Diagnostic and management difficulties in a case of multiple intracranial juvenile xanthogranuloma

Introduction

Juvenile xanthogranuloma (JXG) preferentially occurs in childhood, and its characteristics have been thought to be benign and with slow growth. JXG is classified as an inflammatory disease, which forms multiple lesions in the patients’ head, neck, and other organs and typically skin. JXG is rare, and few case reports have been published in the past, particularly with multiple intracranial lesions, which as in our case, is an extremely rare finding.

Case

Patient is a 4-year-old boy who presented with polydypsia and polyuria for 1 year. He had been followed up only under l-deamino-8-d-arginine vasopressin until he started vomiting and his level of consciousness deteriorated. Then, magnetic resonance imaging (MRI) revealed multiple intracranial lesions. He underwent biopsy via small craniotomy, and pathology was confirmed as juvenile xanthogranuloma. The patient received chemotherapy, in complete compliance with JLSG-02 protocol.

Findings

JXG is characteristic with homogenous enhancement with contrast matter and, most importantly, high intensity on diffusion-weighted image (DWI). The DWI was high when the degree of diffusion of water is restricted, as seen in inflammation and, additionally, the change of intensity after administration of steroid would reflect its anti-inflammatory nature. However, though the steroid therapy made high-intensity lesions decrease signal intensity, the size and the number of lesions did not change at all. As we expected, after we stopped steroid administration to the patient, his consciousness deteriorated and we found again the very-high-intensity lesions. We consider the intensity on DWI to reflect progression of the lesions.     

Intraluminal exfoliated cancer cells and effectiveness of bowel ligatures during sigmoidectomy for sigmoid colon cancer

Purposes

To establish the efficiency of bowel ligatures in colon cancer surgery, focusing on the extent to which exfoliated cancer cells are shed in the colonic lumen during sigmoidectomy.

Methods

Twenty consecutive patients who underwent sigmoidectomy for sigmoid colon cancer were prospectively randomized into two groups: the “ligatures group”, in which bowel ligatures were placed, 3, 5, 10 cm from the tumor proximally and distally before dissection; and the “no ligatures group”, in which the corresponding sites were ligated only immediately before taking the specimen out. Each colonic segment ligated was irrigated with saline and samples were sent for blind cytological examination.

Results

Cancer cells were found in the colonic segment where the tumor was located, in 18 of 20 samples. The frequency of free cancer cells decreased from 50 to 0 % (p < 0.04) in the distal 3–5 cm colonic segment and from 80 to 20 % (p < 0.03) in the proximal colonic segment after performing bowel ligatures. Free cancer cells were confirmed in 1 of 10 samples at both colonic segments 5–10 cm from the tumor, even after bowel ligatures.

Conclusions

Intraluminal exfoliated cancer cells could be eliminated by placing bowel ligatures during sigmoidectomy. Measures should be considered to eliminate exfoliated cancer cells during colectomy, even after placing bowel ligatures.     

Extraduodenal Papillectomy: a Feasible Alternative Method of Total Papillectomy

Rational treatment for neoplasms of the duodenal papilla (NDPs) is still controversial, especially for early stage lesions. Total papillectomies are indicated in patients expected to have adenomas, adenocarcinoma in an adenoma, or mucosal adenocarcinomas with no lymph node metastases. However, the preoperative pathological evaluation of NDPs is still challenging and often inaccurate, mainly because of the complicated anatomical structures involved and the possibility of an adenocarcinoma in an adenoma. Herein, we introduce a new method of total papillectomy, the extraduodenal papillectomy (ExDP). In this method, papillectomy is undertaken from outside of the duodenum, instead of resection from the inside through a wide incision of the duodenal wall as is done in conventional transduodenal papillectomy (TDP). The advantages of ExDP are precise and deeper cutting of the sphincter and shorter exploration time of the tumor compared to conventional TDP. We demonstrate three representative patients, all of whom had an uneventful postoperative course. One of them subsequently underwent a pylorus preserving pancreatoduodenectomy after detailed postoperative pathological evaluation. Including that patient, no recurrence has occurred with 37–46 months of follow-up. In conclusion, ExDP is regarded as a “total biopsy” for early stage borderline lesions and a feasible, less demanding alternative method for the treatment of NDPs.     

Intra-procedural anticoagulation and post-procedural hemoglobin fall in atrial fibrillation ablation with minimally interrupted direct oral anticoagulants: comparisons across 4 drugs

Journal of Interventional Cardiac Electrophysiology - Thromboembolic or hemorrhagic complications related to atrial fibrillation (AF) ablation are rare, and thus, it is difficult to compare their...