The valvular segment of the lower limbs venous system: anatomical, physiological and physiopathological aspects.

The valvular segment is a distinct venous structure, which, from a morphological point of view, is comprised of the following components: the valvular insertion, the valvular gorge entrance orifice, the valvular defile, the valvular gorge exit orifice, the valvular sinus. Endoscopic and echo Doppler examinations are used to identify the normal and the pathological morphology of the valvular segment, and the hemodynamic phenomena occurring at this level. Cusps' integrity and size as well as valvular dynamics are key elements directly involved in shaping the valvular segment in general, and the valvular sinus in particular. The valvular sinus shows an obvious hemodynamic determinism. Valvular segment pathology is the outcome either of a progressively long evolving process initialized by gravitational venous pressure overcharges, or of a rapidly evolving process such as the hemodynamic shock following intense physical efforts. Valvular defunctionalisation implies a different mechanism and a different type of cusp lesion.

Axillary and perianal leiomyosarcoma: report of two cases.

Soft tissue leiomyosarcoma is a relatively rare malignant tumor. It may be difficult to be distinguished from gastrointestinal stromal tumors and Schwann cell neoplasms. To make a correct identification of soft tissue leiomyosarcoma, immunostaining with several smooth muscle differentiation markers (actin, calponin and desmin), and negative staining results with S100 (to rule out Schwann cell neoplasm), c-kit and CD34 (to rule out gastrointestinal stromal tumors) is needed. Prompt diagnosis and referral are desirable, since the size of the tumor at presentation is a continuous variable for the risk of local recurrence and metastatic disease. Chemosensitivity varies according to the tumor subtype, and the tumor grade, the patient's age, performance status, and the timing of metastatic disease further influence the likelihood of a response and survival. Chemotherapy is palliative for most patients with unresectable or metastatic disease. Ifosfamide and doxorubicin are routinely used in this setting; doxorubicin as a single agent is considered the drug of choice.

Ileal iterative spontaneous perforation from foreign body granuloma: problems of histopathologic diagnosis.

Spontaneous ileal perforation is a very rare cause of peritonitis. It occurs, in most of the cases, as a complication of Crohn's disease or intestinal tuberculosis. We present the case of a 23-year-old female patient with multiple surgical interventions during the last year, for iterative ileal spontaneous perforation with generalized peritonitis of which cause was initially assigned to intestinal tuberculosis. Actual episode of generalized peritonitis was determined once again by an ileal perforation of 5 mm at 70 cm from the ileo-cecal valve situated on a suture scar. Distally, a bowel stricture and a non-complicated Meckel's diverticulum were also noted. We performed an enterectomy including all three aforementioned lesions with end-to-end anastomosis. The histopathologic report revealed granulomatous giant-cellular inflammation in the margins of the perforation. The tuberculous etiology was questioned because of the negativity of the PCR-test and multiple recidives of perforation under specific anti-tuberculous medical therapy. The discovery of some rests of non-resorbable suturing material in a granuloma on an ancient enterorraphy scar in the resected specimen, finally established the cause. The granulomatous giant-cellular inflammation of foreign body is a rare cause of ileal perforation. The histopathologic differential diagnosis is difficult needing correlation with clinical data. Usage of resorbable suture material avoids that risk.

Tuberous sclerosis complex: report of two intrafamilial cases, both in mother and daughter.

Tuberous sclerosis complex (TSC) is a multisystem syndrome characterized by neurological symptoms and tumors in multiple organs including kidney, brain, skin, eyes, heart and lung. Kidney and brain are the two most frequently affected organs in TSC. TSC is an autosomal disorder with extensive clinical variability. We described TSC in a family at a mother and her daughter. We emphasized the importance of Computed Tomography in the discovery of some asymptomatic organic involvement as bilateral renal angiolipoma in the mother.

Subungual exostosis of the big toe.

The subungual exostosis is a benign bone tumor on the distal phalanx of a digit, beneath or adjacent to the nail, often bringing in discussion many differential diagnosis. We present a 14-year-old boy with a cutaneous nodular lesion, painful to the easy touch on the latero-internal half of the nail of right big toe with extension in the cutaneous part of this. He suffered many treatments, especially cauterization, but with recurrence. In the present, the radiological findings of the affected finger and the histopathological ones from the fragment excised confirmed the diagnosis of subungual exostosis. The local excision of the entire region with the removal of the cartilaginous cap has been followed by a silent period without recurrences of almost two years when he as revised.

Metastasized squamous cell carcinoma developed on lupus vulgaris.

Lupus vulgaris (LV) is the most frequent cutaneous tuberculosis, representing more than 55% of the tuberculoses with this location. Malignization can occur after a long latency (10-30 years), in 1-2% of the cases, and it is mainly in squamous cell carcinoma. The histological exam is highly important in the observation of neoplasic transformations. The authors present a 59-years-old female patient, from the rural environment, working as a farmer, with lupus vulgaris developing since her first childhood years. It started at the age of 2 years, at the right ear lobule, after the empiric perforation for earrings. The evolution was progressive, eccentric, interesting the pinna and the right cheek in the meanwhile. At the first examination, in 2002, a diffuse mass of red-yellowish infiltration was found at the level of the right ear and the right cheek. In the following two years, an ulcero-vegetating tumor developed at the level of the right ear lobule, accompanied by the presence of a right retromandibular adenopathy, of about 1 cm, which was proved by the histopathologic exam to be a squamous cell carcinoma developed from a lupus vulgaris. After scraping out the right retromandibular ganglion, detected by palpation, a histological exam showed ganglion metastasis.

Continuous local analgesia is effective in postoperative pain treatment after medium and large incisional hernia repair.

INTRODUCTION: Incisional hernias are a frequent complication of laparotomy. Open surgery is still an option for the treatment of incisional hernias with medium and large wall defects. Major opioids are routinely used in the treatment of postoperative pain, with several side effects. Continuous local analgesia can be effective in postoperative pain management after various surgical interventions. However, very few reports exist on its application in incisional hernias. PURPOSE: We assessed the effectiveness of ropivacaine in reducing the need for systemic analgesics in postoperative pain management related to these interventions. METHODS: We conducted an open-label, prospective, randomized design study. One hundred patients with medium and large incisional hernias were treated by open surgery. Thirty patients with abdominal defects > 8 cm received continuous postoperative local analgesia with ropivacaine 5 mg/ml. Thirty four and 36 patients (abdominal defects of more, and respectively less than 8 cm) received conventional analgesia. RESULTS: Continuous local anesthesia during the first 72 h after surgery reduced the number of patients needing analgesia with pethidine (17 vs 47% and 53%, p = 0.006), as well as the cumulative doses of pethidine (p < 0.05), tramadol (p < 0.001), and metamizole (p < 0.001) needed to control postoperative pain. Catheter installation for local anesthesia did not increase surgery time (p = 0.16) or the rate of local complications. CONCLUSION: Continuous local analgesia reduces the need for systemic opioids and can be successfully used in the postoperative pain management after medium and large incisional hernias treated by open surgery.

Upper Gastrointestinal Bleeding - Initial Manifestation of Pancreatic Head Carcinoma.

Pancreatic head carcinomas are a rare cause of upper digestive bleeding and the diagnosis and the treatment of these pose particular problems. We selected 6 cases from a number of 283 patients who were hospitalized for surgery between January 2014 and December 2016 with signs of upper digestive bleeding with no varicose origin who were subsequently diagnosed with pancreatic head carcinomas. The diagnosis was established by endoscopic and surgical methods. The evolution of these patients was influenced by whether there was active digestive bleeding or history of digestive bleeding and the possibility of tumor resection. Four patients needed emergency surgery due to continuous bleeding or rebleeding. The resectability of the cephalo-pancreatic tumor was determined and then subsequently performed in two patients who had a favorable postoperative outcome, while in two patients the tumor resection was impossible. The other two patients with upper digestive haemorrhage responded favorable to drug therapy, and digestive endoscopy and CT explorations were negative. After a 5-month interval they presented with clinical signs of a pancreatic neoplasm with invasion into the common bile duct, unwanted weight loss, abdominal pain, and icterus of the sclera and skin. The surgical intervention resulted in the confirmation of locally advanced pancreatic head carcinomas and the performing of bilio-digestive derivations. Pancreatic head carcinomas may be associated with upper digestive tract haemorrhage due to duodenal or bile duct invasion. The clinical picture of these patients can vary from occult haemorrhage to severe upper digestive tract haemorrhage accompanied by hypovolemic shock.

Squamous Esophageal Carcinoma Synchronous to Pericolic Malignant Conjunctive Tumor.

Esophageal carcinoma represents a great diagnostic and therapeutic challenge due to the anatomical situation and physiopathology of the disease. The medical challenge can be even greater since esophageal carcinoma can evolve concomitant to another malignant tumor with different localization. This paper's aim is to present a case of squamous esophageal cancer associated to another primitive malignant tumor-malignant pericolic conjunctive tumor, this kind of association being singular in medical literature from our knowledge. Upon emergency presentation the patient was sketching a sub-occlusive syndrome with mild anemia and inflammatory syndrome, somehow suggesting a possible right colon cancer. However, discreet upper digestive pole symptomatology that, on first sight, seemed secondary, made the consultant to perform a superior digestive endoscopy that raised a strong suspicion of early stage esophageal carcinoma. Further exploration was not completed because occlusive complication occurred and the patient needed emergency surgery. On laparotomy a stenotic right colic angle tumor was discovered that later proved to be extra-mucosal, with conjunctive origin. Our paper focuses on highlighting the crucial importance of the imagistic explorations in the primary diagnosis of esophageal carcinoma, in the correct staging (lymphatic extension, loco-regional or distant metastases) and also for malignant tumors with another localization that can radically modify the therapeutic strategy.

Synchronous diagnosis of signet ring cell colon carcinoma and transitional carcinoma of the left distal ureter.

The presence of synchronous multiple primary carcinomas, although recognized, remains very uncommon. Their etiopathogeny is unclear. The wide spread of imaging techniques currently facilitates diagnosis of simultaneous tumors. We present the rare case of a signet ring cell colon carcinoma coexisting with a transitional cell carcinoma (TCC) of the ureter, which debuted with symptoms of intestinal obstruction in a 75-year-old male patient, with no prior relevant history. Computed tomography showed signs of a tumor mass on the transverse colon, as well as left hydronephrosis with a tumor in the lower third of the ureter, which prompted for immediate emergency surgery. After the appropriate surgical maneuvers, tissue collected from both tumors underwent usual histological preparation and Hematoxylin-Eosin staining, as well as multiple immunostaining with a complex panel of markers. The patient had a favorable postoperative course and during a six-month follow-up, we did not detect any signs of illness.

Bony metaplasia in a caecum adenocarcinoma.

Ectopic bone formation in the digestive tract is a very rare phenomenon in pathology. Most cases of bone metaplasia were found in distal colon tumors, rectum and sigmoid respectively. We present a case of well-differentiated adenocarcinoma of the caecum (the second case of literature) associated with bone metaplasia, which debuted atypical, with symptoms of infectious enterocolitis, in a 72-year-old female patient, with no history of digestive pathology. Highlighting bone metaplasia was achieved by current histological techniques. Patient's evolution was favorable with surgical treatment and chemotherapy.

Study of molecular prognostic factors Bcl-2 and EGFR in rectal mucinous carcinomas.

Colorectal cancer is an important public health problem worldwide, being the fourth most common cancer in men and the third most common in women. Colorectal cancer incidence is higher in developing countries due to the prevalence of obesity associated with reduced physical activity. Rectal mucinous carcinomas, especially the "signet ring cell" type, have a worse prognosis compared with other varieties of colorectal carcinomas, being diagnosed in more advanced stage and more prone to lymph node and peritoneal metastases. Our study comprised 37 cases with rectal adenocarcinoma with mucinous component operated in the Surgical Clinics of the Emergency County Hospital of Craiova, between 2006 and 2010. The aim of this study was to evaluate some molecular prognostic factors for rectal mucinous carcinomas namely B-cell lymphoma 2 (Bcl-2) and epidermal growth factor receptor (EGFR), and their correlations with the main morpho-clinical parameters of these patients. Thus, we immunohistochemically assessed the degree of apoptosis of tumor cells in mucinous rectal carcinomas using the Bcl-2 marker, and tumor aggressiveness using the EGFR responsiveness. In our study, the percentage of Bcl-2+ cases was 43.24%, with no significant statistical correlation between the Bcl-2 expression and histopathological subtype of mucinous adenocarcinoma. The evaluation of tumor aggressiveness in terms of EGFR responsiveness showed a reduced expression in carcinomas correlated with the increase in quantity of the mucinous component. In addition, EGFR reactivity was increased in the tumor invasion front.

Mucinous adenocarcinoma of the colon - a histochemical study.

Colorectal carcinoma is a major cause of cancer associated with a high rate of morbidity and mortality in the western world. One of the pathologic features considered to be important for prognostic is mucin production. Many authors confirmed that colon carcinomas with high mucin content tend to re-occur locally and carry a poor prognosis. For histochemical evaluation of mucin content, we investigated 149 patients who underwent surgical resection of sporadic colon adenocarcinomas, all over a 5-year period. For histological classification we used the WHO recommendation (2000) and to be more accurate we sub-classified mucinous adenocarcinomas by morphometrical analysis in three categories: pure mucinous, with extracellular mucin more than 80% of the tumoral volume; mixed type, with 50-80% extracellular mucin; and mixed type with less than 50% extracellular mucin. For histochemical investigation, we used stains such as: mucicarmine, PAS ÷ Alcian Blue and High Iron Diamine ÷ Alcian Blue. Our study proved the predominance of mixed mucinous adenocarcinomas with less than 50% extracellular mucin, followed by the pure mucinous type. From the biochemical composition's point of view, the predominant cases were those with acidic mucins, especially in pure mucinous adenocarcinomas (>90%), while those with mixtures of acidic and neutral mucins were present in 62% of the cases. In addition, our study showed the prevalence of sialomucins over sulphomucins (68%), particularly in pure mucinous adenocarcinomas (77%). Clinical pure mucinous forms were detected mainly in advanced stages, but in terms of lymph node metastasis rate, they were secondary after mixed type with 50-80% extracellular mucin.

The study of p53 and CA19-9 prognostic molecular markers in colorectal carcinomas.

Immunohistochemistry represents a relatively new identification technique of cellular and tissular antigens due to an antigen-antibody binding interactions, applied more and more in the pathology laboratories for positive and differential diagnosis of premalignant and malignant lesions and also for evolutive prognosis of tumoral formations. Immunohistochemistry coloration is based on the antigen-antibody affinity, the antibody binding situs being identified either by antibody coloration direct methods or by using an indirect method where the marking is supplied by antibodies called secondary or even tertiary. The present study is based on the immunohistochemical investigation of some molecular markers with a prognosis value in colorectal cancers (CCR), like the antibody p53 immune expression and of some factors supposed to have prognosis value, such as CA19-9 (carcinoembryonic antigen, carbohydrate antigen or Lewis antigen). In the last decade, the studies have tried to define the prognosis of the molecular markers that allow the identification of the patients with recurrent risk after surgical treatment and who can benefit from chemotherapy in an efficient way. The purpose of the study on immunohistochemical markers is to aim towards the treatment based on molecular phenotypes of colorectal tumors. In 2000, according to the Consensus Conference of the Colorectal Working Group of the American Joint Committee on Cancer Prognostic Factors (AJC), there were established four categories of prognosis factors in colorectal cancers based on the practical importance and the number of studies referring to them. The present study is centered on the prognosis factors from the second B category (p53 oncoprotein expression) and the fourth category (CA19-9 immunomarker expression).