Definitive Preoperative Diagnosis Research Articles

English

BACKGROUND Multidetector computed tomography (MDCT) is the imaging of choice and the most commonly used investigation in head and neck lesions, because of its fast and readily available nature. Our study focused on contrast enhanced multidetector CT profile of neck masses in determining their nature among different demographic profile. It provides volumetric helical data, optimal multiplanar and 3D reconstructions. METHODS This is a retrospective observational study carried out in the Department of Radiology, Gauhati Medical College and Hospital, Guwahati, among 60 cases of clinically diagnosed neck masses, from December 2011 to June 2013. All patients were selected from out-patient departments (OPD) and indoor wards of various departments (mostly from ENT department). Few cases were also taken from Dr. B. Baruah Cancer Institute. Patients from both sexes and all ages were included as part of the study. Chi square test/Fischer exact test have been used to find the significance of association of CT scan findings with the final diagnosis. Diagnostic statistics such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy have been used to find the correlation of CT scan with the final diagnosis. RESULTS Thin slice scanning with thinner reconstructions, maximum intensity production (MIP), shaded surface display (SSD), multiplanar reformation (MPR) and curved reformatted images are the advantages of MDCT. CT has 100 % accuracy in bony involvement detection and 96 % accuracy in neck lesion diagnosis. Therefore, CT can accurately localise and characterise the neck lesions. CONCLUSIONS The neck lesion location and its characteristics determination has significantly improved because of computed tomography. Bone erosions and expansion are accurately determined by a CT scan. CT scan can accurately delineate the disease that provides a definite pre-operative diagnosis, planning radiotherapy ports and post therapy follow up. KEYWORDS Bone Invasion, Lymph Nodes, Neck Space Extensions, Multidetector-CT

Surgery or Non-surgical Treatment of ≤8 mm Non-small Cell Lung Cancer: A Population-Based Study.

Background: Timing for intervention of small indeterminate pulmonary nodules has long been a topic of debate given the low incidence of malignancy and difficulty in obtaining a definite preoperative diagnosis. We sought to determine survival outcomes of surgical and non-surgical managements in non-small cell lung cancer (NSCLC) ≤8 mm, which may provide a reference for prospective decision-making for patients with suspected NSCLC.Method: A total of 1,652 patients with Stage IA NSCLC ≤8 mm were identified from the Surveillance, Epidemiology, and End Results (SEER) database and categorized into surgery and non-surgery groups. Chi-square test, t-test and Mann-Whitney U test were used to compare the baseline characteristics between groups. Survival curves were depicted using Kaplan-Meier method and compared by log-rank test. Cox proportional hazard model was used for univariate and multivariate analyses. Adjustment of confounding factors between groups was performed by propensity score matching.Results: The surgery and non-surgery groups included 1,438 and 208 patients, respectively. Patients in surgery group demonstrated superior survival outcome than patients in non-surgery group both before [overall survival (OS): HR, 16.22; 95% CI, 11.48–22.91, p < 0.001; cancer-specific survival (CSS): HR, 49.6; 95% CI, 31.09–79.11, p < 0.001] and after (OS: HR, 3.12; 95% CI, 2.40–4.05, p < 0.001; CSS: HR, 3.85; 95% CI, 2.74–5.40, p < 0.001) propensity score matching. The 30-day mortality rates were 3.1 and 12.0% in surgery and non-surgery groups, respectively. Multivariate analysis suggested age, sex, race, tumor size, grade, pathological stage were all independent prognostic factors in patients with ≤8 mm NSCLC. A comparison of surgical resections revealed a survival superiority of lobectomy over sub-lobectomy. In terms of CSS, no statistically significant difference was found between segmentectomy and wedge resection.Conclusion: The current SEER database showed better prognosis of surgical resection than non-surgical treatment in patients with ≤8 mm NSCLC. However, the factors that should be essentially included in the proper propensity-matched analysis, such as comorbidity, cardiopulmonary function and performance status were unavailable and the true superiority or inferiority should be examined further by ongoing randomized trial, especially comparing surgery and stereotactic body irradiation.

Biopsy of Subsolid Nodules Suspicious for Adenocarcinoma: Point-CT-Guided Biopsy of Subsolid Nodules Is a Safe and Effective Means to Establish a Definitive Preoperative Diagnosis.

This article does not include an abstract. Please see the accompanying Counterpoint by Brett M. Elicker and Kimberly G. Kallianos.

A prediction model based on DNA methylation biomarkers and radiological characteristics for identifying malignant from benign pulmonary nodules

BackgroundLung cancer remains the leading cause of cancer deaths across the world. Early detection of lung cancer by low-dose computed tomography (LDCT) can reduce the mortality rate. However, making a definitive preoperative diagnosis of malignant pulmonary nodules (PNs) found by LDCT is a clinical challenge. This study aimed to develop a prediction model based on DNA methylation biomarkers and radiological characteristics for identifying malignant pulmonary nodules from benign PNs.MethodsWe assessed three DNA methylation biomarkers (PTGER4, RASSF1A, and SHOX2) and clinically-relevant variables in a training cohort of 110 individuals with PNs. Four machine-learning-based prediction models were established and compared, including the K-nearest neighbors (KNN), random forest (RF), support vector machine (SVM), and logistic regression (LR) algorithms. Variables of the best-performing algorithm (LR) were selected through stepwise use of Akaike’s information criterion (AIC). The constructed prediction model was compared with the methylation biomarkers and the Mayo Clinic model using the non-parametric approach of DeLong et al. with the area under a receiver operator characteristic curve (AUC) analysis.ResultsA prediction model was finally constructed based on three DNA methylation biomarkers and one radiological characteristic for identifying malignant from benign PNs. The developed prediction model achieved an AUC value of 0.951 in malignant PNs diagnosis, significantly higher than the three DNA methylation biomarkers (0.912, 95% CI:0.843–0.958, p = 0.013) or Mayo Clinic model (0.823, 95% CI:0.739–0.890, p = 0.001). Validation of the prediction model in the testing cohort of 100 subjects with PNs confirmed the diagnostic value.ConclusionWe have shown that integrating DNA methylation biomarkers and radiological characteristics could more accurately identify lung cancer in subjects with CT-found PNs. The prediction model developed in our study may provide clinical utility in combination with LDCT to improve the over-all diagnosis of lung cancer.

The Ultrasonographic Features of Female Reproductive System Extraosseous Ewing's Sarcoma

This study investigated the clinicopathological traits and ultrasound features of female reproductive system extraosseous Ewing's sarcoma (EES) and explored the diagnostic value of ultrasonography for this condition. Cases of female pelvic EES diagnosed and treated at our hospital between June 2009 and June 2019 were included in this study. Pathology data and ultrasound manifestations were assessed retrospectively to summarize the clinical traits and ultrasound features of female reproductive system EES. Based on the results, recommendations for the ultrasonography-based diagnosis of this disease were proposed. During the 10-year study period, 13 female patients were diagnosed with EES in the pelvic cavity based on the results of postoperative pathology tests. The age of the patients ranged from 8 mouth to 40 years, and no patients demonstrated specific clinical symptoms. However, an examination of tumor biomarkers revealed that certain patients had elevated levels of CA125. In the 13 patients, 19 lesions were identified, including 16 that involved the reproductive system. The primary ultrasound manifestation was uneven, low-echo solidity or cystic solidity, exhibiting large size, irregular shape, and unclear boundary. A few patients had concurrent ascites. Although some lesions lacked blood supply, the blood supply of most lesions was medium to abundant, and the blood flow was mostly characterized by low resistant. Almost none of the lesions were definitively diagnosed preoperatively. Preoperative definitive diagnosis of EES in the female reproductive system remains a great clinical challenge. Although certain clinical traits and ultrasound features are associated with this disease, and color Doppler ultrasonography might provide vital information indicating the presence of EES, the final diagnosis still depends on the pathological test results of the patients.

A Case of Renal Inflammatory Pseudotumor Leading to Nephrectomy

Inflammatory pseudotumor (IPT) of the kidney is a rare benign disorder with unknown etiology. In IPT patients, some nonspecific symptoms might present, such as fever, hematuria, and back pain. As it can appear on computed tomography and magnetic resonance imaging as a hypovascular mass with surrounding fat stranding, IPT can be misdiagnosed as a primary tumor. Since the clinical symptoms, radiographic features, and preoperative findings can be inconsistent, it is imperative to confirm IPT based on histopathological assessment. In the present study, we describe a case of renal IPT in a 13-year-old girl. The patient was treated with nephrectomy of the right kidney since the preoperative diagnosis was renal carcinoma. Pathological examination revealed an IPT. This article emphasizes the importance of preoperative definitive diagnosis in avoiding unnecessary nephrectomy.

Fatal course of idiopathic chronic ulcerative enteritis with panenteritis and perforation: a case report and review of literature

BackgroundIdiopathic chronic ulcerative enteritis (ICUE) is a very rare disease with high mortality. Because of clinical rarity, several small case reports have been published and there is a lack of large sample study. Preoperative definite diagnosis is difficult. Although definite treatment for ICUE is radical surgical resection, surgical decision in operative field is difficult.Case presentationA 77-year-old man came to the emergency department with complaints of a 1-day history of abdominal pain and abdominal distension. Abdominal computed tomography revealed ileus and focal free air. Laparotomy revealed multiple small bowel tiny perforations in the ileum. The serosa surface in the whole small bowel had small multiple yellowish tiny discolored lesions. Despite the presence of multiple mucosal ulcers in entire small bowel, the ileum including perforation site was resected segmentally. Microscopically, mucosal ulcers in resected small bowel demonstrated transmural inflammation, no granuloma, and no lymphoid aggregates. These features were consistent with a diagnosis of ICUE with panenteritis and perforation. After surgery, the patient’s general condition gradually aggravated. Unfortunately, the patient died of multiple organ failure on post-operative day 14.ConclusionSurgically, the decision including resection range, anastomosis or enterotomy becomes difficult in ICUE with panenteritis. According to recent 40 year’s revised data, the post-operative mortality of ICUE is about 53.4%. Although ICUE is rare, its recognition is important for appropriate diagnosis and treatment. Retrospective multicenter case studies are required to determine proper treatment and improve prognosis.

Circulating miR-17 as a promising diagnostic biomarker for lung adenocarcinoma: evidence from the Gene Expression Omnibus.

BackgroundA definitive preoperative diagnosis of lung adenocarcinoma (LUAD) is a clinical challenge. Informative and blood-based microRNAs (miRNAs) may provide new insights on LUAD screening and detection but are limited by suboptimal accuracy.MethodsThe raw expression levels of circulating miR-21, miR-155, miR-210, miR-126, miR-182, and miR-17 in LUAD cases and healthy controls from the Gene Expression Omnibus (GEO) database were obtained and analyzed to identify accurate diagnostic miRNAs biomarkers for LUAD detection. We applied a meta-analysis to determine the magnitude of statistically significant miRNAs in LUAD samples, based on estimation outcomes acquired by analyzing raw data. Furthermore, bioinformatics analysis was conducted to reveal the function of significant miRNAs in the comprehensive underlying mechanisms of LUAD biology.ResultsA total of 5 raw microarray datasets, including 87 LUAD samples and 83 healthy controls, were eligible. Through our analysis, the primary outcome measure was that circulating miR-17 showed a favorable accuracy in diagnosing LUAD, and the overall pooled area under the curve (AUC) value was 0.79. Furthermore, a total of 85 predicted target genes were chosen, and 29 gene ontology (GO) items and 3 Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways showed a significant statistical difference, which demonstrated that the target genes are involved in the biological processes of LUAD. A protein-protein interaction (PPI) network analysis revealed 10 hub genes, namely CCND2, E2F3, TNRC6B, AGO1, AAK1, RAB5B, LDLR, FBXO21, UBE3C, and MYLIP, located in the center of the PPI network.ConclusionsIn conclusion, circulating miR-17 may be a quality diagnostic biomarker for LUAD screening, but confirmation by a large, rigorous clinical validation in a longitudinal setting is warranted.

Safety and feasibility of laparoscopic approaches for the management of Mirizzi syndrome: a systematic review.

Laparoscopic approaches for the management of Mirizzi syndrome (MS) are controversial and challenging procedures for high conversion rate. This review aims at evaluating their safety and feasibility. We reviewed studies related to the laparoscopic approaches for the management of MS with detailed data of articles from January 2009 to December 2019 found in PubMed. From 63 articles, we reviewed 17 articles detailing laparoscopic approaches for MS. There were 857 patients with MS; 432 of which were identified from 73,842 patients underwent cholecystectomy. Laparoscopic approaches were attempted in 440 patients and were successful in 290. The conversion rate was 34.09%. Various methods including laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and (LTCBDE) were performed. The preoperative diagnosis of MS was made in 338 of 500 patients (67.60%). The mean operating time ranged from 49.7 ± 27.5min to 270.5 ± 65.5min, and the mean intraoperative bleeding varied from 21.1 ± 15.9ml to 162.81 ± 40.83ml. The mean hospital stay varied from 4.5 ± 3.7 to 7.21 ± 1.61days. Postoperative complications occurred in 27 patients. Various laparoscopic approaches are safe and feasible for the treatment of MS in the hands of experienced laparoscopic surgeons, especially for type I and II of Csendes classification. Definitive preoperative diagnosis and earlier management are essential.

Sclerosing Encapsulating Peritonitis Causing Delayed Intestinal Obstruction

Sclerosing encapsulating peritonitis, also known as abdominal cocoon, is a rare condition of unknown etiology which results in intestinal obstruction due to total or partial encapsulation of the small bowel by a fibrocollagenous membrane. A high index of clinical suspicion is required for preoperative diagnosis. The early clinical features are nonspecific and not recognized, which makes a definite preoperative diagnosis difficult. The radiological diagnosis of abdominal cocoon is now made on computed tomography scan. Surgery plays main role in the management of this disease. Careful dissection and excision of the thick sac with the release of the small bowel loops will lead to complete recovery in the vast majority of cases. Here, we are reporting a case of sclerosing encapsulating peritonitis presented with delayed intestinal obstruction.

Resection of a Posterior Fossa Endodermal Cyst With Exoscopic Assistance: 2-Dimensional Operative Video.

Neurenteric cysts are rare benign congenital tumors of endodermal origin that most commonly occur in the cervical and upper thoracic spine, with only about 10% to 18% of the reported cases occurring intracranially.1 A definitive preoperative diagnosis is complicated by the variable appearance of neurenteric cysts on magnetic resonance (MR) imaging.2 The recommended treatment of neurenteric cysts is complete surgical resection when possible.3,4 We present a case of a posterior fossa neurenteric cyst. A 33-yr-old man without medical history presented with left-sided headache and mild left-sided facial numbness and weakness. Admission MR imaging revealed a nonenhancing mass, which was hyperintense on T1-weighted MR images, compressing the brainstem anteriorly. The lesion was isointense on T2 FLAIR images and hypointense on diffusion-weighted imaging, initially read as possible epidermoid cyst. The patient underwent a left-sided retrosigmoid craniotomy via far lateral transcondylar approach. The tumor was adjacent to both vertebral arteries, the left PICA, and cranial nerves (CN) VII-XII with superior extension to CN V. The cyst was encased in a thin capsule, and its contents were yellowish in color and ranged from thick liquid to colloidal and caseous consistency. The cyst also contained heavily calcified portions, which were excised using sharp dissection. Images of the cyst wall show that it is focally lined with ciliated columnar epithelium with intracellular mucin confirming an endodermal or neurenteric cyst. After the operation, the patient's symptoms resolved, and he was discharged on postoperative day 4. Postoperative MR images confirmed gross total resection. The patient consented to video production.

Cytomorphological Spectrum of Granulomatous Mastitis: A Study of 33 Cases.

Granulomatous mastitis is an uncommon benign breast disease. Varied aetiologies such as tuberculosis, foreign body reactions, sarcoidosis, fungal and parasitic infections and autoimmunity have been suggested. Pre-operative definitive diagnosis is essential for proper treatment. In developing countries like India, fine needle aspiration is still widely used as a reliable technique for preoperative evaluation of palpable breast lumps. The objective of this study is to study the cytomorphological features of different forms of granulomatous mastitis and correlate with other clinical findings including histological features. A total of 33 cases of granulomatous mastitis were reviewed. The patients underwent fine needle aspiration. Cytomorphological features were studied in detail and correlated with histopathological features and other clinical findings. All the 33 patients showed varied cytomorphological features which included epithelioid cells/granuloma with lymphocytes/plasma cells/polymorphs with or without necrosis/caseous necrosis and with or without giant cells. Ziehl Nelson stain showed acid fast bacilli in 13 smears. Out of 17 cases, the eight cases showed positive acid fast bacilli culture. Fungal stain such as Grocott-Gommeri Methane amine did not show fungi. Based on cytomorphological features in aspiration smears, they were grouped into 4 Groups. A total of 27 breast lesions were diagnosed as tuberculous mastitis, the four lesions were diagnosed as idiopathic granulomatous lobular mastitis and two lesions were diagnosed as foreign body granulomatous mastitis. Grocott-Gommeri Methane amine did not showed fungi. Based on cytomorphological features in aspiration smears, they were grouped into 4 Groups. A total of 27 breast lesions were diagnosed as tuberculous mastitis, the four lesions were diagnosed as idiopathic granulomatous lobular mastitis and two lesions were diagnosed as foreign body granulomatous mastitis. Epithelioid granulomas with caseous necrosis with or without acid fast bacilli in cytology smears are diagnostic of tuberculosis. Cytology smears showing epithelioid granulomas with predominant polymorphs without necrosis and acid fast bacilli, a diagnosis of idiopathic granulomatous lobular mastitis must be considered. Histopathological examination is essential for definitive diagnosis in these cases.

A rare incidence of only pancreatic endocrine tissue in Meckel’s diverticulum

Background: A 49-year-old female presented with lower abdominal pain and vomiting. No significant history of any previous illness. CT scan showed acute Meckel’s diverticulitis. Small bowel was resected. Results: Microscopic examination showed ulcerated and necrotic Meckel’s with focal viable areas and clusters 0.3–0.8 mm in maximum dimension, of bland neuroendocrine cells in the muscularis propria and adjacent adventitial adipose tissue. These nests morphologically resembled islets of Langerhans with developed capillary network and stained with synaptophysin, chromogranin. Insulin stained insulin secreting cells towards the centre of the islets and Glucagon stained glucagon secreting cells located peripherally in the islets confirming similar morphology to pancreatic islets of Langerhans. Discussion: Ectopic endocrine pancreatic tissue is histologically present within 20% of Meckel’s diverticula. Only two cases of endocrine only ectopic pancreatic tissue have been reported, in the stomach and Meckel’s diverticulum respectively, both occurring in insulin-dependent diabetics.1 Primary or metastatic neuroendocrine (carcinoid) tumour is the main differential diagnosis. Extensive specimen sampling, examination, immunohistochemistry and awareness of the entity is required for differentiaton.1 It is usually asymptomatic and diagnosed only during examinations for other diseases.2 Definitive preoperative diagnosis is challenging.3 Due to the possible chance of malignant transformation, it should be excised.

Effect of preoperative serum alanine aminotransferase and asparagine aminotransferase ratio on prognosis of patients with gastric cancer

Objective: To study the relationship of liver function index alanine aminotransferase and aspartate aminotransferase ratio (LSR) with clinicopathological factors in patients with gastric cancer and its clinical significance in predicting the survival of patients. Methods: A retrospective case-control study was used. Retrospective analysis was conducted on 891 patients with advanced gastric cancer who underwent gastric cancer surgery at the Gastrointestinal Surgery Department of Harbin Medical University Cancer Hospital from January 2007 to December 2010, having complete postoperative clinicopathological and follow-up data. Case inclusion criteria: (1) preoperative definite diagnosis of gastric cancer, residual gastric cancer and other gastric tumors were excluded; (2) no neoadjuvant therapy before surgery; (3) no other serious diseases such as acute coronary heart disease, cirrhosis, chronic renal failure, etc.; (4) radical gastrectomy was performed, palliative treatment or open laparotomy cases were excluded; (5) complete postoperative pathological data, complete follow-up information; (6) cause of death was associated with gastric cancer. Blood examination was performed during hospitalization. The best cut-off points of LSR, hemoglobin, lymph node metastasis rate, maximum diameter of tumors, alkaline phosphatase, glutamyl transpeptidase, total bilirubin and lactate dehydrogenase were obtained by using receiver operating characteristic curve(ROC). Patients were divided into two groups according to best LSR cut-off points. The relationship between LSR and clinicopathological factors was analyzed, and the overall survival rate of different LSR groups was compared. Relevant clinical factors and LSR were included in the univariate and multivariate survival analysis using the Cox method. Results: The best cut-off point of LSR in ROC curve was 1.43, and 682 cases in LSR<1.43 group, 209 cases in LSR≥1.43 group. The best cut-off points of hemoglobin, lymph node metastasis rate, maximum diameter of tumors, alkaline phosphatase, glutamyl transpeptidase, total bilirubin and lactate dehydrogenase were 130.2 g/L, 18.0%, 4.75 cm, 68.1 U/L, 16.55 U/L, 5.58 μmol/L and 135.8 U/L, respectively. Between patients with LSR<1.43 and LSR≥1.43, age (χ(2)=4.412, P=0.036), depth of tumor invasion (χ(2)=64.306, P<0.001), histological type (χ(2)=8.026, P=0.005), alkaline phosphatase (χ(2)=8.217, P=0.004), glutamyl transpeptidase (χ(2)=33.207, P<0.001), total bilirubin (χ(2)=14.012, P<0.001) and lactate dehydrogenase (χ(2)=63.630, P<0.001) were significantly different. The 1-, 3- and 5-year survival rates of LSR<1.43 group and LSR≥1.43 group were 70.8%, 31.3%, 25.0% and 64.9%, 24.4%, 11.3% respectively, whose difference was significant (χ(2)=10.140, P=0.001). Univariate analysis showed that age, hemoglobin, TNM stage, depth of invasion, lymph node metastasis rate, lymph node metastasis, histological type, maximum diameter of tumors, glutamyl transferase, total bilirubin and LSR were associated with overall survival of gastric cancer (all P<0.05). Multivariate analysis showed that tumor TNM stage (HR=1.605, 95%CI: 1.332 to 1.936, P<0.001), tumor invasion depth (HR=1.299, 95%CI: 1.168 to 1.445, P<0.001), lymph node metastasis rate (HR=2.400, 95%CI:1.873 to 3.076, P<0.001), lymph node metastasis (HR=1.263, 95%CI: 1.106 to 1.478, P=0.007), maximum tumor diameter (HR=1.375, 95%CI: 1.134 to 1.669, P=0.001), and LSR (HR=1.427, 95%CI: 1.190 to 1.711, P<0.001) were independent risk factors for the prognosis of patients with gastric cancer. Conclusions: LSR is an independent risk factor for the prognosis of gastric cancer patients, and the detection is simple and easy. It is a potential marker for the prognosis of gastric cancer. Therefore, in the preoperative comprehensive management stage, it should be possible to restore and improve the liver function in order to obtain a better prognosis of gastric cancer and prolong the survival time of patients.

Urinary Bladder Paraganglioma - A case report and review of literature.

Paragangliomas of the urinary bladder constitute a small part of all bladder tumors. Faced with a wide variety of presenting symptoms, they propose a diagnostic dilemma and lack of a definite preoperative diagnosis may result in inadequate pre-operative preparation with disastrous consequences. We present a case of urinary bladder paraganglioma wherein we were able to achieve definite diagnosis after a cystoscopy guided biopsy of the lesion. This enabled us to adequately prepare the patient for a laparoscopic partial cystectomy. The patient was discharged after an uneventful post operative course.

Resectable pancreatic solid lesions: Time to move from surgical diagnosis?

Benign or malignant conditions can present as pancreatic solid lesions (PSLs), and a thorough diagnostic workup is necessary to differentiate them. The need to acquire a tissue sample to reach a definitive diagnosis should be stratified by the findings at multidetector computed tomography (MDCT) with a pancreatic protocol. Tissue biopsy is currently indicated in patients fit for chemotherapy in whom a metastatic tumor or a locally advanced unresectable lesion are discovered. For these patients, EUS-guided tissue acquisition, with fine-needle aspiration (FNA) or biopsy represents the gold standard to provide a definitive cyto- and/or histopathologic diagnosis, with a high rate of accuracy. For resectable PSLs with a nonhypoenhancing MDCT pattern, which is not disease specific, a tissue diagnosis to distinguish benign from malignant etiologies appears mandatory. On the other hand, for hypo-enhancing PSLs, the debate of whether to obtain a preoperative definitive diagnosis still favors direct surgery. However, availability of novel EUS-guided fine-needle biopsy needles, which can ameliorate the negative predictive value of EUS-FNA and allow performance of DNA and RNA whole-genome extraction and RNA sequencing, coupled with the increasing evidence that preoperative neoadjuvant chemotherapy can be of value for these patients may change completely the diagnostic and therapeutic approach to resectable PSLs. These recent breakthroughs suggest the need for a new multidisciplinary consensus meeting to integrate them into the decision-making process assessing the need for preoperative tissue diagnosis in resectable PSLs.

Benign Tumours and Pseudotumours Within the Porta Hepatis Masquerading as Perihilar Cholangiocarcinoma.

Hilar cholangiocarcinoma (HC), also referred to as Altemeier-Klatskins tumour, is a lethal primary extrahepatic carcinoma of biliary epithelial origin, arising within 2cm of the hilar confluence. Radical surgical excision provides the best chance for a cure; however, the management of patients with HC is challenging not only because of the need for a high level of skill in biliary and hepatic resections, but also because of the difficulty in reaching an accurate diagnosis preoperatively. In fact, the differential diagnosis of HC is a diagnostic dilemma which is currently persisting, as modern, sophisticated diagnostic modalities are not always able to provide a definitive preoperative diagnosis. This difficulty is compounded by the fact that alternative entities that mimic HC may be present in up to 25% of patients with hilar obstruction. This makes precise preoperative characterisation of a hilar stricture extremely important by preventing unnecessary, high-risk, major surgical procedures. Therefore, alternative benign entities masquerading as Altemeier-Klatskins tumour deserve an important place in the differential diagnosis of hilar obstruction. Considering the important clinical implications that a precise diagnosis of the aetiological cause of a biliary obstruction at the liver hilum would have, this paper will focus on the differentiation between HC and benign hilar obstructions and will review benign tumours and pseudotumours masquerading as HC along with their specific diagnostic features.

Vagal nerve Schwannoma- An interesting case presenting as lateral neck swelling

A Schwannoma is a benign nerve sheath tumor composed of Schwann cells. Schwannoma arising from the vagus nerve is an uncommon (2–5%) benign nerve tumor. Less than 1% becomes malignant. Definitive pre-operative diagnosis may be difficult and investigations such as FNAC have low specificity. Surgical removal of tumor is the treatment of choice for vagal schwannomas with nerve preservation. Surgical removal can be done either by intra capsular enucleation or extra capsular excision of tumor. Definitive diagnosis is obtained by means of surgical pathology. Here we present a case of 40 year old male presented with swelling over anterio -lateral aspect of left lower neck region for last four years with mild change in his voice for few months. CECT of the neck was suggestive of left neck cystic necrotic lesion. On FNAC the swelling was misdiagnosed as colloid nodule. The mass was excised. Grossly a single encapsulated globular cystic tissue piece measuring 8.5x7x6 cm was received in histopathology lab, which on cut section show a unilocular cyst filled with blood mixed mucoid material. On Histopathology, a diagnosis of Schwannoma was rendered. Keywords: Benign tumor, Neck swelling, Schwannoma, Vagal nerve.

Hepatic sclerosing hemangioma mimics hepatic malignancies: a case report and multidisciplinary approach

BackgroundHepatic sclerosing hemangiomas (HSH) are rare benign vascular tumors that mimic radiologically hepatic malignancies. HSH is characterized by extensive fibrosis and hyalinosis as a result of degeneration and thrombosis. Pre-operative diagnosis is very difficult and most of the cases undergo surgical resections.Case presentationA 65 years old, hepatitis C virus-infected female presented by an accidentally discovered hepatic focal lesion. Magnetic resonance imaging (MRI) showed a T2 hyperintense mass displaying peripheral enhancement in porto-venous phase. The patient had a simultaneous typical hepatic hemangioma and multiple vertebral bodies’ hemangiomata. Tissue-guided biopsy revealed a densely sclerotic stroma containing vascular spaces with occasional obliteration of the lumen. Immunohistochemical staining was performed for Pan CK, CD34, SMA, VEGF, and c-Kit which confirmed the vascular nature of neoplasm and the involuting phase of hemangioma development. The patient was reassured and recommended for a regular radiological follow-up to reassess the lesion size.ConclusionThe definitive preoperative diagnosis of HSH is still problematic. However, the awareness of surgeons by this entity, peripheral enhancement in porto-venous phase on dynamic MRI, the presence of simultaneous typical hepatic hemangioma in the absence of cancer history could raise suspicion for HSH. Liver biopsy is still the gold standard in approaching the accurate diagnosis.

A case of small in situ perihilar cholangiocarcinoma incidentally accompanied by benign bile duct stricture after open cholecystectomy

BackgroundIn situ cholangiocarcinoma is difficult to detect by imaging studies. Thus, cholangiocarcinoma is rarely resected with a preoperative definitive diagnosis, especially nonpapillary flat type in situ carcinoma, which is extremely rare.Case presentationA 70-year old man was diagnosed with gallbladder cancer and received open cholecystectomy with lymphadenectomy at a local hospital. Histologically, the tumor was localized in the mucosal layer, and no lymph node metastases were found. Three months later, hilar bile duct stricture due to delayed bile duct ischemia was found. Then, biliary drainage was performed with endoscopic biliary stenting. Three months later, the patient experienced cholangitis with septic shock, and percutaneous transhepatic biliary drainage (PTBD) into the left intrahepatic bile duct was performed. Unexpectedly, the aspiration bile cytology of the PTBD catheter showed malignant cells, and the patient was referred to our clinic for possible surgical treatment. According to additional studies, the hilar bile duct stricture was 3 cm in length. None of the imaging studies detected malignant cells in the bile duct around the hilar stricture. The left portal vein was obstructed due to inadvertent puncture of the PTBD. No findings indicated cholangiocarcinoma. We performed left hepatectomy with caudate lobectomy and extrahepatic bile duct resection. The postoperative course was uneventful. In the final pathology, flat type in situ carcinoma was found at the confluence of the right and left hepatic ducts, which was distant from the biliary stricture.ConclusionsWhen a tumor is undetectable but cytology is positive, in situ cholangiocarcinoma may exist; thus, surgery should be carefully considered.