Challenging Lesions Research Articles

Diagnostic utility of cyclin D1 in the diagnosis of small round blue cell tumors in children and adolescents

Small round blue cell tumors (SRBCTs) of children and adolescents are often diagnostically challenging lesions. With the increasing diagnostic approach based on small biopsies, there is the need of specific immunomarkers that can help in the differential diagnosis among the different tumor histotypes to assure the patient a correct diagnosis for proper treatment. Based on our recent studies showing cyclin D1 overexpression in both Ewing sarcoma/primitive peripheral neuroectodermal tumor (EWS/pPNET) and peripheral neuroblastic tumors (neuroblastoma and ganglioneuroblastoma), we immunohistochemically assessed cyclin D1 immunoreactivity in 128 cases of SRBCTs in children and adolescents to establish its potential utility in the differential diagnosis. All cases of EWS/pPNET and the undifferentiated/poorly differentiated neuroblastomatous component of all peripheral neuroblastic tumors exhibited strong and diffuse nuclear staining (>50% of neoplastic cells) for cyclin D1. In contrast, this marker was absent from rhabdomyosarcoma (regardless of subtype) and lymphoblastic lymphoma (either B- or T-cell precursors), whereas it was only focally detected (<5% of neoplastic cells) in some cases of Wilms tumor (blastemal component) and desmoplastic small round cell tumor. Our findings suggest that cyclin D1 can be exploitable as a diagnostic adjunct to conventional markers in confirming the diagnosis of EWS/pPNET or neuroblastoma/ganglioneuroblastoma. Its use in routine practice may also be helpful for those cases of SRBCT with undifferentiated morphology that are difficult to diagnose after application of the conventional markers.

Papillary Lesions of the Breast: A Practical Approach to Diagnosis.

Papillary lesions of the breast span the spectrum of benign, atypical, and malignant. Subclassification of these lesions may be diagnostically challenging, especially with limited sampling via core biopsy. This review outlines the features of papillary lesions of the breast and provides a practical approach to distinguishing diagnostically challenging lesions by using key morphologic features and, when helpful, immunohistochemical studies.

Intraventricular Meningiomas: A Series of 42 Patients at a Single Institution and Literature Review

Primary intraventricular meningiomas (IVMs) make up 0.5%-5% of all intracranial meningiomas and represent one of the most challenging lesions in neurosurgery. Between 1990 and 2013, 42 patients (30 female, 12 male; mean age, 43.6 years) underwent resection of their IVM. The removal was performed by a posterior parietal approach in 19 of the 40 lateral ventricle tumors, and 1 third ventricle meningioma. The transcallosal approach was used for 3 meningiomas, and patients with other lesions underwent temporal (7 cases) and temporoparietal approaches (12patients), respectively. The most common presenting signs were increased intracranial pressure (83.3%), visual impairment (78.6%) and cognitive changes (50%). Forty lesions (95.2%) arose in the lateral ventricles, and 2 (4.8%) in the third ventricle, ranging in size from 3 to 10 cm. Total removal was achieved in 39 cases and the pathology report disclosed World Health Organization grade I lesions in 41 cases. Hydrocephalus, cerebrospinal fluid leakage, and cerebral edema were the postoperative complications (7.15%); 1 patient died of respiratory problems not directly related to surgery. Thirty-five patients (83.3%) showed a 6-month Glasgow Outcome Scale of 5. One patient, who underwent partial resection, presented a recurrence after 1year that remained stable until last follow-up. IVMs usually reach a large size before being diagnosed. Surgical treatment is the most suitable option and total removal should represent the main goal of the procedure. The posterior parietal transulcal approach and the temporoparietal approach are the most common surgical routes used in our series.

Percutaneous Treatment of Coronary Bifurcation Lesions

Coronary bifurcations remain one of the most challenging lesions in interventional cardiology in terms of procedural success rate and long-term adverse cardiovascular events.1 Although numerous techniques and devices have been proposed to address the treatment of bifurcation lesions, there are 2 primary interventional strategies commonly used: one is a more complex approach that implies the systematic implantation of a stent in both the main vessel and the side branch (SB), and the other is the provisional T-stent, consisting in stenting the main vessel only, with the option to place a stent in the SB, if necessary. Provisional stenting often results in worse angiographic performances, but it offers several advantages compared with other more complex techniques: it is simple to perform in most cases, and it is associated with a lower rate of acute and late complications, as well as costs.1 Therefore, in clinical practice, the provisional approach is widely accepted as the default technique in the majority of bifurcation lesions.1 See Article by Hildick-Smith et al In the past decade, several randomized trials have been conducted, using different type of stents and techniques, demonstrating comparable clinical outcome between provisional and 2-stent approaches for the treatment of bifurcations.2–7 Despite …

Contemporary Approach to Coronary Bifurcation Lesion Treatment

Coronary bifurcations are frequent and account for approximately 20% of all percutaneous coronary interventions. Nonetheless, they remain one of the most challenging lesion subsets in interventional cardiology in terms of a lower procedural success rate and increased rates of long-term adverse cardiac events. Provisional side branch stenting should be the default approach in the majority of cases and we propose easily applicable and reproducible stepwise techniques associated with low risk of failure and complications.

A Novel Less Invasive Technique for the Excision of Large Intradural and Extradural Dumbbell Lumbar Schwannomas: The “Dual Approach”

Large schwannomas with intradural and extradural extensions are often challenging surgical lesions. A variety of approaches, usually requiring large exposures, removal of facets and pars interarticularis, and spinal stabilization, have been described. The aim of this study is to describe the "dual approach," a less invasive technique for the excision of these lesions. A large intradural and extradural schwannoma with paraspinal extension (Eden type II) was removed by a unilateral approach-midline, pars and facet sparing and no supplemental instrumentation. Complete excision was achieved through the described approach, with minimal removal of bone and soft tissue disruption. There were no intraoperative or perioperative complications and no evidence of residual tumor or instability/deformity. The dual approach is a novel and unique technique that allows complete and safe removal of large intradural and extradural dumbbell tumors through a less invasive approach and no need for instrumentation.

Reconstitution of the complete rupture in musculotendinous junction using skeletal muscle-derived multipotent stem cell sheet-pellets as a “bio-bond”

Background. Significant and/or complete rupture in the musculotendinous junction (MTJ) is a challenging lesion to treat because of the lack of reliable suture methods. Skeletal muscle-derived multipotent stem cell (Sk-MSC) sheet-pellets, which are able to reconstitute peripheral nerve and muscular/vascular tissues with robust connective tissue networks, have been applied as a “bio-bond”.Methods. Sk-MSC sheet-pellets, derived from GFP transgenic-mice after 7 days of expansion culture, were detached with EDTA to maintain cell–cell connections. A completely ruptured MTJ model was prepared in the right tibialis anterior (TA) of the recipient mice, and was covered with sheet-pellets. The left side was preserved as a contralateral control. The control group received the same amount of the cell-free medium. The sheet-pellet transplantation (SP) group was further divided into two groups; as the short term (4–8 weeks) and long term (14–18 weeks) recovery group. At each time point after transplantation, tetanic tension output was measured through the electrical stimulation of the sciatic nerve. The behavior of engrafted GFP+ tissues and cells was analyzed by fluorescence immunohistochemistry.Results. The SP short term recovery group showed average 64% recovery of muscle mass, and 36% recovery of tetanic tension output relative to the contralateral side. Then, the SP long term recovery group showed increased recovery of average muscle mass (77%) and tetanic tension output (49%). However, the control group showed no recovery of continuity between muscle and tendon, and demonstrated increased muscle atrophy, with coalescence to the tibia during 4–8 weeks after operation. Histological evidence also supported the above functional recovery of SP group. Engrafted Sk-MSCs primarily formed the connective tissues and muscle fibers, including nerve-vascular networks, and bridged the ruptured tendon–muscle fiber units, with differentiation into skeletal muscle cells, Schwann cells, vascular smooth muscle, and endothelial cells.Discussion. This bridging capacity between tendon and muscle fibers of the Sk-MSC sheet-pellet, as a “bio-bond,” represents a possible treatment for various MTJ ruptures following surgery.

Retrosigmoid-transtentorial approach for petroclival meningiomas: operative technique and clinical outcome

Petroclival meningiomas (PCMs) are technically challenging lesions. Although the standard retrosigmoid approach is one of the most effective approaches, this route may have some limitations for the tumors extending into the supratentorial region and middle cranial fossa. We provide a modified surgical technique called retrosigmoid-transtentorial approach (RTTA) to solve these problems. The feasibility and efficacy of the RTTA were studied, by analyzing neurological outcomes and considerations of surgical strategies. We analyzed 64 of 71 PCM patients (90.1 %). All 64 patients had epicenter of tumor in the posterior fossa with varying degrees of extension into the supratentorial area and/or the middle fossa. A conventional retrosigmoid craniotomy was performed following which the tentorium was incised from the attachment of tumor toward the free edge, which improved exposure to the petroclival region by offering additional operative room without resection of the adjacent part of the petrous bone. The rate of gross total resection was 71.9 %. There was no incidence of intraoperative death. One patient died in the postoperative phase. The postoperative permanent morbidity rate was 25.4 %. Follow-up was done with the mean time of 60.7 ± 47.5 months. There were 6 recurrence, 8 progression and 7 death cases and the mean KPS score was 83.2 ± 13.4 in the last follow up. The RTTA achieves the goal of applying a safe, quick, uncomplicated, and lesser invasive access to the petroclival region which is indicated for tumors located in the posterior fossa with some extension into the supratentorial area and/or the middle fossa.

Outcomes With the Use of the Retrograde Approach for Coronary Chronic Total Occlusion Interventions in a Contemporary Multicenter US Registry.

We sought to examine the efficacy and safety of chronic total occlusion percutaneous coronary intervention using the retrograde approach. We compared the outcomes of the retrograde versus antegrade-only approach to chronic total occlusion percutaneous coronary intervention among 1301 procedures performed at 11 experienced US centers between 2012 and 2015. The mean age was 65.5±10 years, and 84% of the patients were men with a high prevalence of diabetes mellitus (45%) and previous coronary artery bypass graft surgery (34%). Overall technical and procedural success rates were 90% and 89%, respectively, and in-hospital major adverse cardiovascular events occurred in 31 patients (2.4%). The retrograde approach was used in 539 cases (41%), either as the initial strategy (46%) or after a failed antegrade attempt (54%). When compared with antegrade-only cases, retrograde cases were significantly more complex, both clinically (previous coronary artery bypass graft surgery prevalence, 48% versus 24%; P<0.001) and angiographically (mean Japan-chronic total occlusion score, 3.1±1.0 versus 2.1±1.2; P<0.001) and had lower technical success (85% versus 94%; P<0.001) and higher major adverse cardiovascular events (4.3% versus 1.1%; P<0.001) rates. On multivariable analysis, the presence of suitable collaterals, no smoking, no previous coronary artery bypass graft surgery, and left anterior descending artery target vessel were independently associated with technical success using the retrograde approach. The retrograde approach is commonly used in contemporary chronic total occlusion percutaneous coronary intervention, especially among more challenging lesions and patients. Although associated with lower success and higher major adverse cardiovascular event rates in comparison to antegrade-only crossing, retrograde percutaneous coronary intervention remains critical for achieving overall high success rates.

Percutaneous coronary intervention for coronary bifurcation disease: 11th consensus document from the European Bifurcation Club.

Coronary bifurcations are involved in 15-20% of all percutaneous coronary interventions (PCI) and remain one of the most challenging lesions in interventional cardiology in terms of procedural success rate as well as long-term cardiac events. The optimal management of bifurcation lesions is, despite a fast growing body of scientific literature, the subject of considerable debate. The European Bifurcation Club (EBC) was initiated in 2004 to support a continuous overview of the field, and aims to facilitate a scientific discussion and an exchange of ideas on the management of bifurcation disease. The EBC hosts an annual, compact meeting, dedicated to bifurcations, which brings together physicians, engineers, biologists, physicists, epidemiologists and statisticians for detailed discussions. Every meeting is finalised with a consensus statement which reflects the unique opportunity of combining the opinions of interventional cardiologists with the opinions of a large variety of other scientists on bifurcation management. The present 11th EBC consensus document represents the summary of the up-to-date EBC consensus and recommendations. It points to the fact that there is a multitude of strategies and approaches to bifurcation stenting within the provisional strategy and in the different two-stent strategies. The main EBC recommendation for PCI of bifurcation lesions remains to use main vessel (MV) stenting with a proximal optimisation technique (POT) and provisional side branch (SB) stenting as a preferred approach. The consensus document covers a moving target. Much more scientific work is needed in non-left main (LM) and LM bifurcation lesions for continuous improvement of the outcome of our patients.

Very large and giant microsurgical bifurcation aneurysms in rabbits: Proof of feasibility and comparability using computational fluid dynamics and biomechanical testing

BackgroundGiant aneurysms are challenging lesions with unacceptable high rates of aneurysm recanalization and rerupture following embolization. Reliable in vivo models are urgently needed to test the performance of new more efficient endovascular devices. Materials and methodsAneurysms were created in 11 New Zealand white rabbits (4.5–5.5kg): A long venous pouch (length 25–30mm) mimicking the aneurysm sac was derived from the external jugular vein and sutured into a microsurgically created bifurcation between both common carotid arteries. After 4 weeks the rabbits underwent 3T Magnetic resonance angiography (3T-MRA). Exemplary computational fluid dynamics (CFD) simulations were performed to compare the flow conditions of giant rabbit and human aneurysms. We used species-related boundary conditions, in particular, we measured blood viscosity values. Biaxial mechanical tests were performed for the mechanical characterization and comparison. Comparison with exisiting method(s)None. ResultsNo peri- or postoperative mortality was observed. 3T-MRA showed aneurysm patency in 10 out of 11 aneurysms (90.9%). Aneurysm lengths ranged from 21.5–25.6mm and aneurysm necks from 7.3–9.8mm. CFD showed complex flow profiles with multiple vortices in both, rabbit and human aneurysms. Lower blood viscosity values of the rabbit (3.92mPas vs. human 5.34mPas) resulted in considerable lower wall shear stress rates (rabbit 0.38Pa vs. human 1.66Pa). Mechanical tests showed lower stiffness of rabbit aneurysms compared to unruptured human aneurysms. ConclusionsThe proposed model showed favorable aneurysm patency rates, low morbidity and good hemodynamic comparability with complex flow patterns. Biomechanical testing suggests that experimental aneurysms might be even more fragile compared to human aneurysms.

Ablating challenging liver lesions: How to get there?

Ablating challenging liver lesions: How to get there?

Bonding brackets on white spot lesions pretreated by means of two methods

Objective: The aim of this study was to evaluate the shear bond strength (SBS) of brackets bonded to demineralized enamel pretreated with low viscosity Icon Infiltrant resin (DMG) and glass ionomer cement (Clinpro XT Varnish, 3M Unitek) with and without aging. Methods: A total of 75 bovine enamel specimens were allocated into five groups (n = 15). Group 1 was the control group in which the enamel surface was not demineralized. In the other four groups, the surfaces were submitted to cariogenic challenge and white spot lesions were treated. Groups 2 and 3 were treated with Icon Infiltrant resin; Groups 4 and 5, with Clinpro XT Varnish. After treatment, Groups 3 and 5 were artificially aged. Brackets were bonded with Transbond XT adhesive system and SBS was evaluated by means of a universal testing machine. Statistical analysis was performed by one-way analysis of variance followed by Tukey post-hoc test. Results: All groups tested presented shear bond strengths similar to or higher than the control group. Specimens of Group 4 had significantly higher shear bond strength values (p < 0.05) than the others. Conclusion: Pretreatment of white spot lesions, with or without aging, did not decrease the SBS of brackets.

Evolution of the Intracranial Approaches to Jugular Foramen Tumors: A Surgeon's Personal Perspective Through Three Illustrative Cases.

Tumors of the jugular foramen remain challenging lesions despite advances in surgical technique and medical technology. Tumors with extensive extra- and intracranial components necessitate both radical neck dissection maneuvers combined with skull base approaches. We present a single surgeon’s perspective in managing these difficult tumors.

Contralateral interlaminar approach for intraforaminal lumbar degenerative disease with special emphasis on L5-S1 level: A technical note.

Background:Intraforaminal disc herniations at the L5-S1 level are extremely surgically challenging lesions. Intracanal approaches frequently require partial or total facetectomy, which may lead to instability. Solely extraforaminal approaches may offer limited visualization of the more medial superiorly exiting and inferiorly exiting nerve roots; this approach is also more complicated at L5-S1 due to the often large L5 transverse process and the iliac wing.Methods:Nine patients with intraforaminal L5-S1 disc herniations, foraminal stenosis, or synovial cysts underwent contralateral interlaminar approaches for lesion resection. Preoperative and postoperative visual analog scale scores were evaluated, and complications were reviewed.Results:All 9 patients demonstrated immediate postoperative clinical improvement. None of the patients exhibited complications and none developed instability or neuropathic disorders.Conclusions:Although the number of cases in our sample was very small (9 in total), the contralateral interlaminar approach appeared to effectively address multiple degenerative L5-S1 foraminal pathologies. Large studies are needed to further evaluate the pros and cons of this approach.

Surgical Treatment for Falcotentorial Meningiomas.

Among intracranial meningiomas, falcotentorial meningiomas, occurring at the junction of the falx cerebri and tentorial dural folds, are extremely rare. Because of their deep location, they are surrounded by critical structures, and have been regarded as one of the most challenging lesions for surgical treatment. In this study, we describe our surgical strategy for falcotentorial meningiomas and provide a review of our experience.

Bridge The Distance Between Breast Pathologists: When The Senopath Network Opens Up To The Telepathology

Introduction/ Background In clinical practice, pathologists commonly face breast lesions, which are difficult to diagnose and which re- quire discussion. In Midi-Pyrenees, the largest region ofFrance, this problem has led us to develop in 2011 a peer group for breast diseases entitled SENOPATH. Aims In order to reduce second opinion delay, erase geographical barrier and provide continuing education, we aimed to introduce an effective online and outline telepathology system in the SENOPATH network. Methods A case review by SENOPATH can be requested by any pathologist in the Midi-Pyrenees region, by filling a form through the ONCOMIP network (organization dedicated to oncology in the Midi- Pyrenees region). The slides are sent for digitalization at The University Cancer Institute - Oncopole, using a Hamamatsu 2.0-RS scanner (until 2014) and a 3DHISTECH Pannoramic 250 scanner, then anonymized and transferred to a shared storage space at Toulouse Paul Sabatier University. Virtual slides can be seen before and/or after the meeting by members of the group by login in the online 3DHISTECHCaseCentervia the Imag’IN platform website. The group, who meets on a monthly basis, has recently developed a synchronized webinar (using 3DHISTECH Case Center and Pannoramic Viewer) coupled with a conference call in order to ease the attendance of pathologists from remote pathology laboratories. A consensual diagnosis and final pathology report are issued for each case and sent to the referent clinician via the patient medical file securely hosted by ONCOMIP. Results From January 2012 to December 2015, 211 cases (39 in 2012, 50 in 2013, 75 in 2014 and 47 in 2015) have been reviewed during 43 meetings. Ten out of 43 meetings (23%) used telepathology. Sixty-one cases out of 211 (29%) were actually digitalized, mainly using theHamamatsu2.0-RS scanner. In average, the number of attending pathologists was9 to 10from 2012 to 2015. The average number of cases reviewed per meeting was 3 in 2012 and 5 between 2013 and 2015. Two main motives for review were identified: diagnostic ‘routine difficulty’ (equivocal or discordant cases, invasive vs in situ lesion, atypical vs malignant lesions, immunohistochemistry scoring pitfalls) or rare tumours. The rare tumour category included among others syringomatous tumour of the nipple, low-grade adenosquamous, myoepithelial, mucoepidermoid or secretory carcinomas, adenomyoepithelioma, atypical microglandular adenosis, sclerosing papillary hyperplasia without myoepithelium and periductal stromal tumour. Molecular analyses requested by the group and implemented in the diagnosis process mainly included immunohistochemistry and fluorescence in situ hybridization (HER2, ETV6, MAML2, MYB). The SENOPATH network committee review for difficult or rare lesions of the breast has considerably improved the pathologist’s network in our region. This working group is regularly requested by oncologists to solve difficult cases. Our aims for the next few years are 1/ to digitalize all of the cases reviewed by the SENOPATH network, 2/ to use telepathology facilities provided by the Imag’IN platform in order to widen the group to a national level, and 3/ to construct a growing online library of virtual slides for breast challenging lesions.

A Systematic Review and Meta-Analysis of Treatment and Outcome of Blister-Like Aneurysms.

Blister-like aneurysms are uncommon but challenging lesions. Their small size and atypical location often make the diagnosis difficult. Microsurgery and endovascular procedures have been used for their treatment, but there is no consensus on the best treatment technique. We conducted a systematic review and meta-analysis of treatments and outcomes of these vascular lesions. We reviewed English-language articles on "blood blister-like aneurysms" published between January 1997 and November 2014. All studies reporting patients with these aneurysms treated with surgery, endovascular procedures, or combined therapy with data on treatment modalities and clinical and/or angiographic outcomes were selected, including case reports and series. We performed a meta-analysis on the 2 largest treatment groups (surgery and endovascular management). Sixty studies with 334 patients met our inclusion criteria. Surgery was performed in 114 patients (34.2%), and endovascular treatment, in 199 patients (59.5%). A combined treatment was used in 19 patients (5.7%). A favorable outcome (mRS 0-2) was reported in 67.4% and 78.9% of patients treated with surgery and with endovascular therapy, respectively (P = .034). Blister-like aneurysms are challenging vascular lesions. The choice of treatment method must be based on the initial clinical presentation and an analysis of the radiologic features of the lesion to select the best technique. Endovascular treatment seems to have lower morbidity and mortality and provides a better outcome compared with surgical approaches. Further prospective studies must be performed to confirm such interesting results.

Surgical Treatment Options for Metastatic Spinal Tumors

Introduction Metastatic spinal tumors are surgically challenging lesions. Around 10 to 20% of all cancer patients develop symptoms of bone metastases that are most common in spine and pelvis. The metastatic tumors can involve any part of the spinal column, invade the spinal canal, and spread to the neighboring tissue and to the mediastinal or retroperitoneal space. The indication for surgery is usually rapidly progressive spinal cord compression as an initial manifestation of a malignant disease. Methods Most of the patients with spinal metastatic disease present with the local pain and/or neurological deterioration. The patients are assessed regarding the severity of the pain and neurological deficit, and there are several systems that are helping us classify the patients (Karnofsky performance score, Tomita and Tokuhashi predicting survival scores, etc.). The main goals of surgical treatment of metastases are preservation and improvement of neurological functions, pain control, and stabilization of the spine. The surgery usually involves a multidisciplinary approach. The type of operative and postoperative treatment depends on the histological nature of the tumor, extension of the tumor, and integrity of the bony elements of the spine. The prognosis and extension of the primary disease and other comorbidities is also to be considered. Variety of surgical options include: microsurgical decompression of the neural structures, posterior, anterior, or lateral fusion, corpectomy, vertebroplasty, or kyphoplasty, and combination of those options. Results In the last years in our department, a single-step posterolateral approach was increasingly utilized, consisting of maximal tumor resection, combined with stabilization. Favorable clinical results and good palliation were achieved in most patients. The additional oncological therapy is usually necessary. Conclusion The prognosis for most patients with metastatic spinal tumors is still very unpredictable. Individual treatment strategy is mandatory for each patient and usually consists of multidisciplinary approach. The surgery has moved from multiple-steps to one-step surgery in the last years and with this a favorable clinical results could be achieved.

Unprotected Distal LMCA Angioplasty with Simulataneous Kissing Stent (SKS) Technique in Left Dominant Coronary Circulation: A Nightmare for Interventionist

Left main coronary artery stenosis is the most challenging lesion in patients with acute coronary syndromes. Since the amount of myocardium at risk is very high, the patient is often in cardiogenic shock, and the risk of death is high and even more so in left dominant coronary system. Left main stenosis is a Class I indication for CABG -ACC/AHA guidelines and has been a relative contraindication to PCI. We report an elderly patient presenting with ACS with ECG showing ST elevation in lead a VR. Coronary angiogram revealed left dominant system with left main stenosis and ostioproximal LAD and LCX disease. Double stenting of the unprotected left main with bifurcation disease done with SKS technique with simultaneous stenting and post balloon dilatation was done with good results. Current guidelines still indicate CABG as optimal treatment for LMCA lesions. The choice of stenting technique for LMCA bifurcations should be based on bifurca- tion morphology.