Risk Of Malignant Degeneration Research Articles

Rapidly fatal metastatic melanoma arising from a congenital nevus in a young female

Melanoma is an aggressive and potentially fatal tumor of melanocytic origin. It may occur at any age yet more rarely at a young age. Melanomas in young patients have overall a more favorable prognosis than in older. However, progression to the metastatic stage and the death of the patient are not exceptional. One of the major risk factors for the development of melanoma in children and young adults is the congenital melanocytic nevus (CMN) [3]. The risk of malignant transformation of all congenital nevi ranges from 0.05% to 10.7%. The risk of malignant degeneration is correlated with size and location [4]. The size of the CMN above 40 cm as well as the presence of satellite nevi and the location in the trunk seem to increase the risk of developing MM. The role of surgical removal in inducing melanomas is controversial. In anatomopathology, melanomas arising from CMNs are usually located in the dermis and hypodermis, while melanocytic proliferation in a melanoma without a CMN starts in the epidermis [3]. Given the differences in the anatomical involvement of the disease, melanoma arising from congenital nevi may be considered a separate entity from the conventional case of melanoma and management may differ. Large excision may not be sufficient to remove all neoplastic cells from the nevi, and adjuvant aggressive systemic therapies may be essential to avoid a fatal outcome. A recent study revealed that congenital nevi preferentially harbor NRAS mutations rather than BRAF mutations commonly seen in other types of nevi, indicating an altered molecular basis of nevogenesis in congenital nevi. Herein, we report the case of a rapidly fatal metastatic melanoma in a young female arising from a congenital nevus of the trunk.

Hepatic adenomal: to cut or to watch?

Background: Hepatic adenomas (HCA) are typically resected when larger than 5 cm in women due to a reported 3% risk of malignant degeneration or bleeding. In practice, their management depends on several factors including: tumor diameter, the presence of symptoms, and patient wishes. Magnetic resonance imaging (MRI) is performed every six months for those undergoing medical management: this has cost and time implications for the patient.

101 A Case Report on Persistent Mullerian Duct Syndrome Presenting as Obstructed Inguinalhernia in an Adult Male

Abstract Persistent Mullerian Duct Syndrome (PMDS) is defined as the presence of müllerian derivatives, uterus, and Fallopian tubes in otherwise normally masculinized 46, XY subjects. It's more common in children with cryptorchidism and is a rare finding during hernia surgery among adults with a risk of malignant degeneration. Here we present the case of a 34-year-old adult male with a history of irreducible swelling in the right groin for 1 day and with a past surgical history of left sided hernia repair 10 years back. On examination a tender, irreducible swelling was noted in the right inguinoscrotal region, opposite side and groin area appeared normal with normal male pattern virilisation. A clinical diagnosis of irreducible right inguinal hernia was made, and the patient was taken up for surgery under spinal anaesthesia. Intraoperatively, right sided sliding hernia with an indirect hernia sac was noted with the contents being degenerated uterus, right fallopian tube connecting to the cornua of uterus along with right gonadal tissue at the fimbrial end within the broad ligament. Consent was taken and hernioplasty was performed after excision of the gonadal tissue along with the fallopian tube. On histopathological examination the gonadal tissue was found to be of testicular origin with fibrosis and degeneration. The diagnosis of persistent Müllerian duct syndrome was confirmed. This case report adds on to the current literature on incidence and presentation of PMDS amongst adults and highlights the importance of knowing the pattern of occurrence of this rare condition.

Sinonasal Inverted Papilloma and Squamous Cell Carcinoma: Contemporary Management and Patient Outcomes.

Simple SummaryInverted papillomas are benign sinonasal tumors that can recur or become cancerous. The mainstay of treatment is surgical resection. We summarize the biology of inverted papillomas and review surgical outcomes in an effort to define the current treatment strategy.Inverted papillomas (IP) are the most common sinonasal tumor with a tendency for recurrence, potential attachment to the orbit and skull base, and risk of malignant degeneration into squamous cell carcinoma (SCC). While the overall rate of recurrence has decreased with the widespread adoption of high-definition endoscopic optics and advanced surgical tools, there remain challenges in managing tumors that are multiply recurrent or involve vital neurovascular structures. Here, we review the state-of-the-art diagnostic tools for IP and IP-degenerated SCC, contemporary surgical management, and propose a surveillance protocol.

Chest wall secondary chondrosarcoma caused by malignant degeneration of an enchondroma: case report and literature review

Abstract Introduction: Enchondromas are benign tumors originating in the cartilaginous tissue of the hyaline gristle, rarely located in the chest wall. They sometimes undergo a sarcomatous transformation, becoming secondary chondrosarcomas. Case presentation: We present the case of a 53-year-old patient who, following a chest computed tomography scan performed after a thoracic trauma, was diagnosed with an osteolytic tumor at the chondrocostal junction of rib 4. Surgery was performed, with partial straight resection of ribs 3–5. Histopathological examination of the resection piece identified the existence of a chest wall chondrosarcoma on the background of malignant degeneration of an enchondromatosis lesion. The postoperative evolution was favorable, and the patient was discharged on the eighth postoperative day. Conclusion: In patients with even asymptomatic chest wall enchondromas, periodic clinical evaluation of these lesions is required, given their risk of malignant degeneration.

Presentation of Congenital Portosystemic Shunts in Children.

Background: Congenital portosystemic shunts (CPSS) are rare vascular anomalies resulting in communications between the portal venous system and the systemic venous circulation, affecting an estimated 30,000 to 50,000 live births. CPSS can present at any age as a multi-system disease of variable severity mimicking both common and rare pediatric conditions. Case presentations: Case A: A vascular malformation was identified in the liver of a 10-year-old girl with tall stature, advanced somatic maturation, insulin resistance with hyperinsulinemia, hyperandrogenemia and transient hematuria. Work-up also suggested elevated pulmonary pressures. Case B: A young girl with trisomy 8 mosaicism with a history of neonatal hypoglycemia, transient neonatal cholestasis and tall stature presented newly increased aminotransferase levels at 6 years of age. Case C: A 3-year-old boy with speech delay, tall stature and abdominal pain underwent abdominal ultrasound (US) showing multiple liver nodules, diagnosed as liver hemangiomas by hepatic magnetic resonance imaging (MRI). Management and outcome: After identification of a venous malformation on liver Doppler US, all three patients were referred to a specialized liver center for further work-up within 12 to 18 months from diagnosis. Angio-computed tomography (CT) scan confirmed the presence of either an intrahepatic or extrahepatic CPSS with multiples liver nodules. All three had a hyperintense signal in the globus pallidus on T1 weighted cerebral MRI. Right heart catheterization confirmed pulmonary hypertension in cases A and C. Shunts were closed either using an endovascular or surgical approach. Liver nodules were either surgically removed if there was a risk of malignant degeneration or closely monitored by serial imaging when benign. Conclusion: These cases illustrate most of the common chief complaints and manifestations of CPSS. Liver Doppler US is the key to diagnosis. Considering portosystemic shunts in the diagnostic work-up of a patient with unexplained endocrine, liver, gastro-intestinal, cardiovascular, hematological, renal or neurocognitive disorder is important as prompt referral to a specialized center may significantly impact patient outcome.

Von Hippel-Lindau Syndrome: Medical Syndrome or Surgical Syndrome? A Surgical Perspective

Von Hippel-Lindau syndrome (VHL) is an autosomal dominant disease caused by a genetic aberration of the tumor suppressor gene VHL and characterized by multi-organ tumors. The most common neoplasm is retinal or cerebral hemangioblastoma, although spinal hemangioblastomas, Renal Clear Cell Carcinoma (RCCC), pheochromocytomas (Pheo), paragangliomas, Pancreatic Neuroendocrine Tumors (PNETs), cystadenomas of the epididymis, and tumors of the lymphatic sac can also be found. Neurological complications from retinal or CNS hemangioblastoma and metastases of RCCC are the most common causes of death. There is a strong association between pheochromocytoma and VHL syndrome, and pheochromocytoma is often a classic manifestation of the syndrome. RCCCs are often incidental and identified during other tests. Between 35 and 70% of patients with VHL have pancreatic cysts. These can manifest as simple cysts, serous cysto-adenomas, or PNETs with a risk of malignant degeneration or metastasis of no more than 8%. The objective of this retrospective study is to analyze abdominal manifestations of VHL from a surgical point of view.

Trichilemmal cyst of the neck: case report and review of the literature

Introduction: Trichilemmal cysts are lesions originating in the isthmus of the hair follicle. They are more common in women and occur in 90% on the scalp. Presentation of case: A 10-year-old female patient presented with a hard, slightly painful, nonexophytic mass in the right cervical region (Ia). After surgical resection in healthy margins, the diagnosis of trichilemmal cyst was made on histopathological examination. Discussion: The age of the patient as well as the cervical location of this type of lesion is an extremely rare presentation of trichilemmal cyst. Follow-up is rigorous in search of a triad: ichthyosis, keratosis, deafness, particularly in this patient. Conclusion: Close follow-up in this clinical case is indicated because the risk of malignant degeneration and development of similar lesions is present. Keywords: Follicular cyst; KID syndrome; Trichilemmal cyst; Neck surgery; Trichilemmal carcinoma

Comparing the clinical impact of pancreatic cyst surveillance programs: A trial of the ECOG-ACRIN cancer research group (EA2185).

TPS10608 Background: The optimal surveillance strategy for pancreatic cysts, which occur in up to 20% of the adult population, is ill defined. Although risk of malignant degeneration of these cysts is low, pancreatic cancer mortality remains high. Two cyst surveillance guidelines, one proposed by an international consensus group (Fukuoka) and the other by the American Gastroenterological Association (AGA), are accepted standards. Both rely on radiographic and endoscopic ultrasonographic imaging. They differ in indications for, and intervals between, imaging tests, with the Fukuoka guideline advocating more intensive imaging. Clinical guidelines that provide discordant recommendations may undercut the quality and/or value of care, and have implications for societal health care costs. The primary objective of this prospective trial is to compare the clinical effectiveness and associated resource utilization of the Fukuoka and AGA guidelines for pancreatic cyst surveillance. Secondary objectives include a comparison of resource utilization and patient reported outcomes. We are also collecting and banking radiomics data and biospecimens to identify novel methods that might improve cancer risk stratification. Methods: 4606 asymptomatic patients with newly identified pancreatic cysts ≥1cm in diameter are being randomized 1:1 to high intensity (Fukuoka) or low intensity (AGA) surveillance. The primary endpoint is a composite of any pancreatic cancer without surgery, unresectable pancreatic cancer or cancer > T1a, N0 at surgery, and benign disease at surgery. This sample size will provide 90% power to identify a 30% relative difference in the primary outcome at 5 years between the two study arms. Study duration is 8 years in total, allowing for 2 years of cohort enrollment, 5 years of prospective follow-up, and six months reserved for study initiation and close out. Study participants must be ≥ 50 years and ≤ 75 years with an ECOG Performance Status 0-1 at baseline. Participants must have received a CT or MRI within 6 months of registration that identifies a new ≥1 cm pancreatic cyst. Patients with a prior diagnosis of a pancreatic cyst, pancreatic malignancy or a history of pancreatic resection are not eligible. Additional exclusion criteria include a history of acute or chronic pancreatitis, a family history of pancreatic adenocarcinoma in 1 or more first degree relatives, imaging findings or clinical signs that would prompt immediate surgical consideration (enhancing mural nodule, solid component in cyst, pancreatic duct > 10mm, cyst causing obstructive jaundice), a comorbid illness that precludes pancreatic cyst resection, pregnancy or current participation in an established surveillance program. As of February 4, 2021, thirty three (33) participants have been enrolled from two hundred (200) potential sites. Clinical trial information: NCT04239573 .

Case study: low grade dysplasia of intraductal papillary mucinous neoplasm progression to metastatic pancreatic adenocarcinoma despite complete pathologic resection

Presenter: Dena Steiner MD | Saint Elizabeth's Medical Center Background: Intraductal Papillary Mucinous Neoplasm (IPMN) management has been closely monitored due to the potentially high morbidity of unnecessary resection and the high mortality of delayed diagnosis of pancreatic cancer. Methods: This case study demonstrates a newly developed pancreatic cancer from the bed of a minimally symptomatic 4x3 cm low grade IPMN found on imaging with pancreatic dilation, mucin, a 15 x 10 mm mural nodule and multiple septations. Endoscopic ultrasound cytology was inconclusive for malignant cells, and a subsequent whipple procedure was revealing for mixed duct IPMN with low grade dysplasia, negative margins and 14 negative nodes. Results: One year later, he presented with bloating and subsequent imaging revealed metastatic cancer at the pancreatic bed and liver. He underwent chemotherapy and received palliative care following this diagnosis. Conclusion: Typically, low grade dysplasia in IPMNs subjugates them to a benign categorization, however this case challenges that determination. Malignant potential remains in these lesions with low grade dysplasia; and the mere presence of an IPMN may be a marker that all the patient’s pancreatic cells are at risk for malignant degeneration. Additionally, subcategorization into gastric, intestinal, pancreaticobiliary and oncocytic subtypes and determination of MUC13 expression may provide improved risk stratification.

Intraperitoneal catheter introduction for pre-operative progressive pneumoperitoneum for abdominal hernia with loss of domain (Goni-Moreno technique).

Neoplastic gallbladder polyps (NGP) are rare; the prevalence in the overall population is less than 10%. NGP are associated with a risk of malignant degeneration and must be distinguished from other benign gallbladder polypoid lesions that occur more frequently. NGP are adenomas and the main risk associated with their management is to fail to detect their progression to gallbladder cancer, which is associated with a particular poor prognosis. The conclusions of the recent European recommendations have a low level of evidence, based essentially on retrospective small-volume studies. Abdominal sonography is the first line study for diagnosis and follow-up for NGP. To prevent the onset of gallbladder cancer, or treat malignant degeneration in its early phases, all NGP larger than 10 mm, or symptomatic, or larger than 6 mm with associated risk factors for cancer (age over 50, sessile polyp, Indian ethnicity, or patient with primary sclerosing cholangitis) are indications for cholecystectomy. Apart from these situations, simple sonographic surveillance is recommended for at least five years; if the NGP increases in size by more than 2 mm in size, cholecystectomy is indicated. Laparoscopic cholecystectomy is possible but if the surgeon feels that the risk of intra-operative gallbladder perforation is high, conversion to laparotomy should be preferred to avoid potential intra-abdominal tumoral dissemination. When malignant NGP is suspected (size greater than 15 mm, signs of locoregional extension on imaging), a comprehensive imaging workup should be performed to search for liver extension: in this setting, radical surgery should be considered.

The management of gallbladder polyps.

Neoplastic gallbladder polyps (NGP) are rare; the prevalence in the overall population is less than 10%. NGP are associated with a risk of malignant degeneration and must be distinguished from other benign gallbladder polypoid lesions that occur more frequently. NGP are adenomas and the main risk associated with their management is to fail to detect their progression to gallbladder cancer, which is associated with a particular poor prognosis. The conclusions of the recent European recommendations have a low level of evidence, based essentially on retrospective small-volume studies. Abdominal sonography is the first line study for diagnosis and follow-up for NGP. To prevent the onset of gallbladder cancer, or treat malignant degeneration in its early phases, all NGP larger than 10mm, or symptomatic, or larger than 6mm with associated risk factors for cancer (age over 50, sessile polyp, Indian ethnicity, or patient with primary sclerosing cholangitis) are indications for cholecystectomy. Apart from these situations, simple sonographic surveillance is recommended for at least five years; if the NGP increases in size by more than 2mm in size, cholecystectomy is indicated. Laparoscopic cholecystectomy is possible but if the surgeon feels that the risk of intra-operative gallbladder perforation is high, conversion to laparotomy should be preferred to avoid potential intra-abdominal tumoral dissemination. When malignant NGP is suspected (size greater than 15mm, signs of locoregional extension on imaging), a comprehensive imaging workup should be performed to search for liver extension: in this setting, radical surgery should be considered.

Molecular and clinical patterns of local progression in the pancreatic remnant following resection of pancreatic intraductal papillary mucinous neoplasm (IPMN)

Intraductal papillary mucinous neoplasms (IPMN) are pancreatic cystic lesions that can progress to invasive carcinoma. Consensus guidelines indicate surgery for IPMN at high risk of malignant progression, as assessed by specific radiological and clinical criteria, whereas an active radiological surveillance is recommended for IPMN at low risk of malignancy. The management of IPMN is further complicated by the risk of developing a distinct new cyst or a ductal adenocarcinoma in the remnant pancreas, either synchronously or metachronously. Several studies therefore investigated local progression in the remnant pancreas following partial pancreatic resection for IPMN and whether an unstable epithelium at risk for malignant degeneration may exist. Understanding the biological mechanisms behind progression of IPMN will help in identifying patients that would benefit from the resection of the entire pancreas.

Cystitis Glandularis: A Rare Benign Condition Presenting as Bladder Tumor

Cystitis glandularis or glandular metaplasia of the urinary bladder, is a benignreactive metaplasia of the urothelium, which occurs in the context of chronic irritation, in less than 2% of the general population. It is a condition in most casesasymptomatic, but also characterized by nonspecific symptoms and paraclinical findings, which is why this condition is underdiagnosed. Its evolution is mainly focused on the risk of malignant degeneration. This condition affects men much more commonly than women. Two forms of cystitis glandularis are recognized: typical and intestinal form. They differ in their histology, incidence, difficulty of diagnosis, and possible association with adenocarcinoma of the bladder. Diagnosis of certainty is histological by careful analysis of chips from bladder endoscopic resection. This rare pathology is managed by endoscopic bladder resection, with repeated cystoscopy as a monitoring tool. Extensive surgical is needed in severe or recurrent cases. We present here-in a case of a female patient having cystitis glandularis presenting with lower urinary tract symptoms. We review equally data reported in literature. To the best of our knowledge our case represents the fourth case of cystitis glandularis affecting a female patient reported in the English literature so far.

Covering the Cover

Covering the Cover

Gastric Polyps in a Digestive Endoscopy Center in Dakar

Introduction: The gastric polyp is a tumor protruding into the gastric lumen. It is asymptomatic most often with a risk of malignant degeneration closely related to its histological nature. These data are very rare in Africa. Objectives: Reporting the frequency and endoscopic and histological characteristics of gastric polyps in the digestive endoscopy center of Aristide Le Dantec hospital in Dakar. Patients and methods: This was a retrospective study carried out in the digestive endoscopy center of Aristide Le Dantec Hospital in Dakar from January 2012 to December 2016. We have included all patients with one or more gastric polyps coupled with histological findings available. Results: There were 60 patients with gastric polyps, hence a prevalence of 0.8%. We included 37 patients. Their mean age was 46 years [21 years - 75 years]. The sex-ratio was 0.48. Epigastralgia was the most frequent endoscopic indication (51.3%). The polyp was unique in 26 patients (70.3%) with an average size of 6.87 mm [2 - 15 mm]. Polyps were sessile in 31 cases (83.8%) and pediculate in 6 cases (16.2%). They were most often in the antrum (51.4%). Antral erosions (13.5%) and fundic atrophy (13.5%) were the main associated endoscopic lesions. These were hyperplastic polyps in 27% of cases and adenoma in 16.2% of cases. Chronic atrophic gastritis (10.8%) and intestinal metaplasia (10.8%) were the main histological lesions associated with polyps. Helicobacter pylori (Hp) were present in 17 patients (45.9%). Conclusion: The prevalence of gastric polyps is 0.8% in the endoscopy center of Aristide Le Dantec hospital. They are usually hyperplastic or adenomatous.

Treatment of branch-duct intraductal papillary mucinous neoplasms of the pancreas: state of the art.

The diagnosis of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) has been dramatically increased. BD-IPMNs are frequently discovered as incidental findings in asymptomatic individuals, mainly in elderly patients. An accurate evaluation of BD-IPMNs with high-resolution imaging techniques and endoscopic ultrasound is necessary. Patients with high-risk stigmata (HRS, obstructive jaundice, enhanced solid component) should undergo resection. Patients with worrisome features (WF, cyst size ≥3cm, thickened enhanced cyst walls, non-enhanced mural nodules, and clinical acute pancreatitis) may undergo either a strict surveillance based on patients' characteristics (age, comorbidities) or surgical resection. Non-operative management is indicated for BD-IPMNs without HRS and WF. Patients with BD-IPMN who do not undergo resection may develop malignant change over time as well as IPMN-distinct pancreatic cancer. However, non-operative management of BD-IPMNs lacking WF and HRS is safe and the risk of malignant degeneration seems relatively low. The optimal surveillance protocol is currently unclear.

What is the risk of malignant transformation of vestibular schwannoma following radiosurgery?

Since the use of radiosurgery to treat vestibular schwannoma (VS) has only become widespread over the last several decades, we are just now beginning to see the long-term outcomes and side effects of this treatment. One particularly concerning complication is malignant transformation of a benign lesion. Although the malignant-inducing potential of radiation is well documented for traditional radiation therapy, there are limited data available regarding this complication in the context of stereotactic radiosurgery (e.g., Gamma Knife [Elektra, Stockholm, Sweden] and Cyberknife [Accuray, Sunnyvale, CA]) for vestibular schwannoma. Compared to standard radiation therapy, the irradiated volume with radiosurgery is significantly smaller, and the high single doses given to this small target should theoretically lead to cytotoxicity and not mutagenicity. However, there have been several recent case reports in the literature of skull base malignancies following stereotactic radiosurgery. These criteria are problematic for our purposes because the diagnosis of a vestibular schwannoma is based on clinical and radiographic diagnosis and pretreatment biopsy is rarely obtained. Given the rarity of aggressive lesions, biopsying every patient that presents with a VS would add time, morbidity, and cost while providing minimal benefit in terms of management and decision making. A recent review by Demetriades et al. found 14 cases of malignant vestibular schwannoma reported in the literature.2 Only six of the 14 patients actually had prior radiotherapy. Of those six, only three had a pathology-proven benign lesion prior to treatment. Of the five cases of malignant VS in the absence of radiosurgery, two even had initial histology showing benign disease.2 These cases highlight the difficulty of definitively establishing a causal relationship between radiosurgery and malignant transformation. A 2014 review by Patel and Chiang examines not only cases of malignant transformation of VS but also cases of radiation-induced malignancy arising from surrounding normal tissue in the treatment field for VS.3 Of 22 cases treated for VS, 13 transformed into malignant peripheral nerve-sheath tumors, whereas five developed glioblastoma multiforme and four developed sarcomas. Overall, the authors estimated the risk of developing a malignancy after stereotactic radiosurgery to be 0.04% at 15 years posttreatment. This calculation is based on stereotactic radiosurgery for any benign lesion. There are significant differences in treatment dose and volume depending on the initial pathology. As with any treatment decision, patient selection is critical. Age at the time of exposure and certain genetic susceptibilities such as neurofibromatosis type 2 (NF-2) have been identified as increasing the risk of radiation-induced oncogenesis. A review by Hosseini et al. also highlighted a possible association with initial tumor size.4 In their review of 17 cases of malignant transformation of VS, none of the patients had a tumor less than 2.5 cm in size. Thirteen of the 17 cases were in patients with NF-2. Hosseini postulates that radiosurgery serves as the final genetic hit that induces malignant transformation in already mutated cells.4 This theory could also explain the increased risk in younger patients. In this scenario, perhaps radiosurgery serves as an earlier genetic insult. Younger patients, having a longer life ahead, have more opportunity to acquire additional mutations in those cells' DNA, eventually leading to malignant transformation. As the duration of posttreatment follow-up increases for these patients, more specific criteria regarding high-risk patients will be established. Hasegawa et al., in a large study of 440 patients treated with gamma knife surgery for VS and followed for a median of 12.5 years, reported only one case of malignant degeneration.5 The patient did not have a preradiosurgery biopsy. Even with the assumption that this lesion was in fact benign pretreatment, the overall malignant transformation rate was calculated as 0.3%, and the annual incidence of malignant change was 0.02%.5 Radiosurgical treatment of vestibular schwannomas is safe and effective. The risk of malignant degeneration is acceptably low for the majority of patients. Caution is particularly required when counseling young patients, patients with genetic susceptibility, and patients with large tumors. This article references one level I, one level III, and three level IV papers.

Management of challenging congenital melanocytic nevi: Outcomes study of serial excision

BackgroundLarge congenital melanocytic nevi (CMN) cause significant deformity and are at risk for malignant degeneration. Techniques used to remove difficult CMN include serial excision, skin grafting, or tissue expansion. Some authors prefer skin grafting or tissue expansion if several stages would be required to serially resect the CMN. The purpose of this study was to determine the efficacy of serial excision for CMN requiring ≥3 procedures. MethodsMedical records and clinical images of patients with CMN treated between 2007 and 2013 were reviewed. Inclusion criteria were: (1) lesions that required ≥3 serial excisions to remove and (2) CMN that could have been treated reasonably with skin grafting or tissue expansion. Patient age, gender, location of the lesion, size of the CMN, number of serial excisions, and complications were recorded. ResultsThe study included 21 patients. Lesions were located on the lower extremity (38.1%), head/neck (33.3%), upper extremity (14.3%), or trunk (14.3%). Nevus size was 2.2%±1.2% total body surface area. The age during the first operation was 4.3years (range 3months to 15years). The number of excisions was 3.5±0.7, spaced 8.2±4.3months apart. Partial suture line dehiscence occurred after 2/72 operations and seroma resulted after 1/72 operations; there were no infections. ConclusionChallenging CMN amenable to serial excision can be removed effectively and safely using this technique. Children are left with a favorable linear scar, do not have donor or recipient site morbidity from skin grafting, and are not subjected to potential tissue expander complications and injections required for expansion.

Gallbladder tumor and pseudotumor: Diagnosis and management

The most common gallbladder disease, by far, is cholecystolithiasis. Nevertheless, the discovery of abnormal thickening of the gallbladder wall or a tumorous lesion (with or without gallstones), is a frequent problem. The physician who confronts this finding must be aware of the various lesions to be considered in the differential diagnosis, whether neoplastic or pseudotumoral, epithelial or not, benign or malignant. Because of the particularly grim prognosis of gallbladder cancer, especially when discovered at a late stage, it is especially important to focus on the potential for malignant degeneration of any gallbladder lesion. Imaging plays an important role in distinguishing these lesions; ultrasound remains the key diagnostic tool for gallbladder disease, but other modalities including CT and MRI may help to characterize these lesions. The resulting treatment strategies vary widely depending on the risk of malignancy. A wide and extensive resection is recommended for malignant lesions; prophylactic cholecystectomy is recommended for lesions at risk for malignant degeneration while observation is indicated for purely benign lesions.