Large Submucosal Mass Research Articles

One stone two birds - Submucosal tunneling endoscopic resection for a large esophageal submucosal mass and esophageal diverticulum.

A-35-year-old woman presented our hospital with half a year's history of solid food dysphagia. An upper gastrointestinal endoscopy revealed a large submucosal mass in an esophageal diverticulum near the gastroesophageal junction. Endoscopic ultrasound (EUS) confirmed a hypoechoic lesion arising from the muscularis propria layer with the size of 25*14 mm. Therefore, submucosal tunneling endoscopic resection (STER) was proposed to remove the large submucosal lesion in addition to targeted septotomy of the esophageal diverticula. A 2-cm longitudinal mucosal access was made at 3 cm above the submucosal lesion, and a submucosal longitudinal tunnel was created until the submucosal lesion revealed using a DualKnife (Olympus, Japan). Meticulous resection was performed with the DualKnife, and the lateral border of the lesion was dissected from muscularis propria layer. It was completely removed the lesion with en bolc resection, and dissected the septum of the diverticulum using the DualKnife. The tunnel access was closed with several hemoclips. Finally, it has been demonstrated to achieve a perfect outcome for the patient. The patient was discharged three days later with symptom resolved on follow-up and to date.

Thyroglossal duct cyst with hoarseness as the sole symptom and an intralaryngeal extension masquerading as a laryngeal mass: Clinical experience and literature review.

A thyroglossal duct cyst is the most common congenital disease in the neck. There are two age groups usually associated with thyroglossal duct cysts: 1-11years in children and 30-60years in adults. These midline neck masses are typically located anteriorly in the neck, inferior to the hyoid bone. We report an extremely rare case of an intralaryngeal thyroglossal duct cyst without a neck mass, presenting with hoarseness as the sole symptom. A 64-year-old man presented with a 3-month history of hoarseness. On physical examination, no neck mass or swelling was observed during cervical palpation. Laryngostroboscopy revealed a large submucosal mass in the right glottis and supraglottis, and mobility of the right vocal cord was restricted. Surgery was performed via an external approach to completely resect the cyst, together with the middle part of the hyoid bone. Histopathologic examination of the cyst led to a diagnosis of thyroglossal duct cyst. The patient recovered well and his voice returned to normal. Attention should be paid to the occurrence of rare types of thyroglossal duct cyst in unusual clinical sites. Adequate radiological examinations should be performed, and reading the computed tomography or magnetic resonance imaging scans carefully before surgery is important to avoid misdiagnosis.

1735 A Rare Case of Coexisting Achalasia and Pseudoachalasia

INTRODUCTION: Achalasia is an esophageal motility disorder in which the lower esophageal sphincter fails to relax and there is a loss of esophageal peristalsis. Pseudoachalasia closely mimics achalasia. We present a rare case of a patient who was initially diagnosed with pseudoachalasia but was later found to have achalasia after symptoms persisted following the resection of an esophageal leiomyoma. CASE DESCRIPTION/METHODS: A 39 year-old male was evaluated for weight loss and progressively worsening dysphagia to solids and eventually liquids with a 100 pound weight loss over 3 years. Esophageal manometry was consistent with achalasia with esophageal compression, subtype II (Figure 1). He underwent laparoscopic exploration and planned Heller myotomy and Dor fundoplication. During surgery, a very large submucosal mass was found in the distal esophagus extending to the gastroesophageal junction. The mass was enucleated and a Dor fundoplication was performed. Pathologic analysis showed the mass to be a leiomyoma measuring 6.7 centimeters in maximum diameter (Figure 2). Postoperatively, his symptoms of dysphagia persisted andrepeat esophageal manometry remained consistent with achalasia. He underwent Heller myotomy and redo Dor fundoplication 5 months after the initial surgery. His symptoms completely resolved after the second surgery and he has remained asymptomatic on follow-up. DISCUSSION: Patients with achalasia typically present with progressive dysphagia, initially to solids and then to liquids, due to the degeneration of ganglion cells within the myenteric plexus in the distal esophagus resulting in the loss of peristalsis. Pseudoachalasia closely mimics the presentation of idiopathic achalasia and is the diagnosis in approximately 4% of patients with achalasia-like symptoms. Intraluminal evaluation with endoscopic ultrasound may be a valuable tool to evaluate muscular wall thickness in motility disorders and could result in earlier diagnosis of pseudoachalasia. Intraoperative esophageal pressure monitoring is not used frequently but may have also been beneficial in this case. This case is unique since the patient was discovered to have an esophageal leiomyoma after he was diagnosed with primary achalasia. There are no documented cases of a patient with both primary achalasia and pseudoachalasia based on a literature review.

Rare Case of Intestinal Lipomatosis Presenting With Hemorrhage

Introduction Diffuse intestinal lipomatosis is a very rare disease characterized by multifocal infiltration of mature adipose tissue into the intestinal submucosal or subserosal layers. The disease is mostly asymptomatic but complications like intussusceptions, obstruction, bleeding or perforation have been reported. Gastrointestinal (GI) lipomas occur in colon, small bowel, stomach and esophagus in decreasing frequency. Lipomas >2cm size are more prone to having complications. We here in describe a very rare care of diffuse intestinal lipomatosis presenting with hemorrhage. Case Report A 59-year-old Caucasian woman with hypothyroidism presented with worsening shortness of breath and dark stools for few days. Physical exam was remarkable for mucosal pallor. Laboratory studies showed severe anemia with hemoglobin of 4.7 gm/dL. Diagnostic upper endoscopy showed a large friable mass with overlying small old clot in second portion of duodenum (D2) adjacent to the ampulla. There were multiple other submucosal mass lesions in the entire examined small bowel. Colonoscopy also showed multiple (˜20) submucosal lesions throughout the colon suggestive of likely diffuse intestinal lipomatosis. Endoscopic ultrasound (EUS) done for elucidation of nature of D2 lesion revealed an oval hyperechoic lesion measuring 39×24mm arising from the submucosal layer without involving muscularis propria. Fine needle biopsy of the lesion revealed adipocytes. Discussion Solitary lipomas of GI tract are common accounting up to 8% of all GI tumors. However GI lipomatosis is very rare with an incidence of 0.04%. It's etiopathogenesis is unclear. Anomalies in embryonic development, fat dysmetabolism, chronic inflammation, alcohol use and hamartomatous syndromes have been implicated. Ileum is the most common site of enteric lipomas (25% of all GI tract lipomas) with duodenum being least frequent (4%). Endoscopic signs suggestive of lipomas include: tenting sign, cushion sign and the ‘naked fat’ sign (fat protruding from the biopsy site). A lipoma rarely can present with overt GI bleeding from apical ulceration. Ulceration results from pressure atrophy of mucosa and necrosis of the overlying epithelial layers due to abnormal peristalsis. Ulceration can be extensive with profuse bleeding requiring aggressive endoscopic, radiological or surgical management. Endoscopic modalities of managment include snare / endoloop resection and submucosal dissection.1870_A Figure 1. Multiple rounded submucosal lesions in the small bowel with positive cushion sign consistent with lipomas (A); large submucosal mass lesion in D2 adjacent to the ampulla (B).1870_B Figure 2. EUS showing an oval hyperechoic, heterogenous lesion measuring arising from the submucosal layer1870_C Figure 3. Fine needle biopsy showing adipocytes and mucosal epithelial cells

A Case of Upper Gastrointestinal Bleeding Due to a Large Gastric Lipoma Within a Hiatal Hernia

Gastric lipomas are rare mesenchymal tumors with a prevalence of 0.03-0.18% in the general population. They account for 5% of gastrointestinal tract lipomas and represent 3% of benign gastric tumors. They are usually asymptomatic, but can cause symptoms of abdominal discomfort, obstruction, intussusception, or bleeding. Most gastric lipomas (75%) are located in the antrum. We present a case of a large, proximal lesser curvature gastric lipoma contained within a hiatal hernia that presented as an upper gastrointestinal hemorrhage. A 78 female with a remote history of stroke on clopidogrel was admitted after two days of melena. She was hemodynamically stable with mild tachycardia. Melena was preceded by two days of mid-epigastric discomfort. She endorsed rare use of aspirin for headaches. Hemoglobin dropped from baseline of 14 gm/dL to 6.8 gm/dL requiring transfusion. Upper endoscopy revealed a 4-5 cm, smooth, soft, submucosal mass on the proximal lesser curvature of the stomach with a 1 cm clean based ulcer overlying the mass. The mass was located within a large hiatal hernia. Mucosal biopsies obtained during the procedure showed fundic type mucosa with active gastritis, necroinflammatory changes, and were negative for Helicobacter pylori. A CT scan of the chest, abdomen, and pelvis showed a lipomatous, lower mediastinal mass within a hiatal hernia measuring 11.5 x 9.4 x 8.2 cm concerning for gastric lipoma versus low grade liposarcoma. The patient underwent laparoscopic mobilization of a large Type III hiatal hernia with conversion to open for subsequent wedge resection of the gastric mass and hiatal hernia repair. Pathologic examination revealed a well-differentiated, mature, encapsulated, fatty neoplasm consistent with gastric lipoma with necrosis and ulceration of the overlying gastric mucosa. MDM2 gene amplification was not detected, confirming the diagnosis of benign lipoma. The patient had an uneventful recovery and is doing well post-operatively. While gastric lipomas harbor no malignant potential, they should be treated when they present with complications. Traditionally, symptomatic gastric lipomas are managed with surgical resection or enucleation. Endoscopic resection and submucosal dissection have been used to manage these tumors, but these techniques are technically challenging and carry an increased risk of perforation with larger masses.Figure: Axial CT scan image showing the large lipomatous mass in the lower mediastinum within a hiatal hernia.Figure: Large submucosal mass with overlying clean based ulcer as seen on retroflexion during endoscopy.Figure: Endoscopic image of submucosal mass and ulcer appreciated along the proximal lesser curvature with the diaphragmatic hiatus seen in the background.

Two different protein expression profiles of oral squamous cell carcinoma analyzed by immunoprecipitation high-performance liquid chromatography

BackgroundOral squamous cell carcinoma (OSCC) is one of the most dangerous cancers in the body, producing serious complications with individual behaviors. Many different pathogenetic factors are involved in the carcinogenesis of OSCC. Cancer cells derived from oral keratinocytes can produce different carcinogenic signaling pathways through differences in protein expression, but their protein expression profiles cannot be easily explored with ordinary detection methods.MethodsThe present study compared the protein expression profiles between two different types of OSCCs, which were analyzed through immunoprecipitation high-performance liquid chromatography (IP-HPLC).ResultsTwo types of squamous cell carcinoma (SCC) occurred in a mandibular (SCC-1) and maxillary gingiva (SCC-2), but their clinical features and progression were quite different from each other. SCC-1 showed a large gingival ulceration with severe halitosis and extensive bony destruction, while SCC-2 showed a relatively small papillary gingival swelling but rapidly grew to form a large submucosal mass, followed by early cervical lymph node metastasis. In the histological observation, SCC-1 was relatively well differentiated with a severe inflammatory reaction, while SCC-2 showed severely infiltrative growth of each cancer islets accompanied with a mild inflammatory reaction. IP-HPLC analysis revealed contrary protein expression profiles analyzed by 72 different oncogenic proteins. SCC-1 showed more cellular apoptosis and invasive growth than SCC-2 through increased expression of caspases, MMPs, p53 signaling, FAS signaling, TGF-β1 signaling, and angiogenesis factors, while SCC-2 showed more cellular growth and survival than SCC-1 through the increased expression of proliferating factors, RAS signaling, eIF5A signaling, WNT signaling, and survivin.ConclusionsThe increased trends of cellular apoptosis and invasiveness in the protein expression profiles of SCC-1 were implicative of its extensive gingival ulceration and bony destruction, while the increased trends of cellular proliferation and survival in the protein profile of SCC-2 were implicative of its rapid growing tumor mass and early lymph node metastasis. These analyses of the essential oncogenic protein expression profiles in OSCC provide important information for genetic counseling or customized gene therapy in cancer treatment. Therefore, protein expression profile analysis through IP-HPLC is helpful not only for the molecular genetic diagnosis of cancer but also in identifying target molecules for customized gene therapy in near future.

Acute intussusception on a lipoma of the left colon: report of a case

Introduction: Lipomas of the colon are rare benign tumors. Colo-colonic intussusception caused by colonic lipoma is more rare. Case report: We report a case of a 52-year-old patient presenting with recurrent colonic obstruction which occurred in recent days. Colonoscopy revealed a large submucosal mass having benign appearance. Abdominal computed tomography scan diagnosed colo-colonic intussusception due to a large lipoma of the sigmoid colon. Diagnosis was confirmed during operative reduction and resection. He had segmental left colectomy. The postoperative course was uneventful. Conclusion: Computed tomography scan and colonoscopy seem important for diagnosing both lipoma and intussusception. The treatment may be surgical or endoscopic.

A Plunging Case of Intermittent Dysphagia

Question: A 71-year-old woman with a history of gastroesophageal reflux disease and chronic intermittent dysphagia presented with progressively worsening dysphagia for solid foods over the past three days. The patient also complained of reflux, without weight loss, and has never had food impaction requiring bolus removal. Upon presentation, the patient denied any nausea, vomiting, abdominal pain. Laboratory results were unremarkable. Esophagogastroduodenoscopy (EGD) 6 months before admission was unremarkable. However, current endoscopy revealed a large, 4- to 5-cm subepithelial lesion in the mid esophagus at around 30 cm from the incisors. The lesion appeared smooth with normal overlying smooth tissue and no obvious ulcerations (EGD; Figure A). As the scope passed, the lesion plunged into the stomach, shown with the scope retroflexed (EGD; Figure B). CT of the chest with and without contrast confirmed the presence of a large submucosal mass 5.5 cm in width in the distal esophagus. Biopsy was performed under endoscopic ultrasonography (EUS; Figure C) with subsequent histology demonstrating a spindle cell neoplasm, combined with immunohistochemical analysis positive for CD117 (C-Kit) and negative for HMB-45. No extraesophageal masses were identified. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Gastrointestinal stromal tumors (GIST) normally present in a vague manner, and vary depending on which region of the gastrointestinal tract in involved.1Sjogren P.P. Banerji N. Batts K. et al.Rare presentation of a gastrointestinal stromal tumor with spontaneous esophageal perforation: a case report.Int J Surg Case Rep. 2013; 4: 636-639Crossref PubMed Scopus (6) Google Scholar Many present with abdominal discomfort and weight loss and, as a mass-occupying lesion, may also present as an obstruction.1Sjogren P.P. Banerji N. Batts K. et al.Rare presentation of a gastrointestinal stromal tumor with spontaneous esophageal perforation: a case report.Int J Surg Case Rep. 2013; 4: 636-639Crossref PubMed Scopus (6) Google Scholar Sixty percent of tumors arise from the stomach, with primary esophageal origin quite rare (<1%).2Demetri G.D. von Mehren M. Antonescu C.R. et al.NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors.J Natl Compr Cancer Network. 2010; 8: S1-S41Crossref PubMed Scopus (769) Google Scholar When present in the esophagus, it may result in dysphagia and mimic symptoms of gastroesophageal reflux disease. Surgery as initial therapy along with a tyrosine kinase inhibitor such as imatinib remain the standard of care for treatment.2Demetri G.D. von Mehren M. Antonescu C.R. et al.NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors.J Natl Compr Cancer Network. 2010; 8: S1-S41Crossref PubMed Scopus (769) Google Scholar, 3Miettinen M. Lasota J. Gastrointestinal stromal tumors: review on morphology, molecular pathology, prognosis, and differential diagnosis.Arch Pathol Lab Med. 2006; 130: 1466-1478Crossref PubMed Google Scholar The patient’s transient periods without dysphagia most likely correlated with times when the neoplasm was plunged into the stomach. As the neoplasm ascended back into the esophagus, the patient’s bouts of dysphagia reemerged. The patient was started on neoadjuvant chemotherapy with imatinib with future plans for operative resection. Andrew C. Berry's current affiliation is the Department of Medicine, University of South Alabama, Mobile, Alabama.

A Large Submucosal Mass With Prominent Superficial Vessels

A man in his 40s presented with a multiple-year history of difficulty breathing throughhis left nostril. Severalmonthsprior topresentation, he began to experience left-sided epistaxis occurring up to 10 times per month, which was controlled with direct pressure. More recently, a friend noticed bulging of his left lateral nasal sidewall. Physical examination revealed a large submucosal mass with prominent superficial vessels within the mucosa almost completely filling the left anterior nasal cavity. Axial computed tomography (CT) showed a well-circumscribedoval-shaped lesionwith intermediate attenuation in the left anterior nasal cavity that shifted the septum to the right with remodelingof thenasalbone (Figure, A). The lesionhadmostlyhigh signalonaxialT2-weightedmagnetic resonance imaging(MRI)within which therewas a reticular pattern of septawith low signal (Figure, B). The lesionhadheterogeneous,mostly low signal on coronal fatsuppressed T1-weighted imaging (Figure, C), as well as prominent heterogeneous contrast enhancement using the same sequence (Figure,D).The lesionwas resectedviaanendoscopicendonasal approach andwas found to be originating from the left superior nasal septumwithnoextensionbeyond the left lateral nasalwallmucosa or the right septal mucosa. What is your diagnosis? A B

A Rare Cause of Acute Abdominal Obstruction in an Adult Due to Intestinal Intussusception from a Fibroblastic Polyp

Purpose: Colonic intussusception is often associated with childhood disease; however, adult intussusception only consists of 5% of all intussusceptions. Frequently, the clinical presentation is with chronic intermittent abdominal pain, nausea, vomiting, and, less often, with acute obstruction. Non-operative reduction (barium enema) is not successful, due to underlying pathology in adult patients with a pathological lead point that requires surgical intervention. We present a rare case of acute abdominal obstruction secondary to benign fibroblastic polyp. A 54-year-old African-American female without any significant past medical history presented with acute onset of diffuse abdominal pain associated with nausea and vomiting. Initial x-rays revealed air fluid levels consistent with bowel obstruction. CT scan showed colo-colonic intussuception of the right colon. A subsequent CT with contrast enema was utilized, and the patient reported relief of her symptoms. With the resolution of obstipation, the patient developed significant diarrhea. She was transferred to a tertiary care center for further evaluation and treatment. A colonoscopy was performed to evaluate the etiology of the colonic intussuception. A large submucosal mass with intussusception of small bowel into the colon was seen in the terminal ileum. The patient was taken to the operating room and a right hemicolectomy was performed, removing a 6x5-cm mass that had intussucepted into the ascending colon again. Pathology was consistent with a benign fibroblastic polyp (positive for Vimentin and CD34 and negative for CD 117 and SMA) with edematous changes secondary to acute and chronic inflammation. Adult colonic intussuception is often linked to malignant tumors, however, 30% of cases are due to benign disease. Typically clinical symptoms are associated with a chronic course; however, patients can have acute presentation with bowel obstruction. This patient had a large fibroblastic polyp in the terminal ileum, which served as the intussuscipiens, resulting in acute colonic obstruction. Although the barium enema temporarily reduced the obstruction, definitive management can only be achieved with resection of the underlying pathology leading to intussusception. This case underlies the need for consideration of intussusception in the differential diagnosis of acute bowel obstruction in adult patients.

Gastric Leiomyoma: A Case Report

Purpose: Leiomyoma is common elsewhere in the gastrointestinal tract, but its presence in the stomach is extremely rare. We present such a case to increase awareness among clinicians and emphasize the need for evidence based management strategies. A 72-year-old male with diabetes, hypertension and a ten-year smoking history underwent endoscopic evaluation for a 3-year duration of acid reflux, non-bloody emesis and abdominal pain partially alleviated with famotidine. The patient had a benign physical exam. Laboratory tests were significant for an elevated aspartate aminotransferase (45 Units/L) and negative Helicobacter pylori serologies. The patient had no family history of gastrointestinal disease or malignancy. Initial endoscopy noted a gastric wall mass for which no biopsy or surgical intervention was performed. The patient was referred to a tertiary care academic center where repeat endoscopy visualized the large submucosal mass in the proximal body of the stomach with a small overlying area of mucosal erythema. The duodenum and esophagus appeared normal. Subsequent endoscopic ultrasound confirmed the mass to be a 22.6 mm X 19.1 mm hypoechoic lesion arising from the submucosa with an intact muscularis propria. Multiple fine needle aspiration passes obtained a fragment of hyaline lesion associated with benign gastric mucosa and few clusters of epithelioid cells with enlarged nuclei and prominent nucleoli. Immunostaining showed the epithelioid cells to be reactive for smooth muscle actin and desmin, the latter focally. CD34, CD117, and pankeratin were negative. This immunoprofile supported the diagnosis of a gastric leiomyoma. The patient underwent a laparoscopic gastric wedge resection with intraoperative endoscopy for removal of the lesion. Leiomyoma is the most common mesenchymal neoplasm of the esophagus, but is rarely encountered in the stomach where leiomyosarcoma has higher incidence and gastrointestinal stromal tumor (GIST) predominates. Discriminating between leiomyoma and GIST is challenging, as radiographic features are nonspecific and EUS findings not particularly sensitive for diagnosis of leiomyoma. Differentiation requires immunohistochemical staining which shows positivity for smooth muscle actin (SMA) and desmin, and negativity for CD117 (c-kit protein) and CD34 transmembrane glycoprotein; an immune profile opposite from that of GIST. Despite progress in identification of leiomyoma, understanding of the surveillance, surgical intervention, and potential for malignancy is limited. Given the low frequency of occurrence, a multi-center case cohort of gastric leiomyoma is warranted to define management and evaluate treatment strategies.

Endoclip Closure of a Large Colonic Perforation Following Colonoscopic Leiomyoma Excision

Endoscopic removal of large colonic submucosal lesions can lead to a higher risk of perforation. Although not as common following diagnostic and therapeutic colonoscopy, it does occur more often following therapeutic colonoscopy. We present a case of a large submucosal mass excised endoscopically, resulting in a large perforation that was closed using endoclips. While endoclips are typically used for smaller perforations, we have found that they can be used safely on a larger defect. A 68-y-old woman presented with a 2.9-cm benign submucosal mass found in the hepatic flexure. It was removed via endoscopic polypectomy, leaving a perforation of 3cm x 3cm. The perforation was closed with endoscopic clips. Histology of the specimen showed clear margins. At 4-wk follow-up, the patient had no complications. A colonoscopy at 6-mo follow-up showed only a scar at the procedure site with no complaints. Large iatrogenic colonic perforations can be managed successfully using endoclips, particularly in a prepped colon.

Dysphagia Due to Adenoid Cystic Carcinoma of the Base of the Tongue

Although oropharyngeal neoplasia can often lead to dysphagia, salivary gland tumors rarely grow within the tongue base. We present the case of a 75-year-old man with adenoid cystic carcinoma of the base of the tongue causing profound dysphagia and weight loss, and provide a current literature review and update on the management of these rare tumors. We present a case report and a literature review. Physical examination performed at the initial visit revealed a firm right base-of-tongue mass with no palpable lymphadenopathy. Flexible fiberoptic laryngoscopy confirmed a large submucosal mass at the right base of the tongue that obscured the right vallecula. Histopathologic analysis of the operative biopsy specimens revealed the classic features of adenoid cystic carcinoma. Treatment included radical pharyngotomy with wide local excision and primary closure, followed by postoperative radiation treatment. We demonstrate the clinical examination findings and histopathologic characteristics of this disease, and review the literature for clinical treatment recommendations for this rare cause of dysphagia.

Laryngeal schwannoma with extralaryngeal extension

Schwannomas of the larynx are rare. Furthermore, a laryngeal schwannoma extending to the neck region is extremely rare. The present case report describes a 37-year-old male patient with a history of hoarseness and cervical swelling on the left side for over 10 years. He presented with dyspnea on exertion. Fiberoptic laryngoscopy revealed a large submucosal mass in the left false and true vocal folds, and the left vocal fold was immobile. Magnetic resonance imaging revealed the presence of multiple tumors throughout the body, in addition to extension of the laryngeal tumor to the left neck region in a dumbbell shape. After analysis of the results of examinations including imaging tests and pathological examinations, a diagnosis of schwannomatosis was made. A tracheostomy was performed, along with resection of the laryngeal tumor. Following disarticulation of the cricothyroid joint and rotate ion of the thyroid cartilage, the intralaryngeal part of the tumor was smoothly removed without median or lateral thyrotomy. At the 3-month follow-up, the patient's vocal fold mobility was found to have recovered. Although uncommon, our procedure was very effective for the treatment of laryngeal schwannomas. By this approach, safe removal of the tumor was possible, without any injury to the laryngeal mucosa.

Hemangiopericytoma of the neck

Hemangiopericytoma (HPC) is an exceedingly rare tumor of uncertain malignant potential. Approximately 300 cases of HPC have been reported since Stout and Murray described HPCs as "vascular tumors arising from Zimmerman's pericytes" in 1942. After further characterization, the WHO reclassified HPC as a fibroblastic/myofibroblastic tumor. Long term follow up is mandatory because the histologic criteria for prediction of biologic behavior are imprecise. There are reports of recurrence and metastasis many years after radical resection. The head and neck incidence is less than 20%, mostly in adults.We report herein a case of HPC resected from the neck of a 74-year-old woman, who presented in our department with a painless right-sided neck mass. The mass was well circumscribed, mobile and soft during the palpation. The skin over the tumor was intact and normal. Clinical diagnosis at this time was lipoma. A neck computer tomography scan showed a large submucosal mass in the neck, which extended in the muscular sites. The tumor was completely removed by wide surgical resection. During surgery we found a highly vascularised tumor. The histopathologic examination revealed a cellular, highly vascularized tumor. The diagnosis was that of solitary fibrous tumor, cellular variant, with haemangiopericytoma-like features. The patient had normal postoperative course of healing and 24 months later she remains asymptomatic, without signs of recurrence or metastases.

Coblation removal of laryngeal Teflon granulomas

AbstractLaryngoscope, 2010

Ｆａｃｉａｌ ｄｉａｍａｓｋｉｎｇ法を用いた側頭下窩血管線維腫例

We report a rare case of extranasopharyngeal angiofibroma of the infratemporal fossa. A seventeen-year-old man had been aware of a swelling mass in the oral cavity for three years. A large submucosal mass was identified at the right soft palate, but there was no obvious lesion in the nasal cavity or nasopharyngeal space. Computed tomography and magnetic resonance imaging demonstrated that the infratemporal fossa was occupied by a large spindle-shaped mass showing strong enhancement and the foramen ovale had been expanded by the mass. Under a diagnosis of trigeminal schwannoma, surgery was performed via the facial dismasking approach. The mass was parallel to a trigeminal nerve, which was sacrificed, and the lesion was removed completely with an addition of cervical approach. Having lost considerable blood, he received a blood transfusion intraoperatively, however, his postoperative clinical course was uneventful. The mass presented a smooth, elastic, pale appearance, and its histopathological diagnosis was angiofibroma. The origin of the lesion was considered the pterygoid (vidian) canal, which is an unusual site for the origin of angiofibroma. The patient did not demonstrate dysarthria or dysmasesis, and there was no apparent cosmetic complication. The patient is currently free from disease two years after surgery. The facial dismasking approach offers excellent access for excision of a tumor involving the infratemporal fossa.

Gastrointestinal Stromal Tumor

A previously healthy 8-year-old girl was admitted with a 12-hour history of melena and hematemesis. She developed nausea and abdominal pain 2 days before admission. She had no history of chronic illness. Laboratory studies revealed a hematocrit of 16% and a C-reactive protein of 1.6 mg/dL. Physical examination revealed tachycardia and pallor. Abdomen was nontender, nondistended, and without evidence of caput medusa, spider telangiectasia, ascites, hepatosplenomegaly or masses. Patient had no evidence of lymphadenopathy. Endoscopy of the stomach (Fig. 1) revealed a large submucosal mass with an obvious denuded surface with no active hemorrhage. Computed tomography scan of the abdomen (Fig. 2) demonstrated a nodular mass residing in the posterior gastric wall consisting of multiple finger-like projections.FIG. 1: Endoscopy of the stomach revealed a large submucosal mass with an obvious denuded surface with no active hemorrhage.FIG. 2: Computed tomography (CT) scan of the abdomen demonstrated a nodular mass residing in the posterior gastric wall consisting of multiple finger-like projections.A diagnosis of gastrointestinal stromal tumor (GIST) was made by tissue histology from the resected tumor. Gastrointestinal stromal tumors were previously classified as leiomyomas and leiomyosarcomas secondary to a belief that these tumors arose from the smooth muscle of the gastrointestinal tract. However, GISTs are mesenchymal tumors arising from the gastrointestinal wall, mesentery, omentum or retroperitoneum.(1) They almost uniformly express c-kit protooncogene protein, a cell membrane receptor with tyrosine kinase activity. The true incidence of GIST is unknown; based on Finnish Cancer Registry data, estimated incidence is approximately 4 per million. These tumors are rare in adults younger than age of 40 years and extremely rare in children. Most of the GISTs are found in the stomach (60%-70%) and small intestine (20%-30%). Surgical resection is the primary treatment of GISTs. Treatment for metastatic or unresectable GISTs has not been effective with standard chemotherapeutics until imatinib mesylate. The patient had partial gastrectomy with complete tumor resection with clear borders. The patient is one-year status postgastrectomy and without evidence of tumor recurrence or malignancy. Submitted by: David L. Suskind Ghassan Wahbeh Dennis Christie Department of Pediatrics Division of Gastroenterology, Hepatology and Nutrition Seattle Children's Hospital and Regional Medical Center University of Washington, Seattle, WA

4736 Percutaneous endoscopic gastrostomy and tumor seeding: an emerging complication of the pull technique in patients with head and neck cancer.

The use of percutaneous endoscopic gastrostomy (PEG) tube for enteral feeding has gained wide acceptance in various clinical settings. Head and neck cancer (HN H&NC and non H&NC.We looked specifically for the complication of tumor seeding at the site of PEG tube placement. Results: 330 cancer patients had PEG tube placed during the period of study using the pull technique. 248 patients had H&NC, mean age 66.5 (39-85) years, male/female ratio was 167/81. The non H&NC were 82 patients, mean age 64 (17-88) years, male/female ratio was 55/27. None of the non H&NC patients had tumor seeding and only two patients with H&NC had tumor seeding at the PEG exit site. The first patient was a 58-year-old man with a history of invasive squamous cell carcinoma (SCC) of the right maxillary sinus involving the palate. Following surgical resection a PEG tube was placed. Fourteen weeks later he presented with a mass around the PEG tube exit. The mass was resected and the histology confirmed SCC. The second patient was a 48-year-old man with a history of SCC of the piriform sinus treated with preoperative chemoradiation. The patient underwent a PEG tube placement prior to surgery. Four months later he presented with a slowly growing granulation tissue with purulent discharge that did not respond to antibiotics and local silver nitrate therapy. A biopsy of the tissue confirmed SCC. The patient underwent endoscopy which showed a large submucosal mass. He underwent wide local excision of the abdominal wall with partial gastrectomy. Conclusions: Metastatic implantation of H&NC at the site of PEG tube is a newly emerging complication following the pull technique. We encounterd 2 patients among 248 H&NC patients (0.8%) who developed this complication. Both of our patients had viable tumor in the oropharyngeal cavity. We recommend careful assessment of the oropharynx prior to PEG tube placement to avoid tumor seeding. In patients with viable tumor in the oropharynx, alternative methods of tube placement should be considered.

Hodgkin's disease of the gastrointestinal tract

Hodgkin's disease (HD) is rarely considered in the differential diagnosis of gastrointestinal (GI) disorders. We report eight cases of GI HD. The patients, ages 16-64, all with stage IV disease of varied histologic subtypes and GI symptoms including pain, upper or lower GI bleeding and/or obstruction. There was diffuse gastric fold thickening in one case, a large submucosal mass along the proximal greater curvature in another case, and a large ulcerating mass along the lesser curvature in the third case. Two cases of jejunal disease manifested as either a short or long segment of luminal narrowing with prominent mucosal nodularity. Another case exhibited a short area of complete mucosal destruction, irregular cavitation and intraluminal filling defect. In one additional case there was diffuse jejunal nodularity. Colonic involvement (two cases) presented as a solitary polypoid mass in transverse colon in one patient and severe narrowing of the descending colon with adjacent mesenteric mass on CT in another. We conclude that although rare in Hodgkin's disease, GI involvement should be considered, particularly in patients with stage IV disease.