Diffuse Tenosynovial Giant Cell Tumor Encircling the First Metatarsal Bone Remodeling after Resection. A Case Report.

Introduction: The term tenosynovial giant cell tumor encompasses a group of rare soft-tissue tumors. A new classification divides the group in localized and diffuse type, depending on the involvement of the surrounding tissues. Due to the unclear origin and heterogeneity in extend of the diffuse-type giant cell tumors, there is only limited evidence on the tumor-specific treatment. Thus, every case report has an added value toward setting disease-specific guidelines. Case Report: Presentation of a diffuse type tenosynovial giant cell tumor encircling the first metatarsal. The tumor had mechanically eroded the plantar aspect of the distal metaphysis, with no signs of tumor spread. After an open biopsy, resection of the mass was performed without debriding or resecting the first metatarsal. Repeat imaging postoperatively showed no recurrence at 4-year follow-up and a bony remodeling of the lesion. Conclusion: Bone remodeling is possible after complete resection of diffuse tenosynovial giant cell tumor when the erosion is caused by mechanical pressure and no intraosseous expansion of the tumor is present.

Phytobezoar-Induced Mechanical Ileus and Incipient Intussusception: A Case Report.

Phytobezoars constitute conglomerates of indigested plant fibers and are a rare cause of acute mechanical ileus. They exhibit an increased prevalence in the elderly population and people with specific predisposing conditions. Radiological imaging can often set a definitive diagnosis and dictate the optimal therapeutic approach, combined with the patient's clinical status. An 81-year-old male presented with deteriorating clinical symptoms of intestinal obstruction, and an exploratory laparotomy was performed following inconclusive radiological findings; multiple phytobezoars and incipient intussusception were revealed intraoperatively. A patient's medical history can often raise clinical suspicion of phytobezoars. However, a careful etiological investigation is imperative in all cases of mechanical ileus in advanced ages; early detection and dissolution of phytobezoars, when applicable, can reduce the need for surgical interventions.

Myxoma of the upper lip: a case report and brief review of the literature.

Myxomas are rare neoplasms of mesenchymal origin, which consist of many undifferentiated stellate and spindle-shaped cells in abundant loose myxoid stroma with collagen fibers. A 74-year-old patient presented in our oral and maxillofacial department with a slow growing mass within the upper lip. The mass was surgically excised in the toto, followed by a histological and immunohistochemical examination. The findings revealed that it was a myxoma. These tumors are very rare and should be included in the differential diagnosis of damage of the upper lip. As long as the myxoma is properly removed, there is no risk of recurrence.

An Easily Missed But Life-Threatening Diagnosis: A Case Report of Gorlin Syndrome.

BACKGROUND Gorlin syndrome, also known as basal cell nevus syndrome (BCNS), nevoid basal cell carcinoma syndrome (NBCCS), and Jaw cyst-Basal cell nevus-Bifid rib syndrome, is a rare multisystemic syndrome that can affect a remarkable number of tissues and organs in the human body. Patients with this syndrome are in jeopardy of developing basal cell skin cancer during puberty or early adulthood. CASE REPORT Herein, we report a case of a 58-year-old woman who had multiple pigmented skin lesions and a palpable tumor of the left scapula. The patient underwent surgical excision of the above-mentioned lesions. The histopathological examination revealed that 10 of them were basal cell skin carcinomas (BCCs); therefore, the patient was proven to have the syndrome. She had a history of similar skin lesions, which were removed before the age of 20. CONCLUSIONS This case highlights that rare phenomena, such as the presence of multiple BCCs, require additional investigations and a multidisciplinary approach since a rare and potentially life-threating condition might be the underlying cause. Early diagnosis of Gorlin syndrome is of paramount importance to facilitate the appropriate therapeutic approach, as directed by a multidisciplinary team. Patients with multiple skin lesions need to have regular assessments by their general practitioner or dermatologist, with dermoscopy serving as an important preventive measure. Furthermore, because pathogenesis of the syndrome is characterized by development of basal cell carcinomas, consecutive follow-up is of a great significance.

Uterine malignant leiomyosarcoma associated with high levels of serum beta-human chorionic gonadotropin: A case report.

We present the case of a 54-year-old woman diagnosed with uterine leiomyosarcoma that produced beta-human chorionic gonadotropin (ß-hCG), evident by both serum and immunohistologic examination. Based on this and similar cases from the available literature, ß-hCG-producing sarcomas tend to have poorer prognosis, indicating that ß-hCG could potentially be used as a marker of disease status and response to the therapy; however, this association is inconsistent and should be further investigated.

Peripheral Osteoma of the Mandibular Condyle-Case Series.

The purpose of this article is to present four new cases of peripheral osteoma of the mandibular condyle and the literature review. A retrospective study of files from our Department of Oral and Maxillofacial Surgery over the last 6 years revealed four cases of peripheral osteomas located in the area of the mandibular condyle. Diagnostic procedure included clinical, radiographic, and histologic criteria. Gardner's syndrome was excluded from patient history and clinical evaluation. One patient had only an aesthetic disturbance, with facial swelling, and the other three patients presented disturbances of the mandibular function, including deviation during mouth opening along with malocclusion. Three of the patients were male and one was female; all were of middle age (45-65 years old). The proposed surgical treatment was accepted by half of the patients, while the remaining half declined the operation after a confirmation of the diagnosis. Peripheral osteomas of the maxillofacial region are uncommon, and some cases with multiple osteomas are related to Gardner's syndrome. An osteoma of the mandibular condyle is very rare and surgical treatment is challenging for the surgeon with regards to the approach selection and the related complications. In the two cases that accepted the proposed surgical treatment, no recurrence and no complication was observed.

Mesothelioma: A Case in a Diagnostic Timeline and the Efficiency of Robot-Assisted Surgery.

We present a case of a 65-year-old male with a difficulty to diagnose mesothelioma. To be specific, three attempts were made to diagnose the disease, and only with a large sample performed with robot-assisted surgery, our pathologists were able to identify the malignancy. The novelty for our case is mostly based on the timeline of the diagnosis along with the tissue samples where we present the course of the transformation from benign to malignancy. All tissue biopsies were checked by two independent pathologists. Conclusively, diagnosis for small local lesions should be performed with an endoscopic method, video-assisted or robot-assisted.

Schwannoma of the lumbar spine, presenting with pain of the knee, like an osteoid osteoma, in a 10-year-old girl.

Localized pain in the absence of local lesion may represent referred pain from the spine, in a child, arising from a benign spinal schwannoma. It can be diagnosed by MRI. Surgical excision of the tumor relieves the symptoms.

Total Pancreatectomy with Splenectomy for Multifocal Intraductal Tubulopapillary Neoplasm (ITPN) of the Pancreas Associated with Invasive Component: Report of a Rare Case.

BACKGROUND Pancreatic intraductal tubulopapillary neoplasm (ITPN) was first described by Yamaguchi in 2009 and was recognized by World Health Organization as a distinct entity in 2010. Since then few case reports and case series have been published. Little is known about its clinicopathologic features and treatment outcomes. We present the seventh case of total pancreatectomy for ITPN reported in the English literature. CASE REPORT Our patient was an 82-year-old male with a previous history of acute evolving-to-chronic pancreatitis. After 2 years of medical consultation, an abdominal magnetic resonance imaging was suspicious for multifocal pancreatic neoplasia. A computed tomography-guided biopsy of the lesion was performed which indicated pancreatic intraductal neoplasia with intermediate dysplasia. After oncology consultation, the patient underwent pylorus-preserving total pancreatectomy with splenectomy. The pathology report showed pancreatic ITPN with intermediate to severe dysplasia and associated invasive carcinoma. All 21 resected lymph nodes were non-metastatic (pT3N0). The postoperative course of the patient was uncomplicated. He received adjuvant gemcitabine (single agent) for 6 months. At 18 months after surgery he was diagnosed with hepatic metastases; he was still alive at the time of this reporting. CONCLUSIONS ITPN has been associated with previous history of acute pancreatitis in some patients. Early diagnosis, radical surgical resection, and adjuvant chemotherapy may lead to long-term survival rates even in cases with associated invasive component. Total pancreatectomy may be a preferable procedure for ITPN in selected patients.

Thyroid Angiosarcoma-Rare Case or Hard to Find.

INTRODUCTION: Thyroid Angiosarcoma is a rare malignant condition of the thyroid gland with higher incidence reported in mountainous Alpine regions (Switzerland, Austria and northern Italy), featured with poor prognosis. CASE PRESENTATION: A 76 years old male patient presented in our hospital complaining about difficulty in breathing, altered voice (hoarseness), fatigue and dysphagia. Careful observation of the frontal neck region revealed hemorrhaging petechiae and purpura, while palpation indicated a large nodule movable with deglutition, presumably derived by the thyroid gland. Serum biochemical thyroid function tests were normal. Ultrasound of the thyroid gland showed enlargement of the right lobe with a nodular lesion. FNAC indicated a "suspicious for malignancy" lesion. After patient's consensus, total thyroidectomy took place accompanied by excision of infiltrated infrahyoid muscles. The cytopathologic results were positive for primary thyroid angiosarcoma. Patient's postoperative condition was regular, but he died of disease progression 6 months later. DISCUSSION: Angiosarcomas are malignant neoplasms arising from endothelial cells of blood vessels. They are most commonly found in skin, soft tissue, breast, bone, liver and spleen. Angiosarcomas tend to be highly hemorrhaging and invasive. Thyroid gland is a rare location of development. Cytopathologically they are grossly characterized by freely anastomosing vascular channels lined by atypical endothelial cells unusually enlarged, often multinucleated with many nucleoli and vacuoles into the cytoplasm containing fragments of erythrocytes. The immunohistological identity of angiosarcomas are endothelial line markers (CD31, CD34 and vimentin). Surgical excision when feasible is the first line treatment while adjuvant radio-and/or chemo-therapy are ambiguous. Infiltration of surrounding tissues and distant metastasis (lymph nodes and lungs) are negative prognostic factors.

Sigmoido-Cecal Fistula: A Rare Case of Complicated Recurrent Diverticulitis and a Review of the Literature.

BACKGROUND Although diverticular disease is well described and treated in daily clinical practice, there are cases that attract great interest because of their complexity and difficulty in management. Herein, we describe a rare case of colo-colonic fistula-complicated diverticulitis that necessitated urgent surgical intervention. CASE REPORT A 76-year-old female patient with a known history of diverticular disease of the sigmoid colon presented in the Emergency Department for evaluation of left lower quadrant abdominal pain. The clinical and radiological examinations revealed a recurrent episode of acute diverticulitis of the sigmoid colon. However, it was of great interest that we detected a sigmoido-cecal fistula in the abdominal computed tomography (CT). The patient was admitted to the hospital for conservative treatment. After 48 hours, the patient's clinical status deteriorated, with pain aggravation, abdominal distension, bloating, and metallic bowel sounds. The simple abdominal x-ray revealed large-bowel obstruction and the CT demonstrated worsening inflammation of the sigmoid colon. An exploratory laparotomy revealed an inflamed dolichol-sigmoid colon forming a fistulous tract with the cecum and thus, mimicking a closed loop obstruction. The sigmoid colon was transected en bloc with the sigmoido-cecal fistula and a Hartmann's procedure was performed. CONCLUSIONS This case is extremely unusual as the patient presented at the same time two complications of diverticular disease, both obstruction and this rare formation of sigmoido-cecal fistula. It is presented in order to acquaint surgeons with the possibility of an unexpected course of this disease which indeed necessitates an individualized management.

Primary hepatocellular carcinoma in a patient with history of treated breast cancer: a case report with challenging diagnosis and treatment.

INTRODUCTION: Breast cancer is the most common malignancy in women worldwide. Long-term survivors among patients treated for breast cancer are at a high risk for developing a second primary malignancy. Hepatocellular carcinoma is the most frequent primary hepatic malignancy and should be ruled out in breast cancer patients who are diagnosed with solitary hepatic lesions. False diagnosis may lead to inappropriate oncologic staging and treatment of the disease. CASE PRESENTATION: We present the case of a 73-year-old female patient who had been treated for invasive ductal breast cancer 7 years ago and was diagnosed with a solid hepatic lesion at segments VI and VII and a small, calcified lesion at the tail of the pancreas on follow-up with an abdominal computed tomography. Oncology council decided that both lesions could be resected after determining whether they were metastatic or second primary malignancies. The patient underwent laparotomy and rapid biopsy which showed primary hepatocellular carcinoma and fibrosis of the pancreas. We performed hepatic segmentectomy (VI-VII) and cholecystectomy, while the pancreatic lesion was left intact. The postoperative course of the patient was uncomplicated and she remains disease free 2 years after the operation without any adjuvant therapy. CONCLUSION: All hepatic lesions detected in breast cancer patients should be evaluated with open mind and liver biopsy should be performed to get a definitive diagnosis and implement the proper treatment strategy.

Endoscopically Assisted Laparoscopic Gastric Resection for Benign and Malignant Lesions: A Report of Two Cases.

BACKGROUND The first gastric resection for stomach cancer was performed in 1879, and the first gastric resection for gastric ulcer disease was performed in 1882. During the 1990s, the first laparoscopic gastrostomies were reported. During the past decade, laparoscopic techniques have developed rapidly, gaining wide clinical acceptance. Minimally invasive surgery is now shifting the balance away from traditional open methods. We report 2 cases of endoscopically assisted laparoscopic local gastric resections for both gastric cancer and gastric ulcer disease. CASE REPORT The first case involves a 67-year-old male patient who suffered from recurrent bleeding from a gastric ulcer located 4-5 cm from the gastroesophageal junction. The patient was subjected to endoscopically assisted laparoscopic wedge resection of the affected part of the stomach, had an uneventful recovery and was discharged on the third postoperative day. The second case involves a 60-year-old female patient who was diagnosed with intramucosal gastric adenocarcinoma and was also subjected to endoscopically assisted laparoscopic wedge gastrectomy. This patient also had an uneventful recovery and was discharged on the second postoperative day. CONCLUSIONS Endoscopically assisted laparoscopic local gastric resection is a minimally invasive procedure which allows the surgeon to operate under direct visualization of the internal part of the stomach. Thus, it enables the surgeon to safely remove the affected part within healthy margins, providing the patient with all the advantages of laparoscopic surgery.

Interferon-γ and Colorectal Cancer: an up-to date.

Colorectal cancer still remains the third cause of cancer death among cancer patients. Early diagnosis is crucial and they can be either endoscopic or with blood biomarkers. Endoscopic methods consist of gastroscopy and colonoscopy, however; in recent years, endoscopic ultrasound is being used. The microenvironment is very important for the successful delivery of the treatment. Several proteins and hormones play a crucial role in the efficiency of the treatment. In the current mini review we will focus on interferon-γ.

Double unilateral functioning adrenocortical adenomas.

Double functioning adrenocortical adenomas, occurring in the same gland is an extremely rare condition. This paper presents two cases of double functioning adrenocortical adenomas within the same adrenal gland, causing primary aldosteronism. Diagnosis was set histopathologically in one case since magnetic resonance imaging (MRI) failed to distinguish the two entities. In each case, a laparoscopic adrenalectomy was conducted. When preoperative imaging studies fail to report the presence of double adrenocortical adenomas, histopathology reports should be comprehensive enough so as to reveal such rare lesions.

Gallbladder Hypoplasia, a Congenital Abnormality of the Gallbladder: A Case Report.

BACKGROUND There are different variations in the anatomy of the gallbladder. Congenital abnormalities of the gallbladder such as agenesis and hypoplasia are rare conditions and difficult to diagnose with imaging studies. Patients are usually asymptomatic or have symptoms that mimic gallstone disease. The diagnosis is often made intraoperatively and is established by histopathological examination. CASE REPORT We report a case of a 62-year-old male who had cholelithiasis symptoms and was falsely diagnosed with gallstone disease by abdominal ultrasound scan. The patient underwent an operation which revealed a rudimentary gallbladder. The histology result showed hypoplastic gallbladder tissue. CONCLUSIONS This case suggests that surgeons need to take into consideration congenital anomalies of the gallbladder intraoperatively in order to avoid any iatrogenic injury to biliary tract during a routine laparoscopic cholecystectomy. Intraoperative cholangiography can be a useful tool to avoid unnecessary surgical risky interventions.

Tocopherols and tocotrienols as anticancer treatment for lung cancer: future nutrition.

Nutrition has been known for ages to shield the immune system against several formulations that deregulate normal DNA repair mechanisms, and induce tumorigenesis. Vitamins and in specific Vit E and its members tocopherols (α-, ß-, γ-, δ-) and tocotrienols (α-, ß-, γ-, δ-) have demonstrated strong association with the prevention of cancer and inhibition of tumor, both in vitro and in vivo. Vitamin E has also demonstrated effective role against chemotherapy resistant cancer cell evolution and a protective role in acute interstitial disease. Several formulations of Vitamin E have been investigated conjugated with different carriers as nano-formulations and administered in different forms. Additionally, several tumorigenic pathways have been investigated separately in an effort to identify which member of Vitamin E inhibits efficiently every pathway. Vitamin E presented efficiency against specific subhistology types of lung cancer. Finally, in the current work up to date information regarding novel formulations with Vitamin E and inhibition pathways are going to be presented and commented.

Hedgehog signaling pathway: the must, the maybe and the unknown.

Lung cancer treatment consists from the basic chemotherapeutic drugs (e.g., platinum analogues) and from pharmaceuticals targeting the different genome of lung tumors (e.g., tyrosine kinase inhibitors). During the last years pharmaceuticals targeting the tumor mutations are approved for first line treatment since they have provided increased overall survival in comparison to standard chemotherapy treatment. Furthermore, due to the increased interest in unrevealing the mechanisms of cell mutation, tumor evolution and tumor cell maintenance the hedgehog pathway has been elicited. Along with Notch and Wnt these three pathways are responsible for progenitor cell development and pulmonary organogenesis. Inhibitors of this pathway have been discovered and their application in the clinical practice is being investigated. However, further understanding of the mechanisms of regulation is needed.