Diagnostic Difficulties in Evaluation of Neck Masses - Idiopathic Lymph Node Infarction.

Palpable neck masses are often the only signs of patients visiting their ENT specialists. Lymphadenopathy may be a primary or secondary manifestation of numerous benign and malignant disorders. The medical history, physical examination, imaging and pathological examination may help to set the appropriate diagnosis. Lymph node infarction is a very rare entity among the various pathologies involving the lymph nodes. We hereby present three cases, in which infarction was the only symptom, no associated condition occurred.

[Fulminant isolated necrotizing fasciitis of the chest wall, complicating thoracic empyema]. / Fulmináns lefolyású, mellkasi empyemát okozó izolált mellkasfali fasciitis necrotisans.

Authors introduce the case of a 64-year-old male patient with fulminant isolated necrotizing fasciitis of the chest wall, complicating empyema thoracis of unknown origin. The patient's co-morbidities were hypertension, ischaemic heart disease, atrial fibrillation with oral anticoagulation. The real etiology was revealed post mortem, due to the rapid progression. The autopsy demonstrated that the fasciitis was caused by a small blunt thoracic trauma (haematoma), not emerged from patient's history and was not visible during physical examination. Authors review diagnostic pitfalls, leading to delayed recognition in addition to this very case. After quick diagnosis surgical debridement, targeted wide spectrum antibiotics and maximal intensive care are the basic pillars of the management of necrotizing fasciitis.

[Insulin-like growth factor-II secreting prostate tumour causing severe hypoglycaemi]. / Inzulinszeru növekedési faktor-2-t termelo prosztatatumor okozta súlyos hypoglykaemia.

The authors present a case of an 82-year-old male patient who presented with frequent hypoglycaemia. Four years prior to the current evaluation the patient had been diagnosed with prostate carcinoma; however, he refused surgical treatment. Initial diagnostic tests indicated organic hypoglycaemia with low serum insulin levels. Insulinoma was excluded and further laboratory tests showed reduced serum insulin-like growth factor-II and normal serum chromogranin A levels as well as normal hypophysis and peripheral hormone values. The authors hypothesised that the severe hypoglycaemia might be the consequence of synthesis and secretion of insulin-like growth factor-II (or its prohormone) by the previously diagnosed prostate tumour. Insulin-like growth factor-II and its prohormone directly increases glucose uptake of the tumour, muscle and adipose tissue, decreases glucose release from the liver and downregulates insulin synthesis due to inhibition of the pancreatic beta cells. The patient required continuous intravenous glucose substitution initially with 5%, subsequently with 20% glucose infusion. Administration of other agents resulted only in temporary improvement. Prostatectomy was again considered but then excluded because of the recurrent hypoglycaemia and the poor general condition of the patient. Hypoglycaemia was finally controlled with glucose and diazoxide therapy, but no improvement in the general condition of the patients was observed and the patient deceased. Immunohistochemistry of the prostate sections showed a carcinoma with strong insulin-like growth factor-II staining, suggesting that insulin-like growth factor-II-secreting prostate tumour caused the severe hypoglycaemia.

Comparing bipolar electrothermal device and endostapler in endoscopic lung wedge resection.

Video-assisted thoracoscopy (VATS) is gaining on thoracic surgery, having newly developed devices next to endostaplers for haemostatic and airtight sealing of lung parenchyma. Though the bipolar electrothermal Ligasure has good results for pulmonary wedge resection, its literature is small in numbers. Authors compared Ligasure and endostapler for pulmonary wedge resection of solitary pulmonary nodules (SPN). Authors performed a retrospective analysis of 44 consecutive patients. The indication of operation was non-verified SPN in all cases. They carried out pulmonary wedge resection for 22 patients with Ligasure-Atlas and 22 patients with ETS Flex endostapler via VATS. Authors examined the gender, average age (62 vs. 49 years), mean hospital stay (6.6 vs. 6.8 days), average operation time (55 vs. 50 min), number of complications (2 vs. 1), average drainage time (2.8 vs. 2.7 days), average fluid loss (190 vs. 160 ml), and instrumental costs (367 euro vs. 756 euro) of both groups. They accomplished the histological analysis of the coagulated lung parenchyma as well. According to the results, the Ligasure-Atlas is eligible for pulmonary wedge resection. The method is safe, easy to use, having minimal rate of complications. It can moderate costs of operation, compared to endostaplers.

[Solitary oesophageal metastasis of breast cancer after 17 years latency]. / Mamma carcinoma solitaer nyelocso-metastasisa 17 éves remissio után.

The authors discuss a case of a 63-year-old woman, who presented with dysphagia, 17 years after radical mastectomy for breast cancer. CT scan showed a juxta esophageal mediastinal tumour. A biopsy via right thoracotomy revealed a metastatic adenocarcinoma of the oesophageal wall from the previous breast carcinoma. Minimally invasive oesophageal intubation was used for palliation. Hormonal manipulation and radiotherapy was commenced postoperatively. The patient was well after eight months follow-up. A combination of high clinical suspicion with EUS and deep oesophageal biopsy can lead to the correct diagnosis of this very rare clinical entity. The biology of metastatic breast cancer may demand palliation by oesophageal intubation or stenting combined with adjuvant chemo, radio or hormonal therapy in such instances.

Erythema Gyratum Repens an Immunological Paraneoplastic Dermatosis.

The authors present a patient with erythema gyratum repens who had a bronchogenic carcinoma. Autoantibodies and complement at the basement membrane zone of the skin was found which suggest that erythema gyratum repens may have an immunological pathogenesis but the nature of the antigen should be further characterised.