Extra-abdominal desmoid tumor: an unusual subcutaneous lesion presenting as shoulder pain

A 50-year-old Hispanic woman presented to the medical walk-in clinic of a local community hospital complaining of shoulder pain. The problem had begun 9 months previously, and first manifested as dull right shoulder pain that developed after she carried a bag of groceries up one flight of stairs. A diagnosis of “muscle strain” and “arthritis” was made for which nonnarcotic analgesics were prescribed. The pain persisted, and 2 months later she was re-evaluated and diagnosed with degenerative joint disease. An orthopedics consultation was sought for further evaluation. During this examination, she pointed out to the physician that she had a “lump in her shoulder,” but she was informed that this was of no consequence and that her complaints were due to arthritis. Roentgenograms of the right shoulder and thoracic spine were performed and determined to be within normal limits. Once again she attempted to control the pain with nonsteroidal anti-inflammatory agents to no avail. Because the pain had become unbearable, she sought relief at the medical walk-in clinic. Physical examination was remarkable for a solitary, skin-colored, firm, deeply-seated tumor measuring 3×4 cm located over the right posterior of the deltoid. The mass was exquisitely tender to palpation and was fixed to the underlying muscle. There was a full range of motion as well as good muscle strength of the shoulder, but movement of the arm in any direction was painful. The patient subsequently underwent a deep, partial excisional biopsy of the lesion, and a firm white tumor mass of about 3 × 3 cm in size was dissected away from the deltoid muscle. Although the majority of the tumor was excised, visible portions of the lesion were not removed because they were present deep within the bulk of the muscle. Histopathologic examination revealed a large, deeply-seated poorly-circumscribed fibrous proliferation containing areas in which there were numerous spindle cells arranged in fascicles ( Figs 1, 2, and 3 ). Neither cellular atypia nor mitotic figures were seen. The diagnosis of extra-abdominal desmoid tumor was made. The patient subsequently underwent a wide re-excision of the area and tolerated the procedure well, developing normal function of the arm following surgery, although there was slight persistent tenderness of the deltoid. Because of the known association of desmoid tumors with familial polyposis coli ¹ , a barium enema was performed. No colonic polyps were demonstrated.

Figure 1 Open in figure viewer PowerPoint Histopathology of desmoid tumor at scanning magnification. There is a large, poorly-circumscribed, diffuse spindle cell proliferation that extends into the subcutis, muscle, and fascia (hematoxylin and eosin; original magnification, ×10)     

Hypogammaglobulinemia and anemia 18 years after thymoma resection

Immunodeficiency with a thymoma (Good's syndrome) is a rare condition occurring in 7% to 13% of patients with adult-onset hypogammaglobulinemia. In 80% of cases, hypogammaglobulinemia is detected within 5 years of the identification of the thymoma. A 70-year-old man was found to have hypogammaglobulinemia 18 years after a thymoma had been resected. Cellular immunophenotyping revealed there were no detectable B cells, decreased CD4⁺ cells, and increased CD8⁺ cells. Both CD4⁺ and CD8⁺ subsets expressed increased populations of CD38⁺ DR⁺ cells and CD45RO⁺ cells. The CD8⁺ CD28⁺ population was markedly reduced. Inducible cytokine production by the patient's peripheral blood mononuclear cells revealed decreased IL-2, IL-10, and interferon-γ production. These data suggest that patients with Good's syndrome have activated memory T cells that have dysregulated cytokine production. (J Allergy Clin Immunol 1997;100:846-8.)     

Identification and content validation of wound therapy clinical endpoints relevant to clinical practice and patient values for FDA approval. Part 1. Survey of the wound care community

Wounds that exhibit delayed healing add extraordinary clinical, economic, and personal burdens to patients, as well as to increasing financial costs to health systems. New interventions designed to ease such burdens for patients with cancer, renal, or ophthalmologic conditions are often cleared for approval by the U.S. Food and Drug Administration (FDA) using multiple endpoints but the requirement of complete healing as a primary endpoint for wound products impedes FDA clearance of interventions that can provide other clinical or patient‐centered benefits for persons with wounds. A multidisciplinary group of wound experts undertook an initiative, in collaboration with the FDA, to identify and content validate supporting FDA criteria for qualifying wound endpoints relevant to clinical practice (CP) and patient‐centered outcomes (PCO) as primary outcomes in clinical trials. As part of the initiative, a research study was conducted involving 628 multidisciplinary expert wound clinicians and researchers from 4 different groups: the interdisciplinary core advisory team; attendees of the Spring 2015 Symposium on Advanced Wound Care (SAWC); clinicians employed by a national network of specialty clinics focused on comprehensive wound care; and Association for the Advancement of Wound Care (AAWC) and Wound Healing Society (WHS) members who had not previously completed the survey. The online survey assessed 28 literature‐based wound care endpoints for their relevance and importance to clinical practice and clinical research. Fifteen of the endpoints were evaluated for their relevance to improving quality of life. Twenty‐two endpoints had content validity indexes (CVI) ≥ 0.75, and 15 were selected as meriting potential inclusion as additional endpoints for FDA approval of future wound care interventions. This study represents an important first step in identifying and validating new measurable wound care endpoints for clinical research and practice and for regulatory evaluation.     

Gastric Outlet Obstruction due to Gastrointestinal Amyloidosis

Journal of Gastrointestinal Surgery - A 64- year-old man with smoldering myeloma presented to the hospital for nausea, vomiting, and PO intolerance. Abdominal CT demonstrated massive gastric...     

The Effect of a Surgery Residency Program and Enhanced Educational Activities on Trauma Mortality in Sub-Saharan Africa

Introduction

To address the need for more surgical providers in low-resource settings, a collaboration to create a surgical residency-training program for local Malawian physicians was established in 2009. This study sought to describe the short-term independent effect of a surgical residency program on trauma mortality at a tertiary trauma center in sub-Saharan Africa.

Methods

We conducted a retrospective analysis of all patients recorded in the trauma surveillance registry of Kamuzu Central Hospital in Lilongwe, Malawi, from 2009 (three residents) through 2014 (11 residents). Log-binominal regression modeling was used to compare the risk ratio of death compared to the referent year of 2009, when the program was started, after adjusting for relevant covariates. Primary injury type was used as a surrogate for injury severity.

Results

In total, 82,534 patients were recorded into the KCH Trauma Registry during the study period. Mean age was 23.1 years (SD 15.7) with a male preponderance (72.1%). Trauma patient volume increased from 8725 patients in 2009 to 15,998 patients in 2014. Each year had a significantly decreased risk of death compared to 2009 when adjusted for primary injury type, age, and gender, with an adjusted risk ratio of 0.73 (95% CI 0.58, 0.90) in 2010 and 0.52 (95% CI 0.43, 0.62) in 2014.

Conclusion

The global burden of surgical diseases cannot be attenuated in the presence of an inadequate surgical workforce. After institution of a surgery residency program, adjusted injury-associated mortality decreased each year despite substantial increases in trauma patient volume. In low-resource settings, establishment of a surgical residency program significantly improves trauma-associated outcomes.

     

Arthrofibrosis Associated With Total Knee Arthroplasty

Background

Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions.