Neuroendocrine Breast Carcinoma: Interesting Images of an Underdiagnosed Entity.

Breast cancer is the most common type of cancer of the female gender. A rare subtype of breast cancer is the invasive breast carcinoma (IBC) with neuroendocrine (NE) differentiation. Its incident is believed to be 0.1% to 5% of all breast cancers. We report a rare case of a 66-year old woman who presented with an isolated nodule of the left breast. The patient underwent modified radical mastectomy. Pathology revealed invasive breast carcinoma with neuroendocrine differentiation. Invasive breast carcinoma is an extremely rare group of neoplasms, the exact frequency of which cannot be determined with current data. Therefore, it is necessary for future studies to focus on the pathophysiology of this subtype of breast cancer and on the potential therapeutic approaches.

Pharmaceutical Management of Secondary Hyperparathyroidism and the Role of Surgery: A 5-Year Retrospective Study.

Background and Objectives: Secondary hyperparathyroidism (SHPT) poses a common condition among patients with chronic kidney disease (CKD) due to the chronic stimulation of the parathyroid glands as a result of persistently low calcium levels. As a first option for medical treatment, vitamin D receptor analogs (VDRAs) and calcimimetic agents are generally used. Apart from cinacalcet, which is orally taken, in recent years, another calcimimetic agent, etelcalcetide, is being administered intravenously during dialysis. Materials and Methods: In a 5-year retrospective study between 2018 and 2023, 52 patients undergoing dialysis were studied. The aim of this study is to highlight the possible effects and/or benefits that intravenously administered calcimimetic agents have on CKD patients. A total of 34 patients (65.4%) received cinacalcet and etelcalcetide while parathormone (PTH) and calcium serum levels were monitored on a monthly basis. Results: A total of 29 out of 33 patients (87.9%) that received treatment with etelcalcetide showed a significant decrease in PTH levels, which rose up to 57% compared to the initial values. None of the included patients needed to undergo parathyroidectomy (PTx) due to either extremely high and persistent PTH levels or severe side effects of the medications. It is generally strongly advised that parathyroidectomies should be performed by an expert surgical team. In recent years, a significant decrease in parathyroidectomies has been recorded globally, a fact that is mainly linked to the constantly wider use of new calcimimetic agents. This decrease in parathyroidectomies has resulted in an important decrease in complications occurring in cervical surgeries (e.g., perioperative hemorrhage and nerve damage). Conslusions: Despite the fact that these surgical complications cannot be easily compared to the pharmaceutical side effects, the recorded decrease in parathyroidectomies is considered to be notable, especially in cases of relapse where a difficult reoperation would be considered based on previously published guidelines.

Tertiary hyperparathyroidism masking an atypical parathyroid tumor.

Atypical parathyroid tumors represent a group of parathyroid neoplasms of uncertain malignant potential. In view of preoperative diagnostic difficulties, suspicious features for malignancy may guide the surgeon to perform a radical surgical approach.

Frequency of Thyroid Microcarcinoma in Patients Who Underwent Total Thyroidectomy with Benign Indication-A 5-Year Retrospective Review.

Background and Objectives: Incidental thyroid cancers (ITCs) are often microcarcinomas. The most frequent histologic type is a papillary microcarcinoma. Papillary thyroid microcarcinomas are defined as papillary thyroid tumours measuring less than 10 mm at their greatest diameter. They are clinically occult and frequently diagnosed incidentally in histopathology reports after a thyroidectomy. The aim of this study is to evaluate the rate of papillary thyroid microcarcinomas (PTMC) in patients who were thyroidectomised with indications of benign disease. Materials and Methods: We retrospectively evaluated the histological incidence of PTMC in 431 consecutive patients who, in a 5 year period, underwent a thyroidectomy with benign indications. Patients with benign histology and with known or suspected malignancy were excluded. Results: Histopathology reports from 540 patients who underwent a total thyroidectomy in our department between 2016 and 2021 were reviewed. A total of 431 patients were thyroidectomised for presumed benign thyroid disease. A total of 395 patients had confirmed benign thyroid disease in the final histopathology, while 36 patients had incidental malignant lesions (33 PTMC-7.67%, one multifocal PTC without microcarcinomas-0.23%, two follicular thyroid carcinoma-0.46%). Out of the PTMC patients, 29 were female and four were male (7.2:1 female-male ratio). The mean age was 54.2 years old. A total of 24 out of 33 patients had multifocal lesions, 11 of which co-existed with macro PTC. Nine patients had unifocal lesions. A total of 21 of these patients were initially operated on for multinodular goitre (64%), while 13 were operated on for Hashimoto/Lymphocytic thyroiditis (36%). Conclusions: PTMC-often multifocal-is not an uncommon, incidental finding after thyroidectomy for benign thyroid lesions (7.67% in our series) and often co-exists with other incidental malignant lesions (8.35% in our series). The possibility of an underlying papillary microcarcinoma should be taken into account in the management of patients with benign-especially nodular-thyroid disease, and total thyroidectomy should be considered.

A Unique Case of Appendiceal Intussusception (Inversion): A Case in Bloom.

A 40-year-old female patient presented to a secondary facility with dull lower abdominal pain and a persistent low-grade fever. Her laboratory results showed elevated inflammation markers. A CT scan revealed two abscesses in the lesser pelvic region in direct contact with the apex of the appendix, the posterior wall of the uterus, and the right-side appendages. The patient responded well to intravenous antibiotics, and an MRI scan revealed the cause to be an appendiceal rupture. The patient was scheduled for an appendectomy. The procedure started laparoscopically but had to be converted to an open one with a midline infra-umbilical incision in order to protect the right appendages. A standard appendectomy was conducted, and the histology report revealed rupture of the appendix with concomitant wall inversion in the context of fibrous adhesions as well as obstruction due to a fecalith. Patient recovery and follow-up were excellent. Acute appendicitis, while frequently encountered in surgical practice, can present a diagnostic conundrum when it manifests in an atypical manner. This unique form of inversion appeared to confer a protective role against peritonitis, primarily through the mechanism of obstruction occurring centrally to the rupture. We suggest that this case should be included in current classifications as a partial inversion of the appendix after rupture and inflammation.

The role of prophylactic parathyroidectomy during thyroidectomy for MTC in patients with MEN2A syndrome.

AIM: To define the role of prophylactic parathyroidectomy in the surgical treatment of medullary thyroid carcinoma (MTC) in multiple endocrine neoplasia type IIa (MEN2A) syndrome through a literature review.

Be(a)ware of Leukocytosis in Papillary Thyroid Cancer.

Leukocytosis can be present at any time during various malignancies. A 42-year-old male was admitted to our department for surgical management of his metastatic papillary thyroid cancer. Persistent white blood cell (WBC) elevation with left shift led to a thorough investigation. Having excluded other causes, leukocytosis was attributed to thyroid cancer itself. Positive immunostaining for IL-6 and CEA, as well as elevated serum levels, established this connection.

Surgical Significance of Berry's Posterolateral Ligament and Frequency of Recurrent Laryngeal Nerve Injury into the Last 2 cm of Its Caudal Extralaryngeal Part(P1) during Thyroidectomy.

Background and Objectives: Recurrent laryngeal nerve injury is one of the major complications of thyroidectomy, with the lateral thyroid ligament (Berry's ligament) being the most frequent site of nerve injury. Neuromonitoring during thyroidectomy revealed three possible anatomical regions of the recurrent laryngeal nerve P1, P2, and P3. P1 represents the recurrent laryngeal nerve's caudal extralaryngeal part and is primarily associated with Berry's ligament. The aim of this systematic review is to identify the anatomical region with the highest risk of injury of the recurrent laryngeal nerve (detected via neuromonitoring) during thyroidectomy and to demonstrate the significance of Berry's ligament as an anatomical structure for the perioperative recognition and protection of the nerve. Materials and Methods: This study conducts a systematic review of the literature and adheres to all PRISMA system criteria as well as recommendations for systematic anatomical reviews. Three search engines (PubMed, Scopus, Cochrane) were used, and 18 out of 464 studies from 2003-2018 were finally included in this meta-analysis. All statistical data analyses were performed via SPSS 25 and Microsoft Office XL software. Results: 9191 nerves at risk were identified. In 75% of cases, the recurrent laryngeal nerve is located superficially to the ligament. In 71% of reported cases, the injury occurred in the P1 area, while the P3 zone (below the location where the nerve crosses the inferior thyroid artery) had the lowest risk of injury. Data from P1, P2, and P3 do not present significant heterogeneity. Conclusions: Berry's ligament constitutes a reliable anatomical structure for recognizing and preserving recurrent laryngeal nerves. P1 is the anatomical area with the greatest risk of recurrent laryngeal nerve damage during thyroidectomy, compared to P2 and P3.

A Review of the Significance in Measuring Preoperative and Postoperative Carcinoembryonic Antigen (CEA) Values in Patients with Medullary Thyroid Carcinoma (MTC).

Background and Objectives: Medullary thyroid carcinoma (MTC) accounts for 1-2% of all thyroid malignancies, and it originates from parafollicular "C" cells. Carcinoembryonic antigen (CEA) is a tumor marker, mainly for gastrointestinal malignancies. There are references in literature where elevated CEA levels may be the first finding in MTC. The aim of this study is to determine the importance of measuring preoperative and postoperative CEA values in patients with MTC and to define the clinical significance of the correlation between CEA and the origin of C cells. Materials and Methods: The existing and relevant literature was reviewed by searching for articles and specific keywords in the scientific databases of PubMedCentraland Google Scholar (till December 2020). Results: CEA has found its place, especially at the preoperative level, in the diagnostic approach of MTC. Preoperative CEA values >30 ng/mL indicate extra-thyroid disease, while CEA values >100 ng/mL are associated with lymph node involvement and distant metastases. The increase in CEA values preoperatively is associated with larger size of primary tumor, presence of lymph nodes, distant metastases and a poorer prognosis. The clinical significance of CEA values for the surgeon is the optimal planning of surgical treatment. In the recent literature, C cells seem to originate from the endoderm of the primitive anterior gut at the ultimobranchial bodies' level. Conclusions: Although CEA is not a specific biomarker of the disease in MTC, itsmeasurement is useful in assessing the progression of the disease. The embryonic origin of C cells could explain the increased CEA values in MTC.

Cardiopulmonary Arrest Caused by Large Substernal Goiter-Treatment with Combined Cervical Approach and Median Mini-Sternotomy: Report of a Case.

INTRODUCTION: Substernal goiter is usually defined as a goiter that extends below the thoracic inlet or a goiter with more than 50% of its mass lying below the thoracic inlet. Substernal goiters may compress adjacent anatomical structures causing a variety of symptoms. CASE REPORT: Here we report a rare case of a 75-year-old woman presenting with cardiac arrest caused by acute respiratory failure due to tracheal compression by a substernal goiter. DISCUSSION: Substernal goiters can be classified as primary or secondary depending on their site of origin. Symptoms are diverse and include a palpable neck mass, mild dyspnea to asphyxia, dysphagia, dysphonia, and superior vena cava syndrome. Diagnosis of substernal goiter is largely based on computed tomography imaging, which will show the location of the goiter and its extension in the thoracic cavity. Surgery is the treatment of choice for symptomatic patients with substernal goiter. The majority of substernal goiters are resected through a cervical approach. However, in approximately 5% of patients, a thoracic approach is required. The most important factor determining whether a thoracic approach should be used is the depth of the extension to the tracheal bifurcation on CT imaging. CONCLUSION: Cardiac arrest appearing as the first symptom of a substernal goiter is a very rare condition and should be treated by emergency thyroidectomy via a cervical or thoracic approach depending on the CT imaging findings.

The Impact of Covid-19 on Surgical Training and Outcomes: A Multicenter Experience (Greece and Romania).

BACKGROUND: The COVID-19 pandemic has posed unprecedented challenges to health systems worldwide-in delivering care to patients and in maintaining training of their care providers. Surgical specialties have particularly struggled to maintain sufficient levels of training as we have seen significant reductions in the number of surgical beds, operating lists and redeployment of surgical staff to COVID-19 departments or Intensive Treatment Units. METHODS: Comparison of the number of surgical operations performed between January 1st 2019 and December 31st 2020 in 3 surgical departments in Romania (Craiova, Timisoara and Bucharest) and 1 surgical department in Thessaloniki, Greece. Cases were compared on a month to month basis, both elective and emergency operations were included and divided into three main categories based on severity (Minor, Medium, Major). RESULTS: Between 2019 and 2020, there was a 37.04% decrease in the number of surgical procedures, 36.95% for open procedures and 37.20% for laparoscopic procedures. Statistically significant overall reduction was observed in all three centers for both open and laparoscopic operations. In all centers, a statistically significant reduction in medium severity procedures was also observed. CONCLUSION: Globally felt detrimental effect on surgical training, patient contact and mental well-being reflected similarly across surgical specialties in both countries.

Lymph node mapping helps in R0 resection for anaplastic thyroid carcinoma-report of a case with prolonged survival.

Anaplastic thyroid carcinoma is a rare tumor, consisting 1-2% of all thyroid malignancies and presenting a high mortality rate. Median survival for patients undergoing primary surgery is approximately 6.6 months. We present a case of a patient treated with R0 resection, including total thyroidectomy and lymphadenectomy of levels III, IV, VI and VII after cervical lymph node mapping, oral 131I administration, and radiotherapy. Proper preoperative research, R0 resection and relatively early diagnosis, led to good prognosis, as the patient is currently totally disease-free, twelve months postoperatively.

Squamous cell carcinoma arising from chronic sacrococcygeal pilonidal disease: a case report.

BACKGROUND: Sacrococcygeal pilonidal disease is a chronic, well-recognized entity, characterized by the recurrent formation of an abscess or draining sinus over the sacrococcygeal area. It is one of the most common surgical problems. Rarely, chronic inflammation and recurrent disease leads to malignant transformation, most commonly to squamous cell carcinoma (SCC). CASE PRESENTATION: We describe an extremely unusual case of SCC developing in a 60-year-old patient with a chronic pilonidal sinus complicated by an anal fistula. After wide surgical excision of the pilonidal sinus and fistulas and because of the poor healing process 6 months later, colonoscopy and a percutaneous fistulography were performed, revealing an anal canal-pilonidal fistula. Patient was treated with a more radical surgical resection with a prophylactic loop colostomy, but healing was not accelerated. Multiple biopsies were then taken from the surgical site at the time, which revealed the development of SCC. CT and MRI imaging techniques revealed SCC partial invasion of the coccyx and sacrum. As a result, aggressive surgical approach was decided. Histological examination revealed moderately to poorly differentiated SCC, and the patient was treated with adjuvant radiation therapy postoperatively. Nine months later, recurrence was found in the sacrum and para-aorta lymph nodes and the patient died shortly after. We discuss the clinical features, pathogenesis, treatment options, and prognosis of this rare malignant transformation. CONCLUSIONS: The development of SCC in chronic pilonidal disease is a rare but serious complication. Symptoms are usually attributed to the sacrococcygeal pilonidal disease (SPD), and diagnosis is often made late by histological examination of biopsies. Malignant transformation should be suspected in chronic SPD with recurrent episodes of inflammation, repeated purulent discharge, poor healing, and chronic complex fistulas.

Adrenal Gland Lymphangiomas.

Lymphangiomas of the adrenal glands (ALs) are benign vascular lesions. Approximately, 53 cases have been reported in the literature. The current study reviews and analyzes the clinical and pathologic features of all reported ALs and additionally illustrates a typical case of adrenal lymphangioma (AL). In order to perform the review analysis, a search of the international literature for ALs in adults was conducted. Thirty-eight related articles were found. Clinical and pathological information were obtained for all the reported cases and a database was created. ALs were detected more frequently in women than men. The mean age of occurrence was 39.5 years, while their mean size was 8.86 cm. Fifty-nine percent of ALs were right-sided. Size and localization were responsible for the presenting symptoms, though 30.4 % were asymptomatic. Diagnosis was made postoperatively in all cases by histological results. ALs are rare and benign lesions. They usually present as an incidental finding after abdominal imaging. The diagnosis is made after the surgical removal by histological and immunohistochemical examinations.

Laparoscopic spleen-preserving distal pancreatectomy in a solitary true pancreatic cyst.

BACKGROUND: Solitary true pancreatic cysts (STPCs), or epithelial cysts, are benign lesions that are extremely rare in adult patients. Advances in radiographic techniques have improved the ability to identify pancreatic cystic lesions. We report a case of a large and symptomatic STPC in a 47-year-old female patient who was treated successfully with spleen-preserving laparoscopic distal pancreatectomy. We also review the clinical and pathologic features of all reported STPCs within the past 25 years. DATABASE: To compose the review, we did a search of the international literature for STPCs that had occurred in adults. Fourteen related articles were found describing cases of STPCs. Clinical and pathologic information was collected for all of the reported pancreatic cysts, and a database was formed. STPCs are detected more frequently in women than in men. The mean age of occurrence is 43.2 years, and the mean cyst size is 5.6 cm. Fifty percent of true cysts are located in the head of the pancreas. Size and site are responsible for the symptoms caused, although 22.8% were asymptomatic. Diagnosis was made postoperatively in all cases by histopathologic studies. No case of malignancy was reported in any STPC. CONCLUSIONS: STPCs are rare and benign lesions commonly discovered incidentally during abdominal imaging. Surgical treatment is considered the appropriate therapy for large and symptomatic STPCs. The definitive diagnosis is established by histopathologic and immunohistochemical studies.

Small bowel perforation due to CMV enteritis infection in an HIV-positive patient.

BACKGROUND: Cytomegalovirus infection of the gastrointestinal tract is common and is more often seen in patients with acquired immunodeficiency syndrome (AIDS). Although small bowel infection is less common than infection of other parts of the gastrointestinal system, it may lead to perforation, an acute complication, with dreadful results. CASE PRESENTATION: This article reports a case of Cytomegalovirus ileitis with multiple small bowel perforations in a young man with human immunodeficiency virus (HIV) infection. The patient developed abdominal pain with diarrhea and fever, and eventually acute abdomen with pneumoperitoneum. The patient had poor prognosis and deceased despite the prompt surgical intervention and the antiviral therapy he received. At pathology a remarkable finding was the presence of viral inclusions in smooth muscle fibers. The destruction of muscle cells was the main cause of perforation. CONCLUSION: Morbidity and mortality associated with perforation from CMV enteritis in AIDS patients are high and the life expectancy is short. Cytomegalovirus disease is multifocal; therefore, excision of one portion of the gastrointestinal tract may be followed by a complication elsewhere. Our case elucidate that muscle cell destruction by the virus is a significant cause leading to perforation.

Necrotizing cellulitis of the abdominal wall, caused by Pediococcus sp., due to rupture of a retroperitoneal stromal cell tumor.

INTRODUCTION: Soft tissue necrotizing infections are a significant cause of morbidity and mortality. The aim of this study is to present a patient with necrotizing infection of abdominal wall resulting from the rupture of a retroperitoneal stromal tumor. PRESENTATION OF CASE: We present a 60-year-old Caucasian male patient with necrotizing infection of abdominal wall secondary to the rupture of a retroperitoneal stromal tumor. The patient was initially treated with debridement and fasciotomy of the anterior abdominal wall. Laparotomy revealed purulent peritonitis caused by infiltration and rupture of the splenic flexure by the tumor. Despite prompt intervention the patient died 19 days later. The isolated microorganism causing the infection was the rarely identified as cause of infections in humans Pediococcus sp., a gram-positive, catalase-negative coccus. DISCUSSION: Necrotizing infections of abdominal wall are usually secondary either to perineal or to intra-abdominal infections. Gastrointestinal stromal cell tumors could be rarely complicated with perforation and abscess formation. In our case, the infiltrated by the extra-gastrointestinal stromal cell tumor ruptured colon was the source of the infection. The pediococci are rarely isolated as the cause of severe septicemia. CONCLUSION: Ruptured retroperitoneal stromal cell tumors are extremely rare cause of necrotizing fasciitis, and before this case, Pediococcus sp. has never been isolated as the responsible agent.

Rupture of right hepatic duct into hydatid cyst.

Echinococcal disease can develop anywhere in the human body. The liver represents its most frequent location. Hepatic hydatid cysts may rupture into the biliary tract, thorax, peritoneum, viscera, digestive tract or skin. We report a rare case with rupture of the right hepatic duct into a hydatid cyst in a woman with known hydatid disease and choledocholithiasis. The increased intra-luminal pressure in the biliary tree caused the rupture into the adjacent hydatid cyst. The creation of the fistula between the right hepatic duct and the hydatid cyst decompressed the biliary tree, decreased the bilirubin levels and offered a temporary resolution of the obstructive jaundice. Rupture of a hydatid cyst into the biliary tree usually leads to biliary colic, cholangitis and jaundice. However, in case of obstructive jaundice due to choledocholithiasis, it is possible that the cyst may rupture by other way around while offering the patient a temporary relief from his symptoms.

Typical image of splenic hydatidosis.

This is a typical case of a splenic hydatid cysts. We present the clinical features, the diagnostic work-up and the management of the disease.