal plate
  • Patterns of Caroli disease • Segmental 83 %. • Diffuse 17 %.
  • Central dot sign
  • Associations of Caroli disease Liver: • Congenital hepatic fibrosis (due to involvement of small ducts). • Caroli syndrome (caroli disease associated with congenital hepatic fibrosis) due to involvement of large & small ducts. Kidney: • Medullary sponge kidney. • Polycystic kidney. • Medullary cystic disease
  • Caroli disease & medullary sponge kidney
  • Complications of Caroli disease • • • • Intraductal stones. Ascending cholangitis & abscess formation. Cholangiocarcinoma. Liver cirrhiosis.
  • Intraductal stones
  • Liver cirrhosis Central dot sign abscess
  • Cholangiocarcinoma
  • Abscess formation
  • Bone cysts