Poor Biointegration of Porcine Acellular Dermal Matrix Associated with Unfavorable Gingival Healing: A Report of Three Cases.

AIM: The aim of the present work was to explain the poor biointegration of acellular dermal xenogeneic matrix, leading to an unfavorable gingival healing following a grafting procedure for the treatment of soft tissue deficiencies. BACKGROUND: Numerous works have demonstrated the successful use of acellular dermal matrix (ADM) in soft tissue augmentation procedures. However, spare human investigations reported adverse healing outcomes at microscopic level. CASE DESCRIPTION: Three patients showing various soft tissue deficiencies (recession, gingival thickening) requiring a gingival augmentation were grafted using an ADM porcine acellular dermal matrices (pADM) as a soft tissue substitute. For this purpose, appropriate soft tissue augmentation surgeries were performed and the grafted pADM was left for proper healing. Biopsies were harvested from two out of the three patients, respectively, at 11 and 27 weeks in order to conduct a histological evaluation of the pADM's doubtful biointegration. Moreover, the ultrastructural analysis of pADM was performed using scanning electron microscopy, and additional histological procedures were used to assess its ability to support human gingival fibroblast cultures. Signs of gingival inflammation persisted several months postoperatively. Histologically, numerous inflammatory cells characterized the grafted site. Indeed, the high number of foreign body giant cell granulomas and the very densified newly formed collagen fibers highlighted a fibrotic process within gingival connective tissue. The ultrastructural and histological analysis showed that pADM was characterized by very thick and dense collagen bundles demonstrating a nonphysiological collagen network organization. Cell culture experiments showed fibroblasts proliferating on the matrix surface, sparing its deeper part, even though the collagen matrix degradation seemed to occur following a gradient from the pADM surface inward. CONCLUSION: The unfavorable clinical results may be caused by the poor colonization of matrix cells and poor angiogenesis leading to the inadequate biointegration of pADM. Hence, the pADM structure in terms of porosity and degradability should be further investigated. CLINICAL SIGNIFICANCE: The present cases highlighted a poor integration of pADM following soft tissue grafting procedures, which was caused by the inadequate ultrastructure of the used pADM. Therefore, despite the utility of such tissue substitutes, their manufacturing improvement could be required to obtain a better biointegration.

Correlations of neck ultrasound and pathology in cervical lymph node of papillary thyroid carcinoma.

Background: High-resolution sonography is becoming a method of choice for the detection and diagnosis of cervical lymph node metastasis in patients with papillary thyroid carcinoma (PTC). The purpose of this study is to assess the diagnostic accuracy of neck ultrasound (US) in the detection of lymph node metastases from PTC.Methods: Data for all patients with papillary thyroid cancers and preoperative neck US were reviewed retrospectively. The diagnostic accuracy of US was determined according to whether histologically confirmed cancer was present in surgical cervical lymph node specimens.Results: A total of 206 patients (149 central and 57 central and lateral lymph nodes dissection) were included. Their mean age was 56 years (14-88 years). Central and lateral lymph nodes were involved in 68% (n = 141 patients; 141/206) and 60% (n = 34 patients; 34/57) of cases, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of US in predicting papillary thyroid carcinoma (PTC) metastasis in the central neck were 69%, 71%, 84% and 51% respectively, and in the lateral neck were 85%, 65%, 78% and 75% respectively.Conclusions: Preoperative neck US is a valuable tool in the detection of cervical lymph node metastases from papillary thyroid cancer and can provide reliable information to assist in surgical management.

PAROTID TUMORS: IS SURGERY ALWAYS THE ONLY WAY?

AIM OF THE STUDY: To analyze the characteristics and management of parotid tumors in a tertiary care center. STUDY DESIGN: Retrospective cohort study. METHODS: All cases of parotid tumors (or masses) in our department between Jan 1, 1999 and December 31st, 2012 were studied. Demographic data, clinical characteristics, histopathology and management were analyzed. We also evaluated the diagnostic value of fine needle aspiration cytology (FNAC) in our center. RESULTS: Of the 216 parotid tumors, 164 underwent parotidectomy and 52 were not managed surgically; 73.1% had a benign tumor (36.6% had Warthin's tumor) and 16.7% had a malignant one. In our center, FNAC was found to have a sensitivity for reporting malignancy of 71.4% and a specificity to rule in malignancy of 100%. CONCLUSION: In our series, Warthin's tumor was the most frequent mass probably related to the high tobacco use. The prevalence of malignant tumors was relatively high in our series. Primary malignant tumors and pleomorphic adenomas should always be treated surgically, however, lymphomas, metastatic and benign inflammatory masses and cases of Warthin's tumors could be managed nonsurgically.

Renal medullary carcinoma in a white adolescent with sickle cell trait.

Renal medullary carcinoma (RMC) is a rare neoplasm of the kidney that has been recently described. It is almost exclusive to young patients of African descent and associated with sickle cell hemoglobinopathy, mainly sickle cell trait and hemoglobin sickle cell disease. The prognosis of RMC is very poor because of the highly aggressive behavior of this neoplasm and its resistance to conventional chemotherapy. Metastatic disease is almost universal at the time of presentation, and the malignancy is minimally responsive to a variety of regimens and/or modalities, including surgery, radiotherapy, chemotherapy, and biological immune-modulation therapy. We report the seventh case of a left RMC occurring in a white child with sickle cell trait, but with a localization of the tumor in the left kidney, considered a nonpredominant side for this type of tumor.

Chemical Meningitis and Syndrome of Inappropriate Antidiuretic Hormone Release (SIADH): A Rare Presentation of Pituitary Adenoma Apoplexy.

Pituitary apoplexy is an uncommon condition typically resulting from a sudden haemorrhage within a pituitary adenoma. This bleed can present clinically with a wide array of signs and symptoms. This report documents the case of a 62-year-old male who presented to the Lebanese Hospital Geitaoui University Medical Center with signs and symptoms of meningeal irritation. He was initially thought to have meningitis, and was started on antibiotics; he was then found to have pituitary adenoma apoplexy that was complicated by syndrome of inappropriate antidiuretic hormone release (SIADH). The patient was successfully treated with antibiotics, and fluid restriction and hypertonic saline after ruling out other more common causes for his hyponatraemia, before undergoing a transsphenoidal resection of the pituitary adenoma. A three-month follow-up evaluation of the patient demonstrated the absence of hormonal imbalances and the absence of residual tumours on imaging. LEARNING POINTS: Pituitary apoplexy has as a wide clinical presentationPituitary apoplexy should be ruled out in patients with aseptic chemical meningitis with a history of pituitary adenomasSIADH can complicate chemical meningitis due to pituitary apoplexy.

Safety of thyroidectomy and cervical neck dissection without drains.

BACKGROUND: Many studies have reported that drainage after thyroidectomy does not decrease the rate of local postoperative complications. We sought to review the safety of thyroidectomy combined with cervical neck dissection (CND) without drainage. METHODS: The medical records of consecutive patients who underwent thyroidectomy without drainage were retrospectively reviewed. Two groups were defined depending on whether CND was or was not performed. The main outcome was identification of patients with cervical bleeding, hematoma or seroma. RESULTS: We included 1127 patients (139 who had CND and 988 who did not). Of these, 207 patients (18%) had transient postoperative hypocalcemia, 9 (0.8%) had permanent postoperative hypoparathyroidism, 56 (5%) had transient postoperative hoarseness and 7 (0.6%) had permanent vocal cord paralysis. A total of 44 patients (4%) experienced postoperative hematoma and/or seroma: 8 patients (6%) who had CND and 36 (4%) who did not. There was no major bleeding in the 2 groups; all patients had minor bleeding or seroma not requiring surgical intervention. The postoperative stay in hospital for both groups was 1 day in 92% of patients. Wound infection occurred in 0.8% of all patients: 1 (0.7%) who had CND and 8 (0.8%) who did not. There was no significant difference between the groups in overall perioperative complications or in time of hospital discharge. CONCLUSION: Thyroidectomy without drains is safe and effective, even in combination with CND.

A Liposarcoma Arising in a Pulmonary Hamartoma, Coexisting With Benign Metastasizing Leiomyoma.

Pulmonary hamartoma is a common benign tumor that rarely degenerates into malignancy. This report documents a unique case of pulmonary hamartoma with malignant transformation into well-differentiated liposarcoma, coexisting in proximity to pulmonary nodules representing benign metastasizing leiomyoma in a 60-year-old woman.

Oral manifestations associated with inherited hyperhomocysteinemia: A first case description.

Hyperhomocysteinemia is a rare disease caused by nutritional deficiencies or genetic impairment of cysteine metabolism. To date, no oral manifestations of hyperhomocysteinemia have been described in humans. Therefore, to our knowledge, the present case report is the first description of a hyperhomocysteinemic patient showing oral tissue alterations leading to both early tooth loss and failed implant osseointegration. The patient presented with a methylenetetrahydrofolate reductase gene mutation (677T polymorphism) leading to mild hyperhomocysteinemia. The radiologic analysis showed hyperdense lesions scattered in the maxillae. The histologic observations indicated alterations in both collagen and elastic networks in the gingiva and dermis. Interestingly, the presence of ectopic mineralized inclusions was noted in both periodontal ligament and gingiva. Strong osteoclastic activity was associated with abnormal calcification of trabecular spaces. Uneven oral tissue remodeling due to high tissue levels of homocysteine could explain the pathologic manifestations observed in this case.

Intestinal presentation of non-Hodgkin lymphoma: Case report.

BACKGROUND: MEITL (monomorphic epitheliotropic intestinal T-cell lymphoma) is a rare primary intestinal T-cell lymphoma associated with high mortality rate. Being intestinal this implies difficult diagnostic workup and management. CASE: We present a case of 59-year-old male presented with abdominal pain and found to have 15 × 11 cm mass in the right iliac fossa. Decision for surgical excision was retained and the Pathological examination determined monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) with CD30 positive immune-histochemical profile. CONCLUSION: MEITL is a rare entity which retains challenging diagnosis and management as well as variable immune-histochemical profile. In the absence of clear guidelines for the management of intestinal manifestation of lymphoma, surgical approach may have its indications.

Are papillary microcarcinomas of the thyroid gland revealed by cervical adenopathy more aggressive?

Therapeutic attitudes for papillary thyroid microcarcinoma (PTMC) range from observation alone to aggressive management. Clinicopathologic features, therapeutic options, and follow-up results are described in a series of PTMC revealed by cervical adenopathies. Twelve patients were enrolled in this retrospective study. They were all treated by total/near-total thyroidectomy with dissection of suspect cervical lymph nodes followed by radioactive iodine (RAI) and suppressive L-thyroxine therapies. Mean age at diagnosis was 32 years with a mean elapsed time to diagnosis of 45.3 months. Fine needle aspiration cytology and excisional biopsy of the lymph node led to a diagnosis in all cases. Cervical mass was ipsilateral to primary tumor in six patients (50%). Multifocality, bilaterality, and capsular invasion were encountered in 66.7, 66.7, and 41.7 per cent of patients, respectively. Lymph node involvement was bilateral in seven patients (58.3%) of whom thyroid foci were unilateral in two. No complications of thyroidectomy were encountered. At 60-month-follow up, no recurrence or metastasis was noted. PTMC revealed by cervical lymph node metastasis shows aggressive clinicopathologic features. They must be considered as papillary thyroid cancers and managed by total/near-total thyroidectomy with bilateral lymph node exploration followed by RAI therapy and suppressive L-thyroxine doses.

ALK gene rearrangement status in non-squamous non-small cell lung carcinoma in the Middle Eastern population.

BACKGROUND: Worldwide, the frequency of ALK rearrangement ranges between 3-6%, however its prevalence in the Middle Eastern population has not been reported. The aim of this study is to determine the frequency of the ALK rearrangement, as well as the clinico-pathologic characteristics of Lebanese patients with ALK-rearranged lung adenocarcinoma. METHODS: 152 patients diagnosed with non-squamous non-small cell lung carcinomas (NSCLC), at Hôtel-Dieu de France University Hospital between February 2014 and July 2016, were included in the study. ALK gene rearrangement expression was screened by immunohistochemistry (IHC) (D5F3 Clone). Positive cases were then sent for confirmation with Fluorescence in situ hybridization (FISH) technique. RESULTS: On immunohistochemistry, patients were distributed as following: score 0: n=108, score 1+: n=26, score 2+: n= 9, score 3+: n= 9. ALK gene rearrangement was detected in 6 out of 18 (2+ and 3+ score) tested patients by FISH technique. The presence of ALK rearrangement was significantly associated with the female gender (n=6, p=0.003) and with non-smoking status (n=4, p=0.0.18). CONCLUSION: This study confirms that the prevalence of the ALK gene rearrangement in the Middle Eastern region is within the worldwide ranges and is almost exclusive to patients with adenocarcinoma subtype and tends to occur more frequently in women and non-smokers.

Epidemiologic and histologic characteristics of CNS lesions: a 20-year experience of a tertiary center in Lebanon.

Aim: Report the epidemiologic and histologic characteristics of CNS lesions in the Lebanese population. Methods: We conducted a retrospective study evaluating 2025 CNS lesions diagnosed between 1998 and 2017 in the pathology laboratory of a Lebanese tertiary center. Results: 52.2% of patients were men with a median age of 50 years. The most frequent symptoms were epilepsy (22.5%), headache (20.6%) and motor impairment (19.9%). 90.7% of tumors were primary. Lung (35.6%) and breast (16.5%) were the most frequent primaries of metastases. 46.2% of primary CNS tumors were glial, predominantly astrocytic (56.4%), and (42.5%) were nonglial, predominantly meningeal tumors (58%). Conclusion: Compared with Western literature, the Lebanese population is characterized by a younger age of onset of brain tumors, a lower rate of meningiomas and a higher rate of gliomas.

The impact of obesity on surgical outcome after pancreaticoduodenectomy.

CONTEXT: The effect of obesity on surgical outcome is becoming an increasingly relevant issue given the growing rate of obesity worldwide. OBJECTIVE: To investigate the specific impact of obesity on pancreaticoduodenectomy. DESIGN: A retrospective comparative study of a prospectively maintained database was carried out to investigate the specific impact of obesity on the technical aspects and postoperative outcome of pancreaticoduodenectomy. PATIENTS: Between 1999 and 2006, 92 consecutive patients underwent pancreaticoduodenectomy using a standardized technique. The study population was subdivided according to the presence or absence of obesity. RESULTS: Nineteen (20.7%) patients were obese and 73 (79.3%) patients were non-obese. The two groups were comparable in terms of demographics, American Society of Anesthesiology (ASA) score as well as nature and type of pancreatico-digestive anastomosis. The rate of clinically relevant pancreatic fistula (36.8% vs. 15.1%; P=0.050) and hospital stay (23.1+/-13.9 vs. 17.0+/-8.0 days; P=0.015) were significantly increased in obese vs. non-obese patients, respectively. Pancreatic fistula was responsible for one-half of the deaths (2/4) and two ruptured pseudoaneurysms. The incidence of the other procedure-related and general postoperative complications were not significantly different between the two groups. Intrapancreatic fat was increased in 10 obese patients (52.6%) and correlated positively both with BMI (P=0.001) and with the occurrence of pancreatic fistula (P=0.003). CONCLUSION: Obese patients are at increased risk for developing pancreatic fistula after pancreaticoduodenectomy. Special surgical caution as well as vigilant postoperative monitoring are therefore recommended in obese patients.

[Retroperitoneal cystic lymphangiomas in adults: four case reports and review of the literature]. / Lymphangiome kystique rétropéritoneal de l'adulte: a propos de 4 cas et revue de la littérature.

Retroperitoneal location of cystic lymphangiomas in adult patients is rare. Their clinical presentation is not specific. Magnetic resonance imaging is the best radiological exam for the diagnosis. These tumors must be distinguished from mesenteric cysts which are more frequent and can degenerate. The authors report four cases of retroperitoneal cystic lymphangioma with a literature review.

Sporadic colon cancer in Lebanon: A clinicopathological study.

Colon cancer is a heavy public health burden. No data has been previously published on colon cancer epidemiology in Lebanon. The objective of this study was to report the clinical and pathological features of surgically operated colon cancer. From July 2005 to July 2012, 187 sporadic colonic tumors were operated in Hotel-Dieu de France Hospital (Beirut, Lebanon). Demographic, clinical, pathological and staging data was collected. The male: female sex ratio was 1.3 and the mean age at diagnosis was 66.0 years. Most tumors occurred at the right colon (54.0%). Histologically, conventional adenocarcinoma had the biggest proportion (88.2%), followed by mucinous adenocarcinoma (9.1%). Most cases operated belonged to stages II, III or IV, leaving only 8.0% of the cases in stage I. Some characteristics were similar to western countries like the predominance of right tumors while others were similar to developing countries like the sex ratio and the high proportion of stage IV tumors at diagnosis. This study reports for the first time in the middle-eastern populations a clinico-pathological analysis of surgically operated colon cancer.

Molecular characteristics of colorectal cancer in a Middle Eastern population in a single institution.

BACKGROUND: The few studies of the molecular biology of colorectal cancer (CRC) in Middle Eastern populations have included only small samples of patients. OBJECTIVE: Evaluate the frequency and prognostic effect of RAS, BRAF, PIK3CA, PTEN, and EGFR somatic mutations as well as mismatch repair (MMR) deficiency in Lebanese Middle Eastern patients. DESIGN: Retrospective single-center descriptive study. SETTING: Lebanese Middle Eastern patients in a tertiary medical cen.ter. METHODS: We included all patients diagnosed with CRC between January 2010 and December 2015, in whom RAS mutational status and the expression of MLH1 and MSH2 proteins were available. MAIN OUTCOME MEASURES: Genetic mutations detected by direct sequencing while MMR protein expression was evaluated by immunohistochemistry. SAMPLE SIZE: 645 patients. RESULTS: RAS, BRAF, EGFR, PI3KCA, and PTEN mutation rates were 38.5%,12.9%, 0%, 11.1% and 0% respectively. The MMR deficiency rate was 20.6%. No factor was associated with RAS mutation whereas MMR-deficient tumors were less likely to be metastatic at diagnosis. Among patients with wild-type RAS females fared better than males (median overall survival [OS]=1734 vs 1079 days respectively, P=.015) even after adjustment for confounding factors by Cox regression analy.sis. This finding was not reproduced in the RAS-mutated group. The median OS of patients with MMR-deficient tumors was not reached, while the median OS was 2475 days in patients who had maintained expression of both MLH1 and MSH2. CONCLUSION: The RAS mutation rate was similar to Western and East Asian countries, but not for the BRAF mutation and MMR deficiency. We also found a prognostic effect for sex in the RAS wild-type group, a finding worthy of further exploration. LIMITATIONS: Retrospective, single center and small sample size. Expression of MSH6 and PMS2 not analyzed. CONFLICT OF INTEREST: None.

Careful examination of thyroid specimen intraoperatively to reduce incidence of inadvertent parathyroidectomy during thyroid surgery.

OBJECTIVE: To assess the incidence and clinical relevance of inadvertent parathyroidectomy during thyroidectomy, and the possibility of reducing its occurrence. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: Consecutive patients who underwent thyroidectomy from 1999 to 2005, divided into 2 groups (group 1, those with inadvertent parathyroidectomy; and group 2, those without inadvertent parathyroidectomy). Patients who underwent surgical procedures for recurrent thyroid disease, intentional parathyroidectomy, and resection of central compartment viscera were excluded. INTERVENTIONS: All pathology reports were reviewed for the presence of any parathyroid tissue in the resected specimen. Age, sex, preoperative diagnosis, thyroid hormonal status, substernal thyroid extension, number of parathyroid glands identified and spared at the time of surgery, autotransplantation of parathyroid gland, and final histologic findings were recorded. MAIN OUTCOME MEASURES: Identification of parathyroid tissue in resected specimens and postoperative symptomatic hypocalcemia. RESULTS: A total of 307 patients were included. Surgical procedures included bilateral or unilateral thyroidectomy (95% and 5% of procedures, respectively). Central neck lymph node dissection was performed in 5% of cases. Pathologic findings showed inadvertent parathyroidectomy in 12% of cases. Of these, 32% were recognized intraoperatively. The parathyroid tissue was found in extracapsular locations in 37% of cases, intracapsular locations in 39%, and intrathyroidal locations in 24%. There was no statistical difference between the 2 groups in terms of sex, preoperative diagnosis, substernal extension, extent of surgery, pathologic diagnosis, and occurrence of postoperative hypocalcemia, except for the presence of thyroiditis. CONCLUSION: Careful examination of the surgical specimen intraoperatively decreases the incidence of inadvertent parathyroidectomy during thyroidectomy.

A benign cause of obstructive jaundice with von Hippel-Lindau disease. A case report and review of the literature.

CONTEXT: Von Hippel-Lindau disease is a genetic disorder characterized by neoplasms with multiple organ involvement, the pancreas being involved in about half of the cases. Conservative treatment is indicated because the disease is usually asymptomatic with long-term follow-up. CASE REPORT: We herein present the case of a 64-year-old man with von Hippel-Lindau disease who presented with obstructive jaundice which resulted as being caused by a fibro-cystic pancreatic nodule. In addition, we reviewed the literature concerning pancreatic involvement in von Hippel-Lindau disease with emphasis on their presentation, type of lesions and appropriate management, especially in cases with obstructive jaundice. CONCLUSION: Conservative management is advocated in the majority of VHL disease patients with pancreatic involvement, but surgery is sometimes required, especially when patients are symptomatic (obstructive jaundice, upper gastrointestinal bleed).