Removal Of Such Lesions Research Articles

Giant Mushroom-like Neglected Basal Cell Carcinoma of the Shoulder with Spontaneous Bleeding: A Successful Surgical Approach.

IntroductionGiant basal cell carcinomas (GBCCs) are extremely rare and typically more aggressive than their predecessor subtype. GBCCs with mushroom-like morphology have rarely been reported, with only one other case identified in the literature. Here we present a unique case of a neglected giant mushroom-like BCC that was treated successfully.Case descriptionAn 81-year-old male patient presented with a large ulcerative mass on his back. He had a medical history of chronic heart failure and atrial fibrillation, which were controlled with heart medication. During a routine visit to change the dressing of the lesion, the central pedunculated stalk underwent spontaneous haemorrhaging which led to massive blood loss. The patient was treated for shock and the lesion was completely excised under emergency surgery. The tumour was sent for histopathological assessment after complete surgical removal. Recovery was successful with good postoperative results and no recurrence was reported in the 12 months following discharge.DiscussionThe patient was under long-standing anticoagulant therapy that contributed to the untimely rupture of the pedunculated lesion and led to spontaneous heavy haemorrhaging. Treatment for such giant lesions can be complex, especially in patients with co-morbid conditions. Careful assessment and early treatment are paramount for successful results.ConclusionComplete removal of such lesions is very successful for treating GBCCs.LEARNING POINTSGiant mushroom-like basal cell carcinoma is a rare phenomenon that may only occur as a result of patient neglect and failure to seek early medical intervention.Patients with such lesions require special attention as multiple co-morbidities can play a role in disease progression.Early aggressive surgical intervention may be the best strategy for successful treatment and to prevent recurrence.

Pulmonary metastasectomy in germ cell tumors and prostate cancer.

Pulmonary oligo-metastases and oligo-recurrences are terms used to define a set of clinical conditions consisting of limited metastatic malignant disease characterized by an intermediate aggressive behavior compared to diffuse metastatic conditions. If the primary tumor has been controlled and extra-thoracic lesions are excluded, there is a suggestion in the medical literature that removal of such lesions could potentially prolong survival. The lungs are a common metastatic spreading site, especially from epithelial malignancies and sarcomas; pulmonary surgical or interventional metastasectomy have been proposed with curative intent in case of limited tumor load (usually less than 5 lesions). There are many series reporting data about colorectal, renal or breast lung metastasectomy, but the absence of multi centric prospective trials determines a lack of definitive evidence, especially for less common tumors such as metastatic germ cell and prostate cancer. They rarely present in the oligo-metastatic form and their management is often based on personal experience. The aim of our article is to review the latest evidence in the treatment of pulmonary metastatic germ cell and prostate tumors. We cover the full range of treatments: from surgery to ablative radiotherapy and combination of local and systemic therapy. Despite the absence of evidence based guidelines, it emerges that pulmonary metastasectomy should always be considered when general criteria for resection have been met. In germ cell tumors surgery should be mainly reserved for residual disease after chemotherapy, whereas in prostate cancer, pulmonary metastasectomy should be preferred to avoid or delay hormonal deprivation therapy and its side effects.

Hybrid operating room for the intraoperative CT-guided localization of pulmonary nodules.

Video-assisted thoracic surgery (VATS) requires preoperative computed tomography (CT)-guided localization of small pulmonary nodules or ground glass opacities (GGOs). However, this traditional two-stage approach is not devoid of potential complications, including wire dislodgement, pneumothorax, and/or hemothorax. With the advent of hybrid operating rooms (HORs), simultaneous single-stage localization and removal of such lesions has become possible. Here, we review the technical developments and the state-of-the-art in the field of intraoperative CT-guided localization and resection of small pulmonary nodules performed within a HOR.

Microsurgical management of benign lesions interior to the cavernous sinus: A case series.

Background:Benign lesion interior to the cavernous sinus (CS) is very rare.Objective:In this series we found nonneoplastic lymphatic aggregation and osteoclastoma inside the CS which is very rare and probably not reported in literature. One interesting postoperative complaint of feeling of tickling down of warm water under the skin forehead was found in the patient of inflammatory disease of CS which is not reported in literature. Here we also describe our experiences of microsurgical management of series of benign lesions inside the CS.Materials and Methods:Benign mass originated from the content of CS or inner side of walls of CS, confirmed peroperatively were included in this series. Prospectively recorded data of microsurgical management was retrogradely studied.Results:Total number of patient was 12. Patient's age range was 30–60 years. Follow-up range was 60 months to 19 months. Three was nonneoplastic lesion (tuberculosis, inflammatory and nonneoplastic lymphoid infiltration). Among the 9 neoplastic lesions, two hemangiomas, two meningiomas, three 6th nerve schwannomas, one osteoclastoma and one epidermoid tumor. Middle cranial fossa-subtemporal extradural approach was used in 9 cases and in two cases extended middle fossa zygomatic approach. New postoperative 3rd nerve palsy developed in 5 cases all recovered completely except one. In seven patients 6th nerve palsy developed after operation; only one recovered. Postoperatively simultaneous 3rd, 4th and 6th nerve palsy developed in four cases. One interesting postoperative complaint of feeling of tickling down of warm water under the skin of left sided forehead was found in the patient of inflammatory disease of CS. Mortality was nil. Total resection was done in 9 cases. There was no recurrence till last follow-up.Conclusion:Though decision for microsurgical removal of such lesions is not straight forward. Probably microsurgery is the best option in treating such benign lesions though it may associate with some permanent cranial nerve palsy.

VH30 Endoscopic Submucosal Dissection (ESD) Assisted Endoscopic Mucosal Resection (EMR) of a Large Sessile Duodenal Adenoma with Central Scarring

Piecemeal snare polypectomy is a conventional EMR technique for removal of large sessile duodenal adenomas. However, scarred tissue may prevent adequate vertical dissection precluding a potentially resectable lesion unresectable endoscopically. Here we describe an ESD-assisted EMR technique in removal of such lesions. A 62 year old female was referred to us for an incidentally found large sessile adenoma in the second part of duodenum just distal to the ampulla.

Endoscope-Assisted Microsurgical Removal of an Epidermoid Tumor within the Cavernous Sinus

Epidermoid tumor of the cavernous sinus is rare. The aim of this case report is to discuss the role of neuroendoscopes in the removal of such lesions. A 21-year-old man presented with 6-year history of progressive headache, diplopia, and visual disturbance. Work-up revealed an epidermoid tumor located in the right cavernous sinus. An extradural transcavernous approach was utilized via a traditional frontotemporal craniotomy with endoscopic assistance. The postoperative course was uneventful with immediate improvement of the patient's headache. Postoperative magnetic resonance imaging demonstrated complete removal of the tumor. There were no signs of recurrence during a 2-year follow-up period. The endoscope is a useful tool for removing epidermoid tumors from the cavernous sinus and enhances visualization of areas that would otherwise be difficult to visualize with microscopes alone. Endoscopes also help minimize the retraction of neurovascular structures.

Unusual Foreign Body of Parotid Gland Presenting as Sialolithiasis: Case Report and Literature Review

This case report highlights an unusual case where a foreign body in the parotid gland was initially thought to be sialolithiasis based on CT scans. The foreign body was safely retrieved from the parotid gland without formal superficial parotidectomy using methylene blue and an image intensifier to localize the lesion. Diagnosis and management of foreign bodies in the parotid gland are reviewed, and surgical options in removal of such lesions are discussed.

Dumbbell-type juvenile xanthogranuloma in the cervical spine of an adult

Adult cases with isolated juvenile xanthogranuloma of the central nervous system are very rare. We report a case with dumbbell-type juvenile xanthogranuloma in the cervical spine. A 38-year-old man presented with moderate numbness of the right ring finger and right little finger and weakness of the right grip. Magnetic resonance imaging (MRI) showed an intra-spinal mass extending into the paravertebral area. The spinal cord was compressed by the lesion, which was isointense with the spinal cord on both T1- and T2-weighted imaging. Homogenous enhancement was observed after gadolinium administration. These findings favored a preoperative diagnosis of a rare tumor, rather than tumor of the nervous system. Complete surgical removal of the tumor was performed through hemilaminectomy combined with facetectomy between C7 and T1. Histological examination and immunohistochemical testing led to a diagnosis of juvenile xanthogranuloma. Two years after complete resection, MRI showed no recurrence. This appears to represent the first report of dumbbell-type juvenile xanthogranuloma in the cervical spine. Total removal of such lesions is recommended because of the high potential risk of tumor recurrence around the central nervous system.

The suction pseudopolyp technique: a novel method for the removal of small flat nonpolypoid lesions of the colon and rectum

Small flat nonpolypoid lesions of the colorectum can be technically difficult to target and completely remove; techniques such as hot biopsy forceps electrocauterization are associated with serositis, delayed bleeding, and perforation. This study aimed to describe a novel technique for the removal of such lesions and demonstrate its safety and efficacy. Patients aged 18 - 80 years with flat nonpolypoid lesions (Paris-Japanese classification 0-IIa and 0-IIb, measuring less than 10 mm) identified at colonoscopy were included in this prospective study. The lesions were removed by the suction pseudopolyp technique (SPT): the lesion is aspirated into the suction channel of the colonoscope and continuous suction applied for 5 seconds whilst the colonoscope is gently retracted. On release of the suction, the resulting pseudopolyp containing the lesion and a margin of normal tissue is easily ensnared and resected. The primary outcomes were endoscopic completeness of polyp resection and complication rate. Over a 12-month period, 1231 polyps were removed during 2656 colonoscopies; 126 polyps (in 101 patients) met inclusion criteria. Complete endoscopic resection was achieved in 100 % of the polyps, without immediate or delayed complication. Of the resected lesions, 57 % had malignant potential (adenomas 47 % and sessile serrated lesions 10 %); a higher proportion of lesions removed from the right colon had malignant potential compared with those from the left colon (75 % vs. 41 %, P = 0.0066). Diminutive flat lesions of the colorectum are predominantly adenomas and sessile serrated lesions. SPT is a safe, effective, and reproducible therapy for removal of these lesions.

Diverticulitis or Cancer? That is the Question

Purpose: Introduction: Isolated diverticulitis is often known to mimic an inflammatory polyp or malignancy. Our patient is a 68 year old man who was found to have a suspicious appearing lesion arising in a diverticular pouch. This case represents the risk of endoscopic removal and appropriate conservative management with antibiotic treatment and laparoscopic removal of the lesion. Case Presentation: During a screening colonoscopy, our patient was found to have a 1.5 cm erythematous fungating lesion located in the sigmoid colon, within a diverticular pouch. The lesion was surrounded by multiple diverticuli. The site was marked with Spot ink for presumptive diagnosis of malignancy. Biopsies showed inflammatory changes and negative for malignancy. He denies abdominal pain, blood in the stool, and change in bowel habits, weight loss or fever. He denies any family history of colon cancer or polyps. Physical exam was unremarkable. His hemoglobin and MCV were within normal limits. The patient was empirically treated for diverticulitis with oral ciprofloxacin and metronidazole for 2 weeks. A colonoscopy was repeated in 2 months. The previously marked location was identified and there was significant improvement in erythema. However, the mucosa appeared multilobulated and suspicious for malignancy. This area was located in a diverticular pouch making endoscopic removal of the lesion high risk. Patient underwent laparoscopic resection of the affected colonic segment, which showed polypoid granulation tissue/inflammatory pseudopolyp arising in an inflamed diverticulum. Discussion: The prevalence of diverticulosis increases with age. By age 85, 65% of the population has diverticulosis. Most patients are asymptomatic (70%), however 15 to 25 percent develop diverticulitis, and 5 to 15 percent develop diverticular bleeding. Up to 30 percent of patients with uncomplicated diverticulitis require surgical intervention during the initial attack. Surgery has generally been advised after a first attack of complicated diverticulitis or after two or more episodes of uncomplicated diverticulitis. When compared to open sigmoid resection, laparoscopic colonic resection is associated with shorter recovery time. A laparascopic approach appears to be best suited for patients in whom the episode of acute diverticulitis has resolved and in patients with Hinchey classification stage I or II disease. Inflammation of a diverticulum can have a similar appearance to an inflammatory polyp or malignancy. Endoscopic removal of such lesions can lead to bowel perforation. Antibiotic treatment with or without laparoscopic removal should be recommended.

Regional Lipectomy via Remote Incisions for Lipomatosis of the Upper Extremities-Case Report

Background: The development of lipomatosis over the extremities can be distracting to affected individuals because of their deforming conspicuousness, this being especially the case for those where such lesions occur over the denuded upper extremities. Although lipomatosis are painless and pathologically benign, discomfort and disfigurement encourage these patients to seek the removal of such lesions. Aim and Objectives: The traditional surgical method of lipomatosis removal through an incision can lead to the need for countless incisions and significant post-operative disfigurement. However, the other alternatives in less-deforming and less-invasive approach, such as liposuction with/without the addition of an endoscope etc, are also associated with some drawbacks. Herein, we employed the minimally invasive technique to overcome these problems in treating such cases with surgery. Materials and Methods: We demonstrated the minimally invasive technique of regional lipectomy via remote incisions in detail and illustrated this technique with a case suffering from lipomatosis over upper extremities. Results: All lipomas were successfully removed via remote incisions and there was no significant complication or sequelae postoperatively. All our patients were satisfied with the results of their surgery as being assessed at the six-month to one-year follow-up. Conclusions: With our techniques, it is easily achievable to excise lipomatosis of the upper extremities completely and to btain as aesthetically pleasing results as possible. In addition, these incisions eventually became reusable incisions to facilitate the future management of any newly emerging lipomas without the need to create new incisions.

Transfacial nasal approach to paranasal sinuses, nasopharynx and anterior skull base

There are different surgical approaches to remove lesion involving the large central lesions of nasal cavity, sinus and nasopharynx with anterior skull base and retromaxillary extension depending on the site extent and the type of tumor. In this paper, we are describing a method that is rhinological and is a direct approach for removal of such lesions in 6 patients.

Surgical Pearl: Removal of large oval lesions with a smaller round punch

M any patients request the removal of common moles and other unwanted lesions with entirely benign clinical features for cosmetic reasons or because they are repeatedly traumatized by clothing, shaving, jewelry, or body movements. The goal is to efficiently remove such lesions while minimizing the chance for recurrence and scarring. A variety of methods for removal of such lesions are available and include: elliptical, round, and shave excisions; shave excision followed by electrodessication; cryotherapy combined with curetting or scissor excision; and punch excision. The standard punch excision technique uses disposable punches, which are available in 3, 4, 5, 6, and 8 mm. Generally, a punch is chosen that is at least .2-mm larger than the maximum diameter of a mole or other benign lesion. Round excision of this type preserves normal tissue, but dog-ears may be produced when the wound is closed. In the case of keratinous cysts, pilar cysts, and lipomas, larger lesions can be removed through a small punch incision opening. We often encounter lesions that are larger in one diameter than the punch that would be chosen based on the narrower width of a lesion. In addition, an oval lesion measuring 6 3 11 mm might be considered too large to remove with the largest 8 mm—diameter punch. Using a modified punch excision technique, lesions with benign clinical appearance that exhibit these features are readily excised. Staff and physician time is preserved by avoiding a freehand wedge excision and the wound created has an oval shape that produces excellent cosmetic results.

Lesionectomy in the pediatric age

Due to the development of electrophysiological recordings and the advancement in neuroimaging, which has allowed the identification of underlying focal abnormalities, in some patients with partial seizures, the surgical removal of such lesions has gained widespread recognition as a treatment modality for medically intractable epilepsy. In patients having a well-defined lesion, a good correlation between clinical and electrophysiological features, suggesting a zone of seizures onset around (or even in) the lesion, is the best guarantee to achieve good seizure control by "lesionectomy". However, other factors correlate with the seizure outcome. The persistency of seizures was found to be significantly associated with the completeness of the resection of the lesion and the preoperative duration of epilepsy, and, in some cases, the de novo brain damage induced by the surgical procedure itself. However, given the benefits of seizure control on the developing brain and the risk of secondary epileptogenesis, early surgery is recommended in children.

Base Excision Repair: AP Endonucleases and DNA Polymerases

The DNA base lesions in living cells occur permanently and with high frequency as a result of the action of exogenous and endogenous factors. The main mechanism providing removal of such lesions is base excision repair.

Significance of endometrial polyps detected hysteroscopically in eumenorrheic infertile women.

To determine if the incidence of small endometrial polyps detected hysteroscopically in an infertile eumenorrheic population differed from that in an apparently fertile eumenorrheic population. Evidence was sought to determine whether removal of such lesions would enhance reproductive performance. In a prospective study, 266 consecutive infertile women had undergone complete fertility evaluation. None of the women had experienced any change in their menstrual cycle. They were divided into two groups; 235 infertile patients (group 1) and 31 requesting a reversal of a previous tubal sterilization (group 2). All patients were examined by simultaneous combined laparoscopy and hysteroscopy as part of their routine infertility evaluation. When endometrial polyps were noted they were removed by hysteroscopy and histopathologically examined. Patients in whom the only apparent finding was endometrial polyps were followed up to determine their reproductive outcomes subsequent to removal of the polyps. Of the 224 uterine cavities successfully visualized in the infertile group, 134 were judged to be normal (60%) and 90 were abnormal (40%). Endometrial polyps were noted in 35 patients of group 1 and in one patient of group 2 (P < 0.01). Most polyps were located in the region of the utero-tubal junction and proved to be functional. A 50% pregnancy rate was achieved by hysteroscopic polypectomy. Fertility-related factors in women whose only apparent finding was endometrial polyps before and after hysteroscopy were comparable. Diagnostic hysteroscopy should be used routinely in the work-up of infertile woman, even in the presence of eumenorrhea. Persistent functional endometrial polyps, even if small, are likely to impair fertility in this select patient group. Removal of such lesions may improve subsequent reproductive performance.

Author reply

We appreciate Dr. Jackman's concerns regarding our recent report.1 We would like to provide additional information on the 19 patients who were omitted from the analysis because the biopsy procedure did not meet our qualifications.2 Seven patients had lesions that were not biopsied correctly. These patients underwent rebiopsy, and a definitive diagnosis was made. For the remaining 12 patients, we were unable to identify microcalcifications in the biopsy specimen roentgenographically. It is possible that the calcified tissue was lost during suction3; alternatively, the microcalcification may have simply been overlooked. Five of these 12 patients had Breast Imaging and Reporting System (BI-RADS) Stage III lesions and were followed for more than 2 years; no suspicious findings were made. The remaining seven patients had BI-RADS Stage IV lesions and underwent either rebiopsy or surgery. Of these seven patients, four had malignancies (two ductal carcinomas in situ [DCIS] and two invasive carcinomas), whereas three had benign lesions. Thus, whenever there is discordance between the pathologic result and the roentgenographic appearance of the lesion, a rebiopsy is indicated.4 Recalculating the false-negative rate as Dr. Jackman suggests yields a rate of 0.17% (5 of 2886 lesions). Dr. Jackman is correct in pointing out that we did not perform follow-up mammograms for all patients who had benign diagnoses. Dr. Jackman also raises the issue of lobular carcinoma in situ (LCIS). The detection of LCIS on vacuum-assisted biopsy is controversial. LCIS commonly is detected in breast tissue samples that are removed for other reasons.5 Liberman et al.6 suggest the removal of such lesions when the histologic features of LCIS overlap with DCIS, when a high-risk lesion is present, or when there is discordance between imaging findings and histologic findings. The pathologists at the Berlin-Buch Breast Unit believe that LCIS is an incidental finding when the pathologic diagnosis agrees with the imaging result, and they recommend follow-up in such cases. At other centers involved in our study, the response to LCIS was variable. Fifteen of 18 patients with LCIS underwent surgery; invasive lobular carcinoma was found in 3 of these patients. The three patients who did not undergo surgery were followed and exhibited no evidence of malignancy after 2 years. We agree that this issue is complicated and requires further study.

Management of postmenopausal bleeding in Sweden: a need for increased use of hydrosonography and hysteroscopy.

The objective was to determine how postmenopausal bleeding (PMB) is managed in Sweden today, and to relate the findings to a new evidence-based algorithm for the management of PMB. A questionnaire regarding the role of ultrasound and the use of different endometrial biopsy methods in the management of PMB was sent to all 61 gynecologic departments in Sweden. Fifty-nine of the 61 departments (97%) satisfactorily answered the questionnaire. Ultrasound was either always (n = 54, 92%) or most commonly (n = 5, 8%) used in the diagnostic work-up of PMB. In women with endometrial thickness < or =4 mm, 18 of the departments (31%) routinely sampled the endometrium; 12 (15%) followed the women with ultrasound; three (5%) did both sampling and follow-up with ultrasound; and the remaining 29 (49%) used expectant management (i.e. no biopsy or routine follow-up). In women with endometrium > or =5 mm, hydrosonography was performed routinely in two departments (3%), occasionally in 37 departments (63%), and never in 20 departments (34%). In women with endometrium > or =5 mm, endometrial biopsy was obtained routinely by Endorette/Pipelle in 39 departments (66%), while in 26 departments (44%) operative hysteroscopy was never performed. More than one-third of the gynecologic departments in Sweden never perform hydrosonography to rule out focal lesions or operative hysteroscopy for the removal of such lesions. Hydrosonography and hysteroscopy have a central role in the new guidelines for the management of PMB. Therefore, a need exists to broaden the use of hydrosonography and hysteroscopy.

Anterior Transcranial (Craniofacial) Resection of Tumors of the Paranasal Sinuses: Surgical Technique and Results

Transfacial approaches, traditionally used for malignant tumors of the paranasal sinuses, provide limited exposure when several sinuses are involved and are unsuitable for tumors that erode through the floor of the anterior cranial fossa. A transcranial approach may aid in the removal of such lesions. To better understand the risks and benefits of this surgical approach, we reviewed all patients (n = 76) who underwent a transcranial approach as part of the excision of paranasal sinus lesions between 1984 and 1993 at our institution. The spectrum of disease included adenocarcinoma (13 patients), squamous cell carcinoma and olfactory neuroblastoma (11 patients each), adenoid cystic carcinoma and poorly differentiated forms of carcinoma (6 patients each), melanoma (5 patients), and miscellaneous others (24 patients). Most patients had ethmoid sinus involvement; tumors were also commonly found in the cribriform plate, sphenoid sinus, and nasal fossa. In each patient, a bifrontal craniotomy was performed with extradural dissection to the floor of the anterior fossa and osteotomies for resection of involved elements. In 47 patients (62%), disease in the orbit, the anterior nasal cavity, or the soft tissues of the face required transfacial as well as transcranial resections. Bony defect in the anterior fossa floor was repaired with a pedicled pericranial flap. Patients with major complications included six patients with epipericranial and/or epidural hematomas requiring evacuation, three with transient cerebrospinal fluid leaks, two who developed bifrontal cerebral infarcts, and one who died soon after surgery. No meningitis was seen. To date, 26 patients (34%) have died; of those living (mean follow-up, 34 mo), 42 (84%) remain in full remission. The transcranial approach can achieve removal of erosive, invasive tumors from this area with predictable morbidity and may be considered whenever sinus tumors breach the anterior cranial base or extend beyond the reach of conventional transfacial approaches.

The Action ofEscherichia coliEndonuclease III on Multiply Damaged Sites in DNA

Energy deposition by ionizing radiation can lead to the formation of clustered DNA damage, i.e. more than one lesion situated within a helical turn of DNA. Among the postulated lesions are those characterized by damaged bases and abasic sites on opposite strands. Enzymatic removal of such lesions may inadvertently lead to the formation of double-strand breaks. To test this hypothesis, we have constructed model substrates containing damaged bases (5,6-dihydrothymine) or abasic sites set one, three, five and seven bases apart on opposite strands, and examined the reactivity ofEscherichia coliendonuclease III towards these substrates. Endonuclease III demonstrates two activities; as a glycosylase that removes saturated pyrimidine bases, such as dihydrothymine, and as an AP lyase that cleaves DNA strands at abasic sites. Analysis of endonuclease III-treated dihydrothymidine containing plasmid DNA by agarose gel electrophoresis indicated that the enzyme generated only single-strand breaks when the base damage was set one and three base-pairs apart, and only slowly introduced double-strand breaks in the other substrates. Endonuclease III treatment of the abasic site-containing DNA, however, readily yielded double-strand breaks. Taken together, these results indicate that the glycosylase activity of the enzyme, but not the AP lyase activity, is inhibited by the presence of a closely positioned break in the opposite strand.