Granular Cell Tumor: Report of 13 Cases in a Veterans Administration Hospital.

INTRODUCTION: Granular cell tumors (GCTs) are of neuroectodermal origin and account for 0.5% of soft tissue tumors. They are most prevalent in African-Americans in the fourth to sixth decades, with a predilection for the head and neck regions. GCTs usually resemble more common lesions and hence are difficult to diagnose preoperatively. The tumor is readily identified on needle biopsy. Although usually benign with a malignancy rate of only 2-3%, the malignant form has a reported 3-yr mortality of 60%. MATERIALS AND METHODS: Clinical records of the Gulf Coast Veterans Healthcare System were surveyed for the period 1996-2016. Thirteen cases of GCT were found and reviewed for demographics, clinical course, method of diagnosis, management, and outcome. RESULTS: All patients had a solitary GCT. Eleven lesions were benign and two were atypical. Sites involved were skin (8), colon (2), larynx (1), bronchus (1), and esophagus (1) (see Table I). The two atypical lesions occurred in the skin and larynx. Skin tumors were slow-growing, painful nodules, and, except for the two with preoperative needle biopsies, were misdiagnosed as epidermal inclusion cysts, lipoma, and papillary condyloma. Two colon lesions resembling a sessile polyp and submucosal lipoma, respectively, were found on colonoscopy performed for occult blood in the stool. The bleeding was attributed to adenomatous polyps also present. An atypical laryngeal GCT, found on laryngoscopy for hoarseness, was removed by submucosal resection. A bronchial GCT, excised during bronchoscopy for atelectasis, required re-excision 3 mo later. The esophageal GCT was an incidental finding on EGD for a dilated esophagus and gastric outlet obstruction. The patient declined surgical excision and elected MRI follow-up. CONCLUSION: Granular cell tumors are infrequent and usually resemble more common lesions. Although almost always benign, the malignant form has a very poor prognosis. It is important to identify GCT preoperatively by fine-needle aspiration or core needle biopsy to improve outcome.

Cytoreductive surgery in the management of malignant ascites from adenocarcinoma of unknown primary (ACUP).

A case report is presented of a 62-year-old man with adenocarcinoma of unknown primary (ACUP) who was admitted with massive ascites from intraperitoneal carcinomatosis secondary to a gastrointestinal tract malignancy. A computed tomography scan of the abdomen and pelvis confirmed extensive neoplasm. A near-total omentectomy was performed, and he was given postoperative systemic chemotherapy. Although his expected survival was 3 to 6 months, he lived 20 months, enjoying a good quality of life until the end. Cytoreductive surgery should be offered to some patients with peritoneal carcinomatosis because it may provide significant palliation.

Classic groin hernia repair...lest we forget.

Currently, operative repair of inguinal hernia is most often performed using one of the open mesh procedures or laparoscopic techniques. These newer approaches minimize anatomical dissection critical to the time-honored traditional hernia surgery described by Bassini, Halsted, McVay, Laroque, Shouldice, and other early pioneers. The familiarity with groin anatomy and the technical skill gained in performing these operations is currently missing from present-day surgical residency training. This article reviews 5 classic hernia operations described by the surgeons whose name they bear, with a view toward better understanding the authors' techniques and philosophies. Each of these operations, though considered by some as of historical interest only, offers today's surgeon reliable alternatives when the simple application of mesh by open or laparoscopic technique is inappropriate. (Curr Surg 62:249-252. Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery.).

History of surgery for breast cancer: radical to the sublime.

The historic milestones that have brought the surgical management of breast cancer to its current state are recounted. The Halsted radical mastectomy, once considered the ideal cancer operation, no longer has a place in the routine management of patients with breast cancer. Breast conservation in the form of segmental mastectomy, axillary node dissection, and radiation is often chosen over the modified radical mastectomy, popular in the 1980s. Axillary lymphadenectomy, shown to be of questionable therapeutic value in breast cancer, is certainly of prognostic significance. Studies are ongoing to establish the validity of the less-invasive sentinel node biopsy in determining axillary nodal status. Perhaps the most significant change in today's approach to breast cancer is the reliance on well-controlled prospective studies to evaluate outcome and determine the appropriate surgical procedure.

Fractured heterotopic bone in a midline abdominal wound.

PURPOSE: Heterotopic bone formation, although most often reported after trauma and elective joint surgery, can occur in abdominal surgical scars. The lesion may not be discovered for a long period of time after it occurs, and the patient, except in rare circumstances, is asymptomatic. METHODS: A patient is reported who developed heterotopic bone formation in an upper midline incision after a Nissen fundoplication with complications. The heterotopic bone became symptomatic after it had undergone complete fracture. Symptoms disappeared after the bony mass was removed. The English-language literature was reviewed to study the clinical significance of heterotopic bone formation, particularly in abdominal wounds. RESULTS: Literature reports of heterotopic bone formation in an abdominal wound are uncommon, and the etiology remains obscure. Symptoms are unusual and are often related to the patient's activity. This case appears to be the only report of fracture of heterotopic bone in an abdominal scar. CONCLUSIONS: Heterotopic bone formation should be considered when a hard mass develops in an abdominal surgical scar. Excision is not indicated unless the patient develops symptoms.

Acute embolic occlusion of the distal aorta.

PURPOSE: Acute occlusion of the abdominal aorta requires rapid diagnosis and intervention to prevent loss of life or limb. The overall mortality due to embolic occlusion is reported to be over 30%. The most common source of emboli is the heart, secondary to atrial fibrillation or myocardial infarction. METHODS: A patient is herein presented who arrived at the emergency department 6 hours after onset of classic signs of acute arterial occlusion. RESULTS: She had a saddle embolus of the distal abdominal aorta with extension of the clot into both iliac and femoral arteries. CONCLUSIONS: Heparin therapy and embolectomy successfully reestablished blood flow. The etiology, presentation and management of aortoiliac occlusion is discussed.

Historical landmarks in operations on the colon--surgeons courageous.

PURPOSE: The nearly 300-year history of surgery of the colon is replete with creative daring among surgeons who conquered the challenges of operating on this highly contaminated organ, housed in the sacrosanct peritoneal cavity. METHODS: Alexis Littre's suggestion in 1710 that a colostomy may be successful in treating an infant with imperforate anus began an evolutionary process of extraperitoneal colostomy for obstructing carcinomas, and then, an intraperitoneal approach, which enhanced surgical evaluation of the tumor and optimal placement of the stoma. Reybard's introduction of sigmoid resection in 1823, followed by post-Lister contributions of Mickulicz, Paul, Murphy, Miles, Hartmann, and other 19th- and early 20th-century surgeons, paved the way for current successes in colon surgery. RESULTS: The morbidity and mortality, which still accompanies surgery on the colon, often results from a failure of today's surgeon to apply those principles so meticulously documented by colon and rectum surgery historians. CONCLUSIONS: The individual, who performs a Miles abdominoperineal resection, a Hartmann procedure, or any other of the classic operations on the colon, gains much by studying the original philosophy and technique of these pioneers in the field.