Importance of a careful clinical evaluation in the diagnosis of cystic pancreatic tumors.

INTRODUCTION: Intraductal papillary mucinous neoplasms (IPMN) are a rare group of pancreatic neoplasms. Often are asymptomatic and, when are symptomatic, patients complain sensation of weight in the abdomen or compression at the neighboring structures. In many cases the diagnosis is incidental, during a CT or MR performed for other raisons. CASE REPORT: We report a case of a 59-year-old woman with diagnosis of post-pancreatitis pseudocyst who, instead, was affected by an intraductal papillary mucinous neoplasm (IPMN), treated by us with pancreatoduodenectomy. DISCUSSION: The diagnosis of IPMN has increased in recent years thanks to an improvement in radiological investigation. The study of pancreatic lesions must be very careful and it is absolutely necessary that diagnostic imaging be accompanied by a correct clinical evaluation of the patient. CONCLUSION: A thorough anamnesis is required in patient with history of acute pancreatitis to avoid the mistake of exchanging an IPMN for a pseudocyst.

Thyroid hemiagenesis associated with multinodular goiter and Hashimoto's thyroiditis.

Thyroid hemiagenesis is a rare congenital abnormality in which one of the thyroid lobes is not developed. It can be associated with various thyroid diseases, such as Grave's disease, nodular goiter and thyroid neoplasm, rarely with hyperparathyroidism. We report a case of a 50-year old woman with left thyroid lobe agenesis diagnosed by ultrasonography and scintigraphy. Right thyroidectomy was performed and the histopathological examination showed diffuse hyperplasia, multinodular goiter and Hashimoto's thyroiditis. To our knowledge, this is the first description of multinodular goiter and Hashimoto's thyroiditis in a patient with thyroid hemiagenesis.

Unusual presentation of retroperitoneal Schwannoma: case report.

Schwannoma is a rare tumor that develops from the Schwann cells in the nerve sheath. A 42 years old woman was found incidentally to have a bulky mass in epigastric region. Abdominal ultrasonography CT and MRI have been of aid to know the position and size of the tumor. A massive capsulated retroperitoneal lesion was identified. It moved forward the hepatoduodenal ligament, inferior vena cava laterally and aorta medially. The mass is exte-riorized and detached from adhesions. There were no complications after the operation and the patient was discharged on the fourth post-operative day. The microscopically examina-tion showed features suggestive of Cellular Schwannoma. After 8 months during follow-up, the patient did not report any neurological deficit and control CT did not suggest the presence of recurrent disease.

Cystic pancreatic tumors: should we resect all of them?

OBJECTIVE: Pancreatic cystic tumors are relatively rare tumors and only 1% of them are malignant. They are often asymptomatic and detected as incidental findings through diagnostic imaging. Currently there are no universal guide lines for the correct clinical approach to pancreatic cystic lesions. Cross-sectional imaging demonstrates some typical morphological features that determine the pre-operative diagnosis of the pancreatic cystic lesions (serous or mucinous cystadenoma, intraductal papillary mucinous neoplasms). In addition, endoscopic ultrasonography permits the collection and analysis of the fluid content. The aim of this paper is to describe our case load in the management of pancreatic cystic neoplasms and propose some criteria for choosing between surgical or conservative approaches. PATIENTS AND METHODS: 12 patients with pancreatic cystic neoplasms were retrospectively evaluated. They were studied using cross-sectional imaging modalities (computed tomography and magnetic resonance); endoscopic ultrasonography was performed in 7 patients. RESULTS: In each patient a careful evaluation of several factors (age, comorbidity, imaging features, symptoms, life expectancy) conditioned our clinical decision. Among our 12 patients, surgical resection was performed in 7 cases. DISCUSSION: The treatment of pancreatic cystic lesions is still a dilemma because even in the presence of malignant potential, pancreatic surgery remains very complicated and demolitive. Many factors need to be considered in the management of cystic pancreatic tumors. The most important include histological type, location, size, age and clinical condition of the patient. CONCLUSIONS: A correct multidisciplinary pre-operative diagnosis is mandatory. Surgery should only be performed in selected cases.

[Myasthenia gravis and intestinal resection: is dehiscence likely to occur?]. / Myasthenia gravis e resezione intestinale: deiscenza in agguato?

Experimental and clinical data have proved that anticholinesterase drugs are responsible for vigorous peristaltic contractions and for an increase of the intraluminal pressure, because they determine muscarinic effects on the smooth muscle of the intestine both in small and large intestine. Therefore, a greater incidence of intestinal anastomotic disruption has been supposed when anticholinesterases are used both in the early postoperative period, to reverse curarization, and in myasthenic patients. The authors report a case of a patient with myasthenia gravis who received maximal doses of pyridostigmine and underwent left hemicolectomy and small intestine resection and afterwards total colectomy in order to treat a sigmoid perforated diverticulitis. In the postoperative course an anastomotic leak developed after both surgical operations. The authors believe that pyridostigmine could have had an important role in the pathogenesis of the leak and assert that, when an intestinal resection has to be performed in a myasthenic patient, it could be useful to reduce in the preoperative period the administration of anticholinesterase drugs and always perform a protective ileostomy.

[Chordoma. Diagnostic and therapeutic problems]. / Il cordoma. Problematiche diagnostiche e terapeutiche.

The chordoma is a rare mesodermic tumor derived from the notochord which arises and growths inside the vertebral bodies. It is a slow development tumor with late clinical manifestations, rarely metastatic often with local reoccurrences. The treatment of choice of this tumor is surgical and the access must be individualized to the single clinical case: anterior, posterior or combined antero-posterior respect to the spine. Recently videolaparoscopy has been proposed when an anterior approach is indicated without increased morbidity or mortality. Chemotherapy is not indicated because low tumoral responsness. Radiotherapy is indicated as a palliative procedure when a surgical approach ca't be radical. Its application is useful to treat pains and to control the post-operative course increasing the disease-free interval. The authors report the case of an old symptomatic lady with a chordoma in the sacral region. The patient underwent subtotal absportation an anterior transperitoneal approach. Because the extension of the tumor, its biological characteristics and the patient's age the authors adopted this less invasive approach.

[Primary localization of a hydatid cyst in the major dorsal muscle: report of a case]. / Localizzazione muscolare primaria di cisti idatidea del gran dorsale: caso clinico.

A case of primary hydatidosis of major muscle dorsal is reported. Hydatid cyst, though known to occur in many areas of the body, is rare in skeletal muscle. Echinococcosis of muscle is caused by the larval stage of Echinococcus granulosus or, rarely, by the more aggressive Echinococcus multilocularis. Although Echinococcus is the most common cause of liver cyst, hydatidosis of muscle appears to be uncommon, as muscle is involved in only 3% of echinococcal infection. We report a case of a 65 year old woman, of rural origin, with an infestation of the major muscle dorsal. We discuss the serologic and instrumental diagnosis, methods and the hypothesis of a primary muscular localization and surgical and clinical management of these atypical lesion. This authors recommend total pericystectomy Postoperative results were satisfying: no recurrence but one was found at follow up.

[Primary carcinoma of the medium and distal third of the biliary tract. Personal experience in diagnosis and treatment]. / Carcinoma primitivo del terzo medio e distale della via biliare principale. Diagnosi e trattamento nella nostra esperienza.

A group of 36 patients, observed between 1985 and 1995, with primary carcinoma localized in the medium and distal third of biliary tract is presented. Sixteen patients (44.4%) have undergone radical surgical treatment and the other twenty (55.5%) received a palliative procedure with an average survival of 33.7 months and 8.8 months for the first and second group respectively. The actual location of the tumor was obtained by ERCP and its final stadiation occurred during operation mainly trough intraoperative ultrasonography. The preoperative biliary drainage led to a better postoperative outcome and to a better prognosis. In the case where the tumor was localized only in the third medium of the biliary tract, a limited resection of the biliary tract with Roux's reconstruction was carried out. Otherwise in the cases where the lesion was localized in the border between the medium and distal third and in the distal tract, a duodenocephalopancreasectomy was performed. Even if this is a group of lesions with a poor prognosis, when it is possible to have an early diagnosis it is necessary to carry out an aggressive surgical treatment considering the higher percentage of survival compared to any other palliative procedure.

Surgical treatment of anterior callosal tumors.

OBJECTIVE: Thirteen patients with neoplasm of anterior corpus callosum have undergone our observation during the last two years. METHODS: For the diagnosis, all the patients underwent TC, NMR and stereotactic biopsy. In 6 cases with glioblastomas, a radiation treatment was adopted. The other 7 patients underwent total surgical treatment in 5 cases, and partial in 2 cases, as documented by postoperative contrast-enhanced CT scanning. Histologically, there were: 3 glioblastomas, 1 grade III astrocytoma, 1 neuroblastoma (PNET), 2 pilocytic astrocytomas. RESULTS: Neuropsychological tests carried out on the 5 patients still living showed persistent disturbances of verbal memory in all five and disturbances of verbal phonological fluency in 3 cases. No patient presented apraxia, dysgraphia and dyslexia. CONCLUSIONS: Thus, no severe neuropsychological deficits developed after surgical treatment of anterior callosal tumors.