Contrast-enhanced ultrasound in the preoperative, intraoperative and postoperative assessment of liver lesions.

The use of contrast agents (CA) with liver ultrasound (US) has gained recently an established role for the diagnosis of various hepatic diseases due to their safety, high versatility and low costs (contrast-enhanced ultrasound: CEUS). The purpose of this review is to provide a state-of-the-art summary of the available evidence for their use in the characterization of focal liver lesions. A published work search was conducted for all preclinical and clinical studies involving CA on hepatic US imaging. CEUS increases the sensitivity for lesion detection and the specificity to differentiate between benign and malignant diseases due to the enhanced visualization of the tumor microcirculation. Results achieved seem at least equivalent to those of spiral computed tomography or magnetic resonance imaging. The association of CA with intraoperative ultrasound has changed the surgical approach in 25% of patients and guarantees complete ablations by a single session in most of them. CEUS provides detailed information about tumor vasculature, improves the preoperative characterization and therefore the therapeutic strategy, and can evaluate the intraoperative completeness of the ablation.

Contrast-enhanced ultrasound detects perfusion defects in an ex vivo porcine liver model: a useful tool for the study of hepatic reperfusion.

Following transplantation, areas of hypoperfusion can be associated with metabolic changes and poor organ recovery. Our study evaluated contrast-enhanced ultrasound (CEUS) agents for the detection of such areas. Livers were collected from ten pigs, connected to extracorporeal circuits and perfused using autologous blood. After 1 and 4 h livers were scanned with an ultrasound machine following the administration of CEUS agents. Biopsies from perfused and non-perfused areas were collected. The entire parenchyma enhanced strongly on non-contrast ultrasound at 1 h with no perfusion defects. Four hours later multiple perfusion defects manifested not evident with non-contrast ultrasound. Histology confirmed non-perfused areas corresponded to ischemic zones. In our model the addition of CEUS revealed perfusion defects after 4 h. This might facilitate detection and characterization of perfusion defects in transplanted livers.

Addition of a kidney to the normothermic ex vivo perfused porcine liver model does not increase cytokine response.

The addition of a kidney to the ex vivo liver perfused model may facilitate the circuit homeostatic balance of important biochemical parameters (i.e. pH changes, urea and creatinine, or glucose levels) but might also increase the inflammatory reaction produced. In this study, we compared the production of various cytokines between liver-kidney and liver-alone circuits. Seven livers were harvested from female pigs and perfused for 6 h. In five additional experiments, a kidney was also harvested and connected in parallel. Blood samples for interleukins (IL) 1, 2, 4, 6, 8, 10, and 12, interferon (IFN)-γ and tumor necrosis factor (TNF)-α were collected before perfusion and at hours 1, 2, 4 and 6 postperfusion. In the combined liver-kidney circuit, a significant increase was present only for IL-6 and IL-8, but this did not differ significantly from those recorded in the liver-alone circuit. All other cytokines were not modified from baseline levels. The addition of a kidney to the perfusion circuit does not stimulate a greater inflammatory reaction than that of the liver alone and therefore further confirms the safety of the experimental setups in view of more delicate experiments requiring strict homeostatic conditions.

Coexistence of carcinoma and tuberculosis in one breast.

BACKGROUND: The coexistence of breast cancer and tuberculosis is very rare. This can create a dilemma in the diagnosis and treatment as there are no pathognomonic symptoms or signs to distinguish both diseases. CASE PRESENTATION: A female patient was seen in the breast clinic for a right breast lump. Clinical examination and investigation confirmed cancer and tuberculosis of the right breast. She underwent right mastectomy and axillary clearance and received chemo and radiotherapy. Unfortunately, she died of wide spread metastases. CONCLUSION: The simultaneous occurrence of these two major illnesses in the breast can lead to many problems regarding diagnosis and treatment. Though rare, surgeons, pathologists and radiologists should be aware of such condition.

Combined endocrine and exocrine tumours of the pancreas.

BACKGROUND: Cystic neoplasms of the pancreas comprise 10%-15% of pancreatic cystic lesions, with the serous cystadenoms being the commonest. The association of exocrine and endocrine tumours of the pancreas unrelated to Von Hipple Lindau disease is very rare. Very few cases have been reported in the literature. We present another case of both these tumours in one patient. CASE PRESENTATION: A female patient was seen in the surgical clinic for a pain in the right groin. Clinical examination and investigations confirmed a diagnosis of combined endocrine and exocrine tumours of the pancreas. She underwent surgery and is under regular follow-up in the surgical clinic. CONCLUSION: Biphasic differentiation of pancreatic stem cell during embryological development could happen and may result in combined endocrine and exocrine tumours of the pancreas. Imaging studies are excellent in diagnosing theses lesions. Surgery has a central role and could be curative.

Breast metastasis from a renal cell cancer.

BACKGROUND: Metastases to the breast from extramammary tumours are uncommon, and metastatic renal cell carcinoma to the breast is extremely rare. We report a metastasis to the breast from a renal primary with the radiological and histopathological features. CASE PRESENTATION: An 81-year-old lady was seen in the breast clinic for a right breast mass after sustaining a fall. Clinical examination and investigations revealed a metastatic cancer from a renal primary. She received surgical treatment only and is under regular follow-up in the oncology clinic. CONCLUSION: The treatment strategy for metastatic breast diseases is based on a proper assessment of such cases by surgeons, radiologists and histopathologists.

Targeted microbubbles in the experimental and clinical setting.

BACKGROUND: Microbubbles have improved ultrasonography imaging techniques over the past 2 decades. Their safety, versatility, and easiness of use have rendered them equal or even superior in some instances to other imaging modalities such as computed tomography and magnetic resonance imaging. Herein, we conducted a literature review to present their types, general behavior in tissues, and current and potential use in clinical practice. METHODS: A literature search was conducted for all preclinical and clinical studies involving microbubbles and ultrasonography. RESULTS: Different types of microbubbles are available. These generally improve the enhancement of tissues during ultrasonography imaging. They also can be attached to ligands for the target of several conditions such as inflammation, angiogenesis, thrombosis, apoptosis, and might have the potential of carrying toxic drugs to diseased sites, thereby limiting the systemic adverse effects. CONCLUSIONS: The use of microbubbles is evolving rapidly and can have a significant impact on the management of various conditions. The potential for their use as targeting agents and gene and drug delivery vehicles looks promising.

The autologous normothermic ex vivo perfused porcine liver-kidney model: improving the circuit's biochemical and acid-base environment.

BACKGROUND: The ex vivo porcine liver perfused model isolates the organ from extrinsic regulatory mechanisms, facilitating an improved understanding of the organ physiology and reaction to various conditions. We have assessed the influence of the addition of a porcine kidney to the circuit. METHODS: Eight livers were harvested and perfused for 6 hours. In 5 additional experiments a kidney also was connected in parallel. Hourly arterial blood gases were collected to analyze glucose, acid base, and renal parameters. The primary end point was an evaluation of the influence of the kidney on glucose, pH, and electrolyte levels. RESULTS: In the combined porcine liver-kidney circuit all the parameters significantly improved compared with the liver circuit alone. This was particularly evident for glucose values because normoglycemia was reached by the end of the perfusion, and for pH and electrolyte values that were maintained at initial levels. CONCLUSIONS: The addition of a porcine kidney to the perfusion circuit improves the biochemical milieu. This might produce more consistent and reliable results, particularly during studies requiring a steady-state environment.

Unusual contents of the femoral hernia.

Different contents in the femoral hernia have been reported in the literature, but herniation of the fallopian tube in a femoral hernia is very rare due to its normal anatomical position. Case Presentation. A female patient was admitted to the surgical ward for a lump in the right groin. Clinical examination confirmed a right femoral hernia. The patient underwent surgery to repair the hernia. Intraoperatively, the right uterine tube was found in the hernia. The tube was reduced back into the pelvic cavity and the hernia was repaired. After making good recovery, the patient was referred to the gynaecologist for further assessment. Conclusion. This case is educational as it highlights the importance of managing women with femoral masses with care.

An unusually long appendix in a child: a case report.

INTRODUCTION: Appendicitis is the most common surgical emergency, but its diagnosis in children can be a challenge to the treating surgeon. CASE PRESENTATION: A 10 years-old girl was admitted to the paediatrics surgical ward with a right sided abdominal pain. The initial clinical presentation was vague. She underwent an appendicectomy which revealed a very long appendix. CONCLUSION: About half of the adult patients with appendicitis present with the known classical signs and symptoms, but the clinical scenario might be completely different in children. This case is educational as it highlights the importance of the atypical presentations of an unusually long appendix in children.

Apple-core lesion of the colon: a case report.

INTRODUCTION: The appearance of the apple-core lesion of the colon can be caused by several diseases. CASE PRESENTATION: A male patient was referred to the surgical clinic with melaena and weight loss. Clinical examination and investigations confirmed an apple-core lesion of the colon. He underwent surgery, but unfortunately, died of a chest infection two weeks after the operation. CONCLUSION: This case shows the use of computed tomography in demonstrating the primary cause of iron deficiency anaemia, and at the same time, staging the disease for loco-regional metastasis.

Primary cutaneous melanoma of the breast: A case report.

BACKGROUND: Primary cutaneous melanoma of the breast is a very rare tumour, accounting for < 5% of all malignant melanomas. CASE PRESENTATION: A young lady was seen in the breast clinic for a skin lesion in the right breast. Clinical examination and investigations confirmed a diagnosis of a primary cutaneous melanoma of the breast. The lesion was excised and the patient made good recovery. She has shown no signs of local recurrence and is under regular follow-up in the dermatology clinic. CONCLUSION: This case is educational as it shows that the treatment of breast cutaneous melanoma is similar to that for any skin parts with surgery remaining the main therapeutic option. It also shows that mastectomy is unnecessary as it does not improve the results obtained by wide local excision of melanoma.

Sebaceous carcinoma of the skin of the breast: a case report.

INTRODUCTION: Sebaceous gland tumours are rare and their presence should be considered as a marker for Muir-Torre Syndrome, alerting to search for an occult malignancy. CASE PRESENTATION: A 43-year-old Caucasian female patient underwent excision of a sebaceous cyst. Histopathology confirmed a sebaceous carcinoma. Further investigations revealed multiple intra-abdominal malignancies. She has been under regular follow-up in the relevant clinics. CONCLUSION: Sebaceous carcinoma should be excised completely and followed-up for the detection of possible metastases. Surgical removal of primary or metastatic cancers may be curative and should be attempted wherever possible. It is very important for clinicians not to miss such skin lesions as they may precede the presentation of internal malignancies.

Direct spread of thyroid follicular carcinoma to the parotid gland and the internal jugular vein: a case report.

INTRODUCTION: The parotid gland and the great cervical veins are very rarely involved in a metastatic thyroid cancer. CASE PRESENTATION: We report an interesting case of an unusual metastasis of a thyroid follicular carcinoma including the histopathological and radiological findings. A woman was seen in the otolaryngology clinic with a mass at the angle of the left side of her jaw. Clinical examination and investigations confirmed a thyroid follicular carcinoma with metastases to the parotid gland and the internal jugular vein. CONCLUSION: This is an educational case which highlights the importance of close communication between clinicians, histopathologists and radiologists to ensure that such rare cases are not missed.

Idiopathic benign retroperitoneal cyst: a case report.

INTRODUCTION: Retroperitoneal cysts are uncommon, with an estimated incidence of 1/5750 to 1/250,000. CASE PRESENTATION: A male patient was admitted with an abdominal pain, jaundice and fever. Clinical examination and investigations confirmed an idiopathic benign retroperitoneal cyst. He underwent surgery and was discharged after making good recovery. CONCLUSION: Retroperitoneal cysts are very rare, and most of the time they are discovered incidentally. Patients may be asymptomatic or present with abdominal pain, referred pain to the legs or weight loss. Imaging may help diagnose these lesions, but surgery is the keystone in confirming the diagnosis. This case is very rare and very educational as it highlights an unusual presentation of a benign retroperitoneal cyst. In our patient, the course of the disease was unique as the patient presented with jaundice.

Merkel cell carcinoma in a male breast: a case report.

Merkel cell carcinoma is a rare skin neoplasm and has not been reported yet in a male breast. We present a case of 74-year-old patient who was referred to the breast clinic with a lump in his right breast, which led first to the core biopsy followed by radical mastectomy and axillary clearance. The clinical characteristics, gross, microscopic and immunohistochemical findings and management of this lesion are discussed. Surgical excision remains the main option for treating this lesion including prophylactic lymphadenectomy and local radiotherapy.