Aggressive Surgical Management Research Articles

Disseminated uterine actinomycosis: Case report and review of literature

Actinomyces - It mainly affects the cervicofacial and abdominopelvic organs. These bacteria are of low virulence and their spread requires breakdown or alteration of the normal tissue barrier, which can be due to any surgery, trauma, or infection. Actinomyces infection involving the reproductive organs may often mimic a neoplasm and lead to aggressive surgical management for the patient; it is therefore necessary to recognize the infection which can be effectively managed using a combination of pharmaceutical agents. Imaging such as computed tomography and magnetic resonance imaging aid in determining the extent of the disease. Histopathological diagnosis/culture is necessary to make the final diagnosis. We present a case of actinomycosis of the uterus manifesting as a large uterine mass with dissemination to the pelvis and anterior abdominal wall.

A phase 2 study of neoadjuvant lenvatinib in locally advanced invasive thyroid cancer.

TPS6105 Background: Lenvatinib is a multiple receptor tyrosine kinase (RTK) inhibitor that has demonstrated meaningful benefit in radioiodine (RAI)-refractory differentiated thyroid cancer (DTC). In SELECT, lenvatinib significantly prolonged progression-free survival (PFS) and was associated with an overall response rate (ORR) of 65% in patients with RAI-refractory DTC, with the greatest degree of tumor shrinkage occurring in the first 2 cycles. The robust activity of lenvatinib in DTC suggests that neoadjuvant treatment in patients presenting with bulky neck disease may make surgery more feasible, allows for optimal surgical outcomes and less aggressive surgical management. Neoadjuvant lenvatinib to improve surgical outcomes in locally advanced DTC has not been studied to date. This phase 2 study will examine the efficacy and safety of lenvatinib prior to thyroidectomy, with the goal of achieving more favorable surgical outcomes. Methods: This is a Simon two-stage Phase 2 open-label multicenter clinical trial for adult patients who meet the following criteria: have been diagnosed with locally advanced or persistent/recurrent thyroid and/or cervical nodal DTC, deemed at risk for R2 resection (surgical margins with macroscopic tumor) (as evident by vocal cord paralysis by laryngoscopic exam, imaging documenting extrathyroidal/extranodal extension, or major vessels involvement), have measurable disease per RECIST v1.1, have an ECOG performance status ≤ 1, and no contraindication to surgery. A total of 28 patients will be enrolled from three centers (Massachusetts General Hospital/Massachusetts Eye & Ear Infirmary (MGH/MEEI), Memorial Sloan-Kettering Cancer Center (MSKCC), and MD Anderson Cancer Center (MDACC)). Participants will receive up to 6 cycles of lenvatinib prior to surgery depending on response. Participants will undergo restaging at the end of cycle 2, 4, and 6. Participants with sufficient response to treatment who projected to achieve an R0 or R1 resection will stop lenvatinib and proceed to surgery within 7-10 days from the last dose. Participants who do not have a sufficient response who are tolerating treatment, will receive an additional 2-4 cycles of lenvatinib, followed by surgery. The primary objective is the R0 (surgical margins free from tumor)/R1 (surgical margins free from macroscopic tumor) resection rate. Secondary outcome measures include R0/R1 resection rates in each of 5 pre-specified anatomic target interfaces (perithyroid muscles, cartilage, esophagus, recurrent laryngeal nerve, major vessels), evaluation of the change in surgical morbidity complexity MGH/MEEI-MSKCC-MDACC (MMM) score and the Invasive Thyroid Class, ORR prior to surgery per RECIST v1.1, and the safety of lenvatinib in this patient population. The study is currently accruing with 11 patients enrolled at time of submission. Clinical trial information: NCT04321954 .

Pediatric Laryngeal Coccidioidomycosis: A Case Series in an Endemic Region.

Laryngeal coccidioidomycosis is a rare but life-threatening manifestation of coccidioidomycosis. Data in children are sparse and limited to case reports. We conducted this study to review the characteristics of laryngeal coccidioidomycosis in children. We performed a retrospective review of patients ≤21 years of age with laryngeal coccidioidomycosis who were treated from January 2010 to December 2017. We collected demographic data, clinical and laboratory studies and patient outcomes. Five cases of pediatric laryngeal coccidioidomycosis were reviewed. All children were Hispanic and 3 were female. The median age was 1.8 years and the median duration of symptoms before diagnosis was 24 days. The most common symptoms included fever (100%), stridor (60%), cough (100%) and vocal changes (40%). Airway obstruction requiring tracheostomy and/or intubation for airway management was present in 80%. The most frequent location of lesions was the subglottic area. Coccidioidomycosis complement fixation titers were frequently low and culture/histopathology of laryngeal tissue was necessary to make a definitive diagnosis. All patients required surgical debridement and were treated with antifungal agents. None of the patients had recurrence during the follow-up period. This study suggests that laryngeal coccidioidomycosis in children presents with refractory stridor or dysphonia and severe airway obstruction. Favorable outcomes can be achieved with a comprehensive diagnostic work-up and aggressive surgical and medical management. With the rise in cases of coccidioidomycosis, physicians should have a heightened awareness regarding the possibility of laryngeal coccidioidomycosis when encountering children who have visited or reside in endemic areas with stridor or dysphonia.

O143 Management strategies and outcomes for small bowel neuroendocrine tumours with involvement of the superior mesenteric vascular root: a systematic review

Abstract Introduction Small intestine neuroendocrine tumours (SI-NETs) are the most common small bowel tumours. A particularly challenging subset of these tumours are those that involve the superior mesenteric artery (SMA) or vein (SMV) for which the role and feasibility of surgery is often questioned. This review aimed to identify and evaluate the management strategies used for these complex SI-NETs. Methods Primary studies concerning SI-NETs with SMA and/or SMV involvement were identified from PubMed and Embase review and data abstraction was performed. Results Initial literature search identified 155 potentially eligible studies, from which nine non-randomised primary retrospective studies met inclusion criteria. Treatments identified include stenting the SMV, debulking and resection, auto-transplantation, and endovascular occlusion and tumour excision (EVOTE) procedures. The level of involvement of the SMA and SMV was associated with resectability such that more proximal involvement yielded a lower likelihood of successful resection. Auto-transplantation strategies may show promise in more proximal mesenteric root involvement. To date, one study reported a case of a patient with SMV encasement who was successfully treated with auto-transplantation of ileocolic and ileojejunal segments after resection of the affected structures. Conclusion The present study highlights a role for aggressive surgical and multimodal management in cases of SI-NETs with vascular involvement of the mesenteric root. The use of classification systems to stratify mesenteric masses by level of vascular involvement can help identify patients who could benefit from resection. Large scale prospective studies are needed to better elucidate the effectiveness of surgical management strategies in these challenging SI-NETs.

Infantile Fibromatosis of the Infratemporal Fossa Extending to Oropharynx

The Case Study describes the clinical radiographic Surgical Procedure with reconstruction and histopathology Infantile fibromatosis of infratemporal fossa extending to oral cavity and Oropharynx in a two-year-old male child. This condition is rarer in two-year-old child mainly in infratemporal fossa extending to Oropharynx and protruding into oral cavity leading to tremendous suffering of the child for breast feeding, eating with occasional profuse bleeding. The differential diagnosis, management and long term follow up for two years are also mentioned. The need for aggressive surgical management, rare site and operability in this region is very rarer of rarest. The absence of recurrence after 2 years follow up is significant and we can declare the patient is cured from the primary disease. This paper gives guide to how to approach the disease process.

Genetic Problems, Diagnosis, and Cardiovascular Manifestations of Loeys-Dietz Syndrome.

Loeys-Dietz Syndrome (LDS) is an autosomal dominant connective tissue disorder with multisystem involvement of wide spectrum, found to be associated with transforming growth factor-β pathway. LDS is characterized by craniofacial, skeletal, cutaneous, vascular abnormalities along with aortic aneurysm and aortic dissection contributing to mortality and morbidity at a young age. Therefore, timely diagnosis and intervention in patients with LDS is vital. Several gene mutations have been described as contributing factors of LDS, causing widespread and aggressive vascular disease. Based on these gene mutations, 5 types of LDS have been described so far. Besides aortic aneurysm and dissection, some of the other cardiac manifestations of LDS involve cardiomyopathy, valvular abnormality, atrial fibrillation, patent ductus arteriosus, atrial septal defects, etc. Routine imaging of patients' vasculatures and aggressive medical and surgical management are key factors in managing patients with LDS.

Epidemiology, management, and clinical outcomes of extrapulmonary Mycobacterium abscessus complex infections in heart transplant and ventricular assist device recipients

Nontuberculous mycobacteria are emerging pathogens, yet data on the epidemiology and management of extrapulmonary nontuberculous mycobacteria infections in orthotopic heart transplantation (OHT) and ventricular assist device (VAD) recipients are scarce. We retrospectively reviewed records of OHT and VAD recipients who underwent cardiac surgery at our hospital and developed Mycobacterium abscessus complex (MABC) infection from 2013 to 2016 during a hospital outbreak of MABC linked to heater-cooler units. We analyzed patient characteristics, medical and surgical management, and long-term outcomes. Ten OHT patients and 7 patients with VAD developed extrapulmonary M. abscessus subspecies abscessus infection. The median time from presumed inoculation during cardiac surgery to the first positive culture was 106 days in OHT and 29 days in VAD recipients. The most common sites of positive cultures were blood (n = 12), sternum/mediastinum (n = 8), and the VAD driveline exit site (n = 7). The 14 patients diagnosed when alive received combination antimicrobial therapy for a median of 21 weeks, developed 28 antibiotic-related adverse events, and underwent 27 surgeries. Only 8 (47%) patients survived longer than 12 weeks after diagnosis, including 2 patients with VAD who experienced long-term survival after an explantation of infected VADs and OHT. Despite aggressive medical and surgical management, OHT and VAD patients with MABC infection experienced substantial morbidity and mortality.

Selective sonographic screening for developmental dysplasia of the hip – increasing trends in late diagnosis

There are concerns that selective sonographic screening for developmental dysplasia of the hip (DDH) may be suboptimal. Our aim was to test this hypothesis by identifying trends in presentation and surgical treatment in patients with DDH. This is a retrospective review of children born between 1997-2018 who were treated surgically for DDH at our sub- regional paediatric orthopaedic unit. Demographic data, risk factors, age of diagnosis and surgical treatments were analysed. Late diagnosis was defined as greater than 4 months. 103 children (14 male, 89 female) underwent surgery. 93 hips were operated for dislocation and 21 for dysplasia. 13 patients presented with bilateral hip dislocations. The median age at diagnosis was 10 months (95% CI: 4-15). 62/103 (60.2%) were diagnosed late (after 4 months) and the median age for diagnosis in this group was 18.5 months (95% CI: 16-20.5). Significantly more patients were referred late (p=0.0077). The presence of risk factors (breech presentation or family history) was associated with early diagnosis. Over the duration of our study the operation rate per 1000 live births gradually increased, and on Poisson regression analysis there was a statistically significant increasing trend towards late diagnosis in recent years (p=0.0237), which necessitated more aggressive surgical management. In the UK, the current selective sonographic screening programme for DDH has shown a deterioration over the years of this study and this questions its current effectiveness. It appears that the majority of irreducible hip dislocations are diagnosed late, with an increased need for surgical management.

Palatal Mucoperiosteum-A Redeemable Barrier in Surgical Management of Rhinocerebral Mucormycosis.

Ever since the commencement of the COVID-19 pandemic, post-recovery complications have been in the highlights, out of which rhinocerebral mucormycosis tops the chart. The surgical management of this disease was always aggressive debridement, resection, and antifungal treatment. Oronasal communication after aggressive surgical management always leads to breathing, feeding, and cosmetic impairments. In this study, cases were managed by leaving the palatal mucosa intact after the removal of all the affected hard and soft tissues including the periosteum attached to the mucosa, to preserve the palatal mucoperiosteum and to improve the postoperative complications in patients by maintaining the oronasal separation. Prospective review of the operated case of rhinocerebral mucormycosis in 20 patients was presented. An intraoral approach for hard and soft tissue resection was employed. The palatal mucoperiosteum was salvaged in all patients. Postoperative complications like oronasal communication, ill-fitting prosthesis, and healing were evaluated. A total of 20 patients underwent maxillectomy for mucormycosis involving the maxilla and palate along with other facial bones. The palatal mucosa was preserved and used for oronasal separation. The expected complications of nasal regurgitation, crustation of the maxillary cavity, ill-fitting prosthesis, etc. were evaded due to this. The administration of Inj. liposomal amphotericin B (LiAB) postsurgically has been the backbone of this procedure.

Management of dynamic cervical kyphosis with dorsal epidural lipomatosis: a Hirayama disease variant? Illustrative case.

Hirayama disease, a cervical myelopathy characterized most commonly by a self-limiting atrophic weakness of the upper extremities, is a rare entity, scarcely reported in the literature. Diagnosis is made by spinal magnetic resonance imaging (MRI), which typically shows loss of normal cervical lordosis, anterior displacement of the cord during flexion, and a large epidural cervical fat pad. Treatment options include observation or cervical immobilization by collar or surgical decompression and fusion. Here, the authors report an unusual case of a Hirayama-like disease in a young White male athlete who presented with rapidly progressive paresthesia in all 4 extremities and no weakness. Imaging showed characteristic findings of Hirayama disease as well as worsened cervical kyphosis and spinal cord compression in cervical neck extension, which has not previously been reported. Two-level anterior cervical discectomy and fusion and posterior spinal fusion improved both cervical kyphosis on extension and symptoms. Given the disease's self-limiting nature, and a lack of current reporting, there remains no consensus on how to manage these patients. Such findings presented here demonstrate the potentially heterogeneous MRI findings that can be observed in Hirayama disease and emphasize the utility of aggressive surgical management in young, active patients whereby a cervical collar may not be tolerated.

Subdural empyema secondary to pansinusitis after coronavirus disease 2019 infection in an immunocompetent patient: illustrative case.

Superimposed intracranial infection is an uncommon but clinically significant complication in patients with active coronavirus disease 2019 (COVID-19), particularly in those with predisposing immunocompromising conditions. The authors describe a case of subdural empyema, secondary to extension from pansinusitis, in a 20-year-old otherwise healthy immunocompetent male who was recently diagnosed with COVID-19. Despite his critical condition at time of presentation, he made a full clinical recovery with aggressive multidisciplinary surgical management between neurosurgery and otolaryngology, despite negative cultures to guide directed antimicrobial therapy. Ultimately, use of molecular-based polymerase chain reaction testing diagnosed Aspergillus fumigatus as the offending pathogen after the patient had already recovered and was discharged from the hospital. This case demonstrates the potential for significant superimposed intracranial infection even in young, healthy individuals, infected by COVID-19 and suggests an aggressive surgical approach to achieve source control, particularly in the absence of positive cultures to guide antimicrobial therapies, may lead to rapid clinical improvement.

Delayed atlantoaxial rotatory dislocation in a child with Crohn's disease: illustrative case.

Atlantoaxial rotatory dislocation (AARD) in children may be caused by neck trauma or an upper respiratory tract infection. Here the authors describe the very rare association between inflammatory bowel disease and AARD in a child. A 7-year-old girl presented with an 11-month history of torticollis that occurred spontaneously without a trauma context. Her history revealed a recent diagnosis of Crohn's disease. Physical exam of the cervical spine revealed a "cock-robin" posture. Neck radiography and three-dimensional computed tomography reconstruction established the diagnosis of AARD. Given the duration of the symptoms and failure of previous conservative treatments, the patient was taken to the operating room and underwent open reduction through posterior approach with a C1-2 fusion according to the Harms technique. The torticollis resolved with no recurrence at the last follow-up and minimal restriction of rotation. This is the third report to describe the very rare association between inflammatory bowel disease and AARD but at a very early age, the youngest in the literature. One should be aware of such association as early diagnosis may prevent aggressive surgical management.

Management of Aesthetic and Functional Deficits in Frontal Bone Trauma.

Frontal bone trauma has an increasing incidence and prevalence due to the wide-scale use of personal mobility devices such as motorcycles, electric bicycles, and scooters. Usually, the patients are involved in high-velocity accidents and the resulting lesions could be life-threatening. Moreover, there are immediate and long-term aesthetic and functional deficits resulting from such pathology. The immediate complications range from local infections in the frontal sinus to infections propagating inside the central nervous system, or the presence of cerebrospinal fluid leaks and vision impairment. We review current trends and available guidelines regarding the management of cases with frontal bone trauma. Treatment options taken into consideration are a conservative attitude towards minor lesions or aggressive surgical management of complex fractures involving the anterior and posterior frontal sinus walls. We illustrate and propose different approaches in the management of cases with long-term complications after frontal bone trauma. The team attending to these patients should unite otorhinolaryngologists, neurosurgeons, ophthalmologists, and maxillofacial surgeons. Take-home message: Only such complex interdisciplinary teams of trained specialists can provide a higher standard of care for complex trauma cases and limit the possible exposure to further legal actions or even malpractice.

A 6-Year Retrospective Study of the Demographics of Glottic Keratosis in a Tertiary Care Voice Centre.

Since Keratosis may be accompanied with severe dysplasia or malignancy; early management of this condition is of essence. However, since this condition has a high rate of recurrence the surgical dilemma remains as to how frequently the surgeries should be performed and what should be the factors to guide this decision.The objectives of our study are to attempt to understand the demographics of laryngeal keratosis and its behaviour pattern including the potential to recur, disease upstaging and malignant transformation. This is a 6-year retrospective study of patients presenting to a Voice and Swallowing Centre. All patients had been operated upon and confirmed to have keratosis with or without cancer. The medical records and stroboscopy videos were reviewed for details such as age, gender, history of smoking, laterality of lesion, location of lesion on the vocal fold, recurrence with any disease upstaging or malignant transformation. In the case of recurrence of lesion the histopathology of the recurrence was compared with the primary histopathology. Chi square test & Fisher's exact test was used for comparison of proportions between two groups. A total of 71 patients were included in the study, 88% were males. Recurrence was seen in 20 patients (28%), 14 with benign recurrence and 6 with malignant. Rate of recurrence when the primary keratosis had been benign was 30.7 and 20.6% when the primary keratosis had been associated with malignancy. A majority of patients with glottic keratosis were males and all that underwent malignant transformation were males. The rate of postoperative recurrence when the primary keratosis had been benign was higher than when it had been keratosis associated with malignancy. This may indicate the need for aggressive surgical management for benign keratosis.

Ovarian resection in anti-N-methyl-D-aspartate receptor encephalitis: A comparison of surgical approaches.

For patients with anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) and ovarian teratoma, "conservative" surgical approaches (complete or partial unilateral oophorectomy or bilateral partial oophorectomies) are associated with clinical improvement. "Aggressive" ovarian resections (complete bilateral oophorectomy or "blind" ovarian resections without pre-operative evidence of teratoma) are also reported, although the evidence supporting these approaches is unclear. To compare the one-year functional outcomes of patients with NMDARE who underwent conservative vs. aggressive ovarian resections. Patients with NMDARE undergoing ovarian resection between January 1st, 2012 and December 31st, 2021 were retrospectively identified from three North American tertiary care centers. Primary outcome was a modified Rankin Scale score of 0-2 one year after ovarian resection. Fisher exact and Wilcoxon rank sum tests were used to compare demographic features, disease characteristics, and functional outcomes between the two surgical groups. A fixed-effects meta-analysis of studies reporting functional outcomes based on surgical approach was also performed. Twenty-three patients were included. Eight underwent aggressive surgical management. There was a non-significant trend toward an association between aggressive surgical management and younger age-at-onset, higher baseline disease severity, and longer delays to treatment. There was no difference between "aggressive" (3/8, 38%) and "conservative" (11/15, 73%) management groups in achieving the primary outcome (OR95% = <0.1-1.9; p = 0.18). Findings were similar when considering data from 52 patients in two published studies (RR = 0.74; CI95% = 0.48-1.13; p = 0.16). Aggressive ovarian resection was not associated with improved outcomes in patients with NMDARE in this series. Group differences may have contributed, recognizing that patients who underwent aggressive resection tended to be sicker, with procedures performed later in the disease course. Based on available evidence, we advocate for function-sparing resection in patients with imaging-confirmed/suspected teratoma, and repeated multi-modal imaging in at-risk patients with NMDARE refractory to conventional treatment.

Prognostic significance of comorbidities in patients with diffuse peritonitis

Summary Background Diffuse peritonitis is a severe disease with high mortality and morbidity rates. Therapy is fundamentally surgical. It is important to identify patients with a significantly worse prognosis and patients who may benefit from more aggressive surgical and postsurgical care such as NPWT (Narrow Pressure Wound Therapy) prior to surgery. We tried to identify a determining factor for higher morbidity and mortality rates resulting in a worse prognosis among initial data and patient comorbidities in order to focus therapy towards more aggressive surgical management. Methods In a group of 274 patients with diffuse peritonitis, we evaluated the type of peritonitis according to effusion, origin, surgery type, and the age, gender, and present comorbidities of the patients, and compared it with the overall mortality, morbidity rate, and duration of hospitalization. Results Patients without comorbidities had a significantly lower burden in both morbidity and mortality. We recorded the highest difference in mortality in patients with two or more comorbidities, with pulmonary and cardiovascular diseases, with malignancy and hypertension. Morbidity was found to be significantly exacerbated by the presence of two or more severe diseases, cardiovascular disease, malignancy, and hypertension. Conclusion We identified age, effusion type, and the presence of comorbidities as key factors for the prognosis of our patients—the morbidity and mortality rates were substantially increased in patients with two or more comorbidities, as well as by the presence of cardiovascular disease, malignancy, and hypertension. A more aggressive approach should be considered to improve the prognosis in these patients.

Huge cerebral pial arteriovenous fistula in a newborn: illustrative case.

BACKGROUNDPediatric arteriovenous malformations (AVMs) and pial/dural arteriovenous fistulas (AVFs) are rare but life-threatening complications that can lead to congestive heart failure and hemorrhagic stroke in newborns and pediatric patients. The pronounced shunting in these conditions is associated with early complications and necessitates aggressive surgical management. Here, the authors describe endovascular treatment of an atypical cerebral pial AVF in a newborn.OBSERVATIONSThis AVF formed direct communication between a major cerebral artery (basilar artery) and a large draining vein (dilated deep cerebral vein). The authors performed earlier subtotal embolization of the AVF using 0.020-inch coils, which led to progressive thrombosis of the fistula with restoration of normal arterial blood flow. The patient was discharged 18 days after surgery, examination at 1.5 and 6 months showed magnetic resonance imaging signs of blood flow absence through the fistula and satisfactory condition of the infant without physical and mental developmental delay.LESSONSSubtotal coiling of a high-flow pial AVF in a newborn can result in a good clinical outcome.

Clinicopathological outcome in 27 children with tuberculous empyema in Shandong Provincial Chest Hospital, Jinan, China

ABSTRACT The literature on childhood tuberculous empyema (TE) is limited. The aim of this study was to examine the clinicopathological characteristics and outcome of paediatric TE and methods of prompt diagnosis and treatment. Between January 2014 and April 2019, 27 consecutive patients with TE aged ≤15 years [mean (SD) 12.2 (3.3), range 6–15] were retrospectively reviewed. The following were reviewed: baseline demographics, symptoms, laboratory and pathological examination, radiographical findings, microbiological data, anti-tuberculous and surgical treatment and clinical outcome. Acid-fast bacillus (AFB) smear, culture, TB real-time (RT) polymerase chain reaction (PCR) and T-SPOT.TB assay were reviewed. Six (60%) of 10 patients were TB-RT-PCR-positive in pus or purulent fluid. Twenty-three of 24 (95.8%) were T-SPOT.TB-positive. Decortication by surgical thoracotomy or thoracoscopy was performed in 22 (81.5%) patients. None of the 27 patients had specific complications such as pyopneumothorax or bronchopleural fistula and all were successfully treated. In childhood TE, aggressive surgical management is associated with a favourable outcome. Abbreviations: AFB, acid-fast bacilli; E, ethambutol; EPTB, extra-pulmonary TB; H, isoniazid; HIC, high-income countries; LMIC, low- and middle-income countries; MTB, Mycobacterium tuberculosis; PCR, polymerase chain reaction; PTB, pulmonary TB; R, rifampicin; RT, real time; TB, tuberculosis; TE, tuberculous empyema; Z, pyrazinamide.

Massive pancreatic serous cystadenomas raise important questions regarding surgical management of incidental pancreatic cystic lesions: a report of two cases

The widespread use of cross-sectional imaging and ultrasound has led to an increase in the diagnosis of pancreatic cystic neoplasms. These lesions have an estimated prevalence of 2.4% of which approximately 10-16% are serous cystadenoma (SCA). SCA is the most common benign pancreatic lesion; the vast majority are asymptomatic and associated with low risk for malignant transformation. Despite improved insight into the natural history of these tumors, recommendations for their management remain contentious. We present two cases of giant SCA that call attention to shortcomings of the current guidelines for management of benign cystic pancreatic lesions. In both cases, patients presented for surgical evaluation late in the disease course despite multiple medical consultations with generalist and specialty providers. Although both lesions were resected, their late presentation may have increased risk for complication and post-operative morbidity. These cases highlight possible discrepancies between medical and surgical perspectives in the field and support future investigation into more aggressive surgical management of SCA.

Radical cystectomy for bladder urothelial carcinoma with aggressive variant histology.

The aim of this study is to report our experience in managing bladder cancer in patients with variant pathology. Retrospective data collection for all patients managed by radical cystectomy over the last 3 years for a variant pathol-ogy was completed. We specifically included micropapillary and nested variants. Ten patients were identified, with eight having micropapillary carcinoma (MPC) and two having nested vari-ants. Nine patients were male. The median age was 75. The two patients with nested variant were 56 and 62 years old, respec-tively, whereas all patients with MPC were over the age of 70. Upon cystectomy of all micropapillary cases, three patients (37.5%) had positive lymph node invasion and the final patholo-gy was T2 (two patients), T3 (two patients), and T4 (four patients). Barring a grade III complication Clavien-Dindo classi-fication due to wound dehiscence that necessitated secondary surgical closure, there were no specific perioperative complica-tions. Given the urethral invasion, cystourethrectomy was per-formed on the female patient. Within a median 13-month fol-low-up, three patients developed local recurrence, including two urethral and one new lateral pelvic mass. Considering the muscle invasive nature of micropapillary and nested bladder cancer, aggressive surgical management should not be postponed. Moreover, due to notable prevalence of concurrent and/or recurrent urethral involvement, initial urethrectomy or early and frequent postoperative ure-throscopy should be provided. Patients with variant histology bladder cancer may benefit from early radical cystectomy when compared to bladder sparing protocols and prostate sparing cystectomy treatment options.