Gastric trichobezoar and Rapunzel syndrome: case report of a very rare condition.

Background: Rapunzel syndrome is a rare trichobezoar variant extending from the gastric cavity into the small bowel. Case description: We report the case of a 22-year-old woman who presented with epigastric pain, nausea, and loss of appetite within the preceding five weeks. She had a palpable mass in the epigastric area with mild localized tenderness. Her abdominal computed tomography scan showed a distended stomach and duodenum, with a heterogeneous solid material, suspicious for a bezoar. Upper gastrointestinal endoscopy revealed a large, densely packed trichobezoar occupying the gastric cavity and extending through the pylorus. Endoscopic removal of the bezoar was unsuccessful. The patient underwent a 6cm-long gastrotomy, and the 150cm-long bezoar, extending from the stomach to the jejunum, was uneventfully removed. The patient was referred postoperatively to a dietitian and psychiatrist for management of her trichotillomania and trichophagia. Conclusion: Trichobezoars are commonly found in young females with a history of trichotillomania and trichophagia and are associated with psychiatric disorders. HIPPOKRATIA 2023, 27 (1):25-27.

Retroperitoneal sarcomas: from diagnosis to treatment. Case series and review of the literature.

BACKGROUND: Retroperitoneal sarcoma is a rare malignancy arising from mesenchymal cells, most commonly presented as an abdominal mass and is associated with poor prognosis. The most effective treatment modality for retroperitoneal sarcomas is complete surgical resection, including sometimes adjacent organs infiltrated by the tumor. Radiotherapy is frequently applied and has shown some benefit, while the role of chemotherapy and molecular-targeted agents is still not clear. Local recurrence is common for retroperitoneal sarcomas and still remains the main cause of death. The major factors associated with the overall survival are tumor grade, histological subtype, complete macroscopic excision and multifocality. AIM: To report our experience via the presentation of patients with retroperitoneal sarcomas managed in our department during the period 2014-18; and to review the current literature. PATIENTS AND METHODS: Eight patients appeared with chronic non-specific complaints including abdominal distension and changes in bowel or bladder habit, while one patient presented with acute abdominal pain due to mass rupture. All of the patients underwent surgical resection of the tumor. RESULTS: Among the patients, seven were operated for primary disease and one only for recurrent. The most common histologic type was liposarcoma (well-differentiated, dedifferentiated), found in five patients; followed by leiomyosarcoma found in two cases. Fibrous histiocytoma was found in only one case. The masses were removed with macroscopically clear margins (R0 and R1 resections) in four cases. In five patient cases adjuvant therapy was required. Three patients are still alive and free of disease. CONCLUSIONS: Retroperitoneal sarcomas present to be a therapeutic challenge based on their location, their extent at the time of diagnosis and the high risk of local recurrence or distant metastasis. Their management requires a multidisciplinary approach, with the surgical resection remaining the mainstay of curative treatment, combined with surveillance for early detection of recurrence or metastases.

Complicated acute appendicitis within a right inguinal hernia sac (Amyand's hernia): report of a case.

BACKGROUND: The term Amyand's hernia refers to a rare clinical situation characterized by the presence of a normal or inflammed appendix within the sac of an inguinal hernia. The situation may be asymptomatic or may present as an incarcerated hernia in case of strangulation or acute appendicitis occurring inside the hernia sac. DESCRIPTION OF THE CASE: We present the case of a right Amyand's hernia on a 88-years-old male that presented to our emergency department with a severely tender and swollen inguinal mass that was diagnosed as a strangulated inguinal hernia - inguinal abcess and underwent emergency operation. The intraoperative findings included a severely inflamed and perforated appendix along with healthy part of the caecum inside the sac. Appendectomy with subsequent primary hernia repair without mesh was performed with excellent outcome. CONCLUSION: Because of the fact that most of such rare cases are managed by urgent surgery with no preoperative diagnosis, every surgeon should be prepared for the possibility of coping with such an unexpected situation.

Seasonal variation in breast cancer incidence. Circumstantial or default event?

UNLABELLED: It has been previously suggested that seasonality in the detection of breast cancer is mostly seen in countries with distinct climatic variations. Patient characteristics and delays have been implicated in the etiology of peak presentation. Seasonality has been more marked in premenopausal women, while delays have been attributed to both patients and health care systems. PATIENTS: A total of 1,411 women who presented with breast cancer to our department were analyzed according to their age, menopausal status, site, stage, grade, ER and PR status, c-erb-2 and Ki-67 (412) during the year. RESULTS: The seasonal variation was statistically significant, but no statistically significant differences were established between corresponding subgroups. CONCLUSION: The seasonal variation most probably reflects temporal, psychosocial and behavioral patterns in the Greek female population. Since we do not have the ability to recognize the actual onset of any cancer and then correlate it with various different independent factors we can not correlate its influence on survival or biological marker manifestations.

Impact of breast cancer surgery on the self-esteem and sexual life of female patients.

Patient satisfaction with cosmetic outcome and the psychological impact of breast cancer surgery were evaluated. A total of 207 patients with primary breast cancer, treated with either breast-conserving surgery (n = 83), modified radical mastectomy without reconstruction (n = 108), or mastectomy with delayed breast reconstruction (n = 16) rated their cosmetic outcome and satisfaction following surgery, and the impact of surgery on their self-esteem and sexual life, by questionnaire. Patients undergoing breast-conserving surgery were most satisfied with their surgery and body image, followed by those treated with mastectomy with delayed reconstruction. Although diagnosis of breast cancer had a negative impact on the psychology of all patients, those undergoing breast-conserving surgery or mastectomy with delayed reconstruction were more satisfied and reported a lower impact on their self-esteem and sexual life versus those who only had mastectomy. Diagnosis of breast cancer has a negative psychological impact on the patient, but the type of surgery has a significant role in post-operative self-esteem and sexual life.

Uncommon locations of hydatid cysts.

Human echinococcosis remains a complex problem that may affect several organs, and requires mostly surgical management. We present two cases with uncommon locations of hydatid cysts that were successfully managed in our hospital during the last two years. The first case was a 62-year-old woman with a multicystic lesion in her right thigh that was radically excised, and histology confirmed the diagnosis of echinococcosis. The second case was a 78-year-old man with multiple large intraabdominal hydatid cysts that required a complex operation, including splenectomy, partial removal of the liver cyst wall and evacuation of the content, and excision of pelvic, mesenteric cysts, and suprahepatic cysts. Both cases have not shown any sign of recurrence to date. Since the disease is still endemic in certain parts of the world and pharmaceutical agents are not radical, specific surgical procedures remain the treatment of choice with good results and acceptable morbidity, mortality and recurrence rates.

Wire localisation biopsy of non-palpable breast lesions: reasons for unsuccessful excision.

Surgical excision following needle-wire localization of nonpalpable, mammographically detected breast lesions is a very valuable diagnostic and therapeutic procedure. No further treatment is usually required after establishing an accurate histological benign diagnosis of indeterminate lesions on preoperative assessment. On the other hand, ductal carcinoma in-situ (DCIS) and early invasive cancer, properly excised, may sometimes require further management depending on specific histologic findings. An uncommon problem of this procedure is the failure to identify, localize or excise the breast lesion. In this review article, factors that contribute to the failed needle localization procedure are presented.

Surgical management of nipple discharge.

PURPOSE: Nipple discharge is reported in 2.5-3% of women with breast carcinoma. Breast carcinoma is found in approximately 8% of surgically treated patients presenting with bloody nipple discharge (ND). METHODS: In the present study 110 women with ND as a presenting symptom were examined. The discharge was spontaneous in 76 and elicited in 11 patients. RESULTS: After surgical intervention benign breast disease was found in 85% of patients. Thirteen women (15%) were found to have malignancy and underwent additional surgery. Cytology of the discharge was positive or suspicious for malignancy in only seven out of 13 patients found to have in situ or invasive carcinoma. CONCLUSION: Women with spontaneous, single duct ND, especially when it is darkish or bloody, should have cytological examination of the fluid and mammography according to their age or additional clinical findings. Most of them will require a microdochectomy, as the possibility of finding a carcinoma among those women is between 10-15%. However, single duct papilloma is the most common cause of bloody discharge.

Paraffinomas of the breast or oleogranulomatous mastitis-a rare entity.

Breast augmentation with the injection of a high-viscosity fluid has been practiced in the past, especially in Asia, resulting in most cases in different varieties of paraffinoma, alternatively known as oleogranulomatous mastitis, a complication of a 'foreign body' reaction type. We report our series of four consecutive cases of destructive paraffinomas that occurred in female patients who had had paraffin injection for cosmetic reasons. Complications due to paraffinoma reactions of breast tissue and skin, as well as progression of the disease and treatment of our patients, are presented here, together with a review of the relevant literature.

Open surgical biopsy for nonpalpable breast lesions detected on screening mammography.

The aim of this retrospective clinical study was the analysis of histologic findings of nonpalpable breast lesions managed by open surgical biopsy. A series of 630 women underwent 664 preoperative localizations of nonpalpable, mammographically detected breast lesions during the last 10-year period. Indications for biopsy were (1) clustered microcalcifications, (2) solid mass, and (3) radiologic parenchymal distortion. The lesions were localized preoperatively using hook-wire methods, and all biopsies were performed under general anesthesia. Histopathology revealed carcinoma in 172 (25.9%) cases; noninvasive in 114 (66.3%) cases and infiltrating in 58 (33.7%) cases. The highest malignancy rate was found in cases with microcalcifications (112 carcinomas out of 323 cases, 34.7%). Lymph node invasion was present in 25% of patients with invasive cancers. The hook-wire localization of nonpalpable breast lesions is a simple, accurate and safe method for detection of early breast cancers. Frozen section is feasible and accurate in the majority of these lesions, and therefore, diagnostic and therapeutic one-step surgical procedures could be performed.

Mondor's disease of the breast: is there any relation to breast cancer?

Ten cases of Mondor's disease of the breast (9 females, 1 male) are described. The diagnosis was based mainly on clinical examination, while breast imaging, used in five cases, was complementary. Most of our cases (9) had complete restoration of the thrombosed subcutaneous breast vein, either spontaneously (4), or after anti-inflammatory medication (5). Only one of our patients had surgical management (vein excision) due to delayed remission. None of our cases was related to breast cancer.

Development of early malignant bilateral breast disease in relation to antidepressant treatment.

The aim of this study is to present two rare cases of young female patients who were under antidepressant medication and developed bilateral breast disease; histology confirmed the noninvasive, malignant nature. The role of that type of agents in the breast pathology is briefly discussed, based on the data of the current literature.

Breast arterial calcifications as an indicator of systemic vascular disease.

PURPOSE: To evaluate the association between mammographically detected arterial calcifications and systemic vascular disease. MATERIAL AND METHODS: The medical records of 77 women who had either breast arterial calcifications or underwent surgery for carotid stenosis, abdominal aortic aneurysm, or femoropopliteal bypass (study groups A and B) were evaluated and compared with 33 women without breast arterial calcifications (group C). Patients in both arms of the study underwent additional vascular tests or mammography. RESULTS: Currently available data indicate that there is a statistically significant correlation between the presence of arterial calcifications on the mammogram and atheromatosis of the carotid or femoral arteries. CONCLUSION: Screening mammograms might be useful in the detection of women at risk for systemic vascular disease.

Metastatic intramammary lymph nodes as the primary presenting sign of breast cancer.

Intramammary lymph nodes (IMLNs) are not uncommon, and are likely to be more frequently identified with the wider use of mammography and breast ultrasound. IMLNs could be invaded by breast cancer influencing the prognosis and the management of patients. The aim of this study is to present the very rare phenomenon of metastatic involvement of these nodes from an occult breast cancer.

Fibroadenomas of the breast: is there any association with breast cancer?

PURPOSE: The experience of our Breast Unit in the diagnosis and treatment of fibroadenomas is presented in this retrospective study, focusing specifically in cancer development within these common benign tumors of young age. MATERIAL-METHODS: 310 women with histologically verified breast fibroadenomas who had surgical management in our Unit over the last 14 years were included in the study. RESULTS: Most of them (n: 255) presented with palpable lesions and had triple assessment preoperatively, while the remaining 55 had nonpalpable lesions and underwent needle-wire localization biopsies. Nine cases had cancer development, usually in situ, within the fibroadenomas (2.9%). CONCLUSION: Coexistence of fibroadenomas and breast cancer is relatively rare, but it should not be ignored by breast surgeons, and patients should be properly informed.

Unusual presentation of renal cell carcinoma metastasis.

The aim of this study is to present an unusual site of renal cell carcinoma metastasis. A 60-year old man presented to our clinic with massive rectal bleeding. A large small intestine metastasis from renal cell carcinoma was evidenced by an elective angiography of the superior mesenteric artery. This metastasis was surgically excised.

Gastrointestinal carcinoid tumors: 10-year experience of a general surgical department.

Gastrointestinal (GI) carcinoids are rare neuroendocrine tumors of great interest because of the multitude of the peptide hormones they produce, their clinical manifestations, the carcinoid syndrome they cause, their biologic behavior, and the methods of their surgical and adjuvant treatment. In this retrospective study, 25 patients with carcinoid tumors admitted and surgically treated in our department during the last 10 years are presented. Most of the cases were located in the ileum (n = 8) and appendix (n = 12). The remaining cases were located in the rectum (n = 2), stomach (n = 1), duodenum (n = 1), and ileocecal valve (n = 1). After tumor resection and postoperative treatment, mainly with somatostatin analogs, our patients had a good recovery, and only five deaths were reported during follow-up. Carcinoids, despite the fact that they are usually silent and diagnosed with advanced stage, have good prognosis and offer, after effective treatment, long survival.

Missed cancers on mammograms: causes and measures of prevention.

Mammographically missed breast cancers remain a major medical and legal issue. In order to clarify causes and methods of the limitations, we present the experience of our Unit on this field. During the years 1999 and 2000, 319 breast cancer patients were admitted for surgical treatment to our Unit. Their files were reviewed in order to identify cases with mammography-related delayed diagnosis. Thirty-three cases of mammographically missed cancers were found (10.3%). The usual reasons for the delayed diagnoses were: retrospectively visible cancers, in benign looking lesions no further action was taken, and lesions with a rather malignant appearance were reported as benign. Missed cancers could be reduced by simple measures such as the full assessment of breast patients with clinical, radiologic, and cytologic-histologic evaluation, the double screening of mammograms, and improvement of the mammographic equipment and technique.