Left Inguinal Region Research Articles

Ectopic Fibrogenesis Induced by Transplantation of Adipose-Derived Progenitor Cell Suspension Immediately After Lipoinjection

Adipose tissue has its own tissue-specific progenitor cells, a subpopulation of which has been shown to have multipotency and called adipose stem cells or adipose-derived mesenchymal stem cells (1,2). During a clinical trial in which soft tissue is augmented by transplantation of progenitor-enriched adipose tissue (cell-assisted lipotransfer), we have encountered incidence of an unexpected complication: local ectopic subcutaneous fibrogenesis. Patients participating in the trial did so under informed consent approved by individual review boards. Cell-assisted lipotransfer was designed based on the finding that aspirated fat tissue contains many fewer vessels and adipose progenitor cells than intact fat tissue. This may explain the tendency of transplanted aspirated fat tissue to atrophy during the first 6 months posttransplantation (3). In the relevant clinical trial, the stromal vascular fraction (SVF) comprising 10% to 40% adipose progenitor cells was freshly isolated from aspirated fat by means of collagenase digestion and transplanted together with aspirated fat tissue grafts (4). In 146 cases, SVF cells were used as a cell pellet, mixed with and attached to aspirated fat tissue grafts before injecting into fatty and muscular layers of breast mounds. On the other hand, in two cases, SVF cells isolated from 600 mL aspirated fat were separately injected as a cell suspension in 60 mL of saline into both breast mounds (30 mL/side) immediately after conventional lipoinjection. Although grafted fat survived well and fibrogenesis in the breasts or surrounding tissues was not seen in the former group, fibrous tissue formation was observed in both cases of the latter group 3 months after treatment. In the two cases, breast mounds were somewhat hard to the touch; inspection by CT scan detected unexpected fibrosis in the subcutaneous fat layers. In the thinner patient of the two (Fig. 1), fibrous tissue approximately 10 mm thick had formed on the sternum and caused anterior elevation of the skin, which was treated with local injections of triamcinolone acetonide at 6 and 8 months. Furthermore, lymphadenopathy was seen at the left abdominal wall and the left inguinal region at 3 months and gradually disappeared by 12 months.FIGURE 1.: CT scan images taken before (Pre) and 3, 6, 12, and 36 months after treatment. Normal mammary glands and the thin fatty layers around them are visible before treatment. Substantial fibrosis had occurred, both diffusely in the transplanted fat surviving around the mammary glands and in the subcutaneous layer over the sternum, at 3 months. The fibrotic mass over the sternum was treated twice with local injections of triamcinolone acetonide at 6 and 8 months and dissipated, but diffuse fibrosis in the breasts remains at 36 months.Fibrogenesis results from persistent inflammation, in which tissue remodeling and repair processes are impaired and injured cells are replaced not with cells of the same type but with connective or scar tissue (5). As fibrogenesis was seen only when SVF cells were injected separately as a cell suspension, a nonphysiological microenvironment in which adherent adipose progenitor cells are suspended in saline solution may give rise to the unexpected differentiation and migration of the cells. After large-volume lipoinjection, tissue injury, edema, hemorrhage, and local inflammation are commonly seen, and transplanted adipose progenitor cells are temporarily placed in and stimulated by ischemic and inflammatory microenvironments. These findings provide some insights into a therapeutic strategy for future cell-based therapies involving adherent stem/progenitor cells. Previous experimental studies demonstrated that transplanted bone marrow-derived mesenchymal stem cells differentiated into myofibroblasts and contributed to liver fibrosis after acute or chronic liver injury (6,7). In cell-based therapies using adherent mesenchymal stem cells, the possibility of unfavorable behaviors such as differentiation into myofibroblasts should be taken into account, even if the cells are derived from adult tissue and have not been substantially manipulated. It may be a resolution to adhere adipose-derived adherent stem or progenitor cells to cells, tissue, extracellular matrix, or biological scaffold before administration to avoid their unexpected behaviors. Kotaro Yoshimura Noriyuki Aoi Hirotaka Suga Keita Inoue Hitomi Eto Department of Plastic Surgery University of Tokyo School of Medicine Tokyo, Japan Katsujiro Sato Cellport Clinic Yokohama Yokohama Excellent III Building 2F Kanagawa, Japan Masakazu Kurita Kiyonori Harii Department of Plastic Surgery Kyorin University School of Medicine Tokyo, Japan Toshitsugu Hirohi Ritz Cosmetic Surgery Clinic Tokyo Shinagawa-ku, Tokyo, Japan

Ultrasound‐Guided Balloon Thrombectomy for Treatment of Aorto‐Iliac‐Femoral Thrombosis in a Horse

Ultrasound‐Guided Balloon Thrombectomy for Treatment of Aorto‐Iliac‐Femoral Thrombosis in a Horse

Carotid artery stenting via a femoral bypass graft: technical note

Background We described a case of endoluminal stent placement for a cervical internal carotid artery stenosis in which access was obtained via the femoral bypass graft. Case Description A 70-year-old man with known disease of the carotid, peripheral, and coronary arteries as well as congestive heart failure presented for endoluminal revascularization of a severe right internal carotid artery stenosis. Transradial access was complicated by the left subclavian artery occlusion and hypercalcified aortic arch. Bilateral femoral artery was replaced with bypass graft because of atherosclerosis obliterans. An alternative approach was attempted via the exposed left femoral bypass graft. The left inguinal region was incised, and the left common femoral-popliteal bypass graft was exposed. After placement of a purse string suture at the puncture site, the guiding sheath was introduced into the graft and positioned into the right common carotid artery. Stenting was successfully performed, and the suture was tied after withdrawing the sheath. Conclusions This novel approach should be considered for endovascular procedures for which access to the carotid artery is limited.

Clavus detected incidentally by positron emission tomography with computed tomography

This is the first report showing that positron emission tomography with computed tomography (PET/CT) can detect clavus. A 37-year-old woman diagnosed with epithelioid sarcoma on her left inguinal region was investigated by whole-body PET/CT. The imaging showed some 18F-fluorodeoxyglucose uptake at the right lateral foot. There had been a clavus in exactly the same region. Every dermatologist, radiologist and oncologist needs to know about this finding for making an accurate diagnosis.

Spermatic cord abscess with concurrent prostatic abscess involving the seminal vesicle

Prostatic abscess involving the seminal vesicle has become rare following the development of effective antibiotic treatments. To our knowledge, we report the first case in the English-language literature of a patient with a spermatic cord abscess and a concurrent prostatic abscess. We examined an 81-year-old man for swelling and pain in the left inguinal region and performed computed tomography (CT) that later confirmed the suspected diagnosis of left inguinal hernial strangulation. We performed urgent surgical drainage of a left spermatic cord abscess; and under the correct diagnosis by CT, he was successfully treated further with antibiotics and transperineal drainage of a prostatic abscess extending to the seminal vesicle. We highlight that familiarity with such a rare condition is overwhelmingly essential for patient management and that CT is the most valuable imaging procedure for diagnosing such cases.

Spontaneous Rupture of Iatrogenic (Postinguinal Herniorrhaphy) Venovenous Malformation Managed Endoscopically

Complications of open inguinal hernia repair, such as wound infection, hematoma, seroma, and neuralgia, are known to occur. Vascular injuries during inguinal hernia repair are rare and documented as case reports only. Vascular malformations are known to occur after trauma or sharp injuries. Most of the venous malformations are congenital in origin and usually reported in relation to congenital heart disease or in visceral locations. We encountered an iatrogenic venovenous malformation (VVM) in the subcutaneous space of the left inguinal region following an open inguinal hernia repair. This VVM presented as a spontaneous rupture leading to widespread ecchymosis of the thigh. It was managed endoscopically.

Palisaded myofibroblastoma of lymph node

A 60-year female was presented with swelling in the left inguinal region. Microscopically, the left inguinal lymph node shows typical "amianthoid" fibers (hyalinized areas), spindle cell fascicles and hemorrhagic areas in the interstitial spaces with rim of lymphoid tissue. Preoperatively, patient was non-reactive for HIV I and II. This lesion is usually mistaken as neurilemmoma and Kaposi's sarcoma.

Coincidental association of mycosis fungoides and occupational systemic sclerosis?

We report a 58-year-old man with mycosis fungoides (MF) and occupational systemic sclerosis (SSc) induced by silica exposure. He was engaged in tunnel construction from the age of 18 to 33 years. He developed MF at the age of 30. Diagnosis of silicosis was made at the age of 52 and SSc at the age of 58. Physical examinations revealed sclerotic skin changes on his forearms and fingers and poikiloderma on the left popliteal fossa and inguinal region. Both antinuclear antibody and antitopoisomerase-I antibody were positive. We could find no apparent difference between his clinical features and those of idiopathic SSc except for the presence of silicosis and MF. Systemic therapy with interferon-gamma for MF did not improve the skin sclerosis. We discuss the relationship of silica exposure to both MF and SSc.

A Cut Above

A 40-year-old man’s initial diagnoses did not explain all of his signs and symptoms—particularly when they took a calamitous turn. The patient, who had a history of L4-L5 laminectomy for lumbar radiculopathy, presented after 1 week of progressively worsening abdominal pain, difficulty walking, and fever. He had recently undergone rotator cuff surgery, which was complicated by a small wound abscess. His abdominal pain began as dull discomfort in the left inguinal region, spreading deep into the left hip and right inguinal region, with radiation to the back.

Mixed testicular germ cell tumor in an adult with cryptorchidism and Down's syndrome

We here present a case of mixed testicular germ cell tumor in an adult with cryptorchidism and Down's syndrome. A 20-year-old Japanese man with a mass in the left inguinal region underwent orchidectomy as a left testicular tumor was suspected. Histology showed a mixed germ-cell tumor with embryonal carcinoma and yolk sac tumor with syncytiotrophoblastic giant cells occurring in a cryptorchid testis. Chromosomal analysis of peripheral lymphocytes disclosed a karyotype of 47,XY,+21[20]. Our case provides further evidence that these three conditions-Down's syndrome, cryptorchidism and testicular germ cell tumor-may be closely associated. To our knowledge this is the first case of mixed germ cell tumor arising in a patient with Down's syndrome and cryptorchidism.

Epiploic Appendagitis: A Possible Work-Related Etiology

To the Editor: Two patients were recently evaluated and treated for acute onset abdominal pain, which occurred while performing relatively heavy physical activity. The patients were sent by different companies, to separate occupational medicine clinics. One of these patients, a 44-year-old man, was shoveling concrete when symptoms occurred. The other patient, a 30-year-old man, was lifting a heavy palette while twisting and then throwing it when pain occurred in the abdomen. Although uncomfortable, no vomiting, fever, or toxicity was noted in either case. A finding of tenderness to palpation of the epigastric area, right and left lower abdominal quadrants was noted in the 44-year-old patient. The diagnosis of “abdominal pain” and “possible ventral hernia” was made. The 30-year-old patient was noted to have tenderness, and was “very painful” in the left lower abdominal quadrant and the left inguinal region. No acute mass was noted in either patient and vital signs were normal. A urine “dipstick” analysis was normal in the 30-year-old. The 44-year-old patient had a “large, protuberant abdomen” whereas the 30-year-old was not considered obese. The 44-year-old patient was sent to a surgeon and computed tomography (CT) imaging of the abdomen and pelvis was obtained (with contrast). The initial treating practitioner of the 30-year-old patient ordered a CT scan of the abdomen and pelvis (with contrast). Different radiologists interpreted the CT scans from the different patients. The 30-year-old patient was found to have “epiploic appendagitis of the proximal sigmoid colon” on CT scan. The 44-year-old patient exhibited “mild inflammatory change at the anterior aspect of the cecum, most consistent with epiploic appendagitis” on CT. The surgeon also diagnosed abdominal wall strain that was “work-related.” Primary epiploic appendagitis is produced by torsion and inflammation of finger-like projections of adipose tissue and blood vessels that extend from the colon. Symptoms can easily be mistaken for acute appendicitis, diverticulitis, hernia, or cholecystitis. Acute epiploic appendagitis is associated with obesity, hernia, and unaccustomed exercise. Historically, before CT scan was able to identify this entity, patients would sometimes undergo exploratory surgery for suspected appendicitis or acute abdomen. Treated conservatively, epiploic appendagitis generally resolves within 14 days. In the two cases reported here, one case resolved in approximately 3 weeks, and the other in approximately 5 weeks. Primary torsion of the omentum has been described in a jackhammer worker and was considered related to vibration.1 Torsion and inflammation of the epiploic appendages, although perhaps rare, should be a consideration in patients reporting for evaluation of work-related abdominal pain (after considering other serious causes requiring urgent treatment). There is possibility of the association of epiploic appendagitis with heavy physical activities. Carmine J. Pellosie, DO, MPH Richard Goy, MD, MPH Lauren Jacobsen, CRNP HeathWorks, a Division of Lehigh Valley Hospital and Health Network Allentown, PA

Reversal of Signs and Symptoms of a B-Cell Lymphoma in a Patient Using Only Low-Dose Naltrexone

T.M. is a 61-year-old man with a medical history significant for type 2 diabetes mellitus, rheumatoid arthritis, hypothyroidism, and hyperlipidemia. For these, he had been prescribed (via physicians other than the authors) levothyroxine, metformin, glyburide, and fenofibrate. Regarding the diagnosis of follicular lymphoma, T.M. first presented to his primary care provider in April 2004 complaining of enlarged bilateral cervical and inguinal lymph nodes. Shortly before he noticed the lymph nodes, T.M. had experienced a period of profound situational stress followed by a case of Bell palsy. In June 2004, after an initial workup, histological examination of an excised left cervical node revealed follicular lymphoma, grade 1/3 with focal areas of grade 2/3, bcl-2 positive. T.M. was promptly referred to medical oncology by his primary physician, and a chemotherapeutic regimen was prescribed. Fearing the side effects, T.M. declined treatment. The medical oncologist offered no other therapeutic options except for observation. T.M. remained symptomatic with noticeably enlarging lymph nodes. On November 28, 2005, 17 months after the initial medical presentation and 15 months after diagnosis, T.M. presented to the Integrative Medical Center of New Mexico (medical office authors B.M.B. and A.J.B.). There, T.M. revealed a chief complaint of multiple large and enlarging cervical and inguinal lymph nodes. Physical examination revealed the greatest dimension of the largest cervical node (left side) at approximately 7.62 cm and that of the left inguinal region at approximately 12.7 cm. The latter node was particularly symptomatic and painful. The positron emission tomography (PET)/ computed tomography (CT) imaging from December 13, 2005, read as follows:

Synchronous metastatic malignant melanoma and primary adenocarcinoma in the colon

A 77-year-old woman presented with rectal bleeding of 2 days' duration. Six years previously, she had a 2.0-cm pigmented lesion on the sole of her left foot excised, and it was shown to be malignant melanoma (Clark level V). There was no evidence of metastatic melanoma. One year previously, she developed enlarged lymph nodes in the left inguinal region that subsequently were proven to contain metastatic malignant melanoma. A physical examination at the time of the current presentation was unremarkable, except for the 2 surgical scars on the left foot and left inguinal area.

Angiomyofibroblastoma-like tumor (cellular angiofibroma) in the male inguinal region

Angiomyofibroblastoma-like tumor is a rare mesenchymal tumor involving the male genital tract. We report a case of an angiomyofibroblastoma-like tumor that arose in the subcutaneous tissue of the left inguinal region in a 50-year-old man. Ultrasonography of the region demonstrated a well-circumscribed subcutaneous mass. Intralesional fat was revealed on magnetic resonance images. Although these imaging features are nonspecific, radiological findings enable considering the diagnosis of angiomyofibroblastoma-like tumor.

Dermatofibrosarcoma protuberans em região inguinal: relato de caso

O Dermatofibrosarcoma protuberans (DFSP) é uma neoplasia maligna rara em ginecologia com probabilidade de recidiva local e baixo risco para metástases. Paciente com 34 anos com endometriose tratada apresentou dores na região inguinal esquerda. Reportava sensação de aumento gradual em nódulo palpável indolor e de difícil mobilização. Exérese da lesão foi realizada com hipótese diagnóstica de endometriose. A microscopia revelou neoplasia mesenquimal com proliferação de células fusiformes monomórficas e aspecto estoriforme caracterizando o DFSP. DFSP deve ser lembrado no diagnóstico diferencial das afecções da região inguinal em ginecologia, pois, apesar de ser raramente encontrado, representa uma neoplasia maligna.

Sonographic Imaging of the Obturator Nerve for Regional Block

Today, there is a growing appreciation of the importance of the obturator nerve in clinical anesthesia. The aim of this study is to describe the ultrasound appearance of the obturator nerve for potential utility in guiding these nerve blocks. We scanned left and right inguinal regions of 20 volunteers lateral and distal to the pubic tubercle (PT) and assessed visibility, size and shape, and depth from the skin of common obturator nerves and their associated divisions. In addition to the volunteer study, we retrospectively reviewed a clinical series of obturator nerve blocks performed with ultrasound guidance and nerve stimulation. The obturator nerve can be sonographically visualized by scanning along the known course of the nerve; the anterior division characteristically converges toward the posterior division along the lateral border of the adductor brevis muscle to form the common obturator nerve more proximally. In the set of 20 volunteers, 25% (10/40) of common, 85% (34/40) of anterior, and 87.5% (35/40) of posterior obturator nerves were sonographically identified. The common obturator nerve was visualized 1.3 +/- 1.5 cm distal and 2.3 +/- 1.2 cm lateral to the PT. Divisions were visualized 2.1 +/- 2.0 cm distal and 2.1 +/- 1.2 cm lateral to the PT. The nerves (common, anterior, and posterior) averaged 2.7 +/- 1.2 mm, 1.4 +/- 0.6 mm, and 1.7 +/- 0.6 mm in anterior-posterior dimension and 9.0 +/- 4.3 mm, 9.6 +/- 3.9 mm, and 10.9 +/- 4.1 mm in medial-lateral dimension and were 25.9 +/- 7.6 mm, 15.5 +/- 3.9 mm, and 29.3 +/- 7.9 mm below the skin surface. The common obturator nerve and its anterior and posterior divisions are all relatively flat nerves with average anterior-posterior/medial-lateral dimension ratios of 0.32, 0.18, and 0.18, respectively. In the clinical series, nerve identification was confirmed with nerve stimulation (n = 6 block procedures, mean threshold stimulating current for evoked adductor contraction = 0.70 +/- 0.14 mA). The obturator nerve and its divisions are the flattest peripheral nerves yet described with ultrasound imaging. Knowledge of the obturator nerve's ultrasound appearance facilitates localization of this nerve for regional block and may increase success of such procedures.

Pyometra with inguinal herniation of the left uterine horn and omentum in a Beagle dog

AbstractObjective: To describe a unique case of pyometra with inguinal herniation of the left uterine horn and omentum.Case summary: A 7‐year‐old, 19 kg, intact female Beagle dog presented for surgical treatment of presumptive pyometra and biopsy of a caudal abdominal mass in the left inguinal mammary gland region. Ventral midline celiotomy was performed, and a distended, fluid‐filled uterus with passage of the distal aspect of the left uterine horn through the left vaginal process into the inguinal canal was identified. The patient recovered uneventfully following ovariohysterectomy and left inguinal herniorrhaphy.New or unique information provided: This is the first documented report of inguinal herniation of a uterine horn associated with a pyometra.

Nevus lipomatosus cutaneus superficialis (Hoffmann–Zurhelle) in a Chimpanzee (Pan troglodytes)

A 32-year-old, male chimpanzee (Pan troglodytes) kept in a zoo developed a focally extensive, proliferative, cerebriform, dermal mass at the left inner thigh extending to the inguinal region. After surgical removal, the mass recurred and extended progressively over a period of 5 years. At necropsy, a 20 x 20 cm large, well defined, papular and partly verrucous, rubbery mass composed of multiple large, soft nodules measuring up to 4 cm in diameter was observed in the left thigh and inguinal region. Histological examination revealed a multifocal expansion of the dermis by mature adipocytes that were arranged in small islands to large lobular aggregates. Dermal proliferations of adipocytes were almost completely separated from the subcutaneous adipose tissue. This is the first report of a unique lesion that resembles human Nevus lipomatosus cutaneus superficialis in a chimpanzee and is different from lipoma or liposarcoma.

Eosinophilic tumor in a patient with bronchial asthma receiving pranlukast

An eight-year-old boy with bronchial asthma receiving pranlukast suffered from an eosinophilic inguinal tumor and eosinophilia, which completely disappeared three months following the cessation of pranlukast therapy. Leukotriene antagonists (LTAs) are a new group of anti-inflammatory drugs used for the treatment of bronchial asthma [3]. Recently, Churg-Strauss syndrome (CSS) associated with LTAs including pranlukast [2] has been reported, although the precise pathogenic mechanisms underlying the development of this condition remain unclear [1, 3, 6]. CSS is characterized by asthma, eosinophilia and evidence of vasculitis affecting a number of organs [5]. The main histological features include extravascular granulomata, tissue infiltration with eosinophils and necrotizing vasculitis [5]. In this report we describe the occurrence of an inguinal eosinophilic tumor in a patient with bronchial asthma receiving pranlukast. Although the diagnostic criteria of CSS were not fulfilled, this does represent a novel adverse effect of LTAs. An eight-year-old boy with Treacher-Collins syndrome was referred to our hospital for investigation of the left inguinal tumor. The patient had suffered from severe bronchial asthma since 2 years of age and had received treatment with oral theophylline and inhaled fluticasone, cromoglycic acid and procaterol. Oral pranlukast (140 mg/day, 7 mg/kg/day) was started two years before the onset of the present illness. The patient has never taken oral or intravenous corticosteroids previously and the dosage of inhaled fluticasone did not change after the start of oral pranlukast. The patient became aware of the left inguinal tumor and associated discomfort one week before admission but did not complain of any other symptoms including those suggestive of systemic vasculitis. On admission, physical examination revealed a hard, tender and red subcutaneous hard mass (2.0×3.0 cm) in the left inguinal region with associated edema and redness in the left scrotum. The patient was afebrile with a body temperature of 36.4°C. Laboratory studies revealed an eosinophilia (23%, 1748/μl) and an elevated IgE level (1990 IU/l, normal<173). Liver enzymes, renal function, serum electrolytes, C-reactive protein, immunoglobulin and C3 and C4 complement levels were normal. Antinuclear antibody, rheumatoid factor and antineutrophil cytoplasmic antibody were negative whilst the druginduced lymphocyte stimulation test for pranlukast using H-thymidine up-take technique was negative. Computed tomography of the chest and sinuses was unremarkable. Surgical exploration of the left inguinal mass demonstrated that the tumor originated from the left spermatic cord (Fig. 1a). A biopsy of the tumor was performed because the tumor could not be separated completely from the Eur J Pediatr (2007) 166:183–184 DOI 10.1007/s00431-006-0226-9

Laparoscopic resection of metastatic pelvic liposarcoma

We report a pelvic liposarcoma originating from the left spermatic cord that recurred following inadequate excision. In our case, the tumor was resected without performing orchiectomy previously. The patient was managed by laparoscopic resection, before undergoing radical orchiectomy in the left inguinal region. To our knowledge, no case of laparoscopic resection for the recurrent liposarcoma has been described. In addition, the present case serves to demonstrate that radical orchiectomy with wide excision is needed for paratesticular tumor.