888
Images for surgeons
presence of all of these symptoms can be uncommon, and therefore reliance on this classical presentation can lead to the diagnosis being overlooked.1 The patient we describe had vomiting but none of the other classical symptoms. His vomiting and dysphagia combined with the chest X-ray findings lead to a diagnosis of an acute wrap slippage being made. The lack of sepsis or mediastinitis can be attributed to the fact that the contamination had been contained within an abscess cavity. Although an iatrogenic injury is a possibility, we believe that the presentation and operative findings in this case favour a spontaneous oesophageal perforation. This case of spontaneous oesophageal perforation after laparoscopic hiatus hernia repair is likely due to patient vomiting after eating solid food. The air fluid level seen on chest X-ray was not an intrathoracic stomach but rather an abscess cavity.
Reference 1. Janjua KJ. Boerhaave’s syndrome. Postgrad. Med. J. 1997; 73: 265–70.
Martyn L. Humphreys, DM, FRCSEd Bevan Jenkins, BHB, MBChB Jason Robertson, MBChB Michael Rodgers, MBChB, FRACS Department of General Surgery, North Shore Hospital, Auckland, New Zealand doi: 10.1111/ans.12560
Fig. 2. Photograph of an anterior view of the resected specimen showing the site of perforation at the gastro-oesophageal junction.
Dural plasmacytoma: an unusual presentation The patient, a 76-year-old lady with a history of multiple myeloma, presented with short-term memory loss and deterioration in her general functioning over 3 weeks to the point of no longer being self-caring. She also complained of reduced peripheral vision on her left side. There were no symptoms to suggest presence of raised intracranial pressure. She was diagnosed with multiple myeloma 2 years ago after sustaining a pathological fracture of left humeral head. She was subsequently treated with bortezomib. She is also hypertensive. On examination, she had a GCS of 15. Her neurological deficits included left-sided homononymous hemianopia and left-sided hemispatial neglect. Motor and sensory functions were otherwise intact. Magnetic resonance imaging (MRI) of her brain (as depicted in Figs 1–3) revealed a large irregular right parieto-occipital extra-axial mass measuring 60 × 30 × 72 mm which has heterogenous hypointense T1 and intermediate T2 signal. The lesion demonstrated heterogeneous enhancement post contrast injection. There was a significant amount of vasogenic oedema with significant mass effect. However, there was no bony involvement of adjacent calvarium. Burrhole biopsy of the lesion revealed diffuse infiltrate of atypical plasmacytoid cells consistent with a plasmacytoma.
Fig. 1. Axial cut of MRI T1 sequence with Magnevist.
Extraosseous intracranial manifestation of plasmacytoma is uncommon. They present as either diffuse leptomeningeal disease, dural solitary tumour or intraparenchymal lesion without dural or bony involvement.1–4 There are no specific radiological features for © 2014 Royal Australasian College of Surgeons
Images for surgeons
Fig. 2. Coronal cut of MRI T1 sequence with Magnevist.
889
erties of glioblastoma, conventional MR features of glioblastoma multiforme include irregular or nodular rim enhancement, central hypointensity, ill-defined margins and extensive surrounding oedema, all of which are present in the imaging of our patient.7 Despite the past history of multiple myeloma, the large parietooccipital lesion seen in our patient’s MRI was not associated with any calvarial osteolytic lesions to suggest typical multiple myeloma deposits, and considering the poor demarcation and heterogenous appearance of the mass, atypical meningioma and peripherally located glioblastoma multiforme were at the top of our differential diagnosis. There was no other history of malignancy to support the diagnosis of metastatic deposit as a differential, although dural metastasis from multiple myeloma can occur although very rarely.1,5 Intracranial plasmacytoma can mimic the appearance of a wide range of pathological diagnosis including high-grade glioma. It is pertinent that these lesions are at least biopsied to enable appropriate treatment as differing pathologies have very variable prognosis.
References
Fig. 3. Axial cut of MRI T2 sequence.
intracranial plasmacytoma and therefore poses a challenging radiological diagnosis for treating physicians. Tsang et al. reported a case of extensive dural infiltration which was initially thought to be a chronic subdural haematoma.5 Sahin et al. reported a case of which was thought to be initially a meningioma.1 Intracranial metastasis and glioblastoma are the two most common brain neoplasm in adults.6 Although there has been an extensive usage of modern MR techniques to assess biological prop-
© 2014 Royal Australasian College of Surgeons
1. Sahin F, Saydam G, Ertan Y, Calli C, Dönmez A, Tombuloglu M. Dural plasmacytoma mimicking meningioma in a patient with multiple myeloma. J. Clin. Neurosci. 2006; 13: 259–61. 2. Husain MM, Metzer SW, Binet EF. Multiple intraparenchymal brain plasmacytomas with spontaneous intratumoral hemorrhage. Neurosurgery 1987; 20: 619–23. 3. Ferrari S, Tecchio C, Turri G et al. Unusual case of solitary intraparenchymal brain plasmacytoma. J. Clin. Oncol. 2012; 30: e350–2. 4. Leifer D, Grabowski T, Simonian N, Demirjian ZN. Leptomeningeal myelomatosis presenting with mental status changes and other neurologic findings. Cancer 1992; 70: 1899–904. 5. Tsang CS, Ho LC, Tan TC. Intracranial multiple myeloma involving the dura. J. Clin. Neurosci. 2006; 13: 122–3. 6. Lee EJ, Ahn KJ, Lee EK, Lee YS, Kim DB. Potential role of advanced MRI techniques for the peritumoural region in differentiating glioblastoma multiforme and solitary metastatic lesions. Clin. Radiol. 2013; 68: e689–97. 7. Nelson SJ, Cha S. Imaging glioblastoma multiforme. Cancer J. 2003; 9: 134–45.
Muhammad Fahmi Abdul Jalil, MBBS, BMedSc Jin Wee Tee, MBBS, MD Department of Neurosurgery, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia doi: 10.1111/ans.12574
Images for surgeons
presence of all of these symptoms can be uncommon, and therefore reliance on this classical presentation can lead to the diagnosis being overlooked.1 The patient we describe had vomiting but none of the other classical symptoms. His vomiting and dysphagia combined with the chest X-ray findings lead to a diagnosis of an acute wrap slippage being made. The lack of sepsis or mediastinitis can be attributed to the fact that the contamination had been contained within an abscess cavity. Although an iatrogenic injury is a possibility, we believe that the presentation and operative findings in this case favour a spontaneous oesophageal perforation. This case of spontaneous oesophageal perforation after laparoscopic hiatus hernia repair is likely due to patient vomiting after eating solid food. The air fluid level seen on chest X-ray was not an intrathoracic stomach but rather an abscess cavity.
Reference 1. Janjua KJ. Boerhaave’s syndrome. Postgrad. Med. J. 1997; 73: 265–70.
Martyn L. Humphreys, DM, FRCSEd Bevan Jenkins, BHB, MBChB Jason Robertson, MBChB Michael Rodgers, MBChB, FRACS Department of General Surgery, North Shore Hospital, Auckland, New Zealand doi: 10.1111/ans.12560
Fig. 2. Photograph of an anterior view of the resected specimen showing the site of perforation at the gastro-oesophageal junction.
Dural plasmacytoma: an unusual presentation The patient, a 76-year-old lady with a history of multiple myeloma, presented with short-term memory loss and deterioration in her general functioning over 3 weeks to the point of no longer being self-caring. She also complained of reduced peripheral vision on her left side. There were no symptoms to suggest presence of raised intracranial pressure. She was diagnosed with multiple myeloma 2 years ago after sustaining a pathological fracture of left humeral head. She was subsequently treated with bortezomib. She is also hypertensive. On examination, she had a GCS of 15. Her neurological deficits included left-sided homononymous hemianopia and left-sided hemispatial neglect. Motor and sensory functions were otherwise intact. Magnetic resonance imaging (MRI) of her brain (as depicted in Figs 1–3) revealed a large irregular right parieto-occipital extra-axial mass measuring 60 × 30 × 72 mm which has heterogenous hypointense T1 and intermediate T2 signal. The lesion demonstrated heterogeneous enhancement post contrast injection. There was a significant amount of vasogenic oedema with significant mass effect. However, there was no bony involvement of adjacent calvarium. Burrhole biopsy of the lesion revealed diffuse infiltrate of atypical plasmacytoid cells consistent with a plasmacytoma.
Fig. 1. Axial cut of MRI T1 sequence with Magnevist.
Extraosseous intracranial manifestation of plasmacytoma is uncommon. They present as either diffuse leptomeningeal disease, dural solitary tumour or intraparenchymal lesion without dural or bony involvement.1–4 There are no specific radiological features for © 2014 Royal Australasian College of Surgeons
Images for surgeons
Fig. 2. Coronal cut of MRI T1 sequence with Magnevist.
889
erties of glioblastoma, conventional MR features of glioblastoma multiforme include irregular or nodular rim enhancement, central hypointensity, ill-defined margins and extensive surrounding oedema, all of which are present in the imaging of our patient.7 Despite the past history of multiple myeloma, the large parietooccipital lesion seen in our patient’s MRI was not associated with any calvarial osteolytic lesions to suggest typical multiple myeloma deposits, and considering the poor demarcation and heterogenous appearance of the mass, atypical meningioma and peripherally located glioblastoma multiforme were at the top of our differential diagnosis. There was no other history of malignancy to support the diagnosis of metastatic deposit as a differential, although dural metastasis from multiple myeloma can occur although very rarely.1,5 Intracranial plasmacytoma can mimic the appearance of a wide range of pathological diagnosis including high-grade glioma. It is pertinent that these lesions are at least biopsied to enable appropriate treatment as differing pathologies have very variable prognosis.
References
Fig. 3. Axial cut of MRI T2 sequence.
intracranial plasmacytoma and therefore poses a challenging radiological diagnosis for treating physicians. Tsang et al. reported a case of extensive dural infiltration which was initially thought to be a chronic subdural haematoma.5 Sahin et al. reported a case of which was thought to be initially a meningioma.1 Intracranial metastasis and glioblastoma are the two most common brain neoplasm in adults.6 Although there has been an extensive usage of modern MR techniques to assess biological prop-
© 2014 Royal Australasian College of Surgeons
1. Sahin F, Saydam G, Ertan Y, Calli C, Dönmez A, Tombuloglu M. Dural plasmacytoma mimicking meningioma in a patient with multiple myeloma. J. Clin. Neurosci. 2006; 13: 259–61. 2. Husain MM, Metzer SW, Binet EF. Multiple intraparenchymal brain plasmacytomas with spontaneous intratumoral hemorrhage. Neurosurgery 1987; 20: 619–23. 3. Ferrari S, Tecchio C, Turri G et al. Unusual case of solitary intraparenchymal brain plasmacytoma. J. Clin. Oncol. 2012; 30: e350–2. 4. Leifer D, Grabowski T, Simonian N, Demirjian ZN. Leptomeningeal myelomatosis presenting with mental status changes and other neurologic findings. Cancer 1992; 70: 1899–904. 5. Tsang CS, Ho LC, Tan TC. Intracranial multiple myeloma involving the dura. J. Clin. Neurosci. 2006; 13: 122–3. 6. Lee EJ, Ahn KJ, Lee EK, Lee YS, Kim DB. Potential role of advanced MRI techniques for the peritumoural region in differentiating glioblastoma multiforme and solitary metastatic lesions. Clin. Radiol. 2013; 68: e689–97. 7. Nelson SJ, Cha S. Imaging glioblastoma multiforme. Cancer J. 2003; 9: 134–45.
Muhammad Fahmi Abdul Jalil, MBBS, BMedSc Jin Wee Tee, MBBS, MD Department of Neurosurgery, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia doi: 10.1111/ans.12574
