Management of appendiceal neuroendocrine tumors in the light of new guidelines.

PURPOSE: Appendiceal neuroendocrine tumors (ANETs) are the most common in the appendix, detected in histopathological appendectomy specimens, which are resected for acute appendicitis. If tumor detection does not show signs of metastatic disease or obvious features of carcinoid syndrome, preoperative diagnosis remains a challenge. However, the treatment and follow-up algorithm change over time. In our study, we aimed to present 10 years of diagnostic and management experience. MATERIAL AND METHODS: A retrospective study of all patients who underwent emergency appendectomy, with the intention to treat clinically acute appendicitis at Bakirkoy Dr. Sadi Konuk Hospital (Istanbul, Turkey), was undertaken. Patients with diagnoses other than ANETs were excluded. Age, gender, preoperative clinical findings, operative procedure, and histopathological results identified as ANETs were evaluated. RESULTS: ANETs were detected in 24 patients (0.42%) in the histopathological examination of 5720 appendectomy specimens between December 2011 and October 2020. Mean age of patients was 30 years, with 58.3% female. The majority were located at the tip of appendix (62.5%). Eleven patients (45.83%) were graded as T1, one patient (4.16%) as T2, 11 (41.83%) as T3, and one patient (4.16%) as T4. Secondary hemicolectomy was performed in four patients. Median postoperative follow-up was 43 (17-108) months. CONCLUSION: In addition, ANETs are rare and largely detected by chance; therefore, precise examination of routine appendectomy specimens is essential for diagnosis. Accurate tumor staging, in light of new algorithms, has an important place in follow-up and treatment management.

IgG4 producing POEMS syndrome: A rarely recognized subtype.

Serum IgG4 is typically measured for Immunoglobulin G4-related Disease (IgG4-RD), a fibroinflammatory condition associated with polyclonal increase in serum IgG4. Yet, increased IgG4 may still be monoclonal, and little is known about IgG4 POEMS syndrome. We present a case of 40-year-old male with a mass lesion in the left sacral ala. The mass was composed of non-neoplastic fibrous tissue and dense infiltrate of mature plasmacytes with dense eosinophilic cytoplasm and eccentrically placed nuclei that express monoclonal Lambda free light chains and show diffuse positivity for IgG and IgG4. We discuss clinical manifestations and challenges encountered in the diagnosis and treatment of this rare coexistence.

Effect of metformin and detorsion treatment on serum anti-Müllerian hormonelevels and ovarian histopathology in a rat ovarian torsion model

Background/aim: Adnexal torsion is a common gynaecological emergency, and considered to be a problem mostly in reproductive-age women. To evaluatethe effect of metformin and detorsion treatment on reducing ovarian reserve in an ovarian torsion model. Materials and methods: Twenty-four nonpregnant, Wistar Hannover rats were included in the study. Animals were divided into 3 groups: the control group, the detorsion only group, and the metformin + detorsion group. The first group received only laparotomy. In the second group, ovaries were fixed to the abdominal wall after performing 360° ovarian torsion, followed by detorsion after a 3-h period of ischemia. The third group underwent the same torsion and detorsion procedures as the second group, and received 50 mg/kg metformin by gavage for 14 days. Ovarian damage scores, follicle counts, and AMH levels were evaluated. Results: The total damage score was significantly increased in the detorsion only group compared to the metformin+detorsion and control groups. Pre-operative/post-operative AMH decreases were statistically significant in negative direction in the detorsion only group when compared to the metformin+detorsion and control groups (P = 0.001). Conclusion: Metformin+detorsion treatment may be effective in protecting the ovarian reserve after ovarian torsion.

Cutaneous metastasis in prostate cancer: Two cases with similar clinical findings.

Cutaneous metastasis of prostate cancer is rare. Lesions in this type of skin metastasis are usually seen as suprapubic nodules. Here, we presented two cases with skin metastases of prostate cancer characterized by grouped cutaneous and subcutaneous nodules.

The First Successful Case of Transoral Robotic Surgery in a Patient with Sialadenoma Papilliferum.

INTRODUCTION: Sialadenoma papilliferum (SP) is a rare benign tumor, which originates from the minor salivary gland. It occurs at sites that have minor salivary glands, such as the palate, retromolar pads, buccal mucosa, and lips. The most common location for tumor development is on the hard palate. A differential diagnosis consists of ruling out other salivary gland tumors. Transoral robotic surgery (TORS) is a new technology used in head and neck surgery within certain centers around the world. CASE REPORT: Herein, we present the first successful case of SP tumor removal by TORS. CONCLUSION: This particular case highlights the identification of this rare tumor in an unusual location. Furthermore, it demonstrates the utilization of TORS, leveraging the superior visualization to obtain excellent local control with minimal acute and long-term morbidity, in comparison to conventional transoral surgical approaches.

Effects of mesenchymal stem cells and VEGF on liver regeneration following major resection.

PURPOSE: The study aims to determine the effects of mesenchymal stem cell (MSC) therapy and a combination therapy of MSCs transfected with vascular endothelial growth factor (VEGF) for liver regeneration after major resection. METHODS: Thirty-eight rats were divided into four groups: group 1: control (sham operation); group 2: control (70 % hepatic resection); group 3: 70 % hepatic resection + systemically transplanted MSCs; and group 4: 70 % hepatic resection + systemically transplanted MSCs transfected with the VEGF gene. MSCs were injected via the portal vein route in study groups 3 and 4. Expression levels of VEGF, fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), epidermal growth factor (EGF), transforming growth factor (TGF), hepatocyte growth factor (HGF), and augmenter of liver regeneration (ALR) were analyzed in the remnant liver tissue. We investigated the levels of angiogenic factors, VEGF-receptor, angiopoietin-1 (Angpt1) and Angpt2. Biochemical parameters of liver function in blood samples were measured and a histologic assessment of the livers was performed. The postoperative liver weight and volume of each rat were measured 14 days after surgery. RESULTS: The expression levels of all measured growth factors were significantly increased in groups 3 and 4 compared to the control groups. The levels of Angpt1 and Angpt2 correlated with levels of VEGF and thus were also significantly higher in the study groups. There were significant differences between the estimated liver weights and volumes of group 4 and the resected controls in group 2. With the exception of portal inflammation, levels of all histological parameters were observed to be higher in MSC-treated groups when compared with the resected controls in group 2. CONCLUSIONS: Transplanted stem cells and MSCs transfected with VEGF significantly accelerated many parameters of the healing process following major hepatic resection. After the injection of MSCs and VEGF-transfected MSCs into the portal vein following liver resection, they were engrafted in the liver. They increased bile duct and liver hepatocyte proliferation, and secreted many growth factors including HGF, TGFß, VEGF, PDGF, EGF, and FGF via paracrine effects. These effects support liver function, regeneration, and liver volume/weight.

Symplastic Glomus Tumor.

Glomus tumors showing nuclear pleomorphism without any other malignant features have been defined as symplastic glomus tumors. This type of glomus tumor is rarely encountered. Another case of symplastic glomus tumor is described in this study. A 37-year-old woman referred to the hospital with the complaint of a palpable tender nodule on the fourth finger tip of her left hand. The lesion had been present for about a year and aggravation of tenderness upon cold exposure was conspicuous. It was a 0.5 cm well circumscribed lesion with round to cuboidal epithelioid cells showing high grade nuclear pleomorphism. Nests of cells more uniform in shape and showing punched out nucleus representative of typical glomus tumor could also be observed. Immunohistochemical study showed expression of smooth muscle actin, caldesmon and vimentin. Ki-67 labeling index was undetectable. Investment of tumor cells was shown by type IV collagen. In contrast to its atypical cellular morphology, symplastic glomus tumor clinically behaves benign, and it is important to differentiate it from malignant glomus tumor as well as other primary or metastatic malignant tumors.

The Epidemiology of Non-Melanocytic Benign and Malignant Skin Tumors in Pediatric Patients Attending to the Dermatology Department.

BACKGROUND: Non-melanocytic skin tumors are rarely seen in pediatric patients; although they are mostly benign, they remain to be elucidated by histopathological examination. The objective of the study was to describe the epidemiology of non-melanocytic skin tumors in children attending to our dermatology department. METHOD: The histopathologic studies of all skin punch and excisional biopsies of children up to 16 years old referred to our dermatology department between January 2007 and January 2012 were reviewed retrospectively. Melanocytic tumors and cystic and infectious lesions were excluded. Age, sex, location, and histopathologic diagnosis were recorded. The skin tumors were categorized. RESULTS: A total of 4,126 skin tumors were analyzed histopathologically, and 203 of the lesions were from children up to 16 years of age. Ninety-seven of the lesions from 91 patients were non-melanocytic skin tumors. Forty-seven (51.64%) were male, 44 (48.36%) were female, and mean age was 10.55 ± 4.31 years. Malignant tumor was 1.03% (one tumor) and benign tumors were 98.97% (96 tumors) of all. The most frequent non-melanocytic skin tumor was pilomatricoma with 22 lesions (22.68%), followed by pyogenic granuloma with 18 lesions (18.54%), and nevus sebaceous with 10 (10.3%) lesions. Cutaneous leukemic infiltrate was found to be the only malignant skin tumor in the study group. The most frequently affected age group was children aged > 13 to ≤ 16 years, which included 38 patients (41.7%). The majority of lesions were on head and scalp (32 tumors, 32.96%), followed by trunk (28 tumors, 28.84%) and upper limbs (22 tumors, 22.75%). CONCLUSION: The ratio of malignant to benign skin tumors in pediatric patients is found to be small. Pilomatricoma, pyogenic granuloma and nevus sebaceous are found to be the most frequent non-melanocytic skin tumors of children. The ratio of malignant tumors is very rare.

Marjolin's Ulcer Presenting with In-Transit Metastases: A Case Report and Literature Review.

Marjolin's ulcer is an aggressive cutaneous malignancy common in previously traumatized or chronically inflamed skin. It has high regional metastasis and fatality rates. Our patient presented with subcutaneous nodules and ulcerations on the right limb. He had a history of osteomyelitis of the fifth toe. Histopathological examination of the nodule and ulceration demonstrated squamous cell carcinoma. The nodules and ulcerations were in-transit metastases of Marjolin's ulcer. Here, we present a case of squamous cell carcinoma arising at a site of a chronic osteomyelitis with resultant in-transit metastases.

Solid-pseudopapillary neoplasm of the pancreas: Clinicopathologic and immunohistochemical analysis of nine cases.

BACKGROUND: Solid-pseudopapillary neoplasm (SPPN) of the pancreas is a distinctive tumor of low malignant potential with a predilection for female patients in the second and third decades of life. We studied nine cases of SPPN of the pancreas and reviewed the literature concerning these uncommon tumors. MATERIALS AND METHODS: A total of 7 cases of SPPN located in the tail of the pancreas and two located in the head of the pancreas were presented. Distal pancreatectomy in three patients and distal pancreatectomy with splenectomy in two patients Whipple's operation in four patients were performed. Histological diagnosis was made by performing hematoxylin-eosin and periodic acid-Schiff staining, immunohistochemical staining. Follow-up of the patients was between 2 months and 12 years. RESULTS: Computed tomography and magnetic resonance imaging were found as equivocal for diagnosis. Mass containing cystic and solid areas were not characteristic but raised suspicion of SPPN. Pathologic examination showed SPPN in all patients. No metastasis or recurrence was detected during follow-up. CONCLUSIONS: Solid-pseudopapillary neoplasm is a relatively rare tumor, and patients tend to survive for a long period. Preoperative imaging is not characteristic. Pathologic examination is the mainstay in the diagnosis. Complete surgical removal is the best choice of treatment.

Microvascular anastomosis using fibrin glue and venous cuff in rat carotid artery.

Conventional anastomosis with interrupted sutures can be time-consuming, can cause vessel narrowing, and can lead to thrombosis at the site of repair. The amount of suture material inside the lumen can impair the endothelium of the vessel, triggering thrombosis. In microsurgery, fibrin sealants have the potential beneficial effects of reducing anastomosis time and promoting accurate haemostasis at the anastomotic site. However, there has been a general reluctance to use fibrin glue for microvascular anastomoses because the fibrin polymer is highly thrombogenic and may not provide adequate strength. To overcome these problems, a novel technique was defined for microvascular anastomosis with fibrin glue and a venous cuff. Sixty-four rats in two groups are included in the study. In the experimental group (n = 32), end-to-end arterial anastomosis was performed with two stay sutures, fibrin glue, and a venous cuff. In the control group (n = 32), conventional end-to-end arterial anastomosis was performed. Fibrin glue assisted anastomosis with a venous cuff took less time, caused less bleeding at the anastomotic site, and achieved a patency rate comparable to that provided by the conventional technique. Fibrin sealant assisted microvascular anastomosis with venous cuff is a rapid, easy, and reliable technique compared to the end-to-end arterial anastomosis.

Congenital Granular Cell Tumor of the Arm: A Rare Presentation.

Congenital granular cell tumors are uncommon benign tumors of newborns that mainly affect oral mucosa, especially the maxillary alveolar ridge. They are predominantly seen in female newborns, and cutaneous involvement is extremely rare. In this report, we present a case of congenital granular cell tumor on the arm of one of the male monozygotic twins and discuss the differential diagnosis of granular cell phenotype.

The efficacy of the hemostatic agent Ankaferd blood stopper on end-to-end unilateral sleeve fish-mouth anastomosis.

OBJECTIVE: The aim of this study was to examine if the application of Ankaferd Blood Stopper (ABS) reduces the number of sutures and therefore reduces anastomosis completion time in a unilateral end-to-end sleeve fish-mouth anastomosis model. METHODS: Femoral artery end-to-end unilateral fish-mouth anastomosis models were created from the right and left femoral arteries of 14 male Wistar albino rats (weight: 250 to 300 grams) and divided into 2 equal groups. Rats in Group A received ABS and Group B was the control group. Rats were further divided into equal 2 subgroups, and anastomoses of rats in Group 1A and 1B were explored on the 7th day and on the 14th day in Group 2A and 2B. The groups were compared for anastomosis completion time, macroscopic and microscopic patency, existence of microaneurysm and inflammatory response. RESULTS: In the ABS group (1A and 2A), mean anastomosis completion time was 13:00±1.50 minutes, and 18:56±2.5 minutes in the control groups (1B and 2B). This difference was statistically significant (p=0.001). CONCLUSION: Ankaferd Blood Stopper may be used to reduce the number of sutures and shorten the completion time of artery-to-artery anastomosis of arteries with small diameter and low blood flow rate.

How does a biopsy of endoscopically normal terminal ileum contribute to the diagnosis? Which patients should undergo biopsy?

BACKGROUND: Terminal ileum endoscopy and biopsy are the diagnostic tools of diseases attacking the ileum. However, abnormal histological findings can be found in endoscopically normal terminal ileum. OBJECTIVE: This study was performed to evaluate the histopathological results of biopsies from endoscopically normal terminal ileum in order to determine pre-procedure clinical and laboratory factors predicting abnormal histopathological results, if any. METHODS: A total of 297 patients who underwent colonoscopy and terminal ileum biopsy and had normal terminal ileum or a few aphthous ulcers in the terminal ileum together with completely normal colon mucosa were included in the study. The patients were grouped into two arms as normal cases and cases with aphthous ulcers. Histopathological and pre-procedural laboratory results of patients were analyzed according to their indications. RESULTS: The terminal ileum was endoscopically normal in 200 patients, and 97 patients had aphthous ulcers. Chronic ileitis rate was present in 5.5% of those with endoscopically normal terminal ileum and in 39.2% of the patients with aphthous ulcers. In both groups, the highest rate of chronic ileitis was detected in the patients with known inflammatory bowel disease (IBD) (15.4 and 50%, respectively), anemia (9.5 and 43.5%, respectively), and in the patients having chronic diarrhea together with abdominal pain (7.7 and 44.8%, respectively). We found that the sensitivity of mean platelet volume for predicting chronic ileitis was 87% and the specificity was 45% at a cut-off value lower than 9.35 fl. CONCLUSION: In anemia indication or chronic diarrhea together with abdominal pain, the frequency of aphthous ulcers detected by ileoscopy and the frequency of chronic ileitis detected histopathologically despite a normal-appearing ileum were elevated.

A retrospective multicenter evaluation of cutaneous melanomas in Turkey.

BACKGROUND: We defined melanoma distribution in a large series of Turkish patients and evaluated the prognostic parameters of melanomas. MATERIALS AND METHODS: A total of 1574 patients' data was retrospectively collected at 18 centers in Turkey. Demographic characteristics were questioned and noted. Prognostic parametres were evaluated based on sentinel lymph node involvement. RESULTS: Mean age was 56.7 (4-99) years. While 844 (53.6%) cases were male, 730 (46.4%) cases were female. One thousand four hundred forty-seven (92%) cases were invasive melanoma and 127 (8%) cases were in-situ melanoma. The most common histopathological form was the superficial spreading melanoma (SSM) which was found in 549 patients (37.9%). It was followed by nodular melanoma in 379 (26.2%), acral lentiginous melanoma (ALM) in 191 (13.2%) and lentigo maligna melanoma in 132 (9.1%), respectively. On univariate analysis, lymphovascular invasion (p<0.001), tumor thickness (p<0.001), histopathological subtype (p<0.001), Clark level (p=0.001), ulceration (p<0.001), ≥6/mm2 mitosis (p=0.005), satellite formation (p=0.001) and gender (p=0.03) were found to be associated with sentinel lymph node positivity. Regression was associated with sentinel lymph node negativity (p=0.017). According to multivariate analysis, lymphovascular invasion and tumor thickness were significant independent predictive factors of SLN positivity. Patient age, tumor localization, precursor lesions, lymphocytic infiltration and neurotropism were not related with sentinel lymph node involvement. CONCLUSIONS: In this retrospective analysis, it was found that the prevalence of SSM is at a lower rate while the prevalence of ALM is at a higher rate when compared to western countries. According to Breslow index; most of the melanoma lesions' thickness were greater than 2 mm, corresponding Clark IV. Vascular invasion and tumor thickness are the most important factors for sentinel lymph node involvement.

The role of nitric oxide in an experimental necrotising enterocolitis model.

BACKGROUND: Necrotising enterocolitis (NEC) causes a significant life-threatening gastrointestinal system (GIS) disease with severe mortality and morbidity, particularly in premature infants. Nitric oxide (NO) has many functions in the GIS. Therefore, in the present study, we evaluated the effects of NO in experimentally induced NEC of newborn 1-day-old rats following hypoxia/reoxygenation (HR). MATERIALS AND METHODS: Thirty Wistar albino rats (weight, 5-8 g) were randomly divided into three groups: group 1 (HR), group 2 (HR + nitroglycerine), and group 3 (control). HR was achieved by placing the rat in carbon dioxide (CO2) for five minutes at 22°C, which was followed by five minutes of 100% oxygen. After HR, nitroglycerine was administered for three days at 50 µg/Kg/day. On day 4, the rats were decapitated and the intestines between the duodenum and sigmoid colon were resected and histopathologically examined. RESULTS: The histopathological findings of groups 1 and 2 were characteristic of NEC. Intestinal injury in group 1 was significantly more prevalent than that in group 2 (χ2 = 21.55, P = 0.000). The intestinal injury score in group 3 was significantly lower than that in the other groups (P < 0.05). CONCLUSIONS: NO treatment was effective for treating experimentally induced NEC.

Signet cell carcinoma of colon in a nineteen-year-old patient: a case report.

Signet cell carcinoma, which is a subtype of adenocarcinoma, usually originates from the stomach. However, it can also originate from the colon, rectum, gallbladder, pancreas, urinary bladder, and breast. We represent a 19-year-old boy diagnosed with signet cell tumour while he was being evaluated for an initial diagnosis of inflammatory bowel disease.

Comparison of perivascular and intramuscular applied botulinum toxin a pretreatment on muscle flap ischemia-reperfusion injury and chemical delay.

BACKGROUND AND PURPOSE: Muscle flaps are known to be prone to local ischemia more than other flaps. The local and systemic injury that ensues after reperfusion of ischemic skeletal muscle is an important clinical problem in flap surgery. Flap delay may be applied chemically or sympathetically. Early use of botulinum toxin A (Btx-A) in muscle flap surgery relied on chemical denervation; however, in our study, we tried to emphasize a possible chemical delay mechanism of Btx-A, through the release of substance P and calcitonin gene-related peptide (CGRP) and vascular endothelial growth factor (VEGF). METHODS: Pretreatment with perivascular or intramuscular Btx-A was applied 1 week before the flap elevation, 3.5 units in 2 experimental groups each containing 8 Sprague-Dawley rats. The control groups (2 groups, each containing 8 rats) received 0.07 mL saline perivascularly and intramuscularly. The right gastrocnemius muscle flap was used as the experimental model. Ischemia-reperfusion cycle was applied to all groups. On the seventh day, the gastrocnemius flap was elevated, and perivascular tissues were observed macroscopically. Comparisons between perivascular Btx-A and intramuscular Btx-A groups were made, and the animals were killed. Muscle biopsies were taken. Damaged myocytes were counted using McCormack technique, and chemical delay was shown as angiogenesis, lymphocyte counts, and edema formation with VEGF3-R, CGRP, and substance P markers as immunohistochemical staining. RESULTS: The amount of muscle necrosis was the highest in intramuscular Btx-A admitted groups. The intramuscular and perivascular Btx-A groups showed significant angiogenesis scored blindly by the senior pathologist. CONCLUSIONS: Potential role of Btx-A in ischemic preconditioning of muscle flaps achieved through the release of substance P, CGRP, and VEGF was investigated. Chemical delay was shown objectively by Btx-applied groups.