En-bloc Excision Research Articles

A Clinical, Radiologic, and Immunopathologic Study of Five Periorbital Intraosseous Cavernous Vascular Malformations

To correlate the clinical, radiographic, histopathologic, and immunohistochemical features of 5 primary periorbital intraosseous cavernous vascular malformations. Retrospective interventional case series. Clinical and operative records and radiographic images were reviewed. Histopathologic slides were evaluated with hematoxylin-eosin, trichrome, and elastin stains. Immunohistochemical studies were performed with a spectrum of monoclonal antibodies directed at antigens of vascular cells. Three men and 2 women ranged in age from 36 to 64 years. Vision was unaffected and there was no proptosis or globe displacement. The slow-growing lesions measured 13-25 mm in greatest diameter (mean 16.4 mm). Computed tomographic studies revealed that 2 lesions were situated in the maxillary bone, 2 in the frontal, and 1 in the zygoma, all anteriorly and with circumscribed, lucent, honeycombed, or sunburst characteristics. Histopathologically the lesions were composed of cavernous or telangiectatic channels; 1 showed advanced fibrotic vascular involution. Immunohistochemistry demonstrated CD31/34 positivity for vascular endothelium and D2-40 negativity for lymphatic endothelium. A typically thin mural myofibroblastic cuff was smooth muscle actin positive, weakly calponin positive, and desmin negative. Glucose transporter-1 and Ki-67 were negative in the endothelium. Intraosseous vascular lesions resemble orbital cavernous venous malformations (not true hemangiomas), except that their vascular walls are thinner owing to the constraints imposed by neighboring bone spicules, which limit the amount of interstitium from which mural myofibroblasts can be recruited. The bony trabeculae conferred the honeycomb or sunburst appearances observed radiographically. En bloc excision of these lesions was successful and avoided complications (mean follow-up, 46 months).

Solitary Osteochondroma Arising from the Dorsal Vertebral Spinous Process

Introduction: Osteochondroma are benign tumors which arise from aberrant cartilage nodules within the periosteum. They can be either pedunculated or sessile and are more common in the extremities and rarely seen in spine. En-bloc excision is the preferred treatment.
 Case Report: We present a case of 20 year female, who came with a swelling and pain in lower back for two years which was diagnosed to be thoracic vertebra(D11) osteochondroma on x-ray and computed tomography. Excision biopsy was done and confirmed it to be osteochondroma. There has been no recurrence even after 16 months of follow up.
 Conclusion: Although rare, osteochondroma of the vertebra should be kept in mind as a differential diagnosis when evaluating mass in spine. En bloc excision should be performed.

Outcomes following attempted en bloc resection of cervical chordomas in the C-1 and C-2 region versus the subaxial region: a multiinstitutional experience.

Chordomas involving the mobile spine are ideally managed via en bloc resection with reconstruction to optimize local control and possibly offer cure. In the cervical spine, local anatomy poses unique challenges, limiting the feasibility of aggressive resection. The authors present a multi-institutional series of 16 cases of cervical chordomas removed en bloc. Particular attention was paid to clinical outcome, complications, and recurrence. In addition, outcomes were assessed according to position of tumor at the C1-2 level versus the subaxial (SA) spine (C3-7). The authors reviewed cases involving patients who underwent en bloc resection of cervical chordoma at 4 large spine centers. Patients were included if the lesion epicenter involved the C-1 to C-7 vertebral bodies. Demographic data and details of surgery, follow-up course, exposure to adjuvant therapy, and complications were obtained. Outcome was correlated with presence of tumor in C1-2 versus subaxial spine via a Student t-test. Sixteen patients were identified (mean age at presentation 55 ± 14 years). Seven cases (44%) cases involved C1-2, and 16 involved the subaxial spine. Median survival did not differ significantly different between the C1-2 (72 months) and SA (60 months) groups (p = 0.65). A combined (staged anteroposterior) approach was used in 81% of the cases. Use of the combined approach was significantly more common in treatment of subaxial than C1-2 tumors (100% vs 57%, p = 0.04). En bloc resection was attempted via an anterior approach in 6% of cases (C1-2: 14.3%; SA: 0%; p = 0.17) and a posterior approach in 13% of cases (C1-2: 29%; SA: 0%; p = 0.09). The most commonly reported margin classification was marginal (56% of cases), followed by violated (25%) and wide (19%). En bloc excision of subaxial tumors was significantly more likely to result in marginal margins than excision of C1-2 tumors (C1-2: 29%; SA: 78%; p = 0.03). C1-2 tumors were associated with significantly higher rates of postoperative complications (C1-2: 71%; SA: 22%; p = 0.03). Both local and distant tumor recurrence was greatest for C1-2 tumors (local C1-2: 29%; local SA: 11%; distant C1-2: 14%; distant SA: 0%). Statistical analysis of tumor recurrence based on tumor location was not possible due to the small number of cases. There was no between-groups difference in exposure to postoperative adjuvant radiotherapy. There was no difference in median survival between groups receiving proton beam radiotherapy or intensity-modulated radiotherapy versus no radiation therapy (p = 0.8). Compared with en bloc resection of chordomas involving the subaxial cervical spine, en bloc resection of chordomas involving the upper cervical spine (C1-2) is associated with poorer outcomes, such as less favorable margins, higher rates of complications, and increased tumor recurrence. Data from this cohort do not support a statistically significant difference in survival for patients with C1-2 versus subaxial disease, but larger studies are needed to further study survival differences.

Recurrent Giant Apocrine Hidrocystoma of the Eyelid : A Case Report

Apocrine hidrocystomas are small, asymptomatic, benign cysts commonly found in face. These tumors when in the region of the eyelids can cause significant functional and cosmetic morbidity despite their benign nature. Various modalities of treatment for such lesions have been enumerated in the literature. Here, we are describing a case of giant solitary recurrent apocrine hidrocystoma which is being managed by en-bloc excision with reconstruction of lower eyelid.

501 Incidence and Risk Factors for Sedation-Associated Complications in Gastrointestinal Endoscopy — Initial Data From the German Prosed Registry a Prospective, Multicenter Study by Members of the Working Group of Leading Hospital Gastroenterologists (Algk) in Germany

501 Incidence and Risk Factors for Sedation-Associated Complications in Gastrointestinal Endoscopy — Initial Data From the German Prosed Registry a Prospective, Multicenter Study by Members of the Working Group of Leading Hospital Gastroenterologists (Algk) in Germany

Recurrent primary lumbar vertebra chondrosarcoma: Marginal resection and Iodine-125 seed therapy.

Chondrosarcomas are uncommon in the spinal column. En bloc excisions with wide margins are of critical importance but not always feasible in spine. We report the outcome in a case of recurrent lumbar vertebral chondrosarcoma treated with marginal resection and iodine-125 seeds placed in the resected tumor bed.

Myoepithelial carcinoma of the ear: A rare case report and review of the literature

The aim of this study was to present a unique case report of myoepithelial carcinoma arising from the external auditory canal and presenting as a huge tympanomastoid mass along with a review of the literature. A 52-year-old woman presented with a large periauricular swelling of a 3-year duration with a recent increase in size over the last 3 months along with pain and bleeding from the mass. The patient was evaluated by clinical examination, haematological and biochemical tests, and computed tomographic and MRI scan of the tympanomastoid region. An incision biopsy was performed before definitive management was initiated. Computed tomographic scan and MRI were suggestive of a large tympanomastoid mass without any intracranial extension. The incisional biopsy report was suggestive of invasive adenocarcinoma. En-bloc excision of the mass including lateral temporal bone resection along with ipsilateral selective (levels I, II and III) neck dissection was performed under general anaesthesia. The resultant defect was reconstructed by a rotational scalp flap. Immunohistochemistry and histopathology of the excised specimen proved the diagnosis of myoepithelial carcinoma. After surgery, the patient was treated with adjuvant radiotherapy. At 1½ years of follow-up, the patient was doing fine, without any recurrence of disease. Myoepithelial carcinoma of the ear has rarely been reported in the literature. Histopathology along with immunohistochemistry is the mainstay of diagnosing of this unusual lesion. Meticulous planning and proper execution of optimum surgical excision is the primary treatment modality, which should be supplemented with radiation therapy. Long-term disease-free survival, although rare, can be achieved as in the present case report.

Chondrosarcoma of the chest wall: Single-center experience

chondrosarcoma is the most common primary tumor of the chest wall. We analyzed cases of chest wall chondrosarcoma to establish the presentation, diagnostic tools, surgical treatment, and outcome. this was a retrospective observational analysis of 45 patients who underwent surgery for chondrosarcoma. the mean age was 42.3 ± 8.5 years, and 57.8% patients were male. Symptoms were a painful chest wall mass in 91.1% of patients. Chest radiography and computed tomography, and biopsy were the diagnostic tools. The tumor was right-sided in 57.8% of patients. It was located in the lateral (71.1%), anterior (26.7%), or posterior (2.2%) chest wall. The mean tumor diameter was 7.6 ± 3.3 cm. Radical en-bloc excision was performed in all patients. Chest wall reconstruction was carried out using methylmethacrylate and Prolene mesh (42.2%), Prolene mesh alone (37.8%), and direct closure (20%). A muscle flap was used for soft tissue reconstruction in 11.1%. Complications were encountered in 6.7%. There was no operative mortality. Follow-up was complete in 66.7% of patients. The mean follow-up period was 3.7 ± 2.1 years. Local recurrences and late mortality occurred in 4.4%. surgery for chondrosarcoma can be performed with acceptable morbidity and mortality. Proper selection of patients and radical en-block excision of the tumor are the keys for successful treatment and better outcomes.

Isolated Caudate Lobe Resection for Huge Hepatocellular Carcinoma (10 cm or greater in diameter)

Isolated caudate lobectomy for huge hepatocellular carcinoma (HCC) (10 cm or greater in diameter) is a technically demanding surgical procedure that entails the surgeon's experience and precise anatomical knowledge of the liver. We describe our clinical experiences and evaluate the results of partial or total isolated caudate lobectomy for HCC larger than 10 cm in the caudate lobe. En bloc excisions combined with adjacent hepatic parenchyma (as part of extended hepatectomies) were excluded. Twenty-seven patients were included in the study (24 male, three3 female). Median age was 43 years (range, 18 to 81 years). All primary diagnoses were HCC. Twenty-one patients had surgical margins lesser than 1 cm. Tumor embolus within the main trunk of the portal vein was found in five patients by intraoperative ultrasound. Median operative time was 288 minutes (range, 160 to 310 minutes), and estimated intraoperative blood loss was 2260 mL (range, 200 to 7000 mL). Median blood transfusion was 1460 mL (range, 0 to 7200 mL). Postoperative morbidity rate was 44.4 per cent. There were no postoperative deaths. Overall survival rates at 1, 3, and 5 years were 80.2, 52.1, and 27.1 per cent, respectively. Nineteen patients (70.4%) had tumor recurrence as of the last follow-up. The recurrence lesion was treated in most of these patients. Isolated caudate lobectomy for huge HCC is a technically demanding but safe procedure, although the procedure is sometimes extremely difficult.

Costal exostosis with fungation: A rare presentation

Costal exostosis occurs either sporadically or as a manifestation of hereditary multiple osteochondromas (HMOs), a disorder that is inherited in an autosomal dominant manner. Costal exostosis may cause chest pain and, on rare occasions, result in intra-thoracic complications. We report a case of a 15-year-old boy with exostosis in the right anterior fifth rib, who presented with protruded painful skin lesions that had ulcerated over the last one month. He previously received a diagnosis of multiple exostoses. There was no evidence of a malignant change on histopathological analysis. Enbloc excision was done and there has been no recurrence to date. To the best of our knowledge, the present case is the only report of costal exostosis presenting as an extrathoracic chest wall ulcerating mass. The present report illustrates this rare clinical scenario and reviews the relevant literature.

Pleomorphic Rhabdomyosarcoma in upper limb in an adult

Rhabdomyosarcoma (RMS) is the most common form of soft tissue sarcoma in the first 2 decades of life, with a peak age incidence in very young children. Due to the rarity of adult RMS, information regarding its clinical and biologic characteristics is very limited. We report a case of pleomorphic RMS of upper extremity in a 50-year-old man. There was no metastasis of the tumor. The patient underwent surgery with enbloc excision of the tumor. Histopathological examination showed typical features of pleomorphic RMS composed of large polygonal pleomorphic cells with eosinophilic cytoplasm and plenty of large multinucleated tumor giant cells having bizarre nuclei. Postoperatively patient took radiotherapy. There was no recurrence of tumor with follow-up of 2 years.

A novel anchoring system for colonic stents: a pilot in vivo study in a porcine model

Colorectal stents have a proven role in colorectal cancer as palliative care or a bridge to surgery. However, their efficacy and anchoring to the tissue varies according to stent design with stent migration rates up to 50%. We present preliminary in vivo results of a new end-luminal anchoring system for stent fixation to the rectal canal. The aim was to assess the efficacy and safety of the stent using the anchoring system while subjecting the device to daily abdominal pressures related to daily activities in a porcine animal model. Ex vivo anatomical and physical studies were performed to improve the system's structure and safety. Four female pigs were followed for the acute and chronic (16weeks) period. Two animals were euthanized and underwent en-bloc pelvic visceral excision and histopathological examination. Device fixation time, animal behavior, device patency, anoscopic examination and histopathological features were assessed. Mean anchoring time was 13.83weeks (standard error±1.38weeks). One of the animals experienced early device expulsion with no complications. No obstruction was noted in any of the animals. Macroscopic examination revealed mild focal submucosal scarring in one animal and a normal examination in the other. Hematoxylin and eosin staining revealed mucosal ulceration and mixed inflammatory cell infiltrate, with no signs of granulomata, foreign body giant cell reaction or microabscess formation. A novel fixation device designed for long-term intrarectal implantation was well tolerated and maintained anal canal patency without migration. Larger studies are needed before its implementation in humans.

Clinical and pathological characteristics of ocular surface squamous neoplasia in an Asian population

In order to evaluate clinical and pathological characteristics of ocular surface squamous neoplasia (OSSN) in Asian population. Medical records were reviewed of 30 eyes of 30 Korean patients who underwent en-bloc excision and biopsy for tumors in the corneal and conjunctival epithelium in the suspicion of OSSN. Tumors developed predominantly in males (21/30 patients, 70%) at the mean age of 64.8 years (range: 39-82 years). Histologic examination revealed that 11 cases were squamous cell carcinoma (SCC), eight were conjunctival or corneal intraepithelial neoplasm (CIN) with dysplastic cells in the epithelium, eight simple hyperplasia, and three inflammatory lesions. The majority of SCC (9/11 eyes, 81.8%) involved the nasal conjunctiva and cornea, while one of eight eyes (12.5%) with CIN was located at the nasal side. Vascularization was combined in all eyes with SCC, in two of eight (25%) with CIN, in two of three with inflammation, and in none with hyperplasia. Both cornea and conjunctiva were involved in ten of 11 eyes (90.9%) with SCC, in six of eight (75%) with CIN, in two of eight (25%) with hyperplasia, and in two of three (66.7%) with inflammation. When classified based on clinical appearance, seven of 11 eyes (63.6%) with SCC were papilliform sessile masses, and four of eight (50 %) with CIN showed gelatinous growth onto the surface. All lesions were treated with en-bloc excision and cryotherapy. Recurrence occurred in seven out of 19 patients (36.8%) with SCC or CIN during the mean follow-up of 30.0 months-four patients with SCC and three with CIN. Hyperplasia or lesions with inflammation did not recur. The recurrence rate was not associated with histological diagnosis of a lesion. However, the use of the postoperative chemotherapy including topical mitomycin C or interferon α 2b had a significant negative correlation with the recurrence. In total, 36.7% of tumors in the corneal and conjunctival epithelium were SCC, and 26.7% were CIN. Recurrence occurred in 36.8% of patients with SCC or CIN after primary excision and cryotherapy. The use of postoperative chemotherapy was a significant factor negatively affecting the recurrence.

En bloc excision and reconstruction of the defect with pasteurized autograft for femoral primary malignant bone tumor in children

To evaluate the efficacy of femoral primary malignant bone tumors treated by limb salvage, with wide en bloc excision and reconstruction of the defect with recycled pasteurized autograft. From January 2008 to January 2011, 11 patients (7 males, 4 females), aged (11.0±2.5) years suffering from femoral primary malignant bone tumors were treated with en bloc excision and reconstruction of the defect with recycled pasteurized autograft. Ten patients were histopathologically diagnosed with high-grade osteosarcoma, and 1 with Ewing's sarcoma.According to the Enneking staging system, all patients were in Stage IIb. All patients were followed-up for 24-65(42±20) months and all showed bony union at the last follow-up. The length of tumor bone resection was (17.5±3.2) cm, the operation time was (180±35) min, the intraoperative blood loss was (1200±250) mL, and drainage volume was (650±125) mL. Local skin necrosis occurred in 1 patient (9.1%), which was resolved by debridement. Nonunion occurred in 3 patients (27.3%), who were treated by secondary iliac crest cancellous bone grafting.Pulmonary metastasis occurred in 1 patient (9.1%) who died 35 months post-operatively. According to the function assessment by the Enneking system, 5 patients had excellent results, 4 had good results, 1 fair and 1 poor results, with a satisfaction rate of 81.2%. A pasteurized autograft can be an easily accessible and economical alternative for children's malignant bone tumor of femurs.

Management of the malignant colorectal polyp: ACPGBI position statement

*Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK, †Torbay Hospital, Torquay, UK, ‡Department of General Surgery, Manchester Royal Infirmary, Manchester, UK, §Royal Infirmary, Glasgow, UK, ¶Department of Histopathology, Royal Bolton NHS Foundation Trust, Bolton, UK, **Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK, ††The Royal Marsden Hospital, London, UK, ‡‡Salisbury NHS Foundation Trust, Salisbury, UK and §§Department of Histopathology, University Hospital of South Manchester, Manchester, UK

Orbital solitary fibrous tumor: A report of two cases

Solitary fibrous tumor (SFT) is a rare spindle-cell neoplasm that can be found in the orbit. Here, we report two cases affected by orbital SFT. Both patients were female, aged 52 years and 59 years, respectively, and had experienced a painless unilateral orbital lesion. Computed tomography (CT) imaging revealed a well-circumscribed and contrast-enhanced soft tissue mass simultaneously. The tumors were located in the laterotemporal extraconal space of the right orbit and the inferior portion of the left orbit, respectively. Both patients underwent complete resection of their tumors. The histological findings showed alternating hypercellular and hypocellular areas composed of bland spindle cells with a fibrous stroma. The strong immunoreactivity for CD34 supported the diagnosis of orbital SFT. There was no recurrence at the 2-year and 3-year follow-up visits, respectively. SFTs should be considered in the differential diagnosis of an orbital tumor. The combination of a CT scan, histologic findings, and immunohistochemical staining will provide an accurate diagnosis. En bloc excision of the tumor is the mainstay of treatment in order to avoid recurrence.

A comparison of cyst wall curettage and en bloc excision in the treatment of aneurysmal bone cysts

BackgroundThe recurrence rate after aneurysmal bone cyst (ABC) treatment is quite high despite its benign nature. In ABC therapy, curettage is the treatment of choice; en bloc excision results in a lower recurrence rate, but more extensive reconstructive surgery is needed with associated morbidity. The aim of the present study was to compare the outcomes of the two treatment options.MethodsA retrospective analysis was performed on 26 patients treated for ABCs: 16 by curettage and 10 by en bloc excision. Each lesion was classified according to Enneking and patients were followed up for a mean time of 9.2 years. On follow-up, radiological examination and functional assessment (range of motion, muscle strength) were performed. Recurrence was defined as the presence of an osteolytic lesion, especially one with a tendency to grow.ResultsOn follow-up, the following symptoms were more prevalent in the en bloc excision group compared to the curettage group: pain (en bloc 20% versus curettage 6.25%), limb length differences (en bloc 20% versus curettage 12.5%), reduced range of motion (en bloc 20% versus curettage 6.25%) and muscle strength impairment (en bloc 50% versus curettage 31.2%); however, the differences were not statistically significant (P >0.05). In the curettage group, two cases of postoperative complications and two cases of recurrence were seen, while in the en bloc excision group one case of complications was noted.ConclusionsCurettage is a standard procedure in ABC management. En bloc excision is another option, albeit more technically demanding, that may be considered in recurrent lesions with extensive bone destruction or for cysts in an expendable location.

Surgeon‐performed intraoperative ultrasonography‐guided excision of nonpalpable breast masses with adequate surgical margins under local anaesthesia

AimWith the improvement of expertise in technique and skills of ultrasonography (US), many surgeons now perform image‐guided procedures for breast masses themselves. To minimize operative time, and to achieve adequate surgical margins with an acceptable cosmetic outcome, we designed a safe and simple hybrid technique to excise suspicious nonpalpable masses, which is described herein for the first time.Patients and MethodsIntraoperatively‐marked incision is performed, and a needle is advanced at a 0.5‐cm distance to the lesion according to real‐time ultrasound measurements. Four deep sutures are passed to fix and hang the predicted specimen adjacent to the needle in four directions. En bloc excision with aimed surgical margins of approximately 0.5 cm is achieved by means of retracting sutures, and confirmed by specimen and tumour bed US.ResultsIn the present study, there were 25 women (17 with malignant and 8 with benign lesions), with a mean age of 50.88 years (range: 30–69) and mean tumour diameter of 10.6 mm (range: 6–15). All lesions were correctly identified and localized by intraoperative US, and free margins of excision were obtained in all malignant lesions by means of the presented technique. The combined operative technical approach with surgeon‐performed intraoperative US‐guided needle placement and retracting sutures were feasible, simple and beneficial. We achieved complete tumour removal in all dimensions with no reexcision. The procedure was performed under local anaesthesia in an outpatient fashion with no complications.ConclusionOur report of the operative technique demonstrates that a combination of surgeon‐performed image‐guided localizations, together with a suture‐oriented fashion to assure negative surgical margins in all dimensions, improves margin clearance rate at the time of first surgical intervention. This method can be performed with operative and cost efficiency, and might become a valuable tool to minimize operative time and yield minimal sacrifice of normal breast tissue with maximal cosmetic outcome.

Radical Surgery with a Therapeutic Lymphadenectomy in a Rare Case of MPNST with Synchronous Regional and Non Regional Lymph Node Metastasis

Sir, Lymph node metastases from adult soft tissue sarcomas (STS) are rare. They are frequently associated with certain histological subtypes which include angiosarcoma, embryonal rhabdomyosarcoma and epithelioid sarcomas. Therapeutic lymphadenectomy is considered appropriate treatment for isolated regional lymph nodes metastasis (RLNM) from STS and can potentially improve long-term survival [1]. The role of surgery in the presence of non regional lymph node metastasis is not clearly defined in literature. A 19-year-old girl presented to us with a recurrent painless swelling in the right supraclavicular region for 4 months duration. She supposedly underwent a surgical excision for a similar swelling a year prior, elsewhere. Clinical examination confirmed the presence of a well circumscribed, multi-nodular swelling measuring 4 × 3cm in the right supraclavicular fossa, with involvement of the overlying skin; which had healed by secondary intention following the first surgery (Fig. 1). There were multiple significant discrete lymph nodes in bilateral cervical and right axillary regions. (Along levels II, III and IV on the right side and levels III and IV on the left side) Histopathology of the trucut biopsy from the supraclavicular swelling with immunohistochemistry correlation suggested a diagnosis of high grade malignant peripheral nerve sheath tumor (MPNST) (Figs. 2 and 3a–d). A PET-CT scan done for staging, showed metabolically active uptakes in the recurrent tumor in the supraclavicular fossa and in the multiple bilateral cervical and right axillary lymph nodes (Fig. 4). Fig. 1 Clinical photograph at presentation Fig. 2 a. H&Ex20—Showing tumor arranged in sheets and vague fascicles composed of round, oval to spindle shaped cells having pleomorphic vesicular nuclei and prominent nucleoli, with peritheliomatous arrangement at certain areas. b IHCX20—Tumor ... Fig. 3 a H&Ex20—Showing tumor with epithelioid and spindle cell areas. b IHCX20—Tumor cells showing immumopositivity to vimentin. c IHCX20—Tumor cells showing immumopositivity to S-100p. d IHCX20—70 % of the tumor ... Fig. 4 PET-CT scan showing metabolically active uptakes in the recurrent tumor in the supraclavicular fossa and in the multiple bilateral cervical and right axillary lymph nodes The patient was taken up for a radical surgery; en-bloc excision of the recurrent tumor along with the overlying skin was done, safeguarding the truck of the brachial plexus. A bilateral selective neck dissection involving levels II to V and a complete right axillary clearance was done. The resultant skin and soft tissue defect in the right supraclavicular region was reconstructed using a right latissimus dorsi myocutaneous flap (Fig. 5a, b). The final histopathology confirmed the preoperative diagnosis of MPNST. 6 out of the 14 right sided cervical lymph nodes, 4 out of the 12 left sided cervical lymph nodes and 9 out of the 15 right sided axillary lymph nodes showed metastatic tumor deposits. The patient completed 60 Grey of adjuvant external beam radiotherapy to the tumor bed and is disease free for the past one and half years following surgery. Fig. 5 a Intra-operative photograph following the en-bloc resection of the tumor and the therapeutic cervical and axillary lymph node dissections. b Immediate post operative photograph following latissimus dorsi flap reconstruction MPNST is currently the recommended term for all malignancies that arise from the peripheral nervous system or that show nerve sheath differentiation [2]. It is the sixth most common type and accounts for about 3–10 % of all STS [3]. Roughly half of all MPNSTs are sporadic; the remaining tumors are found in patients who are diagnosed with Neurofibromatosis Type I. These tumors commonly arise in the buttocks, thigh, brachial plexus, upper arm and para-spinal regions. Clinically, these tumors are aggressive, locally invasive, and highly metastatic. The most common site of distant metastasis is the lung, followed by bone and pleura. RLNM are uncommon, occurring in <10 % of patients, and are mainly seen in conjunction with widespread metastasis. There is currently no standardized treatment for MPNST other than radical surgery even in the presence of RLNM [4]. Patients who present with isolated RLNM have an improved survival compared with patients who present with regional and distant metastasis at diagnosis. Although routine use of FDG PET imaging as part of the initial staging of soft-tissue sarcomas is not recommended [5], it is reported to be useful in certain special circumstances as in our patient wherein the likelihood of distant metastasis was high. The absence of distant metastasis in the PET-CT prompted us to undertake a potentially curative surgery in our patient despite the presence of non regional lymph node metastasis; this case thus expands our knowledge on the biology of MPNST.

Gallbladder-associated ectopic liver: A rare finding during a laparoscopic cholecystectomy

INTRODUCTIONEctopic hepatic tissue is due to an uncommon failure of embryological liver development that is rarely described in the world medical literature. The incidence of ectopic liver (EL) has been reported to be anywhere from 0.24% to 0.47% as diagnosed at laparotomy or laparoscopy. We describe a case of EL adherent to the gallbladder, removed at laparoscopic cholecystectomy. PRESENTATION OF CASEA 37-year-old female was admitted for elective cholecystectomy having had an episode of acute cholecystitis provoked by gallstones. During the procedure, a 30mm×10mm×5mm section of EL tissue attached to the anterior wall of the gallbladder was identified and removed by en-bloc excision during laparoscopic cholecystectomy. Histological examination confirmed the absence of malignant degeneration of the hepatic tissue. The patient recovered well postoperatively and was discharged the day after the operation. She was well when seen six months later. DISCUSSIONEL has been reported in several sites, such as the gallbladder, gastrohepatic ligament, adrenal glands, esophagus, and thoracic cavity. EL is often clinically silent and discovered incidentally during abdominal surgical procedures or autopsies. Because patients with ectopic liver may suffer complications such as torsion, peritoneal bleeding, fatty change, and evolution to cirrhosis or malignant degeneration to hepatocellular carcinoma, any ectopic liver tissue needs to be correctly identified and removed. CONCLUSIONDespite the rare occurrence of EL, it should be recognized and removed by the surgeon to prevent a higher risk of complications and malignant transformation.