Solitary fibrous tumor of the breast: A case report and the review of the literature.

Solitary fibrous tumors (SFT) are rare mesenchymal neoplasms. They were first described as spindle-cell tumors originating from the pleura, but they may arise in any anatomical site. SFT of the breast is an exceedingly rare clinical entity. Our literature review yielded only 21 cases reported so far. We describe a case of a SFT of the breast in a premenopausal patient who presented with a gradually enlarging palpable breast mass. Diagnostic evaluation and management are discussed along with a review of the relevant literature. There are no pathognomonic imaging findings of SFT of the breast. Complete surgical resection with clear margins is the gold standard of treatment. Thorough immunohistochemical analysis is crucial to obtain a definitive diagnosis. Although most SFTs run an indolent course, in some cases the clinical behavior can be unpredictable and a long-term follow-up for all patients is therefore mandatory.

Lymphovascular infiltration in the tumor bed is a useful marker of biological behavior in breast cancer.

PURPOSE: Tumor cells can metastasize by entering existing vessels or new vessels actively recruited into the primary tumor. Invasion of the lymphatics and blood vessels in the periphery of the tumor seems to be a prerequisite step in the metastatic process. The aim of this study was to correlate peripheral lymphatic vessel infiltration (PLI) and peripheral blood vessel infiltration (PVI) in a cohort of patients with invasive ductal carcinoma of the breast with various other prognostic parameters and outcome. METHODS: The study population consisted of 236 female patients with invasive ductal breast carcinomas, who had been operated between 2011 and 2013. The registered data included age at diagnosis, histological subtype, tumor size, TNM stage, histological grade, estrogen (ER) and progesterone receptors (PR), HER-2, p53, and PLI and PVI. RESULTS: Pathological examination revealed that 22.5% of the patients had PVI and 37.3% had PLI at the tumor front. PVI correlated with younger age (p<0.05), higher histologic grade (p<0.05), advanced TNM stage (p<0.05), higher T stage (p<0.05), higher N stage (p<0.05) and positive Ki67 expression (p<0.05). Similarly, PLI correlated with higher histologic grade (p<0.05), advanced TNM stage (p<0.05), higher T stage (p<0.05) and higher N stage (p<0.05). Statistical analysis did not reveal significant correlation between the presence of tumor blood and lymphatic vessels with infiltration in overall (OS) and disease-free survival (DFS). CONCLUSIONS: PLI and PVI are important markers of worse clinical outcome as shown by their association with other established factors, but no association with recurrence and survival could be proven.

Perforated posterior cecal diverticulum: challenges in establishing an accurate preoperative diagnosis of a rare emergency.

Solitary cecal diverticulitis is a rare cause of abdominal pain in Western countries. The preoperative diagnosis is very difficult to establish and most patients are operated on with a presumptive diagnosis of acute appendicitis based on clinical grounds. We describe a very rare case of perforated posterior cecal diverticulum and discuss the challenges in establishing a correct preoperative diagnosis. We conclude that although very rare, the possibility of perforated posteriorcecal diverticulum should always be considered in the differential diagnosis of patients presenting with atypical clinical manifestations of acute appendicitis. A perforation of a posterior cecal diverticulum maybe associated with a mild clinical course without signs of peritonitis. Athorough preoperative evaluation including a computed tomography scan is essential in order to establish a correct preoperative diagnosis which is of utmost importance for treatment planning in the emergency setting. Simple diverticulectomy is an effective surgical treatment in the absence of extensive inflammatory changes and when a colonic tumor can be ruled out.

Choloperitoneum causes extensive coloring of the abdominal wall skin.

Laparoscopic cholecystectomy, because it is the less invasive surgical procedure, has been established as the procedure of choice for the treatment of patients with symptomatic gallbladder stones. However, bile leakage after laparoscopic cholecystectomy should not be overlooked. It is generally due to a minor biliary complication, although it can sometimes herald a major duct injury. Bile leakage rates of 1.2% to 4.0% in laparoscopic cholecystectomies have been reported, which are higher than the incidence with open cholecystectomies.

Enoxaparin-induced spontaneous massive retroperitoneal hematoma with fatal outcome.

Spontaneous retroperitoneal hematoma (SRH) is a severe and potentially fatal complication of anticoagulation therapy. We describe a case of fatal spontaneous massive retroperitoneal hematoma in a female patient receiving bridging therapy with enoxaparin for atrial fibrillation. Physicians should be cautious when prescribing enoxaparin in elderly patients, in patients with impaired renal function, and in patients receiving concomitant oral anticoagulants. Emergency physicians should always consider SRH in the differential diagnosis in patients under enoxaparin therapy presenting with abdominal pain. Computed tomographic scan is the imaging modality of choice for evaluating SRH. Early diagnosis and aggressive treatment are of paramount importance as SRH is associated with high mortality and morbidity rates.

Acute surgical abdomen due to phytobezoar-induced ileal obstruction.

BACKGROUND: Phytobezoar-induced small bowel obstruction is an uncommon clinical entity accounting for 2-4.8% of all mechanical intestinal obstructions. In addition, presentation with features of acute surgical abdomen is extremely rare, accounting for only 1% of the patients. OBJECTIVES: The aim of this report is to present a very rare case of a phytobezoar-induced small bowel obstruction in a male patient who presented with acute surgical abdomen. A correct preoperative diagnosis was made based on the patient's history and characteristic imaging features on the emergency computed tomography (CT) scan. CASE REPORT: A 55-year-old man with previous gastrectomy presented with typical manifestations of acute abdomen. CT scan demonstrated dilatated small bowel loops and an intraluminal ileal mass with a mottled appearance. At exploratory laparotomy, a phytobezoar was found impacted in the terminal ileum and was removed through an enterotomy. CONCLUSIONS: Phytobezoar should be considered in patients with previous gastric outlet surgery who present with bowel obstruction and features of acute surgical abdomen. The presence of a well-defined intraluminal mass with a mottled gas pattern on emergency CT scan is suggestive of an intestinal phytobezoar.

Pneumomediastinum: Experience with 87 Patients.

OBJECTIVE: The aim of the present series was first to present our experience in the management of 37 patients with spontaneous pneumomediastinum (SPM), and further to indicate the necessity of identifying true SPM cases as they are currently inadequately defined. METHODS: This is a single-center, retrospective study, conducted in a university hospital. Consecutive adult patients with pneumomediastinum (PM) between January 2009 and March 2020 were involved in the series. The data about age, gender, symptoms, signs, treatment, length of hospital stay (LOS), and in-hospital mortality were evaluated. RESULTS: In total, 87 cases with pneumomediastinum (37 with spontaneous and 50 with secondary PM) were analyzed. Patients in both groups were of similar ages (P=0.4). Sufferers with secondary PM were more likely to have: an associated pneumothorax (19% vs 58%, P<0.05), a chest tube placed (18.9% vs 58%, P<0.05), an associated pleural effusion (0% vs 18%, P<0.05). They presented with a longer LOS (3.9 vs 5.3 days, P<0.05), and were more likely to die (0% vs 10%, P<0.05). Additionally they showed a higher prevalence of radiologic subcutaneous emphysema (49% vs 74%, P<0.05). CONCLUSION: Spontaneous pneumomediastinum is an onset of clinical importance with a low mortality rate, short LOS and good longterm prognosis. It often presents with chest pain, dyspnea and/or subcutaneous emphysema. However, secondary causes of mediastinal air must be ruled out, due to their potential devastating outcome if not diagnosed promptly. A consensus aimed at an update of the classification guidelines is more than indispensable.

Concomitant Valve Replacement and Coronary Artery Bypass Grafting Surgery: Lessons from the Past, Guidance for the Future? A Mortality Analysis in 294 Patients.

OBJECTIVE: The aims of this study were to analyze parameters influencing early and late mortality after concomitant valve replacement and coronary artery bypass grafting surgery, using early and long-term information from an institutionally available data registry, and to discuss the results in relation to the current treatment strategies and perspectives. METHODS: The study population consisted of 294 patients after combined valve replacement with mechanical prosthesis and CABG surgery. RESULTS: There were 201 men (68.4%) and 93 women (31.6%). Concurrent to the coronary artery bypass grafting, 238 patients (80.9%) underwent aortic-, 46 patients (15.6%) mitral- and 10 patients (3.4%) doublevalve replacement. Cumulative duration of follow up was 1007 patient-years (py) with a maximum of 94 months and was completed in 92.2% (271 cases). Overall hospital mortality (30 days) rate was 6.5% (n = 19). It was significantly higher in patients of female gender, older than 70 y, in those suffering preoperative myocardial infarction, presenting with an additive EuroScore > 8 and being hemodynamically unstable after the operation. Cumulative survival rate at 7.6 y was 78.6%. Determinants of prolonged survival were male gender, age at operation < 70 y, preoperative sinus rhythm, normal renal function, additive EuroScore < 8 and the use of internal thoracic artery for grafting. Subsequent multivariate analysis revealed preoperative atrial fibrillation (HR: 2.1, 95% CI: 0.82-5.44, p: 0.01) and risk group of ES > 8 (HR: 3.63, 95% CI: 1.45-9.07, p < 0.01) as independent predictors for lower long-term survival. CONCLUSIONS: Hospital mortality (30 d) was nearly 2.5-fold higher in female and/or older than 70 y patients. Preoperative atrial fibrillation and/ or a calculated ES > 8 were independent predisposing factors of late mortality for combined VR and CABG surgery. Tailoring the approach, with the employment of the newest techniques and hybrid procedures, to the individual patient clinical profile enables favorable outcomes for concomitant valvular disease and CAD, especially in high-risk patients.

The effects of tobacco smoking on the incidence and risk of intraoperative and postoperative complications in adults.

INTRODUCTION: Despite the warnings of health hazards of cigarette smoking, still one third of the population in industrial countries smoke. This review was conducted with the aim of exploring the effects of preoperative tobacco smoking on the risk of intra- and postoperative complications and to identify the value of preoperative smoking cessation. METHODS: The databases that were searched included The Cochrane Library Database, Medline, and EMBASE. Articles were also identified through a general internet search using the Google search engine. The incidence or risk of different types of intra- and postoperative complications were used as outcome measures. RESULTS: Tobacco smoking has a negative effect on surgical outcome, as has been found to be a risk factor for the development of complications during and after many types of surgery, even in the absence of chronic lung disease. Furthermore, the long-term health hazards of smoking reduce health-related quality of life and premature death. CONCLUSION: It is widely documented that stopping smoking before surgery has substantial health benefits in the longer term and should be recommended to every smoker in order for them to gain maximum benefit from their treatment. However, identification of the optimal period of preoperative smoking cessation on postoperative complications cannot be determined.

Benign cyst of the male breast. An exceedingly rare entity that may pose a diagnostic dilemma. Management and literature review.

Cysts represent the most common cause of a breast mass in women. On the contrary, in men, the presence of a benign apocrine cyst is an exceedingly rare occurrence, with only a few cases reported in the literature. We describe herein a case of benign apocrine breast cyst without concurrent gynecomastia in a 41-year-old male. Diagnostic evaluation and management are discussed, along with a review of the literature. Given the extreme rarity of benign breast cysts in males, a thorough investigation is essential in male patients presenting with cystic breast lesions. Diagnostic breast imaging may be challenging. Surgical resection of the cyst should be considered in the presence of atypical imaging features to exclude underlying malignancy.

Primary ectopic breast carcinoma in the axilla: A rare presentation and review of the literature.

Ectopic breast tissue (EBT) develops as the result of the incomplete embryologic regression of the mammary ridge, which extends bilaterally from the anterior axilla folds to the inguinal folds in the fifth and sixth weeks of gestation. EBT is encountered in 0.3%-6% of women and 1%-3% of men and can be found anywhere along the milk line. It is subject to the same pathologic changes that affect the orthotopic breast. Primary carcinoma arising on the ectopic breast (PEBC) is a very rare occurrence accounting for 0.3%-0.6% of all breast cancers and is most frequently found in the axilla. Due to the rarity and atypical presentation of the disease, the diagnosis is often delayed. We herein present a very rare case of PEBC in the axilla along with a review of the literature. Any subcutaneous hypoechoic nodule located along the milk line without evidence of inflammation should raise concern for ectopic breast carcinoma. Accurate staging and differential diagnosis with detailed immunohistochemical analysis are required. No specific guidelines on diagnosis and treatment are available and the tumor is treated similarly to the orthotopic breast cancer of a similar stage. Physicians should be aware of this rare entity to avoid treatment delays.

Synchronous occurrence of breast cancer and refractory diffuse large B-cell abdominal lymphoma: Management and review of the literature.

The synchronous occurrence of primary breast cancer and lymphoid tissue malignant tumors has been rarely reported in the literature. We present an exceedingly rare case of synchronous breast invasive ductal carcinoma with an abdominal diffuse large B-cell lymphoma (DLBCL). A 78-year-old woman who was diagnosed with a luminal A invasive breast cancer on core biopsy, and complaint of progressively worsening low back pain. An abdominal computed tomography (CT) scan that was performed as part of the preoperative staging showed a large abdominal mass measuring 10.5 × 4.8 × 9.5 cm surrounding the lower part of the abdominal aorta, the right common iliac, right external, right internal iliac, and the left internal iliac arteries. A CT-guided fine-needle aspiration biopsy (FNAB) of the abdominal mass was then performed, to exclude the possibility of being an abdominal tumor metastasis of the known primary breast cancer. Histopathological findings were suggestive of DLBCL. Following a multidisciplinary team discussion, chemotherapy was initiated for DLBCL. The tumor however was refractory to multiple chemotherapy regimens and exhibited a highly aggressive clinical course. The diagnostic evaluation and management of the patient are discussed, along with a review of the relevant literature. This case underscores the fact that the presence of synchronous malignancies may pose both diagnostic and treatment challenges. Accurate staging of both malignancies and multidisciplinary team discussion is of utmost importance to guide an optimal therapeutic approach. Histopathological evaluation is essential for both tumors, for the second malignancy not to be misinterpreted as a secondary deposit of the primary one.

Subtle signs of breast cancer as an important pitfall in mammographic interpretation: Establishing an accurate diagnosis in an equivocal case.

Mammogram is the standard imaging modality for the early detection of breast cancer, and it has been shown to reduce disease-related mortality by up to 30%. Mammogram, however, has its limitations. It is reported that 10-30% of breast cancers may be missed on a mammogram. Delay in the diagnosis and treatment may adversely affect the prognosis of patients with breast cancer. We present a case of multifocal invasive early breast carcinoma, which was misinterpreted twice as intramammary lymph nodes, thus resulting in a delay in diagnosis for eighteen months. The tumors were detected incidentally after the patient presented to our Breast clinic for symptoms related to a concomitant benign lesion involving the same breast. We describe the tumors' imaging features and discuss the possible reasons that likely led to repeated misinterpretation. Awareness of possible causes for missed breast cancer is necessary to avoid delay of treatment initiation that may adversely affect prognosis.

The Current Role of Surgery in the Treatment of Cardiac Metastases from Malignant Melanoma: an Educational Presentation.

A 71 year-old male with a history of multiple excisions of an initial Clark's level V melanoma of the breast followed by combined radiation and interferon treatment, as well as a recurrence, 3 years later, of a BRAF-positive tumor of the shoulder, with subsequent therapy with dabrafenib and trametinib, presented again with progressive intracardiac masses causing significant right ventricular outflow obstruction. Additionally, the patient complained of dyspnea and fatigue on exertion, thus he was scheduled for surgical resection.