Definitive Preoperative Diagnosis Research Articles

Compliance with clinical guidelines for breast cancer management: A population-based study of quality-of-care indicators in France.

BackgroundThe European Society of Breast Cancer Specialists (EUSOMA), which aims to standardize the quality of patient care in Europe, has defined quality indicators (QIs) for breast cancer (BC) care to assess compliance to current care standards. These QIs are a useful tool to evaluate care organizations. Only population-based studies are able to assess health system performance in “real-life” situations. This population-based study aimed to describe compliance with several EUSOMA QIs overall and according to patient and organizational factors in France.Methods1 560 adult women with primary invasive non-metastatic BC diagnosed in 2012 were randomly selected among all incident BC from 16 French geographical areas covered by cancer registries. Twelve EUSOMA QIs were selected regarding diagnosis, treatment and staging.ResultsThe minimum standard as proposed by EUSOMA was met for nine QIs related to pre-operative definitive diagnosis, multidisciplinary discussion and treatment (single surgery, breast conserving surgery (BCS) for small BC (<3cm), radiotherapy after BCS or mastectomy for regional BC (pN≥2a), hormonotherapy, adjuvant chemotherapy and trastuzumab). Low compliance was observed for sentinel lymph node biopsy (SLNB) and staging imaging. Adherence to guidelines was usually lower in older patients and in patients with comorbidities. Multidisciplinary discussion was positively related to adherence to guidelines for diagnosis, staging practices (SNLB, imaging) and systemic treatments. Compliance also varied by area of residence and by place of first treatment.ConclusionThis study provides the first current, comprehensive overview of BC quality care at a population level in France. The guidelines were correctly applied in percentage satisfying the EUSOMA standards for the diagnosis and treatment of BC, although staging practices (SLNB, imaging) can be improved. These results highlight the need for continuous measurement of adherence to guidelines to improve BC care.

Intraductal oncocytic papillary neoplasm of the pancreas: A systematic review

BackgroundIntraductal oncocytic papillary neoplasm of the pancreas (IOPN–P) is a rare subtype of intraductal papillary mucinous neoplasm (IPMN). This study was performed to summarize the clinicopathological features and management of IOPN-P. MethodsEnglish-language articles were searched from MEDLINE and EMBASE from the first report of IOPN-P in 1996 until 1 May 2019 following the methodology in the PRISMA guidelines. ResultsIn total, 66 patients from 24 full articles were included in the final data analysis. The patients’ average age was 61 years, and the male/female ratio was 1. Most lesions were large (average size, 5.50 cm), located in the pancreatic head, and found either incidentally or by uncharacteristic abdominal symptoms. IOPN-P was usually a cystic and solid lesion with or without mural nodules on radiological examination. A definitive diagnosis was often acquired from fine needle aspiration biopsy or postoperative pathology. All tumors were diagnosed as carcinoma in situ or minimally invasive carcinoma, necessitating surgical resection. The prognosis of IOPN-P was better than that of other IPMN subtypes, even when metastasis occurred. Recurrence after surgical resection of IOPN-P was rare. ConclusionsIOPN-P is rare among IPMN subtypes with unique pathological characteristics. Because of the nontypical symptoms and radiological findings, a definitive preoperative diagnosis usually depends on multimodal examinations. Management and surveillance of IOPN-P after surgical resection should be differentiated from those of other pancreatic benign cystic lesions because of its relative malignancy, but IOPN-P should also be differentiated from other IPMN subtypes and malignant cystic tumors because of its favorable prognosis.

An Uncommon An Uncommon Cause of Acute Abdomen in Underprivileged Communities

Oftentimes general surgeons working in poorly resourced communities carry out emergency abdominal surgery in patients with acute abdomen with no definitive preoperative diagnosis. The definitive diagnosis is made at laparotomy. Perforated small bowel obstruction secondary to heavy Infestation with Ascaris Lumbricoides brings a number of intraoperative challenges requiring correct intraoperative surgical management decisions. We present a case of a 17 year-old patient who was admitted with a diagnosis of small bowel obstruction who at laparotomy was found to have perforated gangrenous small bowel volvulus with heavy worm load visible through the bowel wall. Because of faecal peritoneal contamination and haemodynamic instability she underwent a two staged procedure with good outcome.

Localized multiple malignant epithelioid peritoneal mesotheliomas arising from the hepatoduodenal ligament and diaphragm: a case report

BackgroundMalignant peritoneal mesothelioma is a rare aggressive tumor of the peritoneum. We report a rare case of resection of multiple localized malignant peritoneal mesotheliomas.Case presentationA 55-year-old Japanese woman was admitted to our hospital because liver tumors were detected by abdominal ultrasonography during a screening examination. Blood examination findings, including tumor makers, were within normal ranges. She had no evidence of exposure to asbestos. Computed tomography showed four hypervascular, round liver tumors, one in the lateral liver segment adjacent to the hepatic hilus, and the other three on the liver surface. Computed tomography angiography revealed that the tumor in the lateral segment had strong enhancement and was fed from the left gastric artery. In contrast, the other tumors showed no enhancement, and were fed from the right inferior phrenic artery. Abnormal accumulation was identified in the four tumors only with 18F-fluorodeoxyglucose positron emission tomography. It was very difficult to obtain a definitive preoperative diagnosis, but surgical resection was performed because we considered potential malignancy. Laparotomy revealed the principal site of the tumor in the lateral segment was on the hepatoduodenal ligament, and all other tumors were on the diaphragm. A left lobectomy and partial diaphragmatic resection were performed. The final pathological diagnosis was multiple malignant epithelioid mesotheliomas. Our patient has had no recurrence for 20 months postoperatively.ConclusionsIn general, malignant peritoneal mesotheliomas are classified as diffuse tumors, which are often unresectable and have a poor prognosis. However, early diagnosis and treatment, particularly with the localized type, as in our patient, could lead to long-term survival of the patient. We recommend that multiple malignant epithelioid mesotheliomas be included in the differential diagnosis for patients with subcapsular hepatic tumors.

Intraparotid facial nerve schwannoma: a 17-year, single-institution experience of diagnosis and management

Background: Intraparotid facial nerve schwannoma (IFNS) is rare and its definite preoperative diagnosis is challenging.Objective: To improve available knowledge regarding the diagnosis of IFNS and to suggest an appropriate treatment plan.Material and methods: We retrospectively analyzed medical records of IFNS patients at our hospital. Inclusion criteria were surgery (from January 2000, to December 2016) for a parotid mass, pathologically diagnosed as a schwannoma.Results: The study included 42 eligible patients who had undergone tumor resection from 5977 parotid tumor patients. Mostly presented hard-textured (18/39) or medium-textured (15/39), with limited mobility (21/39) mass (three tumors were not palpable). Their facial nerve function outcomes were House–Brackmann Grade I (n = 14), Grade II (n = 7), Grade III (n = 11), Grade IV (n = 5), Grade V (n = 3), and Grade VI (n = 2). Significant differences were noted in results based on different surgical methods used (p = .000) and tumor involvement (p = .002).Conclusions and significance: A hard-textured tumor with limited mobility mass in the parotid gland should prompt the diagnosis of a schwannoma. Tumors involving main trunk usually lead to unsatisfactory facial nerve outcomes. Facial nerve preservation should always be essential, and stripping surgery or intracapsular enucleation could be the preferred surgical methods of choice.

Dual approach for large mediastinal tumors in the thoracic outlet: transmanubrial osteomuscular sparing approach and video-assisted thoracoscopic surgery

BackgroundSelecting the proper surgical approach for mediastinal tumors in the thoracic outlet is difficult. Video-assisted thoracoscopic surgery is ideal because of the less invasiveness; however, it is often difficult to resect tumors only by video-assisted thoracoscopic surgery due to the poor visualization of the cranial side of tumors. We report two successfully treated cases by using a dual approach consisting of the transmanubrial osteomuscular sparing technique and video-assisted thoracoscopic surgery for aiming both the less invasiveness and the good visualization of the cranial side of tumors.Case presentationsWe present two resected cases of the mediastinal tumor in the thoracic outlet. The first case was a 28-year-old woman and the second case was a 37-year-old man. They had a mediastinal tumor in the thoracic outlet which was detected on the roentgenogram. A definitive preoperative diagnosis was unavailable. The surgical resection was started with video-assisted thoracoscopic surgery in the both cases. After the dissection of the caudal side of the tumor, the dissection of the cranial side was judged to be difficult and risky because the tumor was located adjacent to major vessels and the good visualization of this side couldn’t be acquired. Therefore, the transmanubrial approach was sequentially performed and complete resection was safely achieved. Postoperatively, although transient Horner syndrome appeared in both cases, they recovered from this syndrome and were discharged. The final diagnosis was schwannoma for both cases. Neither of the cases had any functional restriction of the upper extremity.ConclusionsThis dual approach for mediastinal tumors in the thoracic outlet is useful in terms of safety and lower invasiveness.

Primary Adenocarcinoma of Jejunum: A Case Report

Malignancy of small intestine is a very rare entity. Duodenum is the most common site for intestinal malignancy. The lesions present with stricture mostly. Small intestinal strictures distal to the duodenum are relatively inaccessible by endoscopy. This leads to difficulty in definitive preoperative diagnosis. The symptoms in case of jejunal malignancy are very nonspecific and a high index of suspicion is required for diagnosis.

Difficult preoperative definitive diagnosis of adenoid cystic carcinoma in the parapharyngeal space: A case report

Difficult preoperative definitive diagnosis of adenoid cystic carcinoma in the parapharyngeal space: A case report

Vagal nerve schwannoma: a rare case from Border Security Force Composite hospital

Cervical vagal schwannoma is an extremely rare entity, slow growing, solitary, asymptomatic benign neck mass associated with vagus nerve. Definitive pre-operative diagnosis may be difficult and investigations such as fine needle aspiration biopsy (FNAB) have low specificity. Surgical excision is the treatment of choice. We describe a 26-year-old female presenting as right neck mass who underwent surgery. Magnetic resonance imaging was done, and patient was operated under general anaesthesia. Intraoperatively, the tumour was found to be originating from the vagus nerve. Final histopathology confirmed our preoperative suspicion of vagal nerve schwannoma. Vagus nerve schwannomas should be distinguished from other tumours that arise in the neck before planning surgery, to minimize the risk of nerve injury. A careful surgical technique is mandatory for tumour clearance and to reduce postoperative complications.

Endoscopic Ultrasound in the Diagnosis of Pancreatoduodenal Groove Pathology: Report of Three Cases and Brief Review of the Literature.

The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy.We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, real-time procedures, such as fine-needle aspiration.

Association of Preoperative Diagnosis with Clinical Yield of Muscle Biopsy.

Background: Muscle biopsy is a common diagnostic marker for myopathy assessment; however, it has a relatively low pathologic yield of less than 60%. Additionally, both diagnostic and non-diagnostic muscle biopsies can provide guidance for treatment, i.e, provide therapeutic usefulness.Purpose: We designed a study to determine if having a documented definitive preoperative differential diagnosis would affect the pathologic yield and therapeutic usefulness of muscle biopsies for myopathy. Methods: This was a retrospective, single institution chart review of 106 consecutive muscle biopsies in adult patients, which looked at the presence or absence of a definitive preoperative differential diagnosis and relation to diagnostic yield and therapeutic usefulness of muscle biopsies. Results: Of 106 muscle biopsies, 50 biopsies (47%) had a definitive preoperative differential diagnosis, 52 biopsies (49%) returned definitive pathology, and 93 biopsies (88%) provided therapeutic information. The presence of a documented differential diagnosis increased the odds of pathologic yield by 3.73 (p-value < 0.01) and therapeutic usefulness by 3.40 (p-value 0.08). If pathology was diagnostic then the therapeutic usefulness of the biopsy was 4.54 times more likely (p-value < 0.01). Conclusion: Documentation of a definitive preoperative differential diagnosis, when pursuing muscle biopsy for myopathy, is associated with an increased pathologic diagnostic yield. Definitive pathology was associated with an increase in the therapeutic usefulness of the muscle biopsy.

Ultrasound findings in extragenital endometriosis.

We present a report on ultrasound findings in extragenital endometriosis and a literature review accompanied by illustrations. Intestinal endometriosis should be considered in female patients of reproductive age who present with constipation, gastrointestinal bleeding, nausea, vomiting, cramp-like abdominal pain, diarrhoea and pelvic pain. Although definitive preoperative diagnosis of endometriosis is difficult, clinical suspicion and appropriate imaging might prevent extensive surgical procedures with higher morbidity. Contrast-enhanced ultrasound is an efficient non-invasive imaging method without any radiation exposure that supports the early diagnosis of intestinal endometriosis and may help assess the vascularization of endometriotic lesions within the distinct layers of the intestinal wall.

Laparoscopic treatment of intestinal obstruction due to a vitelline vascular remnant and simultaneous appendicitis: a case report

BackgroundThe presence of a vitelline vascular remnant is rare, and definitive preoperative diagnosis is difficult. We herein describe a case of intestinal obstruction caused by a vitelline vascular remnant with mild chronic appendicitis successfully diagnosed and treated with laparoscopic surgery.Case presentationA 14-year-old male was admitted to our hospital with sudden-onset right lower abdominal pain and vomiting. A blood test on admission revealed slight leukocytosis. Computed tomography scan showed that the appendiceal wall was enhanced and thickened. Although the ileum was slightly dilated and ascites was present at the recto-vesical pouch, these were thought to be inflammatory changes secondary to appendicitis. Laparoscopic surgery was performed using three trocars. Strangulated small bowel obstruction caused by a band connecting the right medial umbilical fold to the ileal mesentery was found intraoperatively. After reduction, neither ischemic change of the small intestine nor Meckel’s diverticulum was detected. The appendix was slightly inflamed, and serous ascites was present at the recto-vesical pouch; therefore, appendectomy was also performed. The patient was discharged on postoperative day 4 without complications. Pathological examination revealed that the band consisted of blood vessels, and it was diagnosed as a vitelline vascular remnant. The appendix included fecal stones and showed chronic inflammatory change histologically; the patient was thus diagnosed with chronic appendicitis.ConclusionsDefinitive preoperative diagnosis of a vitelline vascular remnant, especially with coexisting appendicitis, might be difficult. Laparoscopic surgery might be useful for patients who demonstrate unusual symptoms because it allows for simultaneous diagnosis and treatment.

The diagnostic value of splenectomy in patients without a definitive preoperative diagnosis

BackgroundThe purpose of this study was to describe the diagnostic value and therapeutic benefit of diagnostic splenectomy. MethodsRetrospective review was performed of patients undergoing splenectomy with an unknown diagnosis (UD), a hematologic malignancy (HM) or idiopathic thrombocytopenic purpura. Surgical indications and postoperative outcomes were evaluated. Results113 splenectomy patients were identified. Of the UD patients undergoing splenectomy, 46% (n = 16) received a definitive diagnosis postoperatively. A change in diagnosis occurred in 12% (n = 4) of HM patients. Complete symptom relief was observed more often in UD patients who received a definitive diagnosis after splenectomy 69% (n = 11), compared to the 47% (n = 9) who did not receive definitive diagnosis postoperatively. ConclusionsThe diagnostic ability of splenectomy was 46% when the diagnosis was unknown preoperatively. Additionally, a majority of patients experienced relief of symptoms postoperatively. Splenectomy may be a useful diagnostic and therapeutic tool in select UD and HM patients.

Excision of mucinous cystadenoma of pancreas is safe and effective: a case report

Background: Pancreatic cysts are frequently detected incidentally, and a definitive preoperative diagnosis remains challenging. Benign cystic lesions have a very high cure rate unless malignant change supervenes. Simple excision of benign cysts of the pancreas is safe and effective. Case presentation: We present a 31-year-old woman with a 3-year history of an enlarging symptomatic benign pancreatic mucinous cystadenoma, which was misdiagnosed radiologically as a pancreatic serous cystadenoma or a mesenteric cyst. This was managed safely by excision and resection with a distal pancreatectomy that was avoided. Conclusions: Excision of benign mucinous cystadenoma of the pancreas is safe and effective, and surveillance for recurrence is not necessary.

Role of Alvarado score and biological indicators of C-reactive protein, procalicitonin and neopterin in diagnosis of acute appendicitis.

The determination of a definitive preoperative diagnosis of acute appendicitis (AA) remains a challenge; however, delays in diagnosis increase complication rates. The aim of this study was to investigate the contribution of the Alvarado score (AS) alone and the AS combined with the use of the biological indicators of C-reactive protein (CRP), procalcitonin (PCT) and neopterin (NP) in the diagnosis. Serum was collected from 100 patients who were admitted to the general surgery clinic of Istanbul University, Cerrahpasa Medical Faculty between March 4, 2014 and July 29, 2015 with the pre-diagnosis of AA and who agreed to take part in the study. The serum samples were stored at -70°C. The patients were divided into 2 groups: AA-positive (n=60) and AA-negative (n=40). The AA positive group was divided into subgroups of complicated (n=11), uncomplicated AA (n=49) and the AS, CRP, PCT, NP levels were compared. The study population consisted of 45 men (45%) and 55 women (55%), with a mean age of 32.8+-13.7 years (range: 18-92 years). There was no significant difference between the groups in age and gender. There were 24 patients with an AS ≤4 (3 had surgery), 35 patients with an AS of 5-7 (22 had surgery), and 41 patients with an AS of 8-10 (38 had surgery). Three of the 63 patients who underwent surgery were diagnosed with a normal appendix. The serum CRP, PCT, and NP measures were found to be inadequate to make an AA diagnosis alone, these values increased the sensitivity and specificity of the AS. The biological indicators were also significant in differentiating between the complicated and uncomplicated AA groups (p<0.05). Although the AS is useful, additional testing and clinical approaches are valuable to inform the diagnostic procedure. When considered alone, serum CRP, PCT and NP values are insufficient for a diagnosis of AA. However, they increased the diagnostic value of the AS and can be helpful in distinguishing complicated AA cases.

Mucocele of the appendix: A case report and review of literature

Mucocele represents mucinous dilation of the lumen of vermiform appendix resulting from obstruction or increase secretion. It is a rare disease with an incidence of 0.2–0.7% of all appendectomies and 8–10% of all appendiceal tumours. The clinical presentation is atypical with most cases usually asymptomatic. Mucocele of the appendix indicates dilation of the appendix lumen irrespective of the aetiology. Four types of appendiceal mucocele are defined by the cause of obstruction: retention cysts, epithelial hyperplasia, mucinous cystadenoma and mucinous cystadenocarcinoma. Mucocele of the appendix is a rare condition of the appendix that requires high index of suspicion for a definitive preoperative diagnosis. The treatment for appendiceal mucocele is typically surgical resection. We report a case of a 37-year-old woman with recurrent right iliac fossa pain of 20 years duration. Abdomen was full, moved with respiration with a positive pointing sign. There was marked right iliac fossa tenderness with rebound tenderness and guarding. She had an abdominopelvic ultrasonography that revealed features of acute appendicitis. She had surgery with intraoperative finding of marked distension of the appendix from the tip to the base with necrosis at the base, a right hemicolectomy was done.

Clinical trends and management outcome of primary intestinal lymphoma

Background: Primary gastrointestinal lymphomas are the most common type of primary extra nodal lymphomas. In particular, primary intestinal lymphomas constitute about 25-40% of all gastrointestinal lymphomas. Our aim in this study is to find out the clinical patterns and surgical outcome in management of patients with primary intestinal lymphoma.Methods: A retrospective study at Sohag University Hospital from January 2013-to February 2017, included 17 cases, diagnosed histopathologically as primary intestinal lymphoma and subjected to surgical treatment. Demographic data, clinical presentations and management outcome were analyzed.Results: Seventeen consecutive patients with primary intestinal lymphoma, presented mainly by abdominal pain and abdominal mass. The definite preoperative diagnosis was detected only in 7 patients (41%) via preoperative histopathologic biopsy (3 by CT guided biopsy, 2 via diagnostic laparoscopy and remaining 2 by lower endoscopic biopsy). The other 10 patients (59%) were discovered incidentally during laparotomy. Radical resection was performed to 11 cases (65%), while palliative resection was employed to the remaining 6 cases. All patients received postoperative adjuvant chemotherapy. Two patients were lost to follow up, while the remaining investigated 15 cases, 3 of them were died (20%), 2 of the 3 total deaths presented with preoperative acute symptoms necessitating urgent laparotomy.Conclusions: Primary intestinal lymphomas are commonly diagnosed incidentally during abdominal exploration and most of them presented with abdominal pain. Complete surgical resection followed by adjuvant chemotherapy seems to be effective treatment in most cases. Surgical outcome of urgent cases of primary intestinal lymphoma carries poor prognosis.

Comparison of 68Ga-PSMA-11 PET-CT with mpMRI for preoperative lymph node staging in patients with intermediate to high-risk prostate cancer

BackgroundTo evaluate the diagnostic value of 68Ga-PSMA-11 PET-CT with multiparametric magnetic resonance imaging (mpMRI) for lymph node (LN) staging in patients with intermediate- to high-risk prostate cancer (PCa) undergoing radical prostatectomy (RP) with pelvic lymph node dissection (PLND).MethodsWe retrospectively identified 42 consecutive patients with intermediate- to high-risk PCa according to D′Amico and without concomitant cancer. Preoperative 68Ga-PSMA-11 PET-CT, pelvic mpMRI and subsequent robot assisted laparoscopic RP with PLND were performed in all patients.ResultsAmong 42 patients assessed, the preoperative PSA value, Gleason score, pT stage and intraprostatic PCa volume of patients with LN metastases were all significantly higher than those without metastases (P = 0.029, 0.028, 0.004, respectively). The average maximum standardized uptake value (SUV) of 68Ga-PSMA-11 PET-CT positive PCa of patients with or without LN metastases were 13.10 (range 6.12–51.75) and 7.22 (range 5.4–11.2), respectively (P < 0.001). 68Ga-PSMA-11 PET-CT and pelvic mpMRI had the ability of succeed on preoperative definite accurate diagnosis and accurate localization of primary PCa in all 42 patients. Fifteen patients (35.71%) had a pN1 stage. 51 positive LN were found. Both 68Ga-PSMA-11 PET-CT and pelvic mpMRI displayed brillient patient-based and region-based sensitivity, specificity, negative predictive value and positive predictive value. There was no statistical difference for the detection of LNMs according to the diameter of the LNMs between 68Ga-PSMA-11 PET-CT and mpMRI in this study.ConclusionsBoth 68Ga-PSMA-11 PET-CT and mpMRI performed great value for LN staging in patients with intermediate- to high-risk PCa undergoing RP with PLND. However, despite excellent performance of 68Ga-PSMA-11 PET-CT, it cannot replace mpMRI that remains excellent for lymph node staging.

Subependymomas Are Low-Grade Heterogeneous Glial Neoplasms Defined by Subventricular Zone Lineage Markers.

Subependymomas are infrequent, low-grade gliomas associated with the ventricular system and the spinal cord. Little is known about the origin and natural history of these slow-growing lesions. We identified all patients with pathologically proven subependymomas presenting to our institution between 1998 and 2016. We retrospectively reviewed clinical, radiographic, histologic, and surgical outcomes data in all patients who underwent surgical resection. Immunohistochemical analyses for cell lineage markers were performed. A total of 31 patients with pathologically proven subependymomas were identified. Of these, 7 asymptomatic lesions were discovered at autopsy and 24 symptomatic cases were treated surgically. There were 15 (48%) lateral ventricle tumors, 11 (35%) fourth ventricular tumors, and 5 (17%) spinal tumors. Symptomatic intracranial lesions most commonly presented with headaches and balance and gait abnormalities. Subependymomas had no distinguishing radiographic features that provided definitive preoperative diagnosis. At last follow-up, no patient treated surgically experienced recurrence. Immunohistochemical analyses demonstrated a diffusely GFAP-positive glial neoplasm with mixed populations of cells that were variably positive for Olig2, NHERF1, Sox2, and CD44. The Ki67 proliferation index was generally low (<1% in many of the tumors). Subependymomas demonstrate mixed populations of cells expressing glial lineage markers as well as putative stem cell markers, suggesting these tumors may arise from multipotent glial progenitors that reside in the subventricular zone. Definitive diagnosis requires surgical sampling. Although the clinical course of subependymomas appears benign, the inability to radiographically diagnose these lesions, and the possibility of an alternative malignant lesion support a low threshold for early and safe maximal resection.