Renal angiomyolipoma: clinicopathologic study of 194 cases with emphasis on the epithelioid histology and tuberous sclerosis association

The majority of renal angiomyolipoma (AML) is sporadic and occasionally it occurs as part of tuberous sclerosis complex (TSC). Epithelioid AML (EAML), an uncommon variant, is considered potentially malignant based on anecdotal case reports. The prognostic significance of epithelioid component in an otherwise typical AML is uncertain. We studied 194 AMLs for the clinicopathologic features of epithelioid and TSC-associated AMLs. Epithelioid component was present in 15 cases (7.7%) with an average amount of 51% (range: 10% to 100%). Histologically, the epithelioid tumor cells were categorized into small, intermediate, and large cell type based on the cell size. Worrisome histologic features were seen in many EAMLs, including coagulative tumor necrosis in 27% (4/15), nuclear atypia in 93% (14/15), mitosis in 47% (7/15), and atypical mitosis in 1 case. All 15 EAML patients had a mean follow-up time of 5.1 years and none had local recurrence or distant metastasis. Sixteen (8.2%) AMLs occurred in patients with definitive TSC. Three histologic features, namely microscopic AML foci, epithelioid component, and epithelial cysts, were present in 10 (62.5%), 4 (25%), and 44% (7/16), respectively, of TSC-associated AMLs, compared with 11 (6.2%), 11 (6.2%), and 6 (3.4%), respectively, in non-TSC-associated AMLs (P value all <0.01). In summary, all 15 cases of EAMLs in our study had benign clinical outcomes despite adverse pathologic features. Epithelioid component, epithelial cysts, and microscopic AML foci are strongly associated with TSC and the presence of all 3 features should raise strong suspicion for TSC.     

Current Trends in the Management of Blunt Solid Organ Injuries

Abstract   The management of patients with solid organ injuries has changed since the introduction of technically advanced imaging tools, such as ultrasonography and multiple scan computerized tomography, interventional radiological techniques and modern intensive care units. In spite of this development in the management of these patients, major solid organ traumas can still be challenging. There has been great improvement in the non-operative management (NOM) of intra-abdominal solid organ injury in recent decades. In most cases treatment of injuries has shifted from early surgical treatment to NOM.     

Ideal screw entry point and projection angles for posterior lateral mass fixation of the atlas: an anatomical study

Although various posterior insertion angles for screw insertion have been proposed for C1 lateral mass, substantial conclusions have not been reached regarding ideal angles and average length of the screw yet. We aimed to re-consider the morphometry and the ideal trajections of the C1 screw. Morphometric analysis was performed on 40 Turkish dried atlas vertebrae obtained from the Department of Anatomy at the Medical School of Ankara University. The quantitative anatomy of the screw entry zone, trajectories, and the ideal lengths of the screws were calculated to evaluate the feasibility of posterior screw fixation of the lateral mass of the atlas. The entry point into the lateral mass of the atlas is the intersection of the posterior arch and the C1 lateral mass. The optimum medial angle is 13.5 ± 1.9° and maximal angle of medialization is 29.4 ± 3.0°. The ideal cephalic angle is 15.2 ± 2.6°, and the maximum cephalic angle is 29.6 ± 2.6°. The optimum screw length was found to be 19.59 ± 2.20 mm. With more than 30° of medial trajections and cephalic trajections the screw penetrates into the spinal canal and atlantooccipital joint, respectively. Strikingly, in 52% of our specimens, the height of the inferior articular process was under 3.5 mm, and in 70% was under 4 mm, which increases the importance of the preparation of the screw entry site. For accommodation of screws of 3.5-mm in diameter, the starting point should be taken as the insertion of the posterior arch at the superior end of the inferior articular process with a cephalic trajection. This study may aid many surgeons in their attempts to place C1 lateral mass screws.     

Inflammatory Myofibroblastic Tumor of the Ileocecal Mesentery Mimicking Abdominal Lymphoma in Childhood: Report of Two Cases

An inflammatory myofibroblastic tumor is an uncommon benign tumor located in various organs that can be misdiagnosed as a malignant neoplasm. We herein present two patients with ileocecal inflammatory myofibroblastic tumors. An abdominal mass was detected in a 13-year-old girl and a 15-year-old boy who presented with paleness, fatigue, intermittent fever, and night sweating. The radiological findings confirmed a mass originating from the ileocecal region. The presumptive diagnosis was Burkitt’s lymphoma. The histopathological diagnosis was inflammatory myofibroblastic tumor. After a surgical resection, all systemic symptoms rapidly resolved. Inflammatory myofibroblastic tumor is a rare pseudosarcomatous clinical and pathological entity. Although this tumor is more commonly reported in the lung, it can be detected in extrapulmonary sites, including the mesentery. Because the choice of treatment for this tumor is conservative surgery, an accurate preoperative analysis is important to avoid any unnecessary aggressive surgical intervention or other therapeutic approaches.     

Assessment of survival rates compared according to the Tamai and Yamano classifications in fingertip replantations

Background:The fingertip is the most frequently injured and amputated segment of the hand. There are controversies about defining clear indications for microsurgical replantation. Many classification systems have been proposed to solve this problem. No previous study has simultaneously correlated different classification systems with replant survival rate. The aim of the study is to compare the outcomes of fingertip replantations according to Tamai and Yamano classifications.Results:Of the 34 fingertips, 26 (76.4%) survived. Ten (66.6%) of 15 digits replanted in Tamai zone 1 and 16 (84.2%) of 19 digits replanted in Tamai zone 2 survived. There were no replantation failures in Yamano type 1 injuries (100%) and only two failed in Yamano type 2 (75%). Replantation was successful in 14 of 20 Yamano type 3 injuries, but six failed (70%). The percentage of success rates was the least in the hybridized groups of Tamai zone 1-Yamano type 2 and Tamai zone 1-Yamano type 3. Although clinically distinct, the survival rates between the groups were not statistically significantly different.Conclusions:The level and mechanism of injury play a decisive role in the success of fingertip replantation. Success rate increases in proximal fingertip amputations without crush injury.     

Rhinorrhoea from a frontal encephalocele after reduction of high intracranial pressure

Acquired non-traumatic frontal sinus encephaloceles are very rare lesions that are usually caused by a tumour or hydrocephalus. We present a 31-year-old woman with a frontal sinus encephalocele who developed rhinorrhoea after a ventriculo-peritoneal shunt to treat her hydrocephalus and underwent radiotherapy for a tectum tumour.     

Peritoneal Carcinoembryonic Antigen Level for Predicting Locoregional and Distant Spread of Gastric Cancer

Purpose Peritoneal recurrence is not an uncommon cause of death after surgery for gastric cancer, even after surgery with curative intent. This indicates that there is undetected residual disease in the peritoneal cavity. We conducted this study to determine the value of peritoneal and serum carcinoembryonic antigen (CEA) levels and peritoneal washing cytology in predicting the locoregional and distant spread of gastric cancer. Methods We prospectively evaluated 70 consecutive patients with gastric cancer by measuring peritoneal CEA (pCEA) and serum CEA (sCEA) levels and peritoneal washing cytology results, and studying their effect on the histopathologic properties. The effect of the pCEA level on disease-free survival (DFS) and overall survival (OS) was also evaluated in patients treated with curative intent. Results Twenty-one (30%) patients had sCEA levels >10 ng/ml, whereas 25 patients (35.7%) had pCEA levels >10 ng/g protein and 26 patients (37.1%) had positive cytology. The pCEA levels were significantly higher in patients with hepatic metastases (P = 0.034), or serosal (P = 0.028), and peritoneal (P = 0.026) involvement, whereas the sCEA levels were significantly higher only in patients with hepatic metastases (P = 0.04). Similarly, positive cytology was mainly detected in patients with hepatic metastases (P = 0.004). The pCEA levels significantly affected DFS (P = 0.002) and OS (P = 0.01) in 34 patients treated with curative intent. Conclusion Since pCEA levels are more useful for predicting locoregional recurrence, their measurement during surgery may help plan the most appropriate surgical strategy and adjuvant therapy.     

Opposite-direction bilateral fracture dislocation of the shoulders after an electric shock

Injuries after an electric shock, such as dermal burns, motor and sensory nerve deficits, fractures and dislocations, are reported in the literature. Posterior dislocation of the shoulder after electric-shock is the common musculoskeletal injury. Bilateral dislocation, either anterior or posterior, is rarely seen and reported. We report a case of bilateral shoulder fracture dislocation in opposite directions following an electric-shock and discuss the mechanism, the diagnosis and the treatment.     

Clear cell papillary cystadenoma of the epididymis and mesosalpinx: immunohistochemical differentiation from metastatic clear cell renal cell carcinoma

Clear cell papillary cystadenoma is a rare epithelial tumor of the epididymis, which may present as an isolated lesion or as a component of von Hippel-Lindau disease (VHLD). Recently, tumors have also been described in the female genital tract with similar histology. Recognition of clear cell papillary cystadenoma is critical because of its association with VHLD and its potential diagnostic confusion with metastatic renal cell carcinoma because of a shared architecture and clear cells. In this study, we report on the immunohistochemical differentiation of 5 clear cell papillary cystadenomas, 3 of the epididymis and 2 of the mesosalpinx, from metastatic renal cell carcinoma. In 2 cases, there was a history of renal cell carcinoma in the setting of VHLD; and in 1 of these cases, an epididymal papillary cystadenoma was initially considered to be metastatic renal cell carcinoma. Immunohistochemically, tumor cells were moderately intensely positive for cytokeratin AE1/AE3 and epithelial membrane antigen, strongly positive for CK7 and negative for CK20 and RCC. Four of 5 cases were negative for CD10. This staining profile contrasts with that reported for clear cell renal cell carcinomas, which are typically negative for CK7 and immunoreactive for renal cell carcinoma (RCC) and CD10. Our findings indicate that, in cases where there is uncertainty about the histologic diagnosis of clear cell papillary cystadenoma, the above immunohistochemical panel helps to rule out metastatic renal cell carcinoma.     

Is pneumoperitoneum harmful during intra-abdominal hemorrhage in rats?

BACKGROUND: Laparoscopic surgical interventions are being used in trauma patients for diagnostic and therapeutic purposes, but there are limited studies on this subject. The effect of pneumoperitoneum during intra-abdominal hemorrhage has not been elucidated. The aim of this study was to investigate the hemodynamic, respiratory, and renal effects of pneumoperitoneum in the splenic injury/ hemorrhagic shock model in rats. MATERIAL AND METHODS: In this study, 80 anesthetized Wistar male rats (294.5 +/- 31.2 g) were randomized into 2 main groups: nontraumatized (group A) and traumatized (group B). After initial preparation and monitoring, each group was divided according to the degree of pneumoperitoneum. The nontraumatized subgroups were A1, sham-operated; A2, 4-8 mm Hg; A3, 9-13 mm Hg; and A4, 14-18 mm Hg. The traumatized subgroups were B1, splenic injury without pneumoperitoneum; B2, B3, and B4, splenic injury with pneumoperitoneum at 4-8 mm Hg, 9-13 mm Hg, and 14-18 mm Hg, respectively. Mean arterial pressure, heart rate, and respiratory rate were monitored continuously. Blood samples were obtained for hemoglobin, hematocrit, arterial blood gases, and biochemical analyses. Twenty-four hour urine output was collected. RESULTS: In group B4, pH, pCO2, and HCO3 levels were lower than in all other groups, while pCO2 and base deficit levels were significantly higher (P < 0.05). Both blood and urine analysis results showed that 24-hour urine output and the glomerular filtration rate of groups A4 and B4 were significantly lower (P < 0.05), while urinary osmolarity and fractional sodium excretion levels were significantly higher (P < 0.05). CONCLUSION: High-pressure pneumoperitoneum in splenically traumatized rats amplifies acidosis, decreases urine output, decreases glomerular filtration rate, and increases urinary osmolarity and fractional sodium excretion significantly.