Giant Appendicolith: A Case Report and Review of the Literature.

Acute appendicitis is one of the most prevalent causes of an acute abdomen. Although the cause of appendicitis is not completely understood, the theory of luminal obstruction is a popular belief, with appendicoliths being a common etiology. While appendicoliths are quite common, giant appendicoliths >2 cm are rare. Although previous reports cite only two or three other occurrences of giant appendicoliths, we found at least 11 reported cases in the literature. We present a young male diagnosed preoperatively on computed tomography to have a large appendiceal mass of 2.2 cm. This case is presented for the rarity of giant appendicoliths along with a review of the literature.

Duodenal Adenocarcinoma at the Ligament of Treitz: Management and Outcome.

Primary small bowel neoplasms at the ligament of Treitz are extremely rare and require advanced surgical technique for extirpation. The insidious onset of disease allows for a delayed presentation, often accompanied by moderate-size growth of the neoplasm, causing intestinal bleeding and bowel obstruction. The partial retroperitoneal location of these tumors pose a unique challenge for surgical resection. We present an unusual case of a primary small bowel adenocarcinoma at the Ligament of Treitz, requiring segmental resection of the fourth portion of the duodenum plus the proximal jejunum.

Recurrent Inactive Hydatid Cyst of the Liver Causing Restrictive Pulmonary Physiology.

Hydatid and alveolar cysts are formed by the helminths Echinococcus granulosus and Echinococcus multilocularis, respectively, which are endemic to pastoral areas, and are more commonly found in South America, the Mediterranean, Russia, and China. Hydatid cysts can cause bacteremia, form abscesses, or cause mass effect by compressing surrounding organs. Strategies to prevent such complications include benzimidazoles, surgical resection, and Puncture, Aspiration, Injection and Re-aspiration (PAIR) procedure. A 71-year-old Egyptian man with remote history of Echinococcus infection one year status post PAIR procedure, presented with dyspnea on exertion. On exam, the patient had a palpable right upper quadrant mass. The patient had a known small hydatid liver cyst on prior ultrasound, however repeat imaging showed growth to 15×19×14cm, with right hemidiaphragm elevation, compressive atelectasis, and compression of the right atrium. He had no peripheral eosinophilia and negative echinococcal serology, consistent with remote infection. The patient underwent repeat PAIR procedure and 3L of serous fluid was drained from the cyst. Fluid analysis was negative for scolices, cysts or hooklets. His symptoms improved; however the cyst re-accumulated 1 month later. Total cystectomy was performed surgically by hepatic wedge resection, with permanent improvement in symptoms. This case is a rare example of Echinococcus infection causing significant respiratory morbidity requiring repeated invasive procedures and surgery, in the setting of inactive disease.

Management of Symptomatic Hepatic "Mega" Hemangioma.

The majority of giant hepatic cavernous hemangiomas are asymptomatic and can safely be observed. However, when a lesion becomes symptomatic, affecting quality of life or cannot be distinguished from a malignancy, then operative therapy should be considered. We herein present a case of a symptomatic 12cm × 14cm × 17cm "mega" hemangioma (>10cm) of the left hepatic lobe. This lesion was initially refractory to transarterial embolization of the left hepatic artery, but was subsequently treated successfully with a left lateral extended hepatic segmentectomy (resection). We thus advocate a rational treatment algorithm for management of hepatic "mega" hemangiomas.

Excess of extracolonic non-endometrial multiple primary cancers in MSH2 germline mutation carriers over MLH1.

BACKGROUND: The lynch syndrome (LS) tumor spectrum involves colorectal cancer (CRC), endometrial cancer (EC), and less frequently various extracolonic non-endometrial cancers (non-EC). The organ-specific survival rates of these patients are well defined, however, the collective survival of all-cancers combined (CRC + EC + non-EC) are unclear. METHODS: Fifty-two MSH2 patients and 68 MLH1 patients were followed for a median of 6.3 years after diagnosis of first cancer, regardless of type. The proportions of CRC only, EC, non-EC, and multiple primary cancers were compared between the two genotypes. Kaplan-Meier curves were developed for survival comparisons. RESULTS: MSH2 patients present less frequently with only CRC (37% MSH2, 62% MLH1, P = 0.0096), manifest more multiple primary cancers (38% MSH2, 18% MLH1, P = 0.013), develop more extracolonic cancers (62% MSH2, 38% MLH1, P = 0.003), non-EC only cancers (46% MSH2, 24% MLH1, P = 0.028) and carry a greater risk for urinary tract cancer (UTC) (13.4% MSH2, 1.5% MLH1, P = 0.024). There was no difference in 10-year survival between the two groups (P = 0.4). CONCLUSION: The additional propensity for UTC in MSH2 carriers argues in favor of UTC screening in MSH2 individuals. Other types of cancer screening should be tailored to the expression history of the specific LS mutation.

Infiltrating mammary carcinoma with osteoclast-like giant cells.

Mammary carcinoma with osteoclast-like giant cells is an uncommon variant. The following case examines a 36-year-old woman incidentally found to have a left breast mass on routine physical exam. Initial ultrasound-guided core biopsies revealed infiltrating mammary carcinoma with focal mucinous features, for which a left breast lumpectomy and sentinel lymph node biopsy were performed. The sentinel lymph nodes were positive for metastatic mammary carcinoma with osteoclast-like giant cells on permanent section corresponding to the lumpectomy breast specimen, thus a left completion axillary node dissection was subsequently performed.

Hepatic hemangiomas and parachuting.

Hepatic hemangiomas are relatively common benign hepatic tumors. Historically, a concern for potential traumatic rupture has influenced clinical judgment regarding optimal treatment. However, a review of the literature fails to demonstrate spontaneous or traumatic rupture as a common phenomenon. The following case report discusses an individual patient incidentally found to have large hepatic hemangiomas on CT scan during work-up for a traumatic minimally displaced pelvic fracture from parachuting. He was admitted to the general surgery service for observation. After several days of hemodynamic stability and pain control, he was released to home with outpatient physical therapy and follow-up with the orthopedic surgery clinic. Interventional radiology was also consulted regarding his fitness to continue parachuting given his large hepatic hemangiomas. Embolization was not recommended, but rather continued observation without any restriction of physical activities. Review of the literature supports an extremely low incidence of traumatic rupture. Consequently, a hepatic hemangioma should not exclude an individual from parachuting.