Stent-Assisted Coil Embolization of a Saccular Visceral Aortic Aneurysm: Case Report and Review of the Literature.

PURPOSE: We present the results of unconventional endovascular treatment of a voluminous (65 mm) saccular visceral aortic aneurysm in a 78-year-old woman. Patient was deemed unfit for open surgery due to comorbidities. Fenestrated or branched endografting was also excluded due to the small diameter of the aorta, the severe stenosis at the origin of celiac trunk, and the anomalous origin of superior mesenteric artery arising infrarenally. CASE REPORT: After a preliminary selective angiography of the superior mesenteric artery showing valid anastomotic network with celiac trunk branches, an aortic self-expandable bare stent (Jotec E-XL) was deployed in the visceral aorta. Aneurysm sac embolization (Penumbra detachable Ruby Coils) in a coil-jailing technique was performed. Finally, an aortic cuff endograft (Gore) was deployed immediately above the origin of the left renal artery to cover the wide neck of the saccular aneurysm and improve sac exclusion. Hospital stay was uneventful, computed tomography (CT) at 12-month demonstrated aneurysm shrinkage to 62 mm without images of endoleak. Literature review showed how this technique has successfully been applied to manage similar cases of postsurgical and posttraumatic saccular aortic aneurysms in high-risk patients; however, long-term results are still unknown. CONCLUSION: Coil-jail technique for the treatment of saccular aortic aneurysms can be considered an alternative when open surgery or conventional endovascular treatment is not feasible. Technical success and mid-term outcomes are promising but strict follow-up is recommended. CLINICAL IMPACT: This study aims to share the unconventional endovascular treatment of a visceral aortic aneurysm in a patient unfit both for open and traditional endovascular surgery. To the best of our knowledge this is one of the first cases published in Literature, for this reason, a step-by-step video has been created to describe the procedure. Literature review was then performed to analyze midterm results of this technique. Despite being a treatment that is not recommended for conventional cases, the knowledge of endovascular devices and techniques may help to manage or simplify complex aortic diseases.

Oncoplastic central quadrantectomies.

Tumors localized in the central quadrant (centrally located breast tumors) have always represented a challenge for the surgeon because of the critical aesthetical matters related to the nipple-areola complex (NAC). Many years of experience with breast cancer patients treated by using various oncoplastic techniques, has allowed us to develop the modified hemibatwing for the treatment of central breast tumors, where the NAC is involved. Modified hemibatwing-along with the removal of the NAC-is a useful oncoplastic technique and it represents an ideal option for the treatment of central tumors because it assures oncological safety, a reduced surgical timetable and greater aesthetical results.

Wire-guided Localization in Non-palpable Breast Cancer: Results from Monocentric Experience.

BACKGROUND: Breast-conserving surgery (BCS) is considered the gold-standard treatment for early breast cancer. Ultrasound-guided percutaneous biopsy or stereotactic biopsy of a breast lesion allows preoperative histological diagnosis. Various techniques have been proposed for identifying non-palpable breast tumors, but the most popular method is the wire-guided localization (WGL) technique. The aim of this study was to propose an alternative technique for optimizing the WGL procedure, facilitating breast surgery and reducing complications. PATIENTS AND METHODS: We performed a prospective study on 40 patients with a single non-palpable breast lesion. For the preoperative localization of mammary lesions, patients were divided randomly into two groups: 20 patients underwent conventional WGL technique and 20 underwent 'optimized' personalized technique. RESULTS: In the group treated with the optimized technique, dislocation of the wire occurred in only 2/20 cases, whereas in those with the conventional technique, dislocation occurred in 9/20 cases (p=0.03). In 5/20 cases of the conventional WGL technique, the wire was accidentally cut by the surgeon, whereas no similar complications were observed in the group that underwent the optimized technique (p=0.047). Re-excision of the surgical margins was necessary in 6/20 cases with the conventional technique, while re-excision was not required for any case using the optimized technique (p=0.02). CONCLUSION: The proposed optimized technique ensures good esthetic results, enabling the surgeon to identify the lesion and perform oncoplastic breast surgery, and allows surgical time to be reduced.

A Randomized Pilot Study of Inositol in Association with Betaine and Boswellia in the Management of Mastalgia and Benign Breast Lump in Premenopausal Women.

Benign mammary lumps and mastalgia are the most common breast disorders; yet, there is no clear-cut consensus about the best strategy for their treatment. We hypothesized that a combination, including boswellic acid, betaine, and myoinositol, would be beneficial in breast disorders by exerting a pleiotropic effect on multiple pathways. Indeed, myoinositol has already been proven to modulate some factors involved in the genesis of breast diseases, such as fibrosis and metabolic and endocrine cues. In our study, 76 women were randomly assigned to either the experimental or the placebo arm. After six months of treatment, statistically significant differences between the two groups were recorded for pain relief (56% vs 17%) and breast density reduction (60% vs 9%). Furthermore, benign breast mass dimension showed a reduction in the experimental group (40% vs 16%). The combination of boswellic acid, betaine, and myoinositol has been demonstrated to be effective in the treatment of breast pain and radiologically and histologically confirmed benign breast mass and in the reduction of breast density, one of the pivotal risk factors for the development of breast cancer, without any side effects.

Nipple-sparing Mastectomy in Patients with Preoperative Diagnosis of Non-invasive Breast Carcinoma. A Single-center Experience.

BACKGROUND: Nipple-sparing mastectomy (NSM) is a recognized treatment for selected patients with breast cancer (BC). Our study aimed to analyze 7 years' experience in NSM and breast reconstruction for patients with preoperative diagnosis of non-invasive BC. PATIENTS AND METHODS: All NSMs with breast reconstruction, performed between January 2007 and December 2013 in patients with preoperative diagnosis of non-invasive BC, were considered. RESULTS: Thirty-five NSMs were performed, 23 cases confirming the diagnosis of non-invasive BC, and in 12 patients it also resulted in findings of an invasive component. Patients were stratified into two groups: breast reconstruction was performed i) with silicone definitive implant, ii) with a temporary breast tissue expander. An invasive component at the postoperative histological examination was significantly associated with tissue expander reconstruction (p=0.03). CONCLUSION: In selected cases, NSM is a valid and safe procedure. Further critical evaluations are required for more evidence on this argument.

Peliosis hepatis: Personal experience and literature review.

Peliosis hepatis (PH) is a disease characterized by multiple and small, blood-filled cysts within the parenchymatous organs. PH is a very rare disease, more common in adults, and when it affects the liver, it comes to the surgeon's attention only in an extremely urgent situation after the lesion's rupture with the resulting hemoperitoneum. This report describes the case of a 29-year-old woman affected by recurring abdominal pain. Computed tomography scans showed a hepatic lesion formed by multiple hypodense areas, which showed an early acquisition of the contrast during the arterial phase. Furthermore, it remained isodense with the remaining parenchyma during the late venous phase. We decided on performing a liver resection of segment VII while avoiding a biopsy for safety reasons. The histopathologic examination confirmed the diagnosis of focal PH. PH should always be considered in the differential diagnosis of hepatic lesions. Clinicians should discuss the possible causes and issues related to the differential diagnosis in addition to the appropriate therapeutic approach. The fortuitous finding of a lesion, potentially compatible with PH, requires elective surgery with diagnostic and therapeutic intents. The main aim is to prevent the risk of a sudden bleeding that, in absence of properly equipped structures, may have a fatal outcome.

Adjuvant Ovarian Suppression, High-dose Chemotherapy and Immunotherapy for Premenopausal Patients with High-risk Breast Cancer.

BACKGROUND: Premenopausal patients with breast cancer and more than 10 positive axillary nodes (BC>10) have a poor prognosis: In these patients the best adjuvant therapy (CT) has not yet been established. PATIENTS AND METHODS: Forty-two BC>10 received, in sequence, the following adjuvant treatments: luteinizing hormone releasing hormone (LH-RH) analog for 5 years; anthracycline-based induction chemotherapy; radiation therapy; platinum-based high-dose CT, with autologous bone marrow transplantation; immunotherapy with interleukin 2 (IL2) and 13-cis retinoic acid (RA); anastrazole given 5 years to estrogen receptor-positive patients. Primary endpoints of the study were disease-free survival (DFS) and overall (OS) survival. A secondary endpoint was toxicity. RESULTS: The median age of patients was 41 years, and the mean number of positive axillary nodes was 14. Estrogen and progesterone receptors were positive in 57% and 29% of patients respectively, while 14% of patients had triple-negative disease. With a median follow-up of 120 months for patients remaining alive at the end of study, median DFS and OS, had not yet been reached. The 20-year DFS and OS rates were 63.8%, and 81.6%, respectively. One to two years after the end of the therapy, three patients had had four full-term pregnancies. CONCLUSION: Treatment with LH-RH analog, high-dose CT, peripheral blood progenitor cells and IL2 with RA for patients with BC>10 is feasible, has moderate toxicity, while preserving ovarian function, seems to improve the expected DFS and OS for these high-risk patients.

A modified sentinel node and occult lesion localization (SNOLL) technique in non-palpable breast cancer: a pilot study.

BACKGROUND: The spread of mammographic screening programs has allowed an increasing amount of early breast cancer diagnosis. A modern approach to non-palpable breast lesions requires an accurate intraoperative localization, in order to achieve a complete surgical resection. In addiction, the assessment of lymph node status is mandatory as it represents a major prognostic factor in these patients. The aim of this study is to evaluate the reliability of a modified technical approach using a single nanocolloidal radiotracer to localize both sentinel node and breast occult lesion. METHODS: Twenty-five patients with a single non-palpable breast lesions and clinically negative axilla were enrolled. In the same day of surgery, patients underwent intratumoral and peritumoral administration of (99m)Tc-labeled nanocolloid tracer under sonographic guidance. A lymphoscintigraphy was performed to localize the sentinel lymph node and its cutaneous projection was marked on the skin in order to guide the surgeon to an optimal incision. During surgery an hand-held gamma-detection probe was used to select the best surgical access route and to guide localization of both occult breast lesion and sentinel lymph node. After specimen excision, the surgical field was checked with the gamma-probe to verify the absence of residual sources of significant radioactivity, thereby ensuring a radical treatment in a single surgical session and minimizing normal tissue excision. RESULTS: Both targeted breast lesion and sentinel lymph node were localized and removed at the first attempt in every patients and histopathological diagnosis of malignancy was confirmed in 25/26 samples. Non-palpable lesions were included within the surgical margins in all patients and in all samples surgical margins were free from neoplastic infiltration thus avoiding any further reintervention. Only two patients showed metastatic involvement of sentinel lymph node. CONCLUSIONS: The modified sentinel node and occult lesion localization (SNOLL) technique performed with a single injection of nanocolloidal radiotracer has shown an excellent intraoperative identification rate of both non-palpable lesion and sentinel lymph node. This procedure offers, as opposed to standard techniques, an accurate, simple and reliable approach to the management of non-palpable breast cancer.

Primitive sarcoma of the breast: new insight on the proper surgical management.

BACKGROUND: Primitive sarcoma of the breast is a rare and challenging disease at high risk of recurrence and with poor prognosis. There are controversies in the diagnosis and management of such solid tumor due to its rarity and heterogeneity. This sarcoma is poorly responsive to both chemotherapy and radiotherapy, thus, surgery is the first and most important therapeutic approach. However, given the rarity of this type tumor it has not be possible to standardize unique guidelines for the proper surgical strategy to adopt. Here, we performed a retrospective study of new 10 cases of primitive sarcoma of the breast that underwent either mastectomy or a more conservative quadrantectomy, in the attempt to better standardize correct surgical indications. METHODS: Ten new cases of primitive sarcoma of the breast were registered between 2002 and 2012 and constituted the study group. They underwent either mastectomy or quadrantectomy and the clinical, prognostic and survival characteristics after surgery were analysed. RESULTS: Within the group of patients treated with mastectomy, two had metastasis and died because of that. Among the five patients treated with quadrantectomy four are alive and free of disease after 3 to 5 years follow-up, while the patient with sarcoma arising in pregnancy, although is still alive, developed lung metastases four years after surgery. CONCLUSIONS: The first and most important therapeutic approach to primary sarcomas of the breast is surgical which has the purpose to achieve radical tumor excision to prevent local recurrence and skip metastases. However, given the rarity of the condition and the consequent small number of cases in this, like in similar studies, it is not possible to draw any definitive conclusions and further studies with larger numbers are necessary. However it would appear that performing a larger procedure such as mastectomy rather than performing a more limited one such as a quadrantectomy, has no advantage in terms of overall prognosis.

Schwannoma of the parotid gland. Case report.

Schwannoma is encapsulated benign tumors arising from nerve cell. Of which ancient schwannoma is one of five variants. Intraparotid facial nerve schwannoma is been documented sporadical throught the medical literature, althought a few ancient schwannomas have been reported in different locations in the head and neck region. In this report, a 31 year old man patient with an misunderstanding tumor of the parotid gland is described and the histopathologic exam was performed to diagnosed the schwannoma.

Typical and atypical lymphatic flows in breast carcinoma.

AIM: The study of sentinel lymph node has greatly increased the knowledge about lymphatic drainage in breast cancer. MATERIAL OF STUDY: The experience of 181 patients operated for breast carcinoma in the last two years, of which 70 undergoing SLN biopsy, allowed us to highlight some peculiarities of lymphatic drainage of the breast and led us to physiological and pathological considerations about lymphatic flow in patients for breast carcinoma. We studied patients undergoing lymphoscintigraphic mapping with SLN biopsy who were candidates for breast cancer surgery. RESULTS: Searching for SLN's location, we found that in 88.6% cases the SLN was at level I, in 8.6% it was at level II, in no case it was at level III and in 2.8% we found lymphatic drainage to the contralateral axilla. DISCUSSION: Thanks to this dynamic study we were able to highlight a preferential subcutaneous lymphatic path from the breast parenchyma reaching the contralateral axilla, crossing anteriorly the thorax. Literature review showed CAM incidence ranges from 3.6% to 6% and can be caused by occult primary cancer of the contralateral breast, contralateral spread of breast cancer and presence of another kind of tumor. CONCLUSIONS: The presence of contralateral axillary metastasis, although known, allowed us to scintigrafically document (for the first time) the pathway of an alternative lymph flow and to suppose the possible causes. Thanks to this observation, considerations can be drawn about clinical, pathophysiological and oncological implications, with an impact on post-operative follow-up.

Rare chondrosarcoma of the breast treated with quadrantectomy instead of mastectomy: A case report.

Breast chondrosarcoma is a rare sarcoma that mainly occurs in females >50 years old. To the best of our knowledge, only 16 cases were reported in the literature prior to 2013 and all patients were surgically treated by mastectomy, with or without lymphadenectomy, which was occasionally preceded by neoadjuvant chemotherapy. However, the literature does not report the benefit of mastectomy compared with a more conservative surgery. The present study reports a novel case of extraskeletal chondrosarcoma of the breast. A 63-year-old female patient presented with a neoplasm localized in the upper-outer quadrant of the right breast. The palpable lesion with sharp margins was a firm parenchymatous mass, which was confirmed by ultrasonography and mammography. The patient underwent conservative quadrantectomy instead of mastectomy, followed by post-surgical chemotherapy. A positron emission tomography scan performed five months subsequent to the surgery revealed no remnants of the disease. The patient underwent a strict clinical and instrumental follow-up, and two and half years after surgery, there are no signs of recurrent disease. In conclusion, the present case is currently one of the two cases in which a more conservative quadrantectomy was performed, instead of mastectomy. This surgical approach did not lead to metastasis and resulted in a good follow-up for the patient.

Microsurgical approach for unusual and unexpected malignant fibrous histiocytoma of the forearm: A case report.

Soft tissue sarcomas are rare tumors with a dismal prognosis. Among the most common histological types of sarcomas of the extremities, malignant fibrous histiocytoma (MFH) is the one with the highest incidence. Surgery is considered to be the first choice of treatment for MFH. To the best of our knowledge, this is the first case report in the literature of a patient with MFH within the abductor pollicis longus (APL) muscle. This unusual location was also unexpected by the treating surgeons, as the preoperative magnetic resonance imaging localized the tumor inside a different muscle. A 79-year-old Caucasian man presented with a swelling in the middle third of the dorsal aspect of the left forearm. MFH was diagnosed following biopsy and instrumental diagnostic examinations. Surgical excision and simultaneous reconstruction was performed by the same microsurgical team, achieving an excellent functional outcome. The present case highlights the significance of microsurgical approach for improving strategic planning in oncologic surgery. Accurate surgical dissection, performed by a team of microsurgeons, allowed for the identification of the unusual and unexpected tumor localization within the APL muscle. For this reason, a change of surgical strategy allowed for preservation of the extensor digitorum communis muscle, which would otherwise have to be resected, with tendon transfer and successful restoration of the thumb abduction function.

Breast Mondor's disease: Diagnosis and management of six new cases of this underestimated pathology.

Mondor's disease is an unusual and little-known pathology of the breast, characterized by superficial thrombophlebitis. The causes are still unresolved. Most of the patients do not fall under case studies of the scientific literature, given the reported incidence rate between 0.5% and 0.8%. The Mondor's disease patients are not always properly identified, and they are frequently treated as outpatients, even considering the benign course of the disease which often spontaneously resolves without any medical therapy. We report here six new cases of Mondor's disease, two of them were likely due to a trauma and were easily resolved with the use of non-steroidal anti-inflammatory drugs; the third one was apparently due to the stretching of the mammary veins in a patient with gigantomastia; the fourth one was subsequent to hormonal stimulation for in vivo fertilization and following gestation; and the last two cases (one was a man) were diagnosed after undergoing surgery for breast carcinoma.

Merkel-cell carcinoma: preoperative clinical diagnosis and therapeutic implications.

The authors report the personal experience of some patients undergoing surgery for carcinoma of Merkel and discuss the diagnosis and therapeutic approach guided by literature and international guidelines. Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine tumour, which prefers the Caucasian race in adulthood. Approximately 78% of patients are over than 59 years, the most common location is at the level of the head and neck (50.8%) and less frequently in the limbs (33.7%). The literature is discordant about the causes and risk factors for this cancer. In fact, some authors describe major risk factor the immunosoppression, still others see prolonged exposition to UV radiation increases the risk for the onset of this tumor. Metastasizes early to the skin (28%), the lymph nodes (27%), liver (13%), lung (10%), bone (10%) and encephalon (6%), and may recur both locally (30-60%) and both locoregional (40-73%). Our experience confirms the difficulty of preoperative clinical diagnosis and a correct therapeutic approach to Merkel cell carcinoma for the lack of specific characteristics as first clinical assessment, which may keep the suspect nature. International guidelines provide a wide excision (3 cm in largeness and 2 cm in depth) to reduce the risk of disease recurrence, preferring adjuvant chemotherapy not radiotherapy. For lesions of stage I-II over the wide excision also regional lymphadenectomy is performed or, more rarely, the technique of sentinel lymph node.

Contralateral axillary metastases from breast cancer. Personal experience and review of literature.

UNLABELLED: The contralateral axillary lymph node metastasis (CAM) from breast cancer are very rare, and pose a number of classification problems and therefore also on the surgery attitude to be adopted and the subsequent surgical oncological approach, making a distinction between synchronous and metachronous cases. You must always wait for a reasonable period of time to exclude the presence of an occult cancer in the contralateral breast. You make assumptions about the lymphatic pathways that determine this metastasis underlining that in the literature (rare) cases are reported in which the lymphoscintigraphic sentinel lymph node search has shown an uptake of contralateral axillary lymph nodes. KEY WORDS: Breast cancer, Controlateral axillary lymph node metastasis, Lymph node metastasis.

Rete testis adenomatous hyperplasia: our experience.

The word "adenomatous hyperplasia of rete testis" (AHRT) was used by M. Nistal et Al. for the first time in an article about the cystic dysplasia of the testis (1976). AHRT is a benign lesion of the testis. The patient who came to our attention was studied with a testicular echo color Doppler that identified a solid, well circumscribed and hypoechoic mass of 4.5 x3.8mm as diameter, localized in the upper third of the right testicle and with a perilesional vascularization pattern. The preoperative study was based on an accurate medical history, on an ultrasound with contrast and on a RMI. The treatment consisted in an echo guided excisional biopsy of the testicular lesion, considering this as the best approach for those testicular neoformation difficult to define, with a lot of benefits for the patients, especially for those monorchid.

Breast sarcoma in a pregnant patient A case report.

Sarcoma of the breast is a rare and heterogeneous lesion. We describe a case of a patient surgically treated for a breast lesion during pregnancy. The lesion resulted in a concentric neoplasia with the histological features of high grade sarcoma growing in a phyllodes tumor which was at the time grown in a fibroadenoma. Key words: Breast sarcoma, Non-epithelial breast tumour, Phillode, Pregnancy.

Personal technique for treatment of perianal fistulas in outpatients.

AIM: Presentation of a personal technique for the treatment of perineal fistulas in outpatients. MATERIAL OF STUDY: 17 patients with complete non-complex linear intersphincteric or trans-sphincteric fistulas were treated with this technique. First we facilitated the cannulation, then we used the same catheters to place the "seton". We had to use a more subtle and smooth, rugged nylon thread, instead of the floss, due to the difference between the large size of the silk thread and the small lumen of the cannula. RESULTS: The elastic traction has determined not only a valid mean of capillary drainage, but also a rapid passage through the tissues without any functional impairment, in times ranging from 2 to 4 weeks. DISCUSSION: The traditional surgery is burdened by a significant number of relapses . This is due to the anatomical characteristics of the anal canal, to the difficulty to ensure the integrity of the sphincteric structures and to the position of the fistula. It's essential to identify the whole extension of the fistula to avoid it's partial removal and the persistence of granulation tissue therefore. With our technique, we got a good drainage of the fistula, avoiding to leave any residues or to create false paths causing relapses as may happen with the explorers. CONCLUSIONS: The discomfort suffered by patients was minimal and the results achieved led us to support a greater diffusion of this technique in outpatients.

Cystosarcoma phylloides of the breast: a rare diagnosis. A case report and review of the literature.

Sarcoma of the breast is a rare condition, with one possible meaning of relapse ad metastastasize, and behaves biologically as a stromal tumor. Surgery is the first choise and mastectomy is the best procedure adopted in these tumors. The aim of our study was to assess diagnostic and treatment options for PT, based on a review of the literature and our experience with a case of breast sarcoma arising from a phyllodes tumor.