Littoral cell angiomas are uncommon primary splenic haemangiomas with rare malignant potential. We report a case of a 76-year-old male with an incidental solitary littoral cell angioma found within an accessory spleen. We provide an overview of the literature of littoral cell angiomas and highlight the diagnostic challenge and treatment of this important differential for general surgeons caring for patients with splenic masses. This is the first case to describe primary resection of a littoral cell angioma with splenic preservation.
INTRODUCTION: Severe acute pancreatitis is associated with high morbidity and mortality. This is a result of the development of pancreatic and extra-pancreatic necrosis with subsequent infection which can lead to multiorgan failure. Complications include localized ileus, abscess formation, mechanical obstruction, rupture and perforation into the gastrointestinal tract and fistula formation (Aldridge et al., 1989; Bassi et al., 2001 [1,2]). CASE PRESENTATION: A 72 year old man attended the emergency department with acute epigastric pain. Biochemistry results were reviewed with a lipase of 1680 U/L (ref range <60 U/L). He was treated conservatively. He had a labile course throughout his admission and on day 7 he had significant deterioration. Abdominal CT scan demonstrated marked mechanical large bowel obstruction at the level of the sigmoid colon, caecum dilated with features suggestive of ischaemia in the caecal wall and backflow dilatation of the small bowel loops. The patient was transferred to a tertiary centre for subsequent laparotomy and bowel resection. DISCUSSION: Colonic complications of acute pancreatitis are uncommon. An analysis of pooled data reports the incidence of colonic complications from acute pancreatitis to be 3.3% and those from severe acute pancreatitis 15% (Bassi et al., 2001 [2]). Knowledge about colonic perforation from acute pancreatitis has been limited to few case reports, thus diagnostic and management dilemmas continue to persist. CONCLUSIONS: We report a rare case of ascending colon perforation in severe acute pancreatitis. This is particularly unusual given the anatomical propensity for splenic flexure involvement or transverse colon involvement being noted in literature. This highlights the high index of suspicion required for colonic complications given the varied, non-specific and often delayed presentation of complications.
INTRODUCTION: Acute appendicitis in older adults is relatively uncommon and could be the first presentation of an underlying colorectal carcinoma. Colonoscopy in these individuals affords the opportunity for earlier diagnosis and treatment. The finding of increased rates of colorectal cancer (CRC) with older patients who have had appendicitis was supported by a number of small studies and case reports in the early 1980s.With the advent of CT scanning and laparoscopic appendicectomy, increased ability to visualize the caecum has been achieved. PURPOSE: A retrospective 12-month study of all patients presenting with acute appendicitis aged 50 years and over from 1st May 2017 to 31st May 2018, and review of post operative screening colonoscopy findings. RESULTS: Forty-three patients met inclusion criteria. The patients' median age was 62 years (range 50-85 years). 47% of the patients were male. 86% of patients had abdominal CT scans prior to surgery with acute appendicitis visualized in 97% of these cases. Acute appendicitis was found in 100% of cases with no clinical suggestion of CRC operatively or pathologically. 46% of patients had pertinent findings on colonoscopy. This included a malignant obstructing tumour at the hepatic flexure and a tubular adenoma in the transverse colon in a second patient. The remaining findings in this cohort of patients included diverticular disease and benign polyps. CONCLUSION: Despite the advancement in visualization of anatomy with CT scan and laparoscopic appendicectomy there is still a role for screening colonoscopy in patients greater than 50 years of age with appendicitis particularly if they have associated bowel symptoms or risk factors for CRC.
INTRODUCTION: Tumour heterogeneity is important in the management of breast cancer. Hormone receptors are established biomarkers for treatment and prognosis of patients with breast cancer. There are three immunohistochemical biomarkers: estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor 2 (HER2). We explore whether heterogeneity in hormone receptor status in synchronous bilateral breast alters therapeutic management. CASE PRESENTATION: This case details a 54 year old woman who was referred to our clinic by her general practitioner for investigation of bilateral breast pain that she had for 6 months. On clinical examination pathological nodes were palpated in bilateral axilla. There was left sided nipple inversion with a palpable mass in the upper outer quadrant of approximately 3 cm diameter. On examination of the right breast there was skin tethering of the nipple and 3 masses were palpated, the largest being in the upper inner quadrant at 5 cm diameter. Ultrasound and mammography of bilateral breasts demonstrated advanced bilateral breast cancer with axillary node metastases. Core biopsies demonstrated invasive carcinoma. The right breast lesion was ER negative whilst the left breast lesion was ER positive. DISCUSSION: In patients with synchronous bilateral breast cancer ER discordance in patients have been associated with higher mortality than ER concordant positive patients and lower mortality than ER concordant negative patients within the first 5 years of surveillance [1]. CONCLUSION: Heterogeneity in hormone receptor status alters the therapeutic management of patients with synchronous bilateral breast cancer. Both hormone therapy and chemotherapy should be considered in these patients. It is of utmost importance to evaluate the tumor receptor status in cases of synchronous bilateral breast tumour and to assess for change in relation to tumour progression or treatment. Further study in the status change of receptors could open up new treatment modalities.
INTRODUCTION: Pneumatosis Intestinalis (PI) can present with a broad range of presentations from chronic and non-specific to acute and life threatening. It is paradoxically one of the few conditions where a pneumoperitoneum found in the diagnostic workup is not necessarily an indication for laparotomy. PRESENTATION OF CASES: The first case is of a 75 year old gentlemen who attended the emergency department after several weeks of worsening abdominal pain and weight loss. At laparotomy, two segments of nodular, abnormal-looking small bowel were identified with bubbles of air seen in the small bowel mesentery. The second case is of an 86 year old man with of a 5-month history of abdominal pain, weight loss, nausea and diarrhoea. A subsequent endoscopy revealed diffuse gastritis with a small antral gastric ulcer with a small amount of blood. The CT scan demonstrated free air within the bowel wall, with a follow up scan performed 3 weeks later revealing an increase in the amount of free air. DISCUSSION: PI is a rare condition characterised by the presence of subserosal and submucosal gas filled cysts occurring anywhere in the gastrointestinal tract from the oesophagus to the anus. Numerous conditions have been associated with PI including bowel obstruction, infections, ischemia and there have been reported cases suggesting as association with Crohn's disease. CONCLUSION: PI is a condition that may manifest with a wide range of symptoms from mild abdominal pain to acute peritonitis. Its treatment is generally medical and even with radiological evidence of perforation laparotomy may not be indicated if the patient is clinically well.
INTRODUCTION: Cutaneous lymphomas represent a unique group of lymphomas. Cutaneous lymphomas are the second most frequent extra nodal involvement; gastrointestinal involvement being the most frequent (Malkan et al. [1]). To the best of our knowledge few cases of cutaneous relapse of Non-Hodgkin Lymphoma (NHL) have been reported where there was an absence of primary cutaneous involvement. CASE PRESENTATION: A case study of a 70-year-old woman who was referred for an excisional biopsy of a lesion on her left cheek in 2017. She had previously been diagnosed with NHL in 2009; disease involved the right groin lymph nodes. The patient completed a course of chemotherapy and was in remission. An excision of the lesion on the left upper cheek confirmed low-grade follicular lymphoma. A PET scan was performed after the histology from the lesion was confirmed which demonstrated moderate fluorodeoxyglucose (FDG) uptake in left cheek, left external iliac lymph nodes and left tonsil consistent with recurrence of lymphoma. DISCUSSION: The majority of relapses of NHL occur in the first 2 years after the completion of treatment. Extra nodal lymphomas comprise 24-48 percent of cases. The reason for multifocal extra nodal lymphoma or preferential involvement of specific extra nodal sites at recurrence is not clear Extra nodal involvement involving skin accounts for 10 percent of cases. NHL typically relapses in the same involvement sites. First line treatment for solitary lesions includes surgical excision, antibiotics and radiotherapy. CONCLUSION: Disease relapse was not present in the primary involvement site. Furthermore, there was a cutaneous relapse where there was no primary cutaneous disease. Treatment involved systemic therapy for this patient given the nodal involvement found on the PET scan.
