Successful laparoscopic surgical removal of a caesarean scar pregnancy (CSP) using temporary uterine artery ligation.

STUDY OBJECTIVE: To demonstrate a laparoscopic technique to remove a scar pregnancy. DESIGN: Stepwise demonstration of the surgical technique. SETTING: Santa Croce and Carle Hospital, Cuneo. INTERVENTION: Patient B.B. is a woman referred to our center for a suspected cesarean scar pregnancy (CSP) at 9 weeks gestation. CSP occurs approximately in 6% of all ectopic pregnancies. The estimated incidence is reported to be 1:1800 to 1:2500 in cesarean deliveries. Depending on its location, CSP can be categorized as either type 1, if the growth is in the uterine cavity, or type 2, if it expands toward the bladder and the abdominal cavity. If inadequately managed, it can lead to severe complications; most of them are hemorrhagic and can threaten the woman's life. There are several therapeutic approaches: local excision seems to be the most effective choice in type 2 CSP. In expert hands, the laparoscopic approach is perhaps the best surgical choice as tissue dissection, electrosurgical hemostasis, and vascular control can be effectively managed with minimal invasive access. Because severe intraoperative bleeding can occur, retroperitoneal vascular control is mandatory in this surgery. In type 1 CSP curettage, aspiration or hysteroscopic approach can be considered if the CSP is of small dimensions. A hysteroscopic approach can also be helpful in type 2 CSP during the laparoscopic removal, as intrauterine guidance. A potassium chloride local injection can be considered in a preoperative stage in the presence of a fetal heart rate. The systemic administration of methotrexate is usually ineffective as single agent, but it can be useful if administered as adjuvant therapy. Uterine artery embolization can be useful in an emergency setting to manage severe bleeding, but it can lead to complications in subsequent pregnancies and, more rarely, to premature ovarian failure. Considering poor bleeding at presentation, feasible dimensions, and the woman's desire for future pregnancy, ultrasound-guided aspiration and curettage was attempted. Because endouterine removal was incomplete, methotrexate injection was proposed as adjuvant therapy, but the administration was postponed as the patient tested positive for coronavirus disease 2019. A month later, beta-human chorionic gonadotropin level dropped from over 16 000 to 271 mU/mL, so an ultrasound and biochemical follow-up was performed. A month later, despite a low beta-human chorionic gonadotropin value, an increase in dimensions was observed at ultrasound, so surgical laparoscopic removal was offered. In this video article, laparoscopic removal of scar pregnancy is discussed in the following surgical steps: (1) Temporary closure of uterine arteries at the origin, using removable clips. (2) Retroperitoneal dissection to safely manage the scar pregnancy. (3) Dissection of the myometrial-pregnancy interface. (4) Double layer suture on the anterior uterine wall. CONCLUSION: Laparoscopic surgical management is a very effective surgical approach to remove CSP. Knowledge of retroperitoneal dissection and vascular control is necessary to carry out this surgical intervention safely and effectively.

A Rare Case of Fatal Self-Poisoning With Sodium Nitrite: Autopsy and Toxicological Findings.

ABSTRACT: Fatal sodium nitrite poisonings are unusual in the forensic setting. Suicide by poisoning includes drug overdose, the inhalation of toxic gasses, and poisoning from pesticides and chemical substances. Sodium nitrite is an inorganic compound usually seen as a crystalline powder that is very water soluble. Sodium nitrite is used mostly in the food industry (as a preservative) and in medical field (as an antidote to cyanide poisoning), and if ingested in large enough amounts, it can be fatal.The ingestion of sodium nitrite can cause severe methemoglobinemia, which is a metabolic disorder characterized by an inability of hemoglobin (which gets oxidized into methemoglobin) to bind (and therefore carry) oxygen. Severe cases of this condition, if not treated, can be fatal.We describe a case of fatal self-poisoning with sodium nitrite; in particular, the article focuses on the autoptic and toxicological investigations that enabled the correct diagnosis to be established.

Selected case from the Arkadi M. Rywlin international pathology slide series: diffuse dendriform pulmonary ossification: report of 2 cases with review of the literature.

Two cases of diffuse dendriform pulmonary ossification (DPO) are presented, one of the secondary type and the other of the idiopathic type. Case 1 was an adult female patient who underwent thoracic surgery to remove a posterior mediastinal bronchogenic cyst, which was discovered on a computed tomography scan performed after an episode of pneumonia when traction bronchiectasis with interstitial lung disease/fibrosis was also suspected in the lungs. Histologic examination performed on the resected lung tissue revealed numerous scattered small osseous spicules on a background of intense interstitial inflammation and fibrosis, leading to further clinical and laboratory investigations and the final diagnosis of DPO secondary to lung involvement by scleroderma. Case 2 was an adult male patient who underwent thoracoscopic exploration after a computed tomography scan, which revealed traction bronchiectasis with linear thickening of the interstitial lung tissue. Histologic examination of the lung tissue specimen revealed numerous osseous spicules in the absence of interstitial septal inflammation. Noteworthy in this case were also some nodules of collagenized tissue similar to those seen in the lungs of patients affected by Ehlers-Danlos syndrome. The absence of any clinical sign or symptoms related to Ehlers-Danlos syndrome attest to the nonspecificity of these pulmonary fibrous nodules. No case of DPO secondary to scleroderma has been reported in the literature so far, although around half of the patients with scleroderma manifest pulmonary diseases. Idiopathic DPO is even rarer, usually discovered postmortem, with only 20 cases diagnosed in life with lung biopsies taken by open surgery or through a thoracoscopic approach. DPO is often misdiagnosed radiologically as bronchiectasis and/or interstitial lung disease/fibrosis.

Chronic myeloproliferative neoplasms with concomitant CALR mutation and BCR::ABL1 translocation: diagnostic and therapeutic implications of a rare hybrid disease.

Myeloproliferative neoplasms (MPNs) are subdivided into Philadelphia (Ph) chromosome-positive chronic myeloid leukemia (CML) and Ph-negative MPNs. BCR::ABL1 translocation is essential for the development and diagnosis of CML; on the other hand, the majority of Ph-negative MPNs are characterized by generally mutually exclusive mutations of Janus kinase 2 (JAK2), calreticulin (CALR), or thrombopoietin receptor/myeloproliferative leukemia (MPL). CALR mutations have been described essentially in JAK2 and MPL wild-type essential thrombocythemia and primary myelofibrosis. Rarely coexisting CALR and MPL mutations have been found in Ph-negative MPNs. BCR::ABL1 translocation and JAK2 mutations were initially considered mutually exclusive genomic events, but a discrete number of cases with the combination of these genetic alterations have been reported. The presence of BCR::ABL1 translocation with a coexisting CALR mutation is even more uncommon. Herein, starting from a routinely diagnosed case of CALR-mutated primary myelofibrosis subsequently acquiring BCR::ABL1 translocation, we performed a comprehensive review of the literature, discussing the clinicopathologic and molecular features, as well as the outcome and treatment of cases with BCR::ABL1 and CALR co-occurrence.

Blunt head trauma in a peculiar case of partial mummification. Murder or accidental event?

The finding of a partially mummified body presenting signs of trauma requires the forensic pathologist to conduct a careful and complex examination; multidisciplinary analysis is often necessary.We report a case where the partially mummified corpse of an elderly man was found in his own home more than seven years after death. Complete post-mortem investigation revealed a cranial fracture and an acute subdural haematoma.An in-depth multidisciplinary analysis provided important information on the modality and cause of death but it was not possible to establish whether the trauma and death resulted from an accidental event or from an assault.

Focal nodular hyperplasia after oxaliplatin-based chemotherapy: A diagnostic challenge.

Chemotherapy could induce benign liver alterations presenting as diffuse or focal lesions mimicking metastases. Oxaliplatin-induced vascular liver injury is described in literature, but the association with FNH-like lesions has been reported in a limited number of cases. We herewith describe the case of a 67-year-old male, who had laparoscopic right-sided hemicolectomy, 8 years ago, because of colonic adenocarcinoma (pT3N0M0) and subsequent adjuvant chemotherapy (capecitabine + oxaliplatin), who referred to the ultrasound service of our Radiology Unit because of abdominal pain. Five-years follow-up was negative for metastases. Ultrasound examination showed 2 small hypoechoic hepatic nodules, in segment VIII and VII, confirmed at CT, suspected for metastases. FDG-PET was negative, and blood tumor markers were within normal ranges. For further evaluation we performed gadoxetic acid (Gd-EOB-DTPA)-enhanced MRI that showed hyperintensity of the nodules in the hepatobiliary phase with central small hypointensity due to a central scar. Considering the previous oxaliplatin-based chemotherapy the findings were compatible with FNHlike lesions and the diagnostic suspicion was confirmed at ultrasound-guided core needle biopsy. Knowledge of the possible occurrence of FNH-like lesions in oncologic setting, along with the detection of typical MRI appearance, is important for appropriate management and may avoid unnecessary biopsy or surgery and reduce patients' anxiety.

A rare case of adrenal ganglioneuroblastoma-intermixed in an adult and a review of literature.

Peripheral neuroblastic tumors are extremely rare in the adult with less just over 20 cases involving adrenal gland described in the literature. We reported herewith the case of a 22-year-old young male who presented with epigastric pain and diarrhea. Imaging studies documented a 3.5cm x 3cm x 4cm solid well-circumscribed right adrenal mass, of heterogeneous structure and with fine calcifications. The lesion turned negative at MIBG scintigraphy. A right robotic-assisted adrenalectomy was performed leading to complete excision of the lesion without complications. Histology was consistent with intermixed stroma-rich ganglioneuroblastoma. A wait-and-see strategy was considered adequate. Two years after diagnosis patient is alive disease-free. Although the definitive diagnosis of a peripheral neuroblastic tumor is obtained after histopathological analysis, CT, and MRI are helpful to further characterize masses and useful in pretreatment risk stratification. Clinicians should be aware of the possibility of GNB development in adult population and its malignant potential.

A rare iatrogenic mesenteric laceration and hemorrhagic shock after colonoscopy. Case report and literature review.

AIM: We report a particular case study of the unexpected death of a 70-year-old caucasian man (affected by crohn's disease) due to the laceration of the ileocolic mesentery and its blood vessels following a colonoscopy procedure carried out only a few hours previously. MATERIAL OF THE STUDY: The autopsy showed that the lacerated blood vessels (i.e. the collateral and terminal branches of the superior mesenteric artery), which run along the section of the intestines between the end of the ileum and the ascending cecum, had led to a severe intra-abdominal hemorrhage and, consequently, fatal hemorrhagic shock. RESULTS: In such cases, both an autopsy and complete histological analysis are essential in order to determine the exact point responsible for the intestinal hemorrhage and to better understand the pathological mechanism involved. DISCUSSION: The unexpected death due to severe peritoneal hemorrhaging following a minimally invasive diagnostic clinical procedure, such as a colonoscopy, is particularly rare in Literature. In fact, amongst the several endoscopy procedures commonly used today, it is one of the safest procedures with the lowest recorded rate of complications. Furthermore, it is an even rarer event that a routine diagnostic colonoscopy can result in a fatality, with only two cases reported. CONCLUSIONS: In the case of sudden death following such a routine diagnostic clinical procedure, the forensic scientist should not disregard the fact that also damage, which appears negligible (caused by the normal procedures used in carrying out a colonoscopy) can actually also result in severe and fatal hemorrhaging. KEY WORDS: Colonoscopy, Fatal hemorrhage, Forensic pathology.

Oncocytic carcinoma of the lacrimal gland in a patient with neurofibromatosis.

Oncocytic carcinoma (OCA) is rare, and although its occurrence in the lacrimal gland has been documented, clinical and histologic data are lacking. The authors report the first case of OCA of the lacrimal gland histologically proven in a patient with neurofibromatosis (NF). An 81-year-old man affected by type 1 NF presented with a 2-year history of left proptosis and visual loss. Orbital CT scan showed a mass in the lacrimal gland fossa infiltrating the globe, lateral rectus muscle, and bone. An incisional biopsy revealed a primary high-grade malignancy, and the patient underwent orbital exenteration followed by postoperative adjunctive radiotherapy. Six months after the operation, the patient was alive, without evidence of recurrent or metastatic disease. OCA is a high-grade neoplasm with infiltrative growth pattern and tendency to recur and metastasize. Its occurrence in association with NF has not been documented before, but clinicians should be aware of this possibility when evaluating proptosis in NF patients. Radical surgical excision, followed by adjunctive radiotherapy, is considered the treatment of choice, but the prognosis remains guarded.

The addition of radiotherapy to chemotherapy does not improve outcome of early stage Hodgkin's lymphoma patients: a retrospective long-term follow-up analysis of a regional Italian experience.

We retrospectively reviewed 139 stage I-II HL patients who were diagnosed and followed up in an Italian northern region (Liguria) from 1995 to 2007, and who received either chemotherapy (CT) alone (mainly doxorubicin, bleomycin, vinblastine, and dacarbazine; ABVD) or a combined modality treatment (chemotherapy + radiotherapy, CT + RT). The two therapeutic groups were comparable for clinical and histologic features. Complete remission rate after CT + RT was higher than what was achieved with CT alone (96% vs. 84%, respectively, p = 0.03). Relapse rate (12%) was the same in both groups and disease-free survival curves were comparable (82% and 83%, p = 0.47). The overall survival of the two therapeutic groups is comparable. No second tumors have been reported among patients receiving chemotherapy alone, whereas a second neoplasia has been diagnosed in four patients (in two cases possibly radiotherapy related) in the CT + RT group (5%, p = 0.09) In conclusion, our retrospective study shows that CT + limited RT is an effective and well-tolerated option for early stage Hodgkin's lymphoma, even if the use of RT is associated with a certain risk of developing a second tumor. However, four to six courses of ABVD can lead to similar, optimal, long-term disease control without exposing patients to the risk of a second neoplasia.

Solitary nodule of the penis as unique manifestation of Rosai-Dorfman disease.

We report the case of a 53-year-old man with a solitary nodule located on the inner surface of the prepuce. The lesion was removed and the final diagnosis was Rosai-Dorfman disease (RDD/sinus histiocytosis with massive lymphadenopathy). This report, being the first case of RDD presenting as a single nodule of the penis, broadens the spectrum of the cutaneous expression of RDD.

Visual loss secondary to orbital apex invasion as the first manifestation of recurrent nasopharyngeal carcinoma.

A 51-year-old white man was referred for evaluation of visual loss in the right eye caused by an apical orbital lesion. His medical history was positive for "lymphoepithelial carcinoma" of the nasopharynx successfully treated with radiotherapy 6 years previously. Cranial CT showed a diffuse orbital mass extending from the pterygopalatine fossa, infiltrating the inferior orbital fissure, the orbital apex, and the cranial cavity. Results from an incisional biopsy of the lesion were consistent with the diagnosis of nasopharyngeal carcinoma, nonkeratinizing lymphoepithelial variant of squamous cell carcinoma. The patient underwent stereotactic radiosurgery, which arrested the tumor progression. Orbitocranial recurrence of nasopharyngeal carcinoma is rare and ocular symptoms may be the first manifestation of the disease.

Robotic wedge resection of a rare gastric perivascular epithelioid cell tumor: A case report.

BACKGROUND: Perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal neoplasm that can arise in many different organs with a broad spectrum of biological behavior, from indolent to aggressive progression. Only ten cases of gastric PEComas have been reported in the English literature, which were treated with endoscopic, laparoscopic, or open resections. Due to its rarity, the optimal surgical management and prognosis of this tumor are still uncertain. CASE SUMMARY: We present a case of robotic wedge resection of a 6.5 cm bleeding lesion of the gastric fundus located 3 cm below the esophago-gastric junction in a 55-year-old man. Biopsy revealed a malignant tumor with epithelioid cells focally positive for muscle markers desmin and smooth muscle actin. In addition, histology revealed that the tumor was positive for HMB-45, melan-A (MART-1), microphthalmia transcription factor and negative for pan-cytokeratin AE1/AE3, CD34, p40, DOG-1, CD117 (c-kit), S100, CD3, CD79a, caldesmon and myogenin. These markers suggested the possibility of a PEComa. The patient underwent a diagnostic laparoscopy via the da Vinci® Si™ system and robotic wedge resection. Final pathology confirmed a malignant gastric PEComa with negative margins. At his 11-mo follow-up visit, the patient remained disease-free. CONCLUSION: Gastric PEComa can be treated with a robotic R0 resection with acceptable postoperative and short-term oncological outcomes.

Sudden Death Secondary to an Undiagnosed B-Cell Lymphoma of the Hypopharynx and Infiltration of the Inferior Constrictor Muscle.

The aim of this presentation was to share an uncommon form of sudden death, suffered by a 64-year-old woman, due to a mechanical obstruction of hypopharynx by an undiagnosed B-cell lymphoma, infiltrating the inferior pharyngeal constrictor muscle. A forensic approach by means of scene investigation, circumstantial data collection, autopsy, and histological and toxicological investigations led to conclude that the cause of death was asphyxia, correlated with B-cell lymphoma of the hypopharynx. The autopsy examination highlighted the presence of a wall thickening, infiltrating, and projecting into the hypopharynx lumen. The histological analysis showed the essential finding of a B-cell lymphoma of the hypopharynx, diffusely infiltrating the inferior pharyngeal constrictor muscle. To conclude, this case demonstrates once more that in the absence of specific data, a thorough forensic investigation including autopsy, histological examination, and circumstantial data collection is mandatory to reach a correct cause of death.

Fatal poisoning by butane sniffing: A forensic analysis and immunohistochemical detection of myocardial hypoxic damage.

Although less widespread than twenty years ago, inhalant abuse remains an on-going problem, whose incidence among U.S. teenagers and young adults ranges from 10 to 15%. Death due to the inhalation of vapor from halogenated hydrocarbons is a well-known phenomenon, yet few cases of fatal butane-gas poisoning have been described. Many cases of volatile substance abuse in prison populations have been reported: drug-addicted inmates often resort to this alternative practice when unable to get their habitual drugs of abuse. A similar pattern occurs especially among adolescents. The study herein described was conducted including all cases of fatal acute intoxication of butane gas examined from 2007 to 2015 at the Institute of Legal Medicine and Forensic Sciences of the University of Genoa. In the absence of overt and specific macroscopic and histological findings indicating cause and pathological mechanism of death, we aimed to assess whether recent cardiac lesions were detectable by way of immunohistochemical (IHC) analysis. Specifically, fibronectin and troponin C expression in myocardial tissues were investigated in deaths from acute butane-gas poisoning so as to better define the underlying pathological mechanisms. IHC findings were indicative of hypoxic cardiac damage. In all cases, positivity to fibronectin and mildly to moderately reduced troponin C expression in cardiac muscle cells were immunohistochemically ascertained.

Fatal disseminated histoplasmosis presenting as FUO in an immunocompetent Italian host.

Histoplasmosis is a relatively rare infectious disease endemic to certain geographic areas such as East Africa, eastern and central United States, western Mexico, Central and South America. Disseminated histoplasmosis has been reported mainly in immunocompromised hosts and in AIDS patients. In this paper we report on a fatal case of undiagnosed disseminated histoplasmosis presenting as fever of unknown origin (FUO) in a 43-year-old Italian woman who, although splenectomized 5years earlier due to a motor vehicle accident, was otherwise immunocompetent. This case report highlights the fact that, even in Europe, histoplasmosis is an emerging sporadic infection which needs be considered in the differential diagnosis of given clinical scenarios. The proposed case is of blatant forensic concern as it addresses the hypothesis of professional responsibility due to a missed diagnosis of histoplasmosis. A timely diagnosis, with appropriate therapies, could have prevented death. The role of the forensic pathologist is also crucial because the post-mortem diagnosis of histoplasmosis (never considered in the differential diagnosis during prior hospitalization) highlights the importance of a meticulous and thorough autopsy to elucidate the cause of death.

Pancreatic metastasis from mycosis fungoides mimicking primary pancreatic tumor.

Mycosis fungoides (MF) is a cutaneous T-cell lymphoma that can undergo local progression with possible systemic dissemination. We report a case of a patient affected by MF with a pancreatic mass that was a diagnostic challenge between primitive tumor and pancreatic metastasis from MF. Clinical setting findings and imaging studies raised the suspicion of a pancreatic primary neoplasm. A diagnostic clue was provided by the combined histomorphologic/immunohistochemical study of pancreatic and cutaneous biopsies, which revealed a pancreatic localization of MF. Considering the rarity of metastatic localization of MF to the pancreas, we next investigated whether chemokine-chemokine receptor interactions could be involved in the phenomenon to provide new insight into the possible mechanisms underlying metastatic localization of MF to the pancreas. Histological analyses of archival pancreatic tissue demonstrated that glucagon-secreting cells of the pancreatic islets expressed the CCL27 chemokine, which may have attracted in our case metastatic MF cells expressing the complementary receptor CCR10.

Renal Leiomyosarcoma. A Report of Two Cases.

BACKGROUND: Leiomyosarcoma represents a rather uncommon malignancy, and reports of cases characterized by a renal genesis are particularly rare. CASES: We describe 2 cases of leiomyosarcoma of the kidney, in a 63-year-old woman and in a 53-year-old man, respectively. Both tumors share a common immunohistochemical profile with a strong positivity for smooth muscle actin, a focal positivity for desmin, and negativity for cytokeratins and other markers. CONCLUSION: We provide a comparison between our findings and the data available in the literature, and we note an interesting relatively long survival in our patients (10 months for the first case and 20 months for the second case).