Deep Muscular Layer Research Articles

The anatomic - magnetic resonance imaging study of distal triceps brachii tendon.

The study aimed to describe the distal triceps brachii insertion on the olecranon and to correlate the findings with those seen in normal MR (Magnetic Resonance) anatomy of the triceps brachii insertion. 14 un-paired fresh frozen elbows were included according to the institution guidelines and dissected. Histologic examination was performed to the distal triceps brachii insertion. The dimension of the distal triceps brachii tendon insertion was measured and defined based on its layer. The measurement of distal triceps brachii insertion was performed with image processing program (Image J, National Institute of Health, Bethesda, Maryland). T1-weighted elbow MR images (3.0T) of a 102 patients were acquired and analyzed according to its sagittal plane. All specimens shows that distal triceps brachii tendon is with three distinct insertional areas in the olecranon which are: (1) capsular, (2) deep muscular, (3) superficial tendinous insertion with the areas of 80.7mm2, 56.4mm2, and 175.2mm2, respectively. The superficial tendinous insertion was observed with a thickened portion, the "central cord" with 0.5 occupation ratio. MR analysis showed that 30% (31/102) of the distal biceps brachii insertion was with a cleft between the bipartite insertion of the superficial tendinous and the deep muscular insertion on olecranon which designated as the "lacuna" which was also found in 35% (5/14) of the specimens. The distal triceps brachii has three distinct insertion on the olecranon. The superficial tendinous layer was separated with the deep muscular layer by a cleft in one third of the cases. Knowledge of this anatomy will help surgeon to understand the partial triceps injury and to avoid iatrogenic injury to the distal triceps tendon during surgery.

A Study of the Prevalence, Origin, Insertion, and Innervation of the Gantzer muscle – A Variant Forearm Muscle

Gantzer muscles are variant muscles found within the flexor compartment of the forearm, located between the intermediate and deep muscular layers. The Gantzer muscle typically arises from the flexor digitorum superficialis muscle (FDS) and inserts either into the flexor digitorum profundus (FDP) or the flexor pollicis longus (FPL) muscle. In this 2020 summer research study, a total of 76 forearms from 38 prosected cadaveric specimens were dissected to investigate the prevalence, origin, insertion, and innervation of Gantzer muscles, when present. In total, Gantzer muscles were present in 68.4% (26/38) of the whole body donors and 60.5% (46/76) of the limbs. Of the 26 donors who possessed a Gantzer muscle, 20 (76.9%) specimens were documented as having this variant forearm muscle bilaterally. In addition, of the 46 forearms that possessed a Gantzer muscle, two limbs (4.3%) contained two Gantzer muscles within the same forearm. Concerning the specimens where the origin, or proximal attachment, of this accessory muscle were still intact within these prosections, 95% (38/40) of Gantzer muscles originated from the flexor digitorum superficialis. When the insertion, or distal attachments was not damaged in these previously dissected forearms, 80% (36/45) of Gantzer muscles inserted into the flexor pollicis longus, with the remainder inserting into the flexor digitorum profundus. In addition, within the intact forearms, 83.9% (25/31) of Gantzer muscles received innervation from the anterior interosseous nerve, with the remainder being innervated by the median nerve directly. Clinically, the presence of the Gantzer muscle can result in various compressive injuries, including impingement of the ulnar, common, or anterior interosseous arteries and neuropathy of the median or anterior interosseous nerve. Moreover, this variant muscle, which is more likely present than absent, should be considered during treatment and surgical management, especially during differential diagnoses for compartment syndrome of the anterior forearm. While only the 2020 results are presented, this study represents a small portion of a multi-year, expanded assessment of the prevalence, origin, insertion, and innervation of the Gantzer muscle.

Sudden Chest Pain Due to Esophageal Intramural Dissection

Sudden Chest Pain Due to Esophageal Intramural Dissection

Application Value of Real-Time Shear Wave Elastography in Diagnosing the Depth of Infiltrating Muscular Layer of Endometrial Cancer.

To explore the clinical value of real-time shear wave ultrasonic elastography in diagnosing the depth of infiltrating muscularis of endometrial cancer. Seventy-one patients with stage I endometrial cancer infiltrating the myometrium and 37 patients with normal physical examination were enrolled and divided into three groups: endometrial cancer superficial muscle infiltration group, endometrial cancer deep muscle infiltration group, and normal control group. After completing 2-dimensional ultrasound examination, each patient switched to the real-time shear wave elastography mode to measure the elasticity values Emax, Emean, and Esd. For control group, comparison of elastic modulus values between superficial muscular layer near the intimal surface and the deep muscular layer near the serosa surface showed no difference (P > 0.05). For endometrial cancer superficial muscular infiltration group, significant difference was found regarding the elastic modulus values of infiltrated muscular layer and uninfiltrated muscular layer (Emax and Emean) without difference for Esd (P > 0.05). A significant difference of elastic modulus was observed between control group and deep myometrial infiltration group (P < 0.05) without difference of Emean or Emax but with difference of Esd. The accuracy in diagnosing muscular layer infiltration was 78.9% for Emax cutoff and 82.5% for Emean cutoff. The rate of using Emax ≥32.22 kPa or Emean ≥27.54 kPa as the ultrasound standard for diagnosing myometrium infiltration was 92.9%. The accuracy for the diagnosis of muscular layer infiltration was 96.1% for Emax cutoff, 94.1% for Emean cutoff and 86.3% for Esd cutoff. Real-time shear wave elastography is helpful to determine the depth of infiltrating myometrium of endometrial cancer.

Lumbar Medial Branch Block Volume-Dependent Dispersion Patterns as a Predictor for Ablation Success: A Cadaveric Study

BackgroundLumbar facet arthropathy is a common cause of low back pain. Literature supports treatment with radiofrequency ablation (RFA) of associated nerves that innervate lumbar facets when alternative conservative therapies have failed. Diagnostic local anesthetic blocks precede therapeutic ablation, but have a false-positive rate of 27%-63%, and some authors have questioned their utility in predicting therapeutic response to RFA. The authors of the current study believe that injectate volume may be a contributing factor to false positivity. ObjectiveTo evaluate the difference in volume dispersion between 0.25 mL and 0.5 mL of injectate when performing lumbar medial branch blocks. We hypothesized that injection volumes greater than 0.25 mL during lumbar medial branch blocks would affect the distal branches of the adjacent medial branches, thus decreasing the specificity of the procedure. Thus, we attempted to demonstrate that injection volumes greater than 0.25 mL during lumbar medial branch blocks would affect the distal branches of the adjacent medial branches, which might increase false positivity of the blocks. Study DesignCadaveric investigation. SettingTertiary care center. ParticipantsNot applicable. Outcome MeasurementsTo demonstrate that the spread of lumbar medial branch blocks using commonly injected volume coats adjacent structures that are not affected by radiofrequency ablation. MethodsSix cadavers were chosen with nondissected lumbar spines. Fluoroscopically guided medial branch injections were performed bilaterally using the posterior oblique approach. A volume of 0.25 mL or 0.50 mL of a 9:1 solution of Omnipaque 240 and 1% medical grade methylene blue were delivered to the left and right sides, respectively. Postinjection computed tomographic imaging was performed, followed by dissection. ResultsBoth volumes adequately coated the medial branches, but in the 0.5-mL injectate cohort there was consistent spread dorsally to the superficial muscles and distal segments of the dorsal branches distant to the target nerves, whereas in the 0.25-mL injectate cohort the spread was contained in the deep and intermediate muscular lumbar layers, close to the intended target. ConclusionWe suggest that a 0.5-mL injectate volume in clinical practice may produce an adjacent-level nerve block in addition to the intended injection level, thus decreasing the specificity of a targeted lumbar medial branch block. A 0.25-mL quantity of injectate reliably contacted the lumbar medial branches without extensive extravasation. Presumably, this means that 0.25 mL total volume for a lumbar medial branch block may provide greater specificity for RFA planning. Level of EvidenceNA

Intramural Esophageal Dissection: A Rare Complication of ERCP

Intramural esophageal dissection (IED) is a rare condition characterized by a mucosal tear leading to an increase in intraesophageal pressure, which potentiates a full separation of the mucosa and/or the submucosa from the deeper muscular layers, resulting in the creation of a true and false lumen in the esophagus. Common causes of IED are iatrogenic; esophagogastroduodenoscopy (EGD), nasalgastric tube placement, transesophageal echocardiogram, variceal sclerotherapy, argon plasma coagulation (APC), dilations, and even biopsy. We present a case of IED in a patient undergoing endoscopic retrograde cholangiopancreatography (ERCP). A 72 year old Caucasian female with no significant past medical history presented with an intertrochanteric fracture from a mechanical fall. Incidentally, the patient was also found to be jaundiced, and her liver function tests were consistent with biliary obstruction. Computed tomography (CT) showed severe intrahepatic biliary dilatation with underlying mass at the porta hepatis, ERCP was recommended for further evaluation. The duodenoscope was unable to easily pass into the esophagus and faced resistance while advancing, prompting its removal. An adult endoscope was placed noting a submucosal tear in the proximal esophagus. A wire catheter was passed into the stomach; contrast was injected and did not reveal any extravasation. The endoscope was then removed and a nasal scope was placed over the wire, confirming a submucosal tear in the esophagus (Figure 1, 2) with no signs of a full thickness tear. An Isovue esophagram revealed a double barrel esophagus compatible with intramural dissection of the esophagus (Figure 3). A covered esophageal stent was later placed. She was able to resume a diet by mouth seven days later. IED is a rare condition with its most common cause being iatrogenic. We present a case of IED in an attempted ERCP. Based on literature review, there are no findings to date referencing IED as a complication of ERCP. Because the side-viewing scope used in ERCPs provides limited visualization of the esophagus, endoscopists should be cognizant of the risk of IED, especially when experiencing resistance in passing the scope. Furthermore, IED should be mentioned when reviewing possible complications of any upper endoscopic procedure.Figure: Endoscopic view of esophageal dissection depicting the true and false lumen.Figure: Endoscopic view of esophageal dissection at the GE junctionFigure: Fluoroscopic evaluation showing a double barrel esophagus.

Ultrasonic imaging research at Ashi points in neck-type cervical spondylosis

To conduct the preliminary positioning and qualitative research of high-frequency ultrasonic imaging at Ashi points (including tender points and trigger points) in neck-type cervical spondylosis and explore the relevant law so as to provide the evidence for the selection of acupuncture scheme. Thirty patients in compliance with the diagnostic criteria of neck-type cervical spondylosis were selected. The trigger points, tender points and placebo points were positioned on any of the three available oriented lines. The point-to-point high-frequency real-time dynamic ultrasonic imaging technology was used to scan and position each point and record the changes in ultrasound gradation anatomy and two-dimensional ultrasound in perimysium, two-dimensional and color Doppler ultrasonography and blood flow. The ultrasound characteristics were analyzed. ①Regarding the changes in ultrasound gradation anatomy and two-dimensional ultrasound in perimysium, the anatomic gradation at trigger points and tender points was in the sequence as cutaneous layer, subcutaneous fat layer, shallow muscular tissue layer, deep muscular tissue layer and vertebrae. The linear high echo presented in cutaneous layer; the low echo in subcutaneous fat layer; the linear high echo in muscular fasciae; the low echo in muscular layer and the clear linear echo in its perimysium; the high echo and declined posterior echo in vertebrae. Compared with the placebo points, 93.3% of trigger points (28/30) presented enhanced or thickened perimysium echo (P<0.05), and 96.7% of tender points (29/30) presented enhanced or thickened perimysium echo (P<0.05). The differences were not significant between the trigger points and the tender points (P>0.05). ②In the two-dimensional ultrasonography, the clear linear echo presented in perimysium, the enhanced or thickened echo in perimysium of trigger points and tender points. In the color Doppler ultrasonography, the blinking unstable dotted blood flow signal or stable short rod-like blood flow signal presented in the trigger points and tender points. ③Regarding the condition of blood flow, 56.7% of trigger points (17/30) presented Ⅱ degree of color blood flow signal and 83.3% of tender points (25/30) presented Ⅱ degree of color blood flow signal; 0% of placebo points presented Ⅱ degree of color blood flow signal. Compared with the placebo points, the differences in the rate of Ⅱ degree of color blood flow signal were significant statistically at both the trigger points and the tender points (both P<0.05). The difference was not significant between the trigger points and tender points (P>0.05). In the high-frequency ultrasound imaging at trigger points and tender points in neck-type cervical spondylosis, the ultrasound imaging characteristics present, which are similar between the trigger points and the tender points. The high-frequency ultrasound imaging is valuable in positioning and quantitative research of Ashi points in cervical spondylosis and has a certain significance to guide treatment.

The effect of a Le Fort I incision on nose and upper lip dynamics: Unraveling the mystery of the "Le Fort I lip".

Postoperative flattening of the upper lip with loss of lip pout and down turning of the corners of the mouth is often seen after Le Fort I surgery. We aim to determine which facial muscles are involved in this phenomenon to update the literature on this subject. In 6 cadavers, a unilateral Le Fort I incision was executed. After removal of the skin, all individual facial muscles were identified and submitted to bilateral tactile traction, comparing incised sides with non-incised sides. All the components of the deep layer of the modiolus alae nasi (transverse part of the nasalis muscle and the myrtiformis muscle) and the deep layer of the midface musculature (levator anguli oris muscle) were transected by the Le Fort I incision. After performing the incision, the majority of the depressor septi nasi is intact. Further, the superficial layer of the midface musculature is intact but it loses tension because of its connection to the deep layer. This study suggests the importance of correctly suturing the deep muscular layers to maintain the 3-dimensional facial contour. Moreover, in this cadaver study, we attempt to predict the functional consequences on the impairment of facial mimics related to the Le Fort I incision.

Endoscopic resection for gastric schwannoma with long-term outcomes.

Gastric schwannoma is not so recognized by clinicians as its counterparts. The efficacy of endoscopic resection has not been described yet. Our aim was to assess the efficacy and safety of endoscopic resection in the management of gastric schwannoma. Retrospective data were reviewed from January 2008 to December 2013 in our center. Fourteen patients who had endoscopic resection with the final pathology result of gastric schwannoma were included in the study. Of the 14 patients, there were 12 females and two males. The median age was 59years (range 32-83). Thirteen tumors (92.9%) were from the muscularis propria and one located in the submucosa. Endoscopic en bloc resection was achieved in 12 patients (12/14, 85.7%), including seven cases of endoscopic full-thickness resection (EFTR). The mean resected tumor size was 1.73±1.10cm (range 0.3-4.0cm). In one case, endoscopic resection was suspended due to the limited experience of EFTR during the early period of the study. In another case, due to the difficult tumor location (gastric angle) and extraluminal growth pattern, the patient was referred to laparoscopic surgery. In the 12 successful endoscopic resection cases, during the median follow-up time of 4years (range 17-77months, one patient lost), no tumor residue, recurrence or metastasis was found. Endoscopic resection is safe and effective in treating gastric schwannoma with excellent long-term outcomes. However, it should be performed with caution because schwannoma is mainly located in the deep muscular layer, which leads to the full-thickness resection of gastric wall.

Clinical value of magnetic resonance diffusion weighted imaging and dynamic enhanced imaging in endometrial carcinoma staging

Objective To study the value of magnetic resonance diffusion weighted imaging (DWI) and dynamic enhanced imaging (DCE) in endometrial carcinoma staging. Methods 200 cases with endometrial carcinoma were selected, DWI and DCE were given before operation.The diagnostic value of two kinds of examination methods for the diagnosis of endometrial carcinoma in general and basic level was compared. Results The overall accuracy of muscle invasion of magnetic resonance DWI was 91.5%(183/200), which was significantly higher than 77.5%(155/200) of magnetic resonance DCE, the difference was statistically significant (χ2=11.231, P<0.05). The accuracy, sensitivity and positive predictive value of the magnetic resonance DWI superficial and deep muscular layer were significantly higher than those of the magnetic resonance DCE (χ2=9.283, 8.231, 9.021, 8.927, 8.142, 9.405, all P<0.05). Compared with pathological results, Kappa value of magnetic resonance DWI was 0.807, Kappa value of magnetic resonance DCE was 0.587. Conclusion Magnetic resonance DWI compared with magnetic resonance DCE, the accuracy and sensitivity of the infiltration of endometrial carcinoma was higher. Key words: Magnetic resonance diffusion weighted imaging; Dynamic enhancement; Magnetic resonance imaging; Uterine tumor

Pathogenic mechanisms of intestinal pneumatosis and portal venous gas: should patients with these conditions be operated immediately?

We aimed to histologically observe portal venous gas (PVG)-causing intestinal pneumatosis (IP) and evaluate pathogenic mechanisms and therapeutic strategies, including decisions on whether emergency surgery should be performed. Autopsy was performed in two cases of nonocclusive mesenteric ischemia (NOMI). We directly histologically observed the pathogenic mechanisms of IP caused by gas-producing bacteria and IP considered to be caused by mechanical damage to the intestinal mucosa. IP can be classified hypothetically into the following types according to pathogenesis: (1) infection, (2) rupture (damage) of the intestinal mucosa + increased intestinal intraluminal pressure, and (3) mixed type. In cases of IP caused by gas-producing bacteria or IP associated with intestinal wall damage extending beyond the mucosa to the deep muscular layer, emergency surgery should be considered. However, it is highly possible that patients who test negative for infection with gas-producing bacteria whose intestinal wall damage remains only in the mucosa can be conservatively treated.

Apoptosis of interstitial cells of Cajal in deep muscular layer of small intestine in rats with multiple organ dysfunction syndrome

To observe the apoptosis of interstitial cells of Cajal in deep muscular layer (ICC-DMP) of small intestine in rats with multiple organ dysfunction syndrome (MODS) as a result of bacterial peritonitis, and the expression of c-kit (an ICC phenotype marker) and Bax/Bcl-2, in order to investigate the mechanism of gastrointestinal motility dysfunction in MODS. According to the random number table, 40 Wistar rats were randomly divided into two groups: control group (n=20) and MODS group (n=20). The MODS model in rats was reproduced by intraperitoneal injection of 8×10(8) cfu/mL Escherichia coli suspension 1 mL, and the control group was given the same amount of normal saline. After 24 hours, the upper small intestine was harvested for examination. Ultrastructure of ICC-DMP was observed using electron microscope. The network structure of ICC-DMP and the expression of c-kit and Bax/Bcl-2 were observed and determined with immunofluorescence and laser scanning confocal microscope. Macroscopic observation revealed that the gastrointestinal motility of rats was normal in the control group. Compared with the control group, gastro intestine was significantly expanded with parulytic ileus in MODS group. It was shown by transmission electron microscopy that intermediate filament structure of ICC-DMP was clear without swelling of mitochondria; chromatin distributed uniformly with small amounts of heterochromatin aggregated in perinuclear. Compared with the control group, intermediate filament structure of ICC-DMP was fuzzy, and mitochondria were swollen obviously in MODS group; chromatin was assembled in nucleus centre. It was shown by laser scanning confocal microscope that the network structure of ICC-DMP was clear, the expression of c-kit and Bcl-2 was strongly and overlapping; the expression of Bax was weak and scatter distributed. Compared with control group, ICC-DMP quantity in MODS group was significantly reduced (cells/HP: 15.80±2.30 vs. 25.70±3.97, t=6.819, P=0.000 ), and ICC network was incomplete. The expression of c-kit and Bcl-2 was significantly decreased as compared with control group [ c-kit (fluorescence intensity): 129.56±36.90 vs. 307.23±40.07, t=10.314, P=0.000; Bcl-2 (fluorescence intensity): 103.23±25.19 vs. 378.92±43.79, t=17.259, P=0.000], whereas, the expression of Bax was significantly increased (fluorescence intensity: 270.94±36.98 vs. 92.57±20.92, t=-13.277, P=0.000 ). The mechanism of gastrointestinal motility dysfunction in MODS maybe closely related to ultrastructural damage of ICC-DMP, changes of c-kit phenotypic and activation of mitochondrial apoptosis pathway.

Expression of Smad4, TGF-βRII, and p21waf1 in esophageal squamous cell carcinoma tissue.

Esophageal squamous cell carcinoma (SCC) possesses one of the worst prognoses out of the digestive carcinomas. Several studies have suggested that transforming growth factor β receptor type II (TGF-βRII), Smad family member 4 (Smad4) and p21 wild-type p53-activated factor 1 (p21waf1) are associated with esophageal SCC. The aim of the present study was to evaluate the effect of Smad4, TGF-βRII and p21waf1 in esophageal squamous cancer tissue and the pathological significance of the effect. An immunohistochemical method was used to evaluate the expression levels of Smad4, TGF-βRII and p21waf1 in specimens of esophageal SCC lesions obtained from 80 patients. It was found that the expression of Smad4, TGF-βRII and p21waf1 in histologically-classified grade I esophageal SCC, without invasion or lymph node metastasis, was markedly higher compared with grade III esophageal SCC that had invaded into the deep muscular or serous layer and metastasized to the lymph nodes (P<0.05). Analysis of the expression level of Smad4, TGF-βRII and p21waf1, as well as the clinical and pathological characteristics of esophageal SCC, revealed that the three proteins may be associated with the carcinogenesis, biological behavior and prognosis of esophageal SCC, parallel to the pathological stage and cell grade.

Myofascial trigger points: New insights in ultrasound imaging

Puncture of trigger points in myofascial syndrome can be performed with greater safety for the patient under ultrasound-guided techniques. The identification of potentially hazardous structures in the path of the needle, together with the development and validation of tools like sonoelastography, spontaneous muscle contraction (twitch response), or vascular dynamics, helps us to be more accurate, specially in cases where the trigger points are in deep fasciae or muscular layers. Ultrasound-guided interfascial block, a known regional anesthetic technique, is emerging as a promising approach with minimum traumatic damage to the muscles.

Symptomatic Extraperitoneal Bladder Perforation Following Transurethral Bladder Surgery: Imaging with CT Urography

An 80 year-old man presented to his primary care physician with painless gross hematuria. He reported having intermittent episodes of pink urine containing small clots for about three months. He was initially treated with a single course of ciprofloxacin for presumed urinary tract infection. His symptoms did not improve with antibiotic therapy and he was then referred to our institution for a computed tomography (CT) urogram. CT urogram showed a 4 x 3.6 centimeter (cm) infiltrating solid mass along the left lateral posterior wall of the urinary bladder (Figure-1). Tumor also extended along the bladder dome. Prostate enlargement and bladder diverticula were also present. He was referred to the urology service and subsequently underwent transurethral resection of bladder tumor (TURBT) with fulguration. No intraoperative complications were noted and he returned to the recovery room in satisfactory condition on continuous bladder irrigation. Pathologic examination revealed a 5 cm transitional cell carcinoma with high grade growth pattern invading the deep muscular layer. On postoperative day one, the patient reported abdominal pain and general discomfort. Physical exam revealed a grossly distended abdomen which was tender to palpation with positive guarding and decreased bowel sounds. He Symptomatic Extraperitoneal Bladder Perforation Following Transurethral Bladder Surgery: Imaging with CT Urography _______________________________________________

OP165: Prophylactic laser surgery of oral cavity’s precancerous lesions: Our experience

Purpose The importance of primary prevention is nowaday accepted as the most useful way to avoid oral cavity precancerosis transformation in malignant conditions. Prevention includes clinical observation, stopping smoking, and removing risk factors. Furthermore the introduction of laser CO2 surgery allows to manage such lesions through evaporation, without any scar retractions and consequent chewing discomfort, thanks to the haemostatic effect and the preserving of muscular layer. The reduction of surgical timing and low relapse of disease make this procedure to be considered safe. Materials and methods Authors show their experience in a series of 93 patients observed (25 female and 36 males, mean age 55 years) from 2002 to 2012. 61 of them underwent to CO2 laser evaporation to remove a total of 157 heterogeneous lesions of oral cavity. Definitive histologic examinations were performed. The procedure included the resection as an excisional biopsy without involving the deep muscular layer. Results In 37% lesions involved the tongue. In 63% pre cancerous lesion were found out and 7% of cases showed squamous cell carcinoma. In a 7 years period of follow up a 4,3% of pathology relapse has been observed. 93% cases have shown a good wound healing, combinig diclofenac mouth washes and ialuronic acid therapy via aerosol were carried out, during the post operative period to improve wound closure. Conclusion Sterilization due to thermic effect permits a better pain control, without any antibiotic in the post operative period, edema reduction. Despite of high temperature laser allows to conserve tissue layer and the margin resection. According to literature our experience could confirm the importance of the laser surgical treatment of all the suspicious lesions of the oral cavity. The histologic diagnosis of precancerosis prevents malignant transformation and so demolitive and reconstructive surgery that may interfere with the patients quality of life.

1758 THE PROGNOSTIC ROLE OF PT2 STRATIFICATION IN BLADDER UROTHELIAL CARCINOMA

INTRODUCTION AND OBJECTIVES: We evaluated the prognostic role of pT2 subtaging according to 2009 TNM staging system in muscle invasive bladder cancer. METHODS: Between January 1998 and October 2010 data of radical cystectomies performed at three different institutions were collected in a prospectively-maintained database. Out of 2224 patients, we selected 368 (16.4%) patients with non metastatic pT2 urothelial carcinoma of the bladder not receiving neoadjuvant therapies. All patients underwent pelvic lymph node dissection at least up to iliac bifurcation. Univariable analysis was performed to test the effect of age, gender, pathological T (pT) and N (pN) stages, lymph-node count (LN-c), lymph-node density (LN-d) and extent of pelvic lymph node dissection (PLND) on disease-free survival (DFS) and cancer specific survival (CSS). Significant variables (log-rank p 0.05) were entered in a multivariable Cox-regression model to identify independent prognostic factors. RESULTS: Out of 368 patients, 152 were pT2a (41.3%) and 216 were pT2b (58.7%). The rate of positive nodes was 46.2%. The median number of nodes removed was 20 (IQR 12-34) and 24 (IQR range 14-41) for the pT2a and pT2b group, respectively. Significant variables at univariable analysis were age, gender, pT, pN, LN-d and extent of PLND. At log-rank test 5yr DFS and CSS of the two groups (pT2a and pT2b) were significantly different (log rank p 0.015 and 0.007 for DFS and CSS, respectively). At Cox regression analysis age, pT and LN-d were independent predictor of DFS [Age: p 0.004, HR 0.98 (95% CI: 0.96-0.99)], [pT2a vs pT2b: p 0.021, HR 1.67 (95% CI: 1.08-2.60)], [LN-d: p 0.001, HR 21.89 (95% CI: 7.17-66.83] and CSS [Age: p 0.001, HR 0.97 (95% CI: 0.95-0.98)], [pT2a vs pT2b: p 0.005, HR 2.07 (95% CI: 1.25-3.42)], [LN-d: p 0.001, HR 25.21 (95% CI: 7.18-88.54)]. CONCLUSIONS: Invasion of deep muscular layer is an independent predictor of oncologic outcome regardless of nodal status and substaging pT2 urothelial carcinomas at radical cystectomy into pT2a and pT2b has a significant prognostic role.

Cholangiocarcinoma accompanied by desmoid-type fibromatosis

Cholangiocarcinoma complicated by intra-abdominal desmoid-type fibromatosis (DTF) is uncommon. There are no reports on patients with this type of fibromatosis, in which the pre-operative treatment (including diagnosis), surgical approach, post-operative pathologic reports, and prognosis are discussed. The clinicopathological features of a 49-year-old man were retrospectively analyzed. Cholangiocarcinoma located in the inferior segment of the bile duct was considered pre-operatively on the basis of clinical findings. At the time of pancreaticoduodenectomy, the mesojejunum was stiff without nodules or a mass at a distance of approximately 80 cm from the ligament of Treitz. Complete excision of the entire lesion of the intestinal mesenteric contracture and its subsidiary was performed. Post-operative pathologic findings confirmed an adenocarcinoma located at the extremity of the common bile duct and infiltrating the full thickness of the common bile duct as well as the deep muscular layer of the duodenum. The contracted jejunal mesentery was shown to have DTF. The patient was alive with no evidence of recurrence after a follow-up of 6 months. The patient had a rare hereditary disease with intra-abdominal DTF, which manifests the characteristics of an aggressive growth pattern and a high rate of local recurrence; conservative therapy is recommended. Complete excision of the fibromatous lesion during pancreaticoduodenectomy may maximally decrease the risk of local recurrence.

Gastrointestinal B-cell lymphoma: a morphologic and immunohistochemical study of 194 cases

To study the morphologic and immunohistochemical features of gastrointestinal B-cell lymphomas. One hundred and ninety-four cases of gastrointestinal B-cell lymphoma were retrieved from the archival file. The clinical features and pathologic findings were reviewed. Immunohistochemical study for B-cell markers, T-cell markers, bcl-6, CD10, bcl-10, cyclin D1, TdT, MUM1 and Ki-67 was carried out. The male-to-female ratio was 1.4:1. The age of patients ranged from 8 to 85 years. Amongst the 194 cases studied, 128 (66.0%) were diagnosed as diffuse large B-cell lymphoma, including 16 cases of large cell lymphoma associated with mucosa-associated lymphoid tissue (MALT) lymphoma component. There were also 40 cases (20.6%) of MALT lymphoma, 8 cases (4.1%) of follicular lymphoma, 5 cases of (2.6%) of lymphoplasmacytic lymphoma, 3 cases (1.6%) of mantle cell lymphoma, 1 case of (0.5%) of B-lymphoblastic lymphoma and 9 cases (4.6%) of indefinite type (including 5 biopsy cases). The site of involvement included stomach (100 cases, 51.5%), small intestine (43 cases, 22.2%), ileocecal junction (26 cases, 13.4%), appendix (1 case, 0.5%), colon (21 cases, 10.8%) and rectum (3 cases, 1.6%). Amongst the 163 cases which had undergone surgical resection, 20 cases (12.3%) cases had invasion down to the mucosa, 20 cases (12.3%) down to the superficial muscular layer, 19 cases (11.6%) down to the deep muscular layer and 104 cases (63.8%) with full-thickness involvement. Histologic examination showed lymphoepithelial lesions in 52 cases, residual lymphoid follicles in 29 cases, coagulative necrosis in 66 cases and nodular growth pattern in 30 cases. The lymphoma cells in all cases were immunoreactive for B-cell marker CD20. There was also various degrees of positivity for bcl-6, CD10, bcl-10, cyclin D1, TdT, MUM1 and Ki-67. Gastrointestinal B-cell lymphomas can be subdivided into two main groups: large B-cell lymphomas and small B-cell lymphomas. The latter group often poses diagnostic pitfalls. Accurate pathologic typing requires correlation with histologic and immunohistochemical findings.

Necrotizing fasciitis of the face: a life-threatening condition

Necrotizing fasciitis (NF) is a highly aggressive infectious process, polymicrobial in nature, involving soft tissues with a high risk of rapid spread through superficial and deep fascial planes and muscular layers. Cervical NF is quite rare, is mostly of odontogenic origin, and may be complicated by descendant mediastinitis with a very high mortality rate. Systemic conditions impairing the patient's immune competence, such as diabetes, may play a predisposing role. An effective treatment strategy includes prompt diagnosis (clinical findings, local microbiological tests, blood culture and, if deemed necessary, histopathology), broad-spectrum antibiotic therapy as early as possible which should be later adjusted according to antibiogram results, stabilization of vital functions and, if possible, elimination/ treatment of predisposing factors. This paper describes a complex and emblematic case.