Difficult Anatomic Locations Research Articles

Safety and effectiveness of balloon catheter-assisted ultrasound-guided percutaneous microwave ablation in difficult-site liver cancer

BackgroundBalloon catheter isolation is a promising auxiliary method for thermal ablation treatment of liver cancer. We aimed to explore the safety and effectiveness of balloon catheter isolation-assisted ultrasound-guided percutaneous microwave ablation (MWA) in treating liver cancer in difficult anatomical locations. MethodsData of 132 patients with 145 difficult-site liver cancer treated with ultrasound-guided percutaneous MWA were retrospectively analyzed. Participants were classified into the isolation (n = 40) and non-isolation (n = 92) groups based on whether the patients were treated using a balloon catheter prior to ablation. The major complication rates, local tumor residuals (LTR), and tumor follow-up for local tumor progression (LTP) at 6 and 12 months post-ablation were compared between the two groups. ResultsThe rates of major postoperative complications did not significantly differ between the isolation and non-isolation groups (2.5% vs. 4.3%, P = 0.609). The postoperative LTR rates were significantly different between the isolation and non-isolation groups (4.8% vs. 17.5%, P = 0.032). Balloon catheter isolation [odds ratio (OR) = 0.225, 95% confidence interval (CI): 0.085-0.595, P = 0.009] and tumor diameter (OR = 2.808, 95% CI: 1.186-6.647, P = 0.019) were identified as independent factors influencing LTR rate. The cumulative LTP rates at 6 and 12 months after ablation showed no significant differences between the isolation and non-isolation groups (2.6% vs. 7.9%, P = 0.661; 4.9% vs. 9.8%, P = 0.676, respectively). Cox proportional hazards regression analysis showed that tumor diameter was an independent risk factor for cumulative LTP rate (OR = 3.445, 95% CI: 1.406-8.437, P = 0.017). ConclusionsBalloon catheter isolation-assisted MWA was safe and effective in the treatment of difficult-site liver cancer. Additionally, tumor diameter significantly influenced LTR and LTP rates after ablation.

Laparoscopic Ultralow Anterior Resection Using a New Articulating Device.

Laparoscopic surgery offers several advantages, but it can be challenging to perform in confined spaces, such as the narrow and deep pelvis, due to poor vision and instrument collisions. Conventional laparoscopic instruments are rigid and straight, which can restrict optimal access to the target organ. Although the use of robotic surgical platforms with flexible wrists has significantly reduced movement restrictions and surgeon fatigue, their high cost remains a barrier to widespread adoption. Recent technological advancements in laparoscopic instruments have led to the development of an articulating flexible hand-held device that enables greater dexterity and easier access to difficult anatomical locations. This technology has the potential to improve surgical outcomes by using multiple degrees of freedom to perform complex surgical procedures with greater precision. The ArtiSential® product line comprises over 30 end-effectors, such as scissors, hooks, and graspers. The benefits of this device are evident throughout the total mesorectal excision, especially when approaching the left lateral side of the mesorectum (the side opposite the surgeon) or the deepest part of the pelvis around the levator ani muscle. The Samsung Medical Center Institutional Review Board approved this study (2022-01-174). A 79-year-old male with rectal cancer located 9 cm from the anal verge underwent an laparoscopic ultralow anterior resection using ArtiSential®. There were no intraoperative complications. The pathologic results showed that the tumor was at pT3N0 stage. The patient was discharged without any complications. The articulating device can be effectively used for laparoscopic surgery, but has some challenges related to the bulky handpiece and learning curve. A multicenter prospective cohort study to compare the outcomes of articulating laparoscopic surgery and robotic surgery for patients with rectal cancer is oncoing (clinicaltrials.gov number: NCT05566249).

Combined Endo-Laparoscopic Surgery (CELS) for the management of complex colorectal lesions

Detection of colon polyps is common and is expected in 20–30 % of screening colonoscopies. As the number of colonoscopies performed increases, the detection of advanced and difficult to resect polyps will also rise. These polyps tend to be larger, greater than 2 cm, have flat morphology, and are in difficult anatomic locations behind haustral folds or at sharp flexures of the colon. Advanced endoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are useful to remove these polyps. However, many polyps remain unresectable with these techniques. Combined endoscopic laparoscopic surgery (CELS) has shown to be an effective technique to facilitate safe removal of complex polyps. CELS encompasses a variety of techniques including laparoscopic assisted ESD/EMR and laparo-endoscopic full thickness excisions (FLEX). Success rate of CELS ranges from 70 to 100 %, with less than 5 % conversion to colectomy. Perioperative outcomes boast shorter hospital length of stay, with low rates of serious post-op complications when compared to colectomy. Malignancy rate after CELS in appropriately selected patients is low, ranging from 1.6 %-10 % of cases. Polyp recurrence rate after CELS is also low, usually less than 10 %. Use of CELS for early-stage cancers remains controversial but maybe adequate in appropriately selected patients. Further evaluation and long-term studies are needed to study its efficacy in cases of known cancer. The purpose of this review is to provide recommendations for use of CELS techniques, appropriate indications, describe technical tips, and review potential future applications.

A Case Report of Blunt Aortic Trauma in a Difficult Anatomic Location with Emergent Intraoperating Room Extracorporeal Membrane Oxygenation

A Case Report of Blunt Aortic Trauma in a Difficult Anatomic Location with Emergent Intraoperating Room Extracorporeal Membrane Oxygenation

Parapharyngeal Nodal Metastasis in Papillary Thyroid Carcinoma: Catching Early.

Metastasis to parapharyngeal space in papillary carcinoma of the thyroid is rare and often missed in routine clinical and radiological investigations. Although contrast CT /MRI can be done to locate the parapharyngeal lesion, the diagnosis of metastasis mostly deepened upon aspiration cytology, which is a challenge in difficult anatomical locations. Here, we have emphasized the management dilemma of parapharyngeal metastasis in papillary carcinoma of the thyroid. A 30-year-old female presented with multiple right-side neck swelling for two months. Ultrasonography of right thyroid showed TIRAD V and left thyroid showed TIRAD II. Aspiration cytology of the right thyroid showed Bethesda III and aspiration cytology revealed thyroid follicles. Due to the diagnostic ambiguity, contrast-enhanced CT scan was advised. It revealed a hypervascular lymph node in the parapharyngeal space besides multiple right cervical lymph nodes and later changed the treatment plan. - Metastasis to parapharyngeal space in Papillary carcinoma of the thyroid is rare and often missed on routine evaluation. Contrast-enhanced CT/MRI can be added as a primary investigation in challenging cases of suspicious malignancy of the thyroid.

Efficacy and safety of laparoscopic liver resection for hepatocellular carcinoma in segment 8: a propensity score-matched two-center study.

The safety and efficacy of laparoscopic liver resection (LLR) have been reported worldwide. However, those of LLR for tumors located in Couinaud's segment 8 are not sufficiently investigated. We retrospectively analyzed 108 patients who underwent liver resection for hepatocellular carcinoma (HCC) in segment 8 at Kobe University Hospital and Hyogo Cancer Center between January 2010 and December 2021. The patients were categorized in LLR and open liver resection (OLR) groups, and 1:1 propensity score matching (PSM) was performed to compare surgical outcomes between the groups. Forty-seven and 61 patients underwent LLR and OLR, respectively. After PSM, each group contained 34 patients. There was no significant difference in operation time between the groups (331min vs. 330min, P = 0.844). Patients in the LLR group had significantly less blood loss (30mL vs. 468mL, P < 0.001) and shorter length of postoperative hospital stay (10days vs. 12days, P = 0.015) than those in the OLR group. There was no significant difference in the occurrence of postoperative complications between the groups (12% vs. 9%, P = 0.690). Further, the 1-year cumulative incidence of recurrence was not significantly different between the groups (16% vs. 19%, P = 0.734). The surgical outcomes and short-term prognosis of LLR were similar or better than those of OLR. LLR could be an effective and safe procedure, even for lesions located in segment 8, which is considered a difficult anatomical location for LLR.

The successful surgical removal of a massive maxillary palatine osteoma in a dog

AbstractA 1.5‐year‐old, spayed, female labrador x kelpie presented with a massive solitary palatine osteoma. En bloc excision required excision of palatine, maxillary and ventral vomer bone. The subsequent defect was closed with a combination of a left angularis oris buccal mucosal interpolation flap, right buccal mucosal rotational flap and rostral advancement of the remaining soft palate. The procedure was tolerated by the patient, with no major complications from the surgery. Histopathological examination of the excised tissue indicated complete excision of the osteoma. At the time of the publication, no recurrence had occurred, and the owners considered the procedure to provide excellent post‐operative results. The use of these soft tissue techniques allowed complete excision of the neoplasia from this difficult anatomic location in a single procedure without the need for revision surgery.

35389 Polidocanol: A review of clinical uses

Polidocanol is a nonionic detergent sclerosant that disrupts the intimal lining of blood vessels by inducing a negative charge on endothelial surfaces. Ultimately, thrombotic occlusion at the site of endothelial damage gives rise to endovascular fibrosis and effective obliteration of the target vessel. Polidocanol is FDA-approved for the treatment of uncomplicated spider veins and reticular veins in the lower extremity. Despite its limited indication, there are numerous reports of polidocanol’s use for a variety of off-label conditions. The purpose of our study was to describe the dermatologic clinical uses of polidocanol and to characterize efficacy and adverse effects associated with its various applications. In a review of literature searchable on PubMed from 2004 to 2020, polidocanol has shown efficacy in the treatment of varicose veins, hemangioma, mucocele of the minor salivary gland, pyogenic granuloma, lymphangioma circumscriptum, digital mucus cyst, mixed skin ulcer, cutaneous focal mucinosis, seroma, glomovenous malformation, acne cyst, and lymphocele. Commonly reported complications of polidocanol therapy include pain, edema, ecchymosis, ulceration, tissue necrosis, and thrombosis of the treated vein. Although not always first-line therapy, polidocanol may be chosen as a treatment method for off-label conditions due to its low cost, ease of use, and adaptability to difficult anatomic locations.

Post-FDA approval "real-world" safety profile of different steerable sheaths during catheter ablation: A Food and Drug Administration MAUDE database study.

Radiofrequency ablation is a universally accepted therapy for various atrial and ventricular arrhythmias.1 During radiofrequency ablation, catheter position and stability are essential and directly affect procedure outcomes. A steerable sheath enables the operator to manipulate the catheter effectively and access difficult anatomical locations while maintaining the catheter’s steadiness. There are several commercially available steerable sheaths; the most commonly used are as follows: Agilis (Abbott, St Paul, MN), a traditional steerable sheath; and Vizigo, a newly available bidirectional guiding sheath (Biosense Webster Inc., Irvine, CA).

28414 Recurrent melanoma treated with talimogene laherparepvec in combination with radiation therapy: A case report

An 88-year-old female presented with an erythematous, rapidly enlarging 5 cm mass involving her right eyelid. Biopsy revealed this to be a recurrence of her melanoma initially biopsied a year prior. The original lesion was a 1.5 cm ulcerated desmoplastic melanoma with a Breslow thickness of 7.06 mm. Final pathology was stage pT4b pN0. Wide local excision was performed with clear margins and the sentinel lymph node biopsy was negative. No evidence of metastasis was found on repeat imaging. Given the high propensity for aggressive local disease seen in pure desmoplastic melanomas and the difficult anatomic location, treatment with Talimogene laherparepvec (T-VEC) and radiation was pursued given surgical intervention would have required enucleation.

Oncoplastic surgery: A suitable alternative to conventional breast conserving surgery in low - Middle income countries; a retrospective cohort study

IntroductionBreast Conserving Surgery (BCS) with whole breast radiation is now standard of care as a safer alternative to Mastectomy in terms of loco-regional recurrence and long-term survival. Despite this, a frequent pitfall of conventional BCS is positive surgical margins and need for second surgery with a reported frequency of 12–59 % in literature. Oncoplastic Surgery can be a safer, more cost effective alternate to conventional BCS owing to its higher rate of negative surgical margins (4–6% vs 12–59 %) and better cosmetic results. We aim to prove utility of Oncoplastic surgery for Low-Middle income countries. ObjectiveThe aim of this study was to determine Oncoplastic Surgery as a more appropriate alternative to Conventional Breast Conserving Surgery for Low-Middle Income countries in terms of its lower positive margins and re-excision rates. MethodologyA retrospective comparative single center study by reviewing patient's medical records from August 2016 to June 2020 was conducted. Rate of positive margins and re-excisions along with mean volume of resection specimen, mean tumor size and quadrant dealt by both surgical procedures were compared. ResultsOut of 421 patients 249 patients underwent oncoplastic surgery and were compared with 173 patients who had conventional breast conserving surgery. Positive margins were seen in 5 patients (2 %) in OPS group whereas in 31 (17.9 %) patients in BCS group (p value < 0.001). Therefore, 2 from OPS group and 17 from BCS group underwent re-excision (p value < 0.002).None in OPS group while 7 out of 17 patients in BCS group underwent mastectomy as second procedure. Mean tumor size in OPS group was 2.26 cm ± SD 1.66 and in BCS group was 1.94 cm ± SD 1.28. Majority of Lobular carcinoma and Ductal carcinoma in-situ, multifocal, upper inner and central quadrant tumors and those unresponsive to neo-adjuvant therapy were treated by Oncoplastic techniques. ConclusionOncoplastic surgery has shown promising results as a safer tool to deal with large, complex tumors, lesions in difficult anatomical locations, multifocal or progressing on neo-adjuvant therapy. With its low Re-excision rates, it is a better alternative to traditional Breast Conserving approach for overburdened and resource limited health care system of Low-Middle Income countries. Multi-center, prospective trials are needed to determine its feasibility.

Intraoperative Scintigraphy With Portable Gamma Camera for the Localization of Interaortocaval Paraganglioma.

A 15-year-old adolescent girl diagnosed of interaortocaval paraganglioma with a positive 123I-MIGB SPECT/CT and 1 unsuccessful prior surgery was operated on with the assistance of a handheld gamma camera. Once the lesion was located and removed, 2 images were taken, one of the surgical field (without 123I-MIGB uptake) and another of the tumor ex vivo (with high 123I-MIGB uptake), confirming that the lesion had been satisfactorily excised. This case highlights the use of a portable gamma camera as a useful tool to locate this rare tumor, with a SPECT/CT positive for 123I-MIGB and a difficult anatomical location suspected.

How to Perform a High-Quality Endoscopic Submucosal Dissection

How to Perform a High-Quality Endoscopic Submucosal Dissection

Surgical treatment of retroperitoneal neuroblastoma in a 14-month-old child

Introduction. Neuroblastoma is the most common malignant embryonic extracranial solid tumor in childhood having a high mortality rate. While treating neuroblastoma, it is extremely important to follow international protocols with their staging systems and groups of risk. Surgical treatment is a compulsory approach, but in some cases it is extremely difficult, and it involves significant risks. However, in some cases, radical removal of the tumor can cure patients without chemotherapy.Material and methods. The article presents a clinical case of 14-month-old child with neuroblastoma of stage 3 and difficult anatomical location after 2 courses of polychemotherapy by NB-2004 protocol. The child had subradical resection of an extensive tumor in the retroperitoneal space and nephrectomy on the right. The authors also describe specific moments during surgery, problems which their faced during child’s treatment as well as follow-up examinations in the postoperative period.Results. Follow-up examinations did not reveal any signs of disease recurrence. Catamnesis lasted for 56 months. The child is in a good state; she is active, attends a nursery school.Conclusion. The discussed case demonstrates that a successful radical surgical removal of neuroblastoma of difficult anatomic location may have good outcomes without adjuvant postoperative therapy.

Management of Cardiac Paragangliomas

Primary cardiac tumors are uncommon with 75% being benign and 25 % malignant. Most benign tumors are relatively easy to manage surgically. There are however, benign tumors that can present management and technical challenges for surgical care. Paraganglioma is one of these tumors. These tumors may present as cathecholamine producing tumors requiring pre-operative preparation for safe resection and tend to be large and in difficult anatomic locations to remove. This manuscript details our approach to these tumors. Primary cardiac tumors are uncommon with 75% being benign and 25 % malignant. Most benign tumors are relatively easy to manage surgically. There are however, benign tumors that can present management and technical challenges for surgical care. Paraganglioma is one of these tumors. These tumors may present as cathecholamine producing tumors requiring pre-operative preparation for safe resection and tend to be large and in difficult anatomic locations to remove. This manuscript details our approach to these tumors.

Prognostic Factors After Neoadjuvant Imatinib for Newly Diagnosed Primary Gastrointestinal Stromal Tumor

IntroductionNeoadjuvant imatinib (Neo-IM) therapy may facilitate R0 resection in primary gastrointestinal stromal tumors (GISTs) that are large or in difficult anatomic locations. While response to preoperative tyrosine kinase inhibitors is associated with better outcome in metastatic GIST, little is known about prognostic factors after Neo-IM in primary GIST. Study DesignPatients with primary GIST with or without synchronous metastases who underwent Neo-IM were retrospectively analyzed from a prospective maintained institutional database for Response Evaluation Criteria in Solid Tumors (RECIST), tumor viability, and mitotic rate. Overall survival (OS) was estimated by Kaplan-Meier and compared by log-rank test. Cox proportionate hazard models were used for univariate and multivariate analysis. ResultsOne hundred and fifty patients were treated for a median of 7.1 months (range 0.2–160). By RECIST, partial response, stable disease, and progressive disease were seen in 40%, 51%, and 9%, respectively. By pathologic analysis, ≤ 50% of the tumor was viable in 72%, and the mitotic rate was ≤ 5/50HPF in 74%. On multivariate analysis, RECIST response and tumor viability were not associated with OS, while post-treatment high mitotic rate (hazard ratio (HR) for death 5.3, CI 2.3–12.4), R2 margins (HR 6.0, CI 2.3–15.5), and adjuvant imatinib (HR 0.4, CI 0.2–0.9) were (p < 0.05). Five-year OS was 81 vs. 38% for low vs. high mitotic rate; 81, 59, and 39% for R0, R1, and R2 margins; and 75 vs 61% for adjuvant vs. no adjuvant imatinib therapy (p < 0.05). ConclusionsIn primary GIST undergoing Neo-IM therapy, progression was uncommon, but substantial down-sizing occurred in the minority. High tumor mitotic rate and incomplete resection following Neo-IM were associated with poor outcome, while adjuvant imatinib was associated with prolonged survival.

INNV-07. THE ROLE OF BIOPSY IN MOLECULAR DIAGNOSIS OF DIFFUSE INTRINSIC PONTINE GLIOMA PATIENTS

Abstract INTRODUCTION Diffuse intrinsic pontine glioma (DIPG) is an aggressive and fatal pediatric brain tumor. Due to its difficult anatomic location and infiltrative nature, DIPGs are not surgically resectable and more than 90% of children die within two years of diagnosis. Historically, standard of care has consisted of clinical and radiological diagnosis followed by palliative radiation for symptomatic relief. Although tumor biopsy is not necessary for diagnosis, there is debate as to whether the procedure provides benefits that outweighs its risk. Recent studies have proposed that biopsy-driven molecular characterization of these tumors can inform prognosis and identify potential treatment targets that could lead to clinical breakthroughs. METHODS This study was a retrospective chart review of 26 patients treated for a DIPG diagnosis between July 1998 and July 2019 at Cohen Children’s Medical Center. We compared outcomes of biopsied vs. non-biopsied DIPG patients through quantitative data analyzing the number and types of treatment given. We analyzed post-surgical data regarding safety of DIPG biopsies which were performed by optical stereotactic needle biopsy or robot-assisted stereotactic biopsy procedures. RESULTS There were no permanent biopsy complications in any patient and biopsy did not delay treatment as average hospital stay was 1.5 days. All biopsies collected sufficient material for next generation sequencing analysis and revealed targetable mutations for available clinical trial therapies. 67% of patients were subsequently enrolled in clinical trials, 75% of which required biopsy results for enrollment. MGMT promoter methylation assay results in all tested DIPG biopsy cases indicated resistance to temozolomide, the most common treatment agent given to non-biopsied patients. CONCLUSION Biopsy of DIPG tumors is a safe and accurate procedure that does not delay treatment and identifies molecular targets for individualized therapy. The role of biopsy in DIPG patients allows for molecular characterization of DIPG tumors which informs and increases treatment options.

EUS-Guided FNA: Tips and Tricks

AbstractThe development of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) technique has been proved to be a great armamentarium to gastroenterologists and other branches including surgery, oncology, hepatology, pulmonary medicine, and internal medicine. EUS-FNA is quite safe and allows tissue acquisition from difficult anatomical locations like retroperitoneum, pancreas, and mediastinum. The current review discusses basic techniques steps of EUS-FNA including tips and tricks. Also, false negative FNA and EUS-FNA in difficult locations are discussed. We also discussed about EUS-guided fine needle biopsy.

A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions.

Introduction of the full-thickness resection device (FTRD) has allowed endoscopic resection of difficult lesions such as those with deep wall origin/infiltration or those located in difficult anatomic locations. The aim of this study is to assess the outcomes of the FTRD among its early users in the USA. Patients who underwent endoscopic full-thickness resection (EFTR) for lower gastrointestinal tract lesions using the FTRD at 26 US tertiary care centers between 10/2017 and 12/2018 were included. Primary outcome was R0 resection rate. Secondary outcomes included rate of technical success (en bloc resection), achievement of histologic full-thickness resection (FTR), and adverse events (AE). A total of 95 patients (mean age 65.5 ± 12.6year, 38.9% F) were included. The most common indication, for use of FTRD, was resection of difficult adenomas (non-lifting, recurrent, residual, or involving appendiceal orifice/diverticular opening) (66.3%), followed by adenocarcinomas (22.1%), and subepithelial tumors (SET) (11.6%). Lesions were located in the proximal colon (61.1%), distal colon (18.9%), or rectum (20%). Mean lesion diameter was 15.5 ± 6.4mm and 61.1% had a prior resection attempt. The mean total procedure time was 59.7 ± 31.8min. R0 resection was achieved in 82.7% while technical success was achieved in 84.2%. Histologically FTR was demonstrated in 88.1% of patients. There were five clinical AE (5.3%) with 2 (2.1%) requiring surgical intervention. Results from this first US multicenter study suggest that EFTR with the FTRD is a technically feasible, safe, and effective technique for resecting difficult colonic lesions.

2148 A Mediastinal Abscess Due to Actinomcyes Odontolyticus Diagnosed by Endoscopic Ultrasound-Guided FNA

INTRODUCTION: Thoracic Actinomyces is a rare infection but potentially aggressive. It is difficult to diagnose most often requiring surgical debridement. Actinomyces species colonize the mucosa of the body with disease potentially related to barrier injury. CASE DESCRIPTION/METHODS: A 29 year old male with history of childhood asthma and recent dental extraction presented with odynophagia. He noted chest discomfort &amp; fevers. Physical exam revealed an obese male but was otherwise unremarkable. Oral exam was unrevealing for lesions. Labs noted a WBC of 16.8 u/L. CT Chest revealed a 5 × 2 × 2 cm posterior mediastinum collection (Figure 1) abutting the esophagus with mid and distal esophagitis. An EGD noted distal esophagitis, posterior extrinsic compression from 25 to 31 cm with a mucosal fistula at 27 cm with purulent drainage. Aspirated Esophageal contents were sent for culture. An IR Guided Drainage approach was not felt to be safe due to possibility of spinal injury. Patient underwent conservative treatment with PPI, Broad spectrum antimicrobial therapy. A repeat CT CAP revealed interval decreased size of mediastinal collection. Fluid cultures from endoscopy were negative. Testing for Coccidiomycosis, HIV, and Tuberculosis were negative. On Hospital Day 4, EGD and EUS was performed to evaluate the mediastinal abscess. EGD showed that the fistula had healed but there was esophageal rings and furrows; This was biopsied. The EUS noted a 1.5 × 2 cm Posterior Mediastinal Abscess. It was loculated and hard; A EUS guided FNA needle was used to obtain material for culture. Biopsies revealed &gt;100 Eosinophil’s per HPF, consistent with esophinophilic esophagitis. FNA culture noted Actinomcyes Odontolyticus. Treatment was tailored for Penicillin-based therapy. On Hospital Day 12 , Repeat CT Chest did not identify a mediastinal collection or evidence of esophageal leak and noted resolving mural thickening of the esophagus. DISCUSSION: Thoracic actinomyces was diagnosed in the setting of active eosinophilic esophagitis. It is possible that EOE predisposes to Actinomyces as Actinomyces is a commensal flora of GI tract and this could have spread to mediastinum directly due to barrier injury. Increasing availability of endoscopic modalities may provide more accessible diagnostic options, which will help in targeted treatment. We report a possible association of EOE and Actinomyces and also successful minimally invasive diagnosis of actinomyces in a difficult anatomical location.