Retroperitoneal Area Research Articles

Recurrence of testicular germ cell tumor as an angiosarcoma: A case report and review of the literature

Testicular germ cell tumor (TGCT) is the most common malignant tumor among young males. TGCT containing a teratoma component may show differentiation into various histopathological subtypes and may rarely recur as angiosarcoma. The present case had TGCT containing a teratoma component, and tumor recurrence occurred first as cartilage tissue and then as an angiosarcoma in the retroperitoneal area. After the diagnosis of angiosarcoma was established, the tumor was considered unresectable. The patient received chemotherapy and radiotherapy. The current study presents a rare case of TGCT, and the researchers also conducted a literature review.

Huge retroperitoneal schwannoma in a young male

Schwannomas are benign tumors mostly found in the head and neck regions. Localization in the retroperitoneal area is rare. We report a case of a 19-year-old male presented to our department complaining of right abdominal pain. An abdominal computed tomography (CT) scan showed a large retroperitoneal mass of 17 cm in diameter. The patient had an ultrasound-guided needle biopsy of the mass and histopathology and immunohistochemistry revealed a schwannoma. Tumor excision was performed through lumbotomy. Histopathological examination confirmed the diagnosis of benign schwannoma. After three years, at follow-up the patient was free of disease. Retroperitoneal schwannoma is a difficult clinical diagnosis and requires a high index of suspicion. Magnetic resonance imaging scan may help in the diagnosis of schwannoma and diagnosis is based on histopathologic examination and immunohistochemistry. Total excision has a therapeutic effect and a good prognosis.

Mimicking pancreatic malignancy: a systemic sarcoidosis

Systemic sarcoidosis that initially presents as a pancreatic mass has rarely been reported. A 47-year-old man presented with idiopathic epigastric abdominal pain. Abdominal CT showed multiple enlarged lymph nodes in the retroperitoneal area and a suspected tumor mass in the pancreatic head region. The preliminary diagnosis was celiac metastasis of a pancreatic malignancy. The definitive diagnosis was systemic sarcoidosis, which was supported by granulomas on histology, clinical radiographic findings, and clinical response to steroids. A review of published reports on sarcoidosis presenting initially as a pancreatic or celiac mass from the Chinese biomedical database (1978–2010) is included.

Critical clinical appraisal of the role of computed tomography-guided minimally invasive aspiration cytology in evaluation of retroperitoneal masses.

Context:Fine-needle aspiration (FNA) is increasing in popularity as a means of diagnosing mass lesions in retroperitoneal area. With use of radiologic guidance for needle placement, this technique is an effective way to obtain diagnostic material.Aims:The aims of the study were (1) to establish the validity and reliability of fine needle aspiration cytology in preoperative diagnosis of retroperitoneal tumor, and (2) to compare the significance of cytological diagnosis with histopathological report.Settings and Design:A prospective, cross-sectional hospital-based study.Materials and Methods:A prospective, cross-sectional study was designed on 45 cases of clinically and radiologically diagnosed retroperitoneal tumor in a tertiary care hospital. Computerized tomography (CT)-guided percutaneous FNA was performed and cytology smears were stained with May-Grünwald-Giemsa stain and conventional Papanicolaou (Pap) stain. Smears were broadly categorized into unsatisfactory, benign, suspicious of malignancy and malignant lesion. The cytological diagnosis was compared with subsequent histopathology report.Statistical Analysis:Positive and negative predictive values, diagnostic accuracy, chi-square test and others.Results:The total number of cases studied was 45, which include both epithelial tumors and mesenchymal tumors. Age group varied from 15 to 70 years. The overall sensitivity in our study to diagnose benign and malignant tumors by FNA cytology is 86% and the specificity is 96% with positive and negative predictive value of 86% and 96%, respectively. Diagnostic accuracy was 93.55% with high statistical significance (P < 0.001).Conclusions:FNA cytology is a simple, fast, reliable and less expensive method for diagnosis of various retroperitoneal neoplasms.

Laparoscopic Transmesenteric Nephrectomy for Nonfunctioning Hydronephrotic Crossed Renal Ectopia with Fusion

Introduction: Laparoscopy with low morbidity and a rapid recovery process than open surgery is a preferred surgical technique.1,2 Crossed renal ectopia is the most common fusion abnormality after the horseshoe kidney abnormality.3 In this video, laparoscopic transmesenteric nephrectomy for nonfunctioning hydronephrotic crossed renal ectopia from left to right with fusion is presented. The aim of this video is to illustrate how we can perform nephrectomy of nonfunctioning crossed renal ectopia with fusion anomalia, giving minimal damage to the normal kidney. Materials and Methods: A twenty-year-old mentally retarded male patient was admitted to the outpatient clinic with the complaint of abdominal pain. The left kidney was not visualisated, but a 15×10 cm cystic lesion in the right retroperitoneal area conjoined to the right kidney was observed in an ultrasonographic examination. In a computed tomographic examination, the absence of the left kidney was confirmed; however, there was a sharply marginated, homogeneous, cystic, without contrast enhancement 14×12×8 cm benign lesion in the lower half of the right kidney. Ventral malrotation of the right kidney and the compression of the lesion to the proximal ureter were observed. Early segmental arteries supplied by the right renal artery and millimetric arteries supplied by the right common iliac artery, extending toward the cystic mass was seen in computed tomography. Additionally, agenesis of the left seminal vesicle was seen. This cystic mass was thought to be left to the right ectopic kidney with these outcomes. Laparoscopic transperitoneal excision of the nonfunctioning, hydronephrotic cross-ectopic kidney was planned. Results: After creating pneumoperitoneum, the mass was seen transmesenterically. Without mobilizing the colon, we pass through the retroperitoneal space transmesenterically. The ectopic kidney was dissected from the surrounding tissues and excised. The operation time was 150 minutes and blood loss was 50 cc. The pathologic examination was reported as cystic kidney disease. After 6 months of follow-up, there was no pathology in the computed tomography. Conclusion: During the ascent of the kidney, it normally rotates anteromedially. Malrotation occurs if it fails to rotate or over-rotates. This anomaly can be unilateral or bilateral. Patients with renal malrotation have no specific complications, but malrotation is usually associated with other renal anomalies, such as ectopia with or without fusion or horseshoe kidney.4 The vesicoureteral reflux and malrotation of kidney may present with crossed renal ectopia. Coexistence of these abnormalities can lead to hydronephrosis and loss of renal function. Crossed renal ectopia should be considered in such patients who apply with nonspecific symptoms with concomitant anomalies. As a minimally invasive procedure, nonfunctioning, cross-ectopic nephrectomy can be performed laparoscopically with transmesenteric access without any damage at mesenteric tissues. None of the authors have any commercial associations that may create a conflict of interest in connection with this video. Runtime of video: 8 mins 26 secs

Retroperitoneal Hemorrhage from Kidney Angiomyolipoma

An 86-year-old woman with end-stage renal disease (etiology unknown) presented with left flank pain for ten hours. She was hypotensive and had a firm, exquisitely tender left flank mass. Computed tomography (CT) scan of the abdomen revealed a 20 cm left renal mass with extensive fatty tissue and associated retroperitoneal hemorrhage (Fig. 1). The patient died from hemorrhagic shock. Based on the large peri-renal fatty masses and the presence of a vessel extending into the renal parenchyma (Fig. 2), we concluded this was a kidney angiomyolipoma.1 Figure 1 CT scan of the abdomen showing retroperitoneal hemorrhage (short arrows) and areas of fatty tissue (arrow heads). Figure 2 CT scan of the abdomen showing the vessel extending to the renal parenchyma (arrow). Kidney angiomyolipomas are benign renal neoplasms, usually detected incidentally on imaging. Approximately 80 % occur spontaneously as in this case, while 20 % occur in association with tuberous sclerosis complex.2 As the lesions increase in size, the vascular supply becomes aneurysmal and hemorrhage risk increases. In one study, the risk of hemorrhage in lesions larger than eight cm was 25–50 %.3 Management is based on the size of the lesion and the presence of symptoms, with a shift toward less invasive treatments. Arterial embolization is used to reduce the size of angiomyolipomas,4 and regrowth does not occur after successful embolization. Some authors suggest arterial embolization if the tumor is symptomatic or greater than four cm.5

Retroperitoneal epidermoid cyst in a dog

Epidermoid cysts (EC) are benign lesions of ectodermal origin lined by a stratified squamous epithelium that resembles normal epidermis, but lacks the skin appendage present in dermoid cysts (Hagr and...

Approaching suspicious lymph nodes on the upper abdomen in gynecologic oncology

During last decades, gynecologic oncologists have acquired skills enough to remove malignant disease located in the retroperitoneal area, especially when it infiltrates the paraaortic and pelvic regions. In some circumstances, specifically when talking about advanced ovarian cancer, debulking all macroscopic disease is crucial to improve survival.

When to perform lymph node dissection in patients with renal cell carcinoma: a novel approach to the preoperative assessment of risk of lymph node invasion at surgery and of lymph node progression during follow‐up

To identify preoperatively patients who might benefit from lymph node dissection (LND). We assessed lymph node invasion (LNI) at final pathology and lymph node (LN) progression during the follow-up for 1983 patients with RCC, treated with either partial or radical nephrectomy. LN progression was defined as the onset of a new clinically detected lymphadenopathy (>10 mm) in the retroperitoneal lymphatic area. Logistic regression analyses were used to assess the effect of each potential clinical predictor (age, body mass index, tumour side, symptoms, performance status, clinical tumour size, clinical tumour-node-metastasis stage, and albumin, calcium, creatinine, haemoglobin and platelet levels) on the outcome of interest. The most parsimonious multivariable predictive model was developed, and discrimination, calibration and net benefit were calculated. The prevalence of LNI was 6.1% (120/1983 patients) and during the follow-up period, 82 patients (4.1%) experienced LN progression. On multivariable analyses, the most informative independent predictors were tumour stage (cT3-4 vs cT1-2, odds ratio [OR] 1.52, P = 0.05), clinical nodal status [cN1 vs cN0, OR 7.09, P < 0.001], metastases at diagnosis (OR 3.04, P < 0.001) and clinical tumour size (OR 1.14, P < 0.001). The accuracy of the multivariable model was found to be 86.9%, with excellent calibration and net benefit at decision-curve analyses. By relying on a unique approach, combining the risk of harbouring LNI and/or LN progression during the follow-up period, we have provided the first clinical presurgery model predicting the need for LND.

Complications in right‐sided paraaortic lymphadenectomy: ventral tributaries of the inferior vena cava

The purpose of this study was to describe the distribution and structure of ventral tributaries leading into the inferior vena cava where right-sided paraaortic lymphadenectomy is performed. The study examined 21 retroperitoneal specimens by graphic reconstruction, statistical evaluation, and histological examination of ventral tributaries (VTs). Seventy VTs were identified. The average number per specimen was 3.33. There were 20, 40, and 40% of VTs found in Levels I, II, and III, respectively. During the preparation, we observed an unusual arrangement of the IVC wall, into which VTs were led through a preformed sleeve-like channel and anchored near the lumen. This finding is a key mechanism that explains the ease with which VTs are extracted during surgery. Knowledge of the distribution and histological structure of VTs allows proper orientation of the retroperitoneal area of the front wall of inferior vena cava, which is essential for uncomplicated right-sided paraaortic lymphadenectomy. The histological structure of the VT ostium within the wall of the inferior vena cava explains why injury is easy during the procedure.

1838 WHEN TO PERFORM LYMPH NODE DISSECTION IN RENAL CELL CARCINOMA PATIENTS: A NOVEL APPROACH TO PREOPERATIVELY ASSESS THE RISK OF LYMPH NODE INVASION AT SURGERY AND NODAL PROGRESSION DURING FOLLOW UP

You have accessJournal of UrologyKidney Cancer: Advanced (I)1 Apr 20131838 WHEN TO PERFORM LYMPH NODE DISSECTION IN RENAL CELL CARCINOMA PATIENTS: A NOVEL APPROACH TO PREOPERATIVELY ASSESS THE RISK OF LYMPH NODE INVASION AT SURGERY AND NODAL PROGRESSION DURING FOLLOW UP Umberto Capitanio, Firas Abdollah, Rayan Matloob, Nazareno Suardi, Andrea Gallina, Paolo Capogrosso, Marco Moschini, Paolo Dell'Oglio, Cristina Carenzi, Alberto Briganti, Francesco Montorsi, and Roberto Bertini Umberto CapitanioUmberto Capitanio Milan, Italy More articles by this author , Firas AbdollahFiras Abdollah Milan, Italy More articles by this author , Rayan MatloobRayan Matloob Milan, Italy More articles by this author , Nazareno SuardiNazareno Suardi Milan, Italy More articles by this author , Andrea GallinaAndrea Gallina Milan, Italy More articles by this author , Paolo CapogrossoPaolo Capogrosso Milan, Italy More articles by this author , Marco MoschiniMarco Moschini Milan, Italy More articles by this author , Paolo Dell'OglioPaolo Dell'Oglio Milan, Italy More articles by this author , Cristina CarenziCristina Carenzi Milan, Italy More articles by this author , Alberto BrigantiAlberto Briganti Milan, Italy More articles by this author , Francesco MontorsiFrancesco Montorsi Milan, Italy More articles by this author , and Roberto BertiniRoberto Bertini Milan, Italy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2221AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Whether to perform lymph node dissection (LND) in renal cell carcinoma (RCC) is still debated. We aimed to preoperatively identify patients who might benefit from a LND. METHODS In 1983 RCC patients treated with partial or radical nephrectomy, we considered as a mutual endpoint the presence of lymph node invasion (LNI) at final pathology and lymph node (LN) progression during the follow-up period. Nodal progression was defined as the onset of a new clinically detected lymphadenopathy (>10 mm) in the retroperitoneal lymphatic area. Moreover, all the variables available before surgery were tested as potential predictors of LNI and/or LN progression. Regression analyses were used to assess the effect of each clinical predictor (age, body mass index, tumor side, symptoms, performance status, clinical tumor size, clinical TNM stage, albumin, calcium, creatinine, haemoglobin, and platelets levels) on the outcome of interest. The most parsimonious multivariable predictive model was developed. Discrimination, calibration and net benefit were calculated. RESULTS The prevalence of nodal invasion was 6.1% (n=120/1983). During the follow-up period, 82 patients (4.1%) experienced nodal progression. Of those, 17 (20.7%), 38 (46.3%) and 27 (32.9%) were pNx, pN0 and pN1 cases at surgery, respectively. Therefore, the rate of patients who experienced lymph node progression resulted 1.5 vs. 5.0 vs. 22.5% in pNx vs. pN0 vs. pN1, respectively. At multivariable analyses, the most informative independent predictors resulted T stage [cT3-4 vs. cT1-2, odds ratio (OR) 1.52, p=0.05], clinical nodal status [cN1 vs. cN0, OR 7.09, p<0.001], metastases at diagnosis (OR 3.04, p<0.001) and clinical tumor size (OR 1.14, p<0.001). The accuracy of the multivariable model resulted 86.9% with excellent calibration and net benefit. The use of a nomogram cutoff of 3% would allow the avoid of roughly 50% of the procedures with a very low false negative rate (7.4%). CONCLUSIONS By relying on an unique approach combining the risk of harbouring LNI and/or LN progression during follow-up period, we provided the first clinical pre-surgery model predicting the need for LND. The model showed excellent accuracy and calibration, with a significant benefit in decision curve analyses. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e755 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Umberto Capitanio Milan, Italy More articles by this author Firas Abdollah Milan, Italy More articles by this author Rayan Matloob Milan, Italy More articles by this author Nazareno Suardi Milan, Italy More articles by this author Andrea Gallina Milan, Italy More articles by this author Paolo Capogrosso Milan, Italy More articles by this author Marco Moschini Milan, Italy More articles by this author Paolo Dell'Oglio Milan, Italy More articles by this author Cristina Carenzi Milan, Italy More articles by this author Alberto Briganti Milan, Italy More articles by this author Francesco Montorsi Milan, Italy More articles by this author Roberto Bertini Milan, Italy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prognostic significance of Bcl-2 and p53 protein expressions and Ki67 proliferative index in diffuse large B-cell lymphoma

To the Editor Here we present a case of multiple granulocytic sarcomas with monocytic differentiation involving the skin and retroperitoneal area. A 19-year-old man presented with the complaints of generalized arthralgia and fixed non-tender nodular lesions (Figure 1). Physical examination revealed generalized immobile, painless violaceous erythematous nodules on his back, bilateral arms and legs, and joints. The largest nodule was 3x2 cm, located on his right posterolateral upper leg. Abnormal laboratory values included hemoglobin of 84 g/L, hematocrit of 27.2%, erythroid sedimentation rate of 58 mm/h, and lactate dehydrogenase of 613 IU/L. Blood smear revealed hypochromia and microcytosis, and bone marrow was normocellular without blasts. However, monocyte and macrophage marker CD163 was positive in 10%-15% of the bone marrow cells. The pathological examination of the nodular lesions revealed medium-sized, irregular-shaped blastic cells with frequent mitotic activity, which infiltrated the dermis. The tumor tissue contained tingible body macrophages with nuclear debris. In immunohistochemical study, these cells were positive for CD163, lysozyme, CD4, and CD43, while CD117, MPO, CD68, langerin, CD1a, S–100, CD35, CD21, clusterin, fascin, factor 13a, CD123, TCL–1, TdT, CD3, CD20, and CD30 were all negative. The Ki–67 proliferation index of the neoplastic cells was 80%. In situ hybridization study with the EBER probe for Epstein-Barr virus was negative. Figure 1 Multiple violaceous skin nodules. Abdominal and thorax computerized tomography (CT) was performed, which revealed a right retroperitoneal mass with blurred margins. A CT-guided biopsy was performed. The biopsy showed pleomorphic cell infiltration with large mononuclear and binuclear cells with clear nucleoli, which were CD163-positive, CD117-negative, and focal MPO-positive. These atypical pleomorphic, monocytic-histiocytic cells did not have blastic morphology. A high dose of cytosine-arabinoside and idarubicin was started. The nodular lesions disappeared 20 days after starting chemotherapy. Arthralgia, dyspnea, and respiratory distress developed consequently. Right pleural effusion was demonstrated in the chest X-ray. The cytological examination of the pleural fluid revealed blastic infiltration. Since the retroperitoneal mass persisted in follow-up abdominal CT, a new chemotherapy regimen containing fludarabine, cytosine arabinoside, and idarubicin was started. However, pleural effusion persisted and required Pleurocan evacuation. Methotrexate (Mtx) was given intrapleurally accompanied with systemic high-dose Mtx. Tumor lysis syndrome developed 28 days after this regimen and required intubation; the patient died due to cardiac arrest 3 days later. Granulocytic sarcoma (GS) is the tumoral infiltration of extramedullary sites with immature myeloid precursor cells; it is associated with 3%-8% of acute myeloid leukemia (AML) cases and rarely with chronic myeloproliferative disorders [1]. Monocytic differentiation of GS is seen mostly in AML M4 and M5 subtypes according to the French-American-British (FAB) classification [2]. Any extramedullary anatomic site may be involved with GS and it might rarely precede but usually occurs simultaneously with acute leukemia. CD163 positivity is controversial in GS. While Lau et al. claimed that CD163 is a highly specific marker for cells of monocyte/macrophage lineage, they did not demonstrate CD163 positivity in GS in their series [2]. Backe et al., however, demonstrated CD163 positivity in myeloid leukemias with monocytic differentiation [3], while Benet et al. demonstrated CD163 positivity in 52% of their cases of leukemia cutis [4]. The prevalence of skin involvement in myeloid malignancies is approximately 3%, and it is usually associated with cases with monocytic differentiation. It is difficult to identify the origin of the tumor when it is not associated with bone marrow infiltration, namely “aleukemic leukemia cutis” [4]. In a series of 173 patients with leukemia cutis, 7.5% of the patients with leukemic skin infiltration had no underlying myeloid neoplasm [4). Skin is one of the most common sites of involvement in GS, with approximately one-quarter of patients with GS having skin involvement [4]. The presented patient had arthralgia and multiple granulocytic nodules on various parts of the body and joints without bone morrow involvement. The morphologic appearance of the skin lesions was typical for leukemia cutis in its color and nodular form, as is immunohistochemistry with monocytic differentiation. Nevertheless, most of the aleukemic GS of skin is known to be associated with infiltration with cells of monocytic differentiation [5]. In conclusion, myeloid leukemias might present with granulocytic sarcomas, particularly in skin without bone marrow involvement. Multiple skin lesions of nodular pattern with violaceous color might suggest an underlying myeloid neoplasm. The positivity of monocytic markers such as CD68 and CD163 is typical for leukemia with a predilection to the skin. Patients with aleukemic granulocytic sarcoma might have a very aggressive course, with evolution to tumor lysis syndrome. Conflict of Interest Statement The authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/ or affiliations relevant to the subject matter or materials included.

Pelvic schwannoma in the right parametrium

Neurilemomas are benign usually encapsulated nerve sheath tumors derived from the Schwann cells. These tumors commonly arise from the cranial nerves as acoustic neurinomas but they are extremely rare in the pelvis and the retroperitoneal area (less than 0.5% of reported cases), unless they are combined with von Recklinghausen disease (type 1 neurofibromatosis). We report the case of a 58-year-old female with pelvic schwannoma, 6.5 × 5.5 cm in size, in the right parametrium. This is the first case reported in the literature. Based on the rarity of this tumor and in order to ensure optimum treatment and survival for our patient, we performed laparotomy with total abdominal hysterectomy and en-block tumor excision. A frozen section was taken during the surgery before complete resection of the mass, which was ambiguous. Because of the possibility of malignancy, complete excision of the mass was performed, with pelvic blunt dissection. Histological examination showed a benign neoplasm, originating from the cells of peripheral nerve sheaths; diagnosis was a schwannoma. There were degenerative areas, including cystic degeneration, hemorrhagic infiltrations, ischemic foci with pycnotic cells, and collagen replacement. Pelvic schwannomas are rare neoplasms that can be misdiagnosed. Laparoscopy is a safe and efficient option for approaching benign pelvic tumors and might offer the advantage of better visualization of structures due to the magnification in laparoscopic view, especially in narrow anatomic spaces.

Pelvic retroperitoneal cyst during pregnancy

ObjectiveThe diagnosis and treatment of adnexal mass during pregnancy is a major challenge for obstetricians. A rare case is reported of retroperitoneal cystic lesion during pregnancy. Case ReportA 31-year-old woman was diagnosed with an adnexal cystic lesion at 8 weeks of gestation and underwent laparoscopic surgery at 14 weeks of gestation. During laparoscopic surgery, the bilateral ovaries and tubes were normal, but the lesion was located on the right-side retroperitoneal area. Aspiration and enucleation were performed successfully by laparoscopy. The pathology report revealed mucinous cystadenoma. The patient had a smooth pregnancy course and delivered a healthy baby at 39 weeks of gestation. ConclusionLaparoscopic surgery is a safe procedure in the management of pregnant women with suspicious adnexal cystic lesions.

Right Extraperitoneal Approach for Sacrocolpopexy Surgery: A Cadaver Feasibility Study for Development a New Minimally Invasive Approach

The aim of the study was to determine the feasibility of a new retroperitoneal approach to sacrocolpopexy using minimal invasive surgery technique at cadaver model. This experimental study performed on a female cadaver at a University Hospital setting. We placed 5 mm laparoscopic trocars in right lumbar area to reach retroperitoneal space. Extraperitoneal and retroperitoneal pelvic view obtained. Anatomical landmarks of retroperitoneal area at the level of sacral promontory to vaginal posterior wall marked.

Kaposiʼs Sarcoma

A 56 y/o HIV-infected African American male presented with non-bloody diarrhea for 3 days. He also complained of diffuse abdominal pain, worse in the epigastric area, for the past 4 months and associated with nausea and intermittent non-bloody, non-bilious vomiting, especially after eating solid food. He admits to 33 pounds weight loss over 6 months. He denies any fever or chills, any rash or skin lesions. His HIV risk factor was intravenous drug use. His CD4 count was 46 cells/mm3 and HIV RNA was 123,664/ml. He was non-compliant with HAART. Co-morbid conditions included polysubstance abuse and HCV infection. There was moderate epigastric tenderness on physical examination. Laboratory studies showed anemia, stool studies were negative for enteric pathogens, but stool occult blood was positive. A CT scan of abdomen with contrast showed prominent lymph nodes in the paraesophageal and retroperitoneal areas. An EGD showed a large, fungating, circumferential mass with no bleeding in the gastric antrum. Biopsies were performed and the pathologic diagnosis was Kaposi's sarcoma (KS). Immunohistochemical stains for HHV-8 were positive.Figure: [648]Conclusion: In the pre-HAART era, the prevalence of KS was over 20,000 times higher in patients with AIDS than in the general population. The use of HAART has led to a decline in the prevalence of AIDS-related KS, but the benefit is limited to patients who adhere to therapy. Skin involvement is characteristic but extracutaneous spread is common, particularly to the oral cavity, GI tract, and respiratory tract. Before the HAART era, GI tract involvement was 40% and occurred without cutaneous disease in many cases. Patient may be asymptomatic or can have weight loss, nausea, vomiting, abdominal pain, malabsorption, GI hemorrhage, intestinal obstruction, or diarrhea. The visual lesions are characteristic and the diagnosis can be confirmed on histopathology. The staging system, developed by AIDS Clinical Trials Group (ACTG) of the National Institute of Health, which consists of 3 parameters: extent of tumor, Immune status and severity of systemic illness, divides patients into good and poor risk categories. Treatment depends on the presence or absence of clinical symptoms as well as on CD4 count, HIV viral load and presence of HHV-8. For symptomatic patients, the treatment is chemotherapy with liposomal anthracyclines as well as antiretroviral therapy to optimize cellular immune function.

Epizootics of sudden death in tammar wallabies (Macropus eugenii) associated with an orbivirus infection

Epizootics of sudden death in tammar wallabies (Macropus eugenii) occurred at six research facilities and zoological gardens in New South Wales, Australia, in late 1998 and at one Queensland research facility in March 1999. There were 120 confirmed tammar wallaby deaths during this period; however, population censuses indicated that up to 230 tammar wallabies may have died. The majority of animals died without premonitory signs. A small proportion of wallabies exhibited increased respiratory rate, sat with a lowered head shortly before death or were discovered in lateral recumbency, moribund and with muscle fasciculations. Gross postmortem findings consistently included massive pulmonary congestion, mottled hepatic parenchyma and subcutaneous oedema throughout the hindlimbs and inguinal region. Approximately 30% of the animals examined also had extensive haemorrhage within the fascial planes and skeletal muscle of the hindlimb adductors, inguinal region, ventral thorax, dorsal cervical region and perirenal retroperitoneal area. The tissues of affected animals became autolytic within a short period after death. Bacteriological examination of tissues from 14 animals did not provide any significant findings. Toxicological examination of the gastric and colonic contents of four animals did not reveal evidence of brodifacoume or other rodenticides. Viruses from the Eubenangee serogroup of the Orbivirus genus were isolated from the cerebral cortex of nine, and the myocardium of two, tammar wallabies and the liver and intestine of another tammar wallaby. A similar orbivirus was also isolated from the cerebrospinal fluid of another tammar wallaby that died suddenly. The disease agent appears to be a previously unrecognised orbivirus in the Eubenangee serogroup. This is the first report of epizootics of sudden deaths in tammar wallabies apparently associated with an orbivirus infection.

Differences in the inflammatory response induced by acute pancreatitis in different white adipose tissue sites in the rat.

BackgroundThere is increasing evidence of the role of adipose tissue on the systemic effects of acute pancreatitis. Patients with higher body mass index have increased risk of local and systemic complications and patients with android fat distribution and higher waist circumference are at greater risk for developing the severe form of the disease. Here we evaluated the changes on different areas of adipose tissue and its involvement on the inflammatory response in an experimental model of acute pancreatitis.MethodsPancreatitis was induced in male Wistar rats by intraductal administration of sodium taurocholate. Orlistat was administered to inhibit lipase activity. Activation of peritoneal macrophages was evaluated by measuring IL1β and TNFα expression. Inflammation was evaluated by measuring myeloperoxidase activity in mesenteric, epididymal and retroperitoneal areas of adipose tissue. Changes in the expression of inflammatory mediator in these areas of adipose tissue were also evaluated by RT-PCR.ResultsPancreatitis induces the activation of peritoneal macrophages and a strong inflammatory response in mesenteric and epididymal sites of adipose tissue. By contrast, no changes were found in retroperitoneal adipose tissue. Inhibition of lipase prevented the activation of macrophages and the local inflammation in adipose tissue.ConclusionsOur results confirm the involvement of adipose tissue on the progression of systemic inflammatory response during acute pancreatitis. However, there is a considerable diversity in different adipose tissue sites. These differences need to be taken into account in order to understand the progression from local pancreatic damage to systemic inflammation during acute pancreatitis.

What is the Role of Enlarged Lymph Node Resection Alone in Patients With Nonseminomatous Germ Cell Tumor Who Had Stage II or III Disease?

BackgroundRetroperitoneal lymph node dissection is an important treatment modality in nonseminomatous germ cell tumors of the testis. However, the role of more limited surgical approaches such as resection of enlarged lymph nodes only is still controversial. Patients and MethodsBetween January 1991 and December 2010, charts of 94 patients who underwent resection of enlarged retroperitoneal lymph nodes alone were reviewed. Pathologic findings, local recurrence, and adverse effects were noted after this surgical approach. ResultsThe median age was 25.5 years. Twenty-one (22.6%) patients had lung metastasis, and 5 (5.4%) patients had nonregional lymph node metastasis at the initial visit. Eighty-seven (91.6%) patients received chemotherapy after inguinal orchiectomy, and the other patients had mass resection only for enlarged lymph nodes without prior chemotherapy. In patients who had chemotherapy before surgery, the median retroperitoneal lymph node size before and after chemotherapy cycles was 55 mm and 32.5 mm, respectively. The pathologic assessment of retroperitoneal masses revealed mature teratoma in 51.6% (n = 47) of patients, viable carcinoma in 20.9% (n = 19) of patients, and necrosis or fibrosis in 27.5% (n = 25) of patients. The median follow-up time was 60.2 months (range, 2.7-334.8 months). During follow-up, 5 (5.4%) patients had radiologic relapse at the retroperitoneal area, and 3 patients developed systemic metastases. Six (6.4%) patients died of their disease, 2 (2.1%) patients were alive with disease, 86 (91.5%) patients were healthy at the last follow-up. Ejaculation status was recorded in 56 patients. Antegrade ejaculation had preserved in 53 (94.6%) of these patients. ConclusionsResection of enlarged lymph node metastases alone is a reasonable treatment option for patients with nonseminomatous germ cell tumors.

Pancreatic-pleural fistula in chronic pancreatitis

Pancreatic-pleural fistula is a rare condition and few data related to its diagnosis and treatment are available. A fistulous connection linking the pancreas with the pleura via the diaphragm or mediastinum through the retroperitoneal area is formed.We report on a case with pancreatic-pleural fistula at its early stages in an alcoholic male patient aged 45years with known chronic pancreatitis. The operation by Roux-en-Y jejuno-pseudocystostomy was followed by chest tube drainage.