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Thyroid metastases from hepatocellular carcinoma (HCC) seldom occur and are often difficult to diagnose because of their asymptomatic clinical course. We evaluated a very rare case of solitary thyroid metastasis from HCC that showed high uptake of fluorine-18 fluorodeoxyglucose (FDG), when imaged using fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). The patient was a 74-year-old man and presented with a remarkably elevated des-gamma-carboxy prothrombin level of 1,157 mAU/ml 22 months after hepatic lobectomy. FDG-PET/CT imaging revealed a hypodense tumor with high FDG uptake, with a maximum standardized uptake value of 5.2 in the thyroid left lobe. Solitary thyroid metastasis from HCC was suspected and subsequent fine needle aspiration did indeed reveal HCC. The patient received left thyroidectomy with left regional lymph node dissection. Two months after left thyroidectomy, contrast-enhanced computed tomography showed local recurrence, and the patient received ongoing radiotherapy treatment. To our knowledge, the present study is the first to demonstrate the feasibility of FDG-PET/CT in the diagnosis and management of clinically diagnosed, asymptomatic, solitary thyroid metastasis from HCC.

In recent years, self-expandable metallic stents (SEMSs) have emerged as a promising treatment alternative for the bridging and sealing of esophageal perforations and extensive anastomotic leaks after esophageal resection or total gastrectomy. A 56-year-old woman underwent a total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric signet ring cell carcinoma. Ten days later, esophagogastroduodenoscopy showed a 2 cm fistula in the distal end of the Roux limb of the anastomosis. This was confirmed by gastrografin esophagography. The patient was started on total parenteral nutrition. Having deemed clipping treatment for this fistula unfeasible, we decided to insert a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, Cook Medical, Winston-Salem, N.C., USA). The stent was removed after ten days. Gastrografin esophagography showed no further contrast extravasation, and esophagogastroduodenoscopy showed closure of the fistula. No clinical complications were observed, and the patient was able to start normal per os nutrition. In conclusion, the treatment of symptomatic leaks in patients who have undergone esophagojejunostomy is challenging, and leakage from the jejunal stump can be a potentially serious complication. In the treatment of leakage after total gastrectomy, plastic stents (which are either too light or exercise too little radial force) and totally covered metallic stents may not adhere sufficiently to the esophagojeujunal walls and, as a result, migrate beyond the anastomosis. The promising results of this report suggest that early stenting, using a partially silicone-coated SEMS, is a feasible alternative to surgical treatment in this category of patients.

Extra-axial restriction on diffusion weighted imaging (DWI) is an unusual finding on brain magnetic resonance imaging (MRI). Intra-axial restriction on DWI, however, is common, and can represent brain parenchymal infarction, tumor, abscess, or toxic-metabolic process. The infrequency of extra-axial DWI restriction and the paucity of clinico-pathological correlation in the literature limit its differential diagnosis. Scant case reports suggest that extra-axial DWI restriction could be a lymphoma, neurenteric cyst, or, in one patient, subdural empyema [1,2,3]. We postulate that pus formation must be excluded first, because it can provoke an aggressive meningo-vasculitis with rapidly fatal, intra-axial infarctions. Our patient was a 45-year-old man, presenting to our hospital with left facial droop and right (contralateral) arm and leg weakness. Initial MRI revealed DWI restriction in the left lateral pons, consistent with a classic Millard-Gubler stroke. Also noted was a subtle, extra-axial area of curvilinear diffusion restriction in the left cerebellar-pontine angle's subarachnoid space. Days later, the patient had a headache, and repeat MRI revealed extension of the two DWI lesions – both the intra-axial pontine infarction and the extra-axial area of restricted diffusion in the subarachnoid space. The patient became comatose, a third MRI revealed more extensive DWI restrictions, and he expired despite aggressive care. Autopsy revealed massive brainstem infarcts, a thick lymphoplasmacytic infiltrate, copious Gram-Positive cocci (likely MRSA) and arteries partially occluded with fibrointimal proliferation. This emphasizes the concept that extra-axial DWI restriction can represent pus development in the subarachnoid space – a radiographic marker to identify a patient at risk for demise due to septic, meningo-vasculitic infarctions.

Background: The simultaneous occurrence of cerebellopontine angle (CPA) meningioma and vestibular schwannoma (VS) in the absence of neurofibromatosis type 2 or history of irradiation is very rare. We report a case with coexistent CPA meningioma and VS, which were radiologically not distinguishable in preoperative imaging. Case Description: A 46-year-old female presented with acute hearing loss, tinnitus and gait ataxia. Otorhinolaryngological diagnostic workup and imaging studies showed an intra- and extrameatal homogenous contrast enhancing lesion. The neuroradiological diagnosis was VS. The patient was operated via the retrosigmoid approach. Intraoperatively two distinct tumors were found: a small, mainly intrameatally located VS and a larger meningioma originating from the dura of the petrous bone. Both tumors were completely microsurgically removed. The patient experienced no new neurological deficit after surgery; particularly facial nerve function was completely preserved. Histopathological examination revealed a fibromatous meningioma and a VS, respectively. Conclusions: The coincidental occurrence of CPA meningioma and VS is very rare. Careful interpretation of imaging studies before surgery is crucial. Even such rare cases should be kept in mind when discussing the therapeutic options with the patient. More studies are needed for a better understanding of mechanisms leading to multiple tumor growth.

Meningiomas are slow-growing intracranial/intraspinal tumours, with a wide range of histopathological variants. The more aggressive atypical and malignant types can disseminate via the venous system, lymphatics or cerebrospinal fluid, with the lungs and pleura being the most common site of extracranial metastasis. We look at a 68-year-old woman presenting with abdominal pain, who had previously been treated for an intracranial meningioma with a ventriculo-peritoneal shunt in situ. Investigation revealed a lesion in segment 4 of the liver with the shunt tip being in close proximity. Biopsy was consistent with metastatic meningioma. A liver resection was subsequently performed. We postulate that this is the first reported case of dissemination of an intracranial meningioma via cerebrospinal fluid by means of a ventriculo-peritoneal shunt.