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  • Author: Marius Coros x
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Abstract

Castleman disease represents a rare lymphoproliferative disorder of unknown etiology. It is usually located in the mediastinum and in very few cases in the retroperitoneal space. We present the case of a 43-year-old male patient with a retroperitoneal tumor that was incidentally diagnosed during an abdominal computed tomography scan. The patient underwent surgery by open approach, and the tumor, which was adherent to the superior pole of the left kidney, was entirely removed. The histology examination revealed a vascular-hyaline-type Castleman disease. The postoperative evolution was uneventful, with no signs of tumor recurrence at the 4-month check-up. The surgeon should be aware of the possible retroperitoneal location of Castleman disease, even if it is a rare occurrence, and a complete removal of the tumor is followed by a favorable long-term prognosis.

Abstract

We present the case of a 48-year-old patient with a recurrent rectovaginal fistula, who we treated surgically by transposing the gracilis muscle. The patient with a history of ulcerative colitis underwent colorectal resection with mechanical anastomosis and diverting ileostomy for rectal cancer. She was subsequently treated by radiation and chemotherapy. Six weeks later, the ileostomy was removed, but afterwards the patient developed a recto-vaginal fistula. A new diverting ileostomy was performed. After eight months, a transvaginal surgical procedure was performed, and the diverting ileostomy was closed after four months. Two years after the last surgery, the patient performed an MRI scan, which revealed the relapse of the rectovaginal fistula. This time the patient was reoperated using a flap of the gracilis muscle interposed between the rectum and the vagina, but the patient refused any diverting stoma. The rectovaginal fistula relapsed again after thirteen days. Fortunately, after six months of intensive systemic and local treatment with aminosalicilic-5-acid, the fistula closed by itself. Our conclusion is that with a well-managed medical treatment, the gracilis flap, because of its good vascular supply, could be successfully used to treat rectovaginal fistulas even in patients with ulcerative colitis who underwent rectal surgery and radiation therapy for cancer.

Abstract

Background: Lymph node status in gastric cancer is known as an independent prognostic factor that guides the surgical and oncological treatment and independently influences long-term survival. Several studies suggest that the lymph node ratio has a greater importance in survival than the number of metastatic lymph nodes.

Aim: The aim of this study was to evaluate the clinical and morphological factors that can influence the survival of gastric cancer patients, with an emphasis on nodal status and the lymph node ratio.

Material and methods: We conducted a retrospective study in which 303 patients with gastric cancer admitted to the Department of Surgery of the Mureș County Hospital between 2008 and 2018 were screened for study enrolment. Data were obtained from the records of the department and from the histopathological reports. The examined variables included: age, gender, tumor localization, T stage, histological type, grade of differentiation, surgical procedure, lympho-vascular invasion, excised lymph nodes, metastatic lymph nodes, lymph node ratio. After screening, the study included a total number of 100 patients, for which follow-up data was available.

Results: The mean age of the study population was 66.43 ± 10 years, and 71% were males. The average survival period was 21.42 months. Statistical analysis showed that the localization of the tumor (p = 0.021), vascular invasion (p ---lt---0.001), T (p = 0.004) and N (p ---lt---0.001) stages, type of surgery (partial gastrectomy 59% vs. total gastrectomy 41%, p = 0.005), as well as the lymph node ratio (p ---lt---0.001) were prognostic factors for survival in patients with gastric cancer undergoing surgical therapy.

Conclusions: The survival of gastric cancer patients is significantly influenced by tumor localization, T stage, vascular invasion, type of surgery, N stage and the lymph node ratio based on univariate analysis. Also, the lymph node ratio proved to be an independent prognostic factor for survival.

Abstract

Introduction: The aim of this presentation is to highlight the usefulness of high-frequency ultrasound (18 MHz) in localized morphea for: identification of the lesion, guided skin biopsy, quantification of skin thickness, evaluating the severity by measuring total echogenicity.

Case presentation: A 62-year-old Caucasian woman was referred to the Dermatology Department for a well-circumscribed indurate plaque localized on the right side of the abdominal wall and thigh. On clinical examination, a large well-delimited, indurate plaque, silvery in the center and surrounded by a purplish-red halo (lilac ring) was noticed on the right side of the abdomen and thigh. An ultrasound-guided punch biopsy was carried out and the microscopic examination of the biopsy revealed moderate interstitial inflammatory infiltrate together with abundant collagen bundles in the dermis and subcutis and a diagnosis of localized morphea (scleroderma) was established. Ultrasonography was performed and skin thickness was measured using high-frequency US (18 MHz) and was found to be 3.1 mm to 3.9 mm.

Conclusion: high frequency ultrasound is an inexpensive, easy to perform, noninvasive method, replacing surgical biopsy and offering a valuable quantification of skin fibrosis.

Abstract

Malignant melanoma is a neoplasia that has its origin in the melanocytes, the melanin-synthesizing pigment cells present in the epidermis or sometimes in the dermis. Sentinel lymph node biopsy (SLNB) is the standard procedure used for staging patients with malignant melanoma in the majority of surgical centers in the world. With a probability of approximately 20% of finding positive lymph nodes, it spares a large number of patients of a complete lymphatic dissection. The aim of this study is to evaluate the factors that can predict the positivity of sentinel lymph nodes in malignant melanoma patients. We performed a retrospective study analyzing the histopathologic reports of patients who underwent SLNB for malignant melanoma between 2012 and 2015. There were 32 patients identified, out of which only three (9.37%) had positive SLN, so the majority of our patients were spared of regional lymphatic dissection. In our series, lymphatic invasion (p = 0.01), Breslow index >4 mm (p = 0.0064), AJCC staging (p = 0.0008), the presence of precursory lesions (p = 002), and microsatellitosis (p = 0.017) were predictive factors for the positivity of the SLN in malignant melanoma patients. Although our results are similar to those published in the literature, we consider that larger cohort studies should be performed to consolidate our results.

Abstract

Background: Clostridium difficile (CD) is the major cause of nosocomial antibiotic-associated infections, having as main manifestation diarrhea and life-threatening inflammation of the colon. Surgery may be necessary in up to 80% of patients due to the frequent complications associated with this condition. The mortality rate of this devastating disease could reach 50% even after proper treatment.

Case report: We report a case of a 24-year-old female who was admitted with clinical signs of an odontal inflammatory process. After repeated surgical treatments and antibiotic therapy, she presented acute abdominal pain on the 14th postoperative day. The explorative laparotomy was negative. Clostridium difficile was isolated from her stool, and she was transferred to the Department of Infectious Diseases. After a few days without any favorable clinical outcome, she was transferred to the intensive care unit (ICU), where she developed acute respiratory distress syndrome. Despite the immediate surgical intervention and ICU care, she died within 15 days after admission.

Conclusions: CD infection is considered a complication of antibiotic treatment, having as main cause the combination of fluoroquinolones with antisecretory drugs. In the first phase, the changes of the colon can be minimal with the manifestation of a false acute surgical abdomen, but toxic colon can develop in evolution, leading to multi-system organ failure and death.

Abstract

Introduction: Sentinel node biopsy is the gold standard for axillary assessment of patients with breast cancer without axillary metastases on clinical and radiological examination. Internationally accepted biopsy methods currently use a radioactive tracer (Te) or different variations of vital stain, or the combination of the two. Due to the high cost of technical and organizational difficulty related to the radioactive material, as well as the disadvantages of using the vital stain method, great effort is being made to find alternative solutions. The aim of this study was to determine the effectiveness of the exclusive use of vital stain versus the radioactive isotope, and the need to use the combined method. A second goal was the comparative analysis of the radioactive method and intraoperative assessment of suspicious (non-sentinel) lymph nodes.

Materials and methods: This article is based on a prospective nonrandomized study conducted on 69 patients with early breast cancer in whom the combined method was used (injection of radionuclide and methylene blue vital stain). The comparatively monitored parameters were the following: the total and mean number of excised sentinel lymph nodes, the number of metastatic ganglia revealed by the 2 methods, and the risk of understaging in case only one technique was used.

Results: We excised 153 sentinel nodes identified by the radioisotope method. Of these only 56 were stained with methylene blue (p <0.0001). We could also identify a significantly higher number of metastatic nodes with the aid of the radioactive method (p = 0.0049). Most importantly, a significant number of patients (57.14%) who would have been declared node-negative using vital staining could only be properly staged using the radionuclide or the combined method. On microscopic examination of 35 non-sentinel lymph nodes, we found 3 lymph nodes with metastases, and in 1 case the metastases were found only in the non-sentinel lymph node.

Conclusions: Given the risk of understaging, exclusive use of the vital stain method is not recommended, especially under the ASGO Z 00011 Protocol, since the more accurate determination of the number of metastatic sentinel lymph nodes in a patient influences the decision whether to perform lymphadenectomy or not. Using the combined method confers benefits only during the learning curve, in our database we found no stained nodes which were not radioactive. It is very important that the intraoperative stage uses the radioactive method and the intraoperative assessment of suspicious lymph nodes, because 35 non-sentinel lymph nodes were identified in our study, 3 of which had metastases, while in 1 case the metastases were in the non-sentinel lymph node.

Abstract

Objective: To evaluate and demonstrate the accuracy of fine-needle aspiration (FNA) in thyroid lesions in our department and to highlight probable causes of errors leading to unsatisfactory sampling, which may depend on the characteristics of the nodule.

Methods: This is a retrospective study conducted on 319 diagnosed cases of thyroid nodules referred to the Surgery Unit of Puls hospital, Tîrgu Mureș in the January 2014 – December 2015 period, who underwent fine-needle aspiration. Histological examination was considered to be the gold standard; therefore we compared the cytological diagnosis with the histological one.

Results: Of the 319 cases, 289 (90.6%) were female and 30 (9.4%) male patients; 210 cases (69.3%) were interpreted as benign, 46 cases (15.2%) as follicular lesion of undetermined significance, 4 cases (1.3%) as suspect for malignancy, 1 case (0.3%) as malignant sampling, and 42 cases (13.9%) as unsatisfactory. We compared the results of fine-needle aspiration cytology (FNAC) with the corresponding histopathological results (49 in total). FNAC achieved a sensitivity of 76.47%, a specificity of 83.1%, a positive predictive value of 35.1%, a negative predictive value of 96.7%, a false positive rate of 16.9%, a false negative rate of 23%, and an overall accuracy of 82.3%.

Conclusions: The results of our study demonstrate the accuracy of the FNA technique in the first-line diagnosis of thyroid nodules.