Bladder paraganglioma — A report of two cases

Introduction

Bladder paragangliomas (BP) are rare tumors, with clinical manifestations ranging from hypertension to hematuria to being asymptomatic. Histologically, they can mimic urothelial carcinomas. Around 200 cases of paragangliomas arising in the urinary bladder have been described in the world literature.

Osteitis or osteomyelitis of the pubis? A diagnostic and therapeutic challenge: report of 9 cases and review of the literature

Osteitis pubis is a noninfective inflammation of the symphysis pubis, without distinct aetiology. It has often been reported after urological or gynaecological procedures, and is also associated with trauma, rheumatic disorders, pregnancy and parturition. Symptoms mostly resolve spontaneously. On the other hand, osteomyelitis of the pubis is a classical infective inflammation of bone. The differential diagnosis between both entities may be difficult. The most common complaint in both inflammatory diseases is pain under load, either local or pseudoradicular in nature. The biochemistry is normal or slightly inflammatory in osteitis pubis, but frankly inflammatory in osteomyelitis. A 3-phase bone scan may be positive in the mineralisation or delayed phase in case of osteitis, and in all three phases in case of osteomyelitis. Aspiration is the ultimate diagnostic test: in case of osteomyelitis pubis, culture of the aspirate will usually lead to the diagnosis, sometimes even after antibiotic therapy.     

Adenocarcinoma and gastro-intestinal stromal tumor: fortuitous association or a single carcinogenic agent? A report of 2 cases

The synchronous development of epithelial and stromal tumors of the digestive tract was rarely reported in the literature. Two such cases are described in this article. One is of a 44-year-old man presenting a high grade gastric stromal tumor associated with an adenocarcinoma of the large bowel. The other is of a 68-year-old man presenting an adenocarcinoma of the head of the pancreas associated with a low grade gastric stromal tumor. The hypothesis that the association is due to a simple coincidence particularly in areas with high rates of digestive cancer is proposed. A possibility of a genetic mutation or a single carcinogenic agent interacting with two tissues in the digestive tract and inducing the development of tumors of different histotype cannot be discarded.     

Acute shoulder infection following acupuncture—A report of three cases

Worldwide, acupuncture is a popular alternative medicine for releasing pain, treating diseases, or promoting health. Although it is generally considered safe, a few complications have been reported. These complications ranged from minor side effects, such as pain, local hematoma formation, or the aggravation of symptoms, to serious complications including mechanical injuries, such as pneumothorax and severe infection requiring surgical treatment. In orthopedic clinics, reports of complications caused by acupuncture are rare. We present three cases who developed severe infection following acupuncture, leading to irreversible osteoarthritic changes in their glenohumeral joints. All of them mentioned a history of acupuncture therapy before their shoulder became swollen and hot and no other infection source could be detected. Possible explanations included: (1) breakdown of the sterile technique; (2) no consensus of acupoint or how deep the needle should be inserted; (3) patient’s comorbidities, such as diabetes mellitus or previous shoulder pathology, were not considered. Although these three patients underwent debridement and proper management with antibiotics according to the culture data, eventually, they still progressed to severe glenohumeral joint destruction. Strict infection control guidelines should be established to lower this type of life-threatening complication.     

Small acoustic neuroma: observation or treatment? A review of 207 cases

The management of small acoustic neuromas (AN) whether localized in an intracanalar position (stage I) or with a small extension of less then 2 cm into the cerebellopontine angle (stage II) remains under debate. Proposed strategies include surgery, stereotactic irradiation and observation. From 1987 to 1997, among 343 AN referred to our department, 207 were small (83 stage I and 124 stage II). Initially, 72 patients were treated conservatively mainly because of their age (over 60-65) and 132 were operated on. Three patients underwent irradiation because of their poor general condition. Significant tumor growth was observed in 15 cases in the conservative treatment group; 14 of these patients underwent secondary surgery and one irradiation. Among the 146 AN operated on (132 initially and 14 secondarily), 142 small AN were operated on via a transpetrosal approach (64% translabyrinthine, 21% middle-fossa and 15% retrosigmoid) and 4 AN, which became large tumors during the observation period, were treated through the translabyrinthine approach. No mortality was observed in our series. Postoperative complications included 11 CSF leakages necessitating reoperation (8%). In 93% of the cases, postoperative facial function at one year was good. Hearing preservation was attempted in 51 selected cases (pure tone average=50 dB, speech discrimination score 100%) with a 51% success rate (53% and 48% through middle-fossa and retrosigmoid approaches respectively). In our opinion, surgery with this risk-benefit ratio is indicated for small AN, except in the elderly for whom conservative management is preferred and in patients in poor clinical condition with a growing AN, for whom irradiation is recommended.     

Does the term scaphocapitate syndrome need to be revised? A report of 6 cases

This is a retrospective study of six patients with displaced fractures of the neck of the capitate. In four of the six patients the diagnosis was delayed by at least 1 week. After open reduction and internal fixation the results were assessed as excellent (three cases), fair (two cases) or poor (one case). In all cases there was a concomitant injury to the radial side of the wrist: in four cases this was a fracture of the waist of the scaphoid. In five of the six cases there was also an injury to the ulnar side of the wrist. As a scaphoid fracture does not always occur with the fracture of the neck of the capitate, we consider the term "scaphocapitate syndrome" inappropriate for this injury.     

Intradural lumbar disc herniation—Is it predictable preoperatively? A report of two cases

BACKGROUND CONTEXT: Intradural disc herniations are thought to be rare events, and there have been relatively few literature reports of intradural disc herniations available with regard to magnetic resonance imaging findings. PURPOSE: The authors describe two patients with intradural lumbar disc herniations, one with and one without preoperative diagnosis, who had different postoperative outcomes. STUDY DESIGN: Case study METHODS: The first patient underwent an extended L3 subtotal laminectomy followed by bilateral medial facetectomy and foraminotomy at L3-L4. A durotomy uncovered large disc fragments comprised of friable disc materials and end plates, after no clear disc herniation was found in the epidural space. The second patient underwent anterior lumbar interbody fusion after a preoperative diagnosis of intradural disc herniation. RESULTS: The first patient experienced a marked reduction of pain and progressive recovery of sensory disturbance, but neurologic examination showed right foot drop postoperatively. Two years after surgery, she can not walk without a cane because the neurologic deficit of the right ankle has shown no improvement. Two days after surgery, the second patient was allowed to ambulate with a lumbar orthosis. Neurologic examination showed no motor deficit. Twenty-one months after surgery, the patient reports minimal back pain when sitting on a chair for prolonged periods of time. CONCLUSION: Our cases highlight the importance of preoperative diagnosis in the treatment of intradural lumbar disc herniations. The potential presence of an intradural disc herniation must always be considered preoperatively on a patient whose magnetic resonance imaging study demonstrates the "hawk-beak sign" on axial imaging as well as abrupt loss of continuity of the posterior longitudinal ligament (PLL). This association results in an adequate surgical approach, thereby reducing the chance of postoperative neurologic deficit. Finally, anterior lumbar interbody fusion can be a reasonable alternative in the treatment of intradural lumbar disc herniations.     

Compartment syndrome or gas gangrene? A case report

A case of forearm compartment syndrome due to a minor trauma is reported. The severe clinical conditions due to a shock state lead to an initial misdiagnosis of clostridial myonecrosis. The patient, 68 y-old woman, was admitted to the intensive care unit of Authors' hospital for a traumatic injury of the right forearm. A diagnosis of gas gangrene due to clostridial myonecrosis was done and forearm amputation suggested. In spite of this indication a decompression fasciotomy of the forearm compartments was performed as well as a hyperbaric oxygene therapy. Since culture of necrotic tissue samples did not demonstrate any bacterial growth, the Authors decided to avoid amputation and perform a radial arteriovenous fistula to improve venous return and reduce distal edema and continuous bleeding, with a complete recovery within 40 days. Good evaluation of patient with suspected compartment syndrome means correct and not delayed treatment, avoiding invalidating outcome.     

Endoscopic ultrasonography coupled with fine needle aspiration biopsy of intraductal papillary-mucinous tumours of the pancreas. Tool or gadget? A report of three cases

We report three cases of intraductal papillary-mucinous tumour of the pancreas, occurring over a brief period in our surgical unit. Symptoms were aspecific in two cases, while only one of the patients presented a picture of acute pancreatitis. Preoperative investigations included ultrasonography, abdominal CT-scan and endoscopic ultrasonography (EUS) with guided fine needle aspiration biopsy (EUS-FNAB) of the cyst. EUS furnished invaluable data about the neoplasm and pancreatic duct morphology, while EUS-FNAB was crucial in revealing cytological features highly suggestive of intraductal papillary-mucinous tumour. All three patients underwent surgical resection, (two pylorus-preserving pancreatico-duodenectomies and one total pancreatectomy). The histological features of the resected specimen confirmed the preoperative EUS-FNAB diagnosis. After a medium-term follow-up, patients have been free of abdominal symptoms with no evidence of recurrence at CT-scan. In the present study we analyse the feasibility and effectiveness of EUS and EUS-FNAB in diagnosing intraductal papillary-mucinous tumours and in predicting their malignancy.     

Is severe intestinal chronic graft-versus-host disease an indication for surgery? A report of two cases

Chronic graft-versus-host disease (cGVHD) frequently complicates allogeneic hematopoietic stem cell transplantation (HSCT), but small bowel involvement with obstruction is rarely observed. We report two patients who underwent allogeneic sibling HSCT and developed severe cGVHD involving the small bowel, causing unremitting obstructive symptoms and malnutrition despite maximal immunosuppression. Both patients underwent ileal resection and stricturoplasties. The first patient promptly improved, and remains asymptomatic 32 months after transplant. Three weeks after the resection of 90 cm of small bowel, the second patient developed leaking stricturoplasty and peritonitis, with a relapse of chronic myelogenous leukemia in accelerated phase. Later, an enterocutaneous fistula required additional small bowel resection and ileostomy. The patient subsequently died from pulmonary infection a few weeks after the last surgical procedure. Similar to inflammatory bowel disease, these two cases highlight that surgery may be a valuable option in patients who present with obstructive severe cGVHD refractory to aggressive immunosuppression.     

Intestinal lymphangiectasia — a report of two cases

Intestinal lymphangiectasia is a rare benign disease characterised by focal or diffuse dilation of the mucosal, submucosal and subserosal lymphatics. Clinically, the patients may present with protein losing enteropathy (PLE), hypoproteinemic oedema, chylous ascites, pleural effusion, acute appendicitis and intestinal obstruction.     

Partner dyspareunia—a report of six cases

One of the rarely cited complications of the use of alloplastic materials in pelvic floor surgery is dyspareunia of the partner caused by prominence or vaginal exposure of the sling material. Even though this entity is real and an important problem, it is rarely reported in literature. We report six cases of partner dyspareunia, in which there were two incidences of partner penile injury, occurring as a complication of synthetic midurethral sling surgery. There were three tension-free vaginal tapes, two transobturator tapes and one anterior intravaginal sling in the series. Time interval between tape insertion and the presentation of complications ranged from 3 to 48 months. Vaginal exposure was seen in five of the six cases and in one patient prominence of sling material without exposure was noted. Recognizing partner dyspareunia as an important complication of the vaginal use of alloplastic prosthesis is not only important in preoperative counseling of patients but also to avoid legal implications.     

Closed acute traumatic rupture of extensor pollicis longus tendon—A report of two cases

Two cases are presented of closed rupture of the extensor pollicis longus due to rotational trauma to the forearm. Case 1 was successfully managed by indicis proprius transfer and the operative findings are described. The rarity of this injury is stressed by a review of the sparse relevant literature.     

Saturday night palsy or Sunday morning hangover? A case report of alcohol-induced Crush Syndrome

Saturday night palsy is a colloquial term given to brachial plexus injuries of the arm resulting from stretching or direct pressure against a firm object, often after alcohol or drug consumption. In most circumstances, this condition gives rise to a temporary plexopathy, which generally resolves. However, if the compression is severe and prolonged, a more grave form of this condition known as ‘Crush Syndrome’ may occur. Skeletal muscle injury, brought about by protracted immobilization, leads to muscle decay, causing rhabdomyolysis, which may in turn precipitate acute renal failure. This condition is potentially fatal and has an extremely high morbidity. The case presented below demonstrates the drastic consequences that can result following an episode of ‘binge’ drinking in a young man. What is most concerning is that this trend is increasing across society and cases like this may not be as rare in the future.     

Is Survival from Infiltrating Lobular Carcinoma of the Breast Different from That of Infiltrating Ductal Carcinoma?

Previous studies of patients with breast cancer have compared survival of invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) with contradictory results. This study examines the effect of the diagnosis of IDC or ILC in conjunction with age at diagnosis, pathologic tumor size, pathologic stage, histologic grade, and lymph node status of 307 women with IDC or ILC in 1992 in the Greater Western region of Sydney in Australia. Survival analysis was conducted using the Kaplan-Meier method. Relative risks associated with IDC or ILC and other important prognostic factors and adjusted for each other were computed using Cox proportional hazard regression. The proportion of grade I tumors was significantly higher in ILC (41%) than in IDC (16%). Conversely, the proportion of grade III tumors was only 18% in ILC as against 41% in IDC (p = 0.020). The 10-year survival of women with IDC was 69%, compared to 84% for ILC (p = 0.073). However, the 15 percentile point difference between overall survival of IDC and ILC was markedly reduced after adjustment for nodal status. The difference was eight percentile points for node-negative patients (p = 0.361) and five percentile points for node-positive patients (p = 0.464). Age at diagnosis, tumor size, pathologic stage, and lymph node status were independent prognostic indicators for 10-year survival. There was no prognostic difference between IDC and ILC. The result shows the importance of adjusting for other important clinicopathologic characteristics before comparing the overall survival of IDC and ILC.