Osteopenia: A Diagnostic and Therapeutic Challenge

We discussed whether we are able to select a subgroup of patients with osteopenia having a high fracture risk, in which anti-osteoporotic drug treatment can be advocated. We concluded that in individuals in whom, based on clinical risk factors, a dual-energy x-ray absorptiometry (DXA) was performed in which osteopenia was diagnosed, anti-osteoporotic treatment should be prescribed in those patients with prevalent vertebral fractures, and in patients chronically using glucocorticoids, in a dosage of 7.5 mg per day or more. Although recent developments with regard to high-resolution imaging techniques (eg, peripheral quantitative computed tomography) seem to be promising, until now they do not provide substantial more reliable information than DXA in the prediction of fractures. We think that more data are urgently needed, since safe and effective drugs are available, but there is uncertainty to which patients with osteopenia these drugs should be prescribed.     

Rhabdomyoma of the Heart: A Diagnostic and Therapeutic Challenge

The sector scan was decisive in establishing the diagnosis of multiple rhabdomyomas of the heart in a newborn infant. Successful resection of the tumors was performed with profound hypothermia and limited cardiopulmonary bypass. Nine months later, the infant died of the complications of tuberous sclerosis. This case report documents the diagnostic accuracy of the sector scan and the potential benefit of aggressive surgical management of this condition.     

Symptomatic Retroperitoneal Cyst: A Diagnostic Challenge

Retroperitoneal cystic masses pose an important diagnostic and therapeutic challenge. Simple drainage, internal or external, is usually not sufficient. We report a case of a large symptomatic retroperitoneal cyst and its management.     

Laparoscopic Management of Massive Hemobilia From an Intrahepatic Aneurysm

Background:

Intrahepatic arterial aneurysms are rare and typically related to trauma, transplantation, iatrogenic injury, or infection. They account for approximately 10% of clinically significant hemobilia.

Case Report:

We present the case of a 49-year-old man with an intraparenchymal hepatic artery aneurysm that presented as massive hemobilia following a laparoscopic cholecystectomy. The aneurysm could not be managed by interventional embolization and required a left hepatic lobectomy, which was performed laparoscopically.

Discussion:

Evaluation of hemobilia requires a multidisciplinary team approach. The diagnosis of hepatic artery aneurysm can be most readily made by MRI or CT scan. Interventional embolization of the aneurysm may be effective treatment but is not always possible due to anatomic considerations. Where indicated, surgical resection in a manner that preserves a maximal amount of normal hepatic parenchyma is the treatment of choice.

Conclusion:

This is the first report of laparoscopic liver resection performed for bleeding from a hepatic artery aneurysm and adds an effective treatment modality to the surgical armamentarium.     

Granulomatous Lobular Mastitis: A Complex Diagnostic and Therapeutic Problem

Background Granulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. Clinical and radiological features may mimic breast carcinoma. Since this entity was first described, several clinical and pathologic features of the disease have been reported, but diagnostic features and treatment alternatives are still unclear. The purpose of this study is to evaluate diagnostic difficulties and discuss the outcome of surgical treatment in a series of 21 patients with granulomatous lobular mastitis. Methods A retrospective review of 21 patients with histologically confirmed granulomatous lobular mastitis treated in our center between January 1995 and May 2005 was analyzed to identify issues in the diagnosis and treatment of this rare condition. Results The most common presenting symptoms were a mass in the breast and pain. Four patients had no significant mammographic findings (MMG), but on ultrasound (US), 2 had irregular hypoechoic mass, and 2 hypoechoic nodular structures had abnormalities—one parenchymal distortion and 1 mass formation in 2 of these 4 patients’ magnetic resonance imaging (MRI). In recurrent cases, limited excision under local anesthesia was performed, as the clinical examination suggested carcinoma. Conclusions Although some findings on MMG and US are suggestive of benign breast disease, these modalities do not rule out malignancy. MRI may be helpful in patients who do not have significant pathology at MMG or US. Fine-needle aspiration cytology may be useful in some cases but diagnosis is potentially difficult because of its cytologic characteristics. Wide excision, particularly under general anesthesia, can be therapeutic as well as useful in providing an exact diagnosis.     

Meningiomas Involving the Internal Auditory Canal: A Diagnostic and Surgical Challenge

Meningiomas are the second most common lesion encountered within the cerebello-pontine angle (CPA) and rarely project into or originate from the internal auditory meatus (IAM). It is important to distinguish between meningiomas and acoustic neuromas preoperatively as the choice of surgical approach may differ depending on the tumour type. Fortunately, most lesions can be accurately diagnosed with gadolinium-enhanced magnetic resonunce imaging (MRI). We report six cases of meningioma involving the IAM, often leading to an incorrect preoperative MRI diagnosis. We highlight the challenges these tumors present to radiologists and surgeons.     

Acinic Cell Carcinoma with Extensive Neuroendocrine Differentiation: A Diagnostic Challenge

Primary salivary gland carcinoma with neuroendocrine differentiation is of rare occurrence, especially so in the parotid gland. Amongst the various reported primary tumors with neuroendocrine differentiation, acinic cell carcinoma (ACC) one such tumor. A 48 year old lady presented with a gradually increasing right infra-auricular swelling for a period of 1 year which enlarged suddenly in a short period. Contrast Enhanced Computed Tomography (CECT) suggested diagnosis of Pleomorphic Adenoma. Fine Needle Aspiration Cytology (FANC) yielded a cystic fluid suggesting a possibility of Warthin’s tumor or Oncocytic lesion. Intraoperative findings were suggestive of a Warthin’s tumor. Initial histopathological examination of the tumor was suggestive of neuroendocrine carcinoma. However, extensive sectioning revealed peripheral islands of ACC. Immunoexpression of S-100, Neuron specific Enolase (NSE), Chromogranin A and Synaptophysin confirmed the diagnosis. The possibility of neuroendocrine differentiation in a primary salivary gland tumor should be kept in mind whenever a salivary gland tumor shows only neuroendocrine histology.     

Aortocaval Fistula Associated with Abdominal Aortic Aneurysm: A Diagnostic Challenge

The purpose of this study is to determine the clinical features with the best preoperative diagnostic value for aortocaval fistulas (ACF) associated with abdominal aortic aneurysm (AAA). A review of our experience of seven patients presenting ACF between 1980 and 1994 as well as an extensive study of the literature provide a clearer picture of the signs and symptoms allowing diagnosis of ACF: edema of the lower extremities and signs of venous hypertension are the most predictive findings; continuous abdominal murmur is noted in 66% of cases and is of good diagnostic value. (Ann Vasc Surg 1997;11:464–466.)     

Facial Nerve Schwannoma of the Cerebellopontine Angle: A Diagnostic Challenge

Facial nerve schwannomas are rare lesions that may involve any segment of the facial nerve. Because of their rarity and the lack of a consistent clinical and radiological pattern, facial nerve schwannomas located at the cerebellopontine angle (CPA) and internal auditory canal (IAC) represent a diagnostic and therapeutic challenge for clinicians. In this report, a case of a CPA/IAC facial nerve schwannoma is presented. Contemporary diagnosis and management of this rare lesion are analyzed.     

Appendiceal Inversion: a Diagnostic and Therapeutic Dilemma

Appendiceal inversion is an uncommon entity that presents a diagnostic dilemma for the gastroenterologist or surgeon. We present 2 cases that illustrate scenarios that may be encountered during colonoscopy. A discussion of the literature on this subject is also presented. An improved awareness of this condition will assist the endoscopist in the identification of this finding and direct the appropriate expectant management.