Small Benign Lesions Research Articles

Surgical audit of minimally invasive adrenalectomy - A retrospective observational study

Background: The laparoscopic adrenalectomy technique is currently the standard of care for resecting small benign adrenal lesions in most countries. Some of the reported benefits of laparoscopic adrenalectomy are similar to the benefits of minimally invasive surgery. Aims and Objectives: The objective is to study the types of adrenal tumors and to review outcomes of minimally invasive adrenalectomies. Materials and Methods: In this retrospective observational study, records of 306 patients undergoing minimally invasive adrenalectomy from January 01, 2001 to September 30, 2019, were analyzed. Results: The types of adrenal tumors were found in patients were adrenal adenoma (38), adrenal Cushing’s (47), adrenal carcinoma (14), and pheochromocytoma (207). Pheochromocytoma was the most common type of tumor seen in 68% of the cases. Intensive care unit was required in case of 59 patients while inotropic support was needed for 58 patients while 6 patients required a ventilator in the immediate post-operative period. Surgical site infection was encountered in 29 patients following minimally invasive adrenalectomy. Fever was seen in 18 patients. Pneumonia was the early post-operative complication in 12 patients while paralytic ileus was encountered in 25 patients. Synchronous metastasis to lymph nodes was seen in 12 and tumor bed recurrence was seen in 12 cases each following adrenalectomy. Conclusion: Minimally invasive techniques cause less trauma to patients, have superior visualization, decreased post-operative pain, shorter hospital stays, an earlier return to work and normal activity, and fewer perioperative and post-operative complications.

A sagittal split osteotomy approach for removal of a large cementoblastoma at the mandibular angle

Benign lesions at the angle of mandible are frequently removed by a conventional intra oral approach to gain access and achieve complete visualisation. This method is quick and effective when dealing with small benign lesions that are superficially located at the angle of mandible. The removal of large and deeply located lesions with a conventional intra oral approach however, bring about a unique set of challenges particularly when the third molar is displaced towards the inferior border of mandible including lack of complete visualisation of the lesion, difficulty in identification and protection of the inferior alveolar nerve and necessitating removal of a considerable amount of osseous structure thus increasing the risk of a mandibular fracture. Alternative techniques for such lesions include an extra oral approach but one which could potentially create a cosmetic defect from cutaneous scarring and can result in facial nerve injury. This case report describes the use of a unilateral sagittal split osteotomy (SSO) in the removal of a mandibular cementoblastoma. This is a safe and effective technique allowing optimal access to the tumor with complete visualisation, identification and protection of the inferior alveolar nerve with minimal bone removal while maintaining mandibular integrity, strength and facial aesthetics.

Gall bladder polyp in a bodybuilder with symptomatic uremia: An educational ultrasound image

Background: Gallbladder polyps are generally small benign lesions that do not enlarge for years. However, follow-up with ultrasound examination is initially recommended to detect unexpected malignancy. The diagnosis of a gallbladder polyp is generally made with ultrasound examination, and in many instances the polyp is detected while performing the ultrasound examination in the diagnostic work-up of a condition not related to the gallbladder.

Gall bladder polyp in a bodybuilder with symptomatic uremia: An educational ultrasound image

Background: Gallbladder polyps are generally small benign lesions that do not enlarge for years. However, follow-up with ultrasound examination is initially recommended to detect unexpected malignancy. The diagnosis of a gallbladder polyp is generally made with ultrasound examination, and in many instances the polyp is detected while performing the ultrasound examination in the diagnostic work-up of a condition not related to the gallbladder.

Improved value of whole-lesion histogram analysis on DCE parametric maps for diagnosing small breast cancer (≤ 1cm).

To determine if whole-lesion histogram analysis on dynamic contrast-enhanced (DCE) parametric maps help to improve the diagnostic accuracy of small suspicious breast lesions (≤ 1cm). This retrospective study included 99 female patients with 114 lesions (40 malignant and 74 benign lesions) suspicious on magnetic resonance imaging (MRI).Two radiologists reviewed all lesions and descripted the morphologic and kinetic characteristics according to BI-RADS by consensus. Whole lesions were segmented on DCE parametric maps (washin and washout), and quantitative histogram features were extracted. Univariate analysis and multivariate logistic regression analysis with forward stepwise covariate selection were performed to identify significant variables. Diagnostic performance was assessed and compared with that of qualitative BI-RADS assessment and quantitative histogram analysis by ROC analysis. For malignancy defined as a washout or plateau pattern, the qualitative kinetic pattern showed a significant difference between the two groups (p = 0.023), yielding an AUC of 0.603 (95% confidence interval [CI]: 0.507, 0.694). The mean and median of washout were independent quantitative predictors of malignancy (p = 0.002, 0.010), achieving an AUC of 0.796 (95% CI: 0. 709, 0.865). The AUC of the quantitative model was better than that of the qualitative model (p < 0.001). Compared with the qualitative BI-RADS assessment, quantitative whole-lesion histogram analysis on DCE parametric maps was better to discriminate between small benign and malignant breast lesions (≤ 1cm) initially defined as suspicious on DCE-MRI. • For malignancy defined as a washout or plateau, the kinetic pattern may provide information to diagnose small breast cancer. • The mean and median of washout map were significantly lower for small malignant breast lesions than for benign lesions. • Quantitative histogram analysis on MRI parametric maps improves diagnostic accuracy for small breast cancer, which may obviate unnecessary biopsy.

Early detection of pancreatic tumors by advanced EUS imaging.

The early detection of pancreatic ductal adenocarcinoma (PDAC) dramatically improves outcome. All available state-of-the-art imaging methods allow early detection with EUS being the best technique for exclusion of PDAC and detection of very early PDAC. Etiological differentiation of small SPL is important to guide individually tailored patients' management including radical surgery in resectable PDAC, medical (neoadjuvant or palliative intended) treatment in patients with non-resectable malignancy, pancreatic parenchyma saving strategies in some non-PDAC, and follow-up in particular in low-grade PanNEN or other small benign lesions. Multimodality EUS imaging including B-Mode assessment, elastography, contrast-enhancement and EUS-guided sampling is the most appropriate technique for diagnosis and risk assessment of small SPL. We present a review discussing modern (endoscopic) ultrasound imaging techniques including contrast enhanced ultrasound and elastography for the early detection and characterization of solid pancreatic lesions.

Hold firmly, coagulate indirectly, and pull gently: A simple and swift technique for radiofrequency-assisted removal of small benign skin lesions

Removal of small benign lesions, such as common warts and skin tags, is a common outpatient procedure, and patient turnover remains high. Cold excision using a surgical blade or scissors is associated with bleeding. Conventional radiofrequency (RF) excision requires cutting from one end of the base of the lesion until it reaches to the other end. It is time consuming and also leads to smoke generation because of prolonged contact of the RF probe with the lesion. RF probes are expensive and, if touched to the patient, can be reused only after sterilization. We describe the more economical use of Allis forceps combined with RF to crush and coagulate for the swift removal of benign skin lesions.

Tireoidectomia Endoscópica Transoral por Acesso Vestibular (Toetva): relato de caso

Introdução: A Tireoidectomia endoscópica transoral, usando a abordagem vestibular (TOETVA) é uma opção cirúrgica segura. O valor potencial desse procedimento se encontra fora do aspecto cosmético e sua utilização persiste ainda como padrão-ouro, entretanto necessita de maior divulgação de casos. Objetivo: Descrever a primeira TOETVA realizada no hospital Memorial São José – PE. Relato de caso: BMTM, mulher, 19 anos, sem história prévia de radioterapia ou cirurgias prévias de cabeça e pescoço, submeteu-se a ultrassonografia de tireoide, observando-se nódulo em lobo esquerdo. Foi realizada a análise anatomopatológica, detectando ausência de malignidade. Adicionalmente foi feito reimplante da paratireoide ectópica presente no músculo esternocleidomastoideo esquerdo. Em concomitância, procedeu-se á testagem do nervo recorrente –R2 e do nervo laríngeo superior-S2, com resultados normais. O estudo respeitou as diretrizes e critérios estabelecidos na Resolução 466/12 do Conselho Nacional de Saúde (CNS). Comentários: A tireoidectomia endoscópica é abordagem favorável para o tratamento de pacientes com câncer de tireoide, que tem nódulo de câncer de 1 a 2 cm sem extensão extratireoidiana. Existem procedimentos endoscópicos diretos (cervical anterior ou lateral) e extracervicais para manter a tireoide exposta, mas várias pequenas cicatrizes permanecem. No entanto, TOETVA é excelente escolha para pacientes selecionados que necessitam de cirurgia dessa glândula, que desejam evitar uma cicatriz no pescoço. Conclusão: TOETVA é um tratamento seguro, efetivo e minimamente invasivo o que proporciona redução da cicatriz pós-operatória na cervical anterior. Opção viável para tireoidectomias realizadas com pequenas lesões benignas.

Monopolar electrosurgical tunneling combined with bipolar coagulation for bloodless resection of sessile benign skin lesions

Monopolar radiofrequency or electrosurgical probes and bipolar forceps can be used for the removal of pedunculated or sessile benign skin lesions. 1 Pangti R. Dixit A. Gupta S. Bipolar forceps of a high-power electrosurgical unit for precise removal of small benign skin lesions [e-pub ahead of print]. J Am Acad Dermatol. 2019; https://doi.org/10.1016/j.jaad.2019.03.026 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar However, broad pedunculated or sessile lesions are supplied by large blood vessels. The monopolar probe, in either cutting or coagulation mode, cannot sufficiently coagulate the large bleeders; thus, bloodless removal is not possible. The bipolar mode is good for bloodless removal of smaller lesions only because the terminals of the bipolar forceps do not work at a distance of more than 4 to 5 mm because of tissue resistance. 1 Pangti R. Dixit A. Gupta S. Bipolar forceps of a high-power electrosurgical unit for precise removal of small benign skin lesions [e-pub ahead of print]. J Am Acad Dermatol. 2019; https://doi.org/10.1016/j.jaad.2019.03.026 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Furthermore, the bipolar mode cannot cut the tissue on its own.

Giant Glomus Tumour of the Forearm- An Unusual Occurrence

Glomus tumour is a rare small benign lesion which is typically located at fingertip. Most patients with glomus tumour have delayed diagnosis. Recognition of the classical triad of glomus tumour which include paroxysmal pain, exquisite tenderness to touch and cold intolerance; and advanced imaging like MRI and biopsy would help in making the diagnosis. Here, a case of an elderly patient is reported with painful right forearm swelling for three years which progressively increased in size. The size of the swelling was unusually large for glomus tumour. Unfortunately, during the same time period he suffered from acute coronary event. MRI revealed subcutaneously located lobulated soft tissue mass. Surgical biopsy with marginal excision was done. Histopathological examination revealed small uniform rounded cells surrounding capillary vessels, consistent with the diagnosis of glomus tumour. There was no recurrence up to 2 year of follow-up and his cardiac symptoms also stabilised.

Integrated Molecular Analysis of Papillary Renal Cell Carcinoma and Precursor Lesions Unfolds Evolutionary Process from Kidney Progenitor-Like Cells

Papillary renal cell carcinoma (PRCC) is the most common type of RCC in end-stage kidney disease (ESKD). Papillary adenoma (PA) is a small benign lesion morphologically similar to PRCC and is suggested to be its precursor. PA is also prevalent in ESKD. The evolution of PAs to PRCCs and their relationship to ESKD are poorly understood. A total of 140 PAs, normal kidneys, ESKDs, and PRCCs were analyzed. Previously described markers of renal tubular progenitor cells were analyzed using immunohistochemistry and quantified with digital analysis. Progenitor cells were significantly increased in ESKD (P<0.0001) and PAs (P=0.02) in comparison with the normal kidney. Pathway analysis using global miRNA and chromosomal copy number variations revealed a common developmental theme between PA and the PRCCs. Whole exome sequencing showed a KMT2C-specific pathogenic mutation among all PAs and PRCCs. KMT2C is a chromosome 7 epigenetic regulator implicated in development and oncogenesis. Collectively, results show possible connection of PRCCs to PA and the progenitor-like cell population, which are increased in response to renal tubular injury. In addition, each PRCC histologic subtype had its own set of mutational changes, indicating divergence from a common precursor. The study reports previously unknown biological aspects of PRCC development and could influence current surveillance criteria and early detection strategies of PRCC tumors.

Characterization of Sub-1 cm Breast Lesions Using Radiomics Analysis.

Small breast lesions are difficult to visually categorize due to the inherent lack of morphological and kinetic detail. To assess the efficacy of radiomics analysis in discriminating small benign and malignant lesions utilizing model free parameter maps. Retrospective, single center. In all, 149 patients, with a total of 165 lesions scored as BI-RADS 4 or 5 on MRI, with an enhancing volume of <0.52 cm3 . Higher spatial resolution T1 -weighted dynamic contrast-enhanced imaging with a temporal resolution of ~90 seconds performed at 3.0T. Parameter maps reflecting initial enhancement, overall enhancement, area under the enhancement curve, and washout were generated. Heterogeneity measures based on first-order statistics, gray level co-occurrence matrices, run length matrices, size zone matrices, and neighborhood gray tone difference matrices were calculated. Data were split into a training dataset (~75% of cases) and a test dataset (~25% of cases). Comparison of medians was assessed using the nonparametric Mann-Whitney U-test. The Spearman rank correlation coefficient was utilized to determine significant correlations between individual features. Finally, a support vector machine was employed to build multiparametric predictive models. Univariate analysis revealed significant differences between benign and malignant lesions for 58/133 calculated features (P < 0.05). Support vector machine analysis resulted in areas under the curve (AUCs) ranging from 0.75-0.81. High negative (>89%) and positive predictive values (>83%) were found for all models. Radiomics analysis of small contrast-enhancing breast lesions is of value. Texture features calculated from later timepoints on the enhancement curve appear to offer limited additional value when compared with features determined from initial enhancement for this patient cohort. 4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1468-1477.

Bipolar forceps of a high-power electrosurgical unit for precise removal of small benign skin lesions

Electrosurgical devices can be either monopolar or bipolar depending on configuration of the electrodes. In the monopolar type, there is a single electrode tip that delivers energy to the area between the electrode and the grounding plate, whereas in the bipolar type, energy is delivered between the 2 electrodes holding the tissue. Monopolar forceps can work in a cutting or coagulation mode. The cutting mode may make precise cuts but does not effectively coagulate the feeding vessels, whereas the coagulation mode coagulates small feeding vessels but causes a lot of collateral damage such as charring and scarring. The bipolar forceps in low-power electrosurgical machines cannot cut and coagulate tissue. They are used solely for hemostasis in dermatologic surgery and not for removal of benign lesions. 1 Pollac S.V. Grekin R.C. Electrosurgery and electroepilation. in: Roenigk R.K. Ratz J.L. Roenigk H.H. Roenigk's Dermatologic Surgery. Informa HealthCare USA, Inc, New York, NY2007: 165-171 Google Scholar

Minimally invasive CT-guided excision of osteoid osteoma and other small benign bone tumours: a single centre case series in South Africa

Background: The management of osteoid osteoma (OO) and other small primary benign lesions of bone has evolved over the past 50 years from open surgery with wide resection margins to less invasive surgical techniques such as image-guided intralesional excision and percutaneous radiofrequency ablation. We aim to evaluate the outcomes of patients treated with computerised tomography (CT-guided) intralesional excision and bone grafting of small benign lesions of bone. Method: A retrospective folder review of patients treated in a large academic hospital in Cape Town, South Africa, between March 2012 and May 2016 was performed. Patient demographics, details of presentation, clinical information and outcome following treatment were analysed descriptively. Pre-operative diagnosis based on radiological examination was compared with histological diagnosis. Result: Eleven patients (five male) with a median age of 16 years (range 5–33) were included. Pain was the most common presenting feature. A histological diagnosis of OO was confirmed in five of nine patients with a suspected diagnosis of OO pre-operatively. Of the four patients whose diagnosis changed after the procedure, the diagnoses included a benign spindle cell lesion, a benign fibrous histiocytoma, subacute osteitis and an osteochondral defect with geode cyst formation. Of the two patients where OO was not suspected pre-operatively, chondroblastoma was confirmed in one while a benign spindle cell lesion was reported in the other.Overall histological yield was thus 100%. There were no complications or repeat procedures at a median follow-up of 42 months (range 30–52 months). Conclusion: CT-guided intralesional curettage is a safe and minimally invasive technique. This is especially useful in less accessible regions of the skeleton as it provides a means of accurately locating the lesion with minimal risk of complications and morbidity to the patient. We consider this to be the optimal method of treatment in our setting as it provides high success rates, few complications and a histological diagnosis without the need for any additional and expensive equipment. Level of evidence: Level 4

Extracapsular parotidectomy – How we do it?

Benign tumors of the parotid gland are the most common salivary tumors. Pleomorphic adenoma is the most common benign neoplasm of the parotid gland. Benign salivary gland tumors can undergo a malignant transformation, the reason for which the salivary tumors need to be excised. Pleomorphic adenomas extend their microscopic pseudopods into the surrounding capsule mainly composed of compressed normal tissue. The facial nerve traverses through the substance of the gland. Although the nerve injury could be avoided, the earlier treatment of pleomorphic adenoma with enucleation was fraught with an unacceptably high incidence of multicentric tumor recurrences. Superficial parotidectomy or excision of the portion superficial to the facial nerve evolved as the procedure of choice for benign parotid lesions. Formal identification of its trunk at the stylomastoid foramen and tracing its branches peripherally up to the facial muscles was an essential component of the procedure. With further understanding, it became evident thatsuperficial parotidectomy (SP) was overkill for small benign lesions in the superficial lobe of the gland with an unnecessary risk to the facial nerve. Extracapsular excision (ECE) of a benign parotid tumor is a procedure that has evolved in the last two decades with the recurrence rates comparable to those following SP with reduced facial nerve dissection-related morbidity. The senior author (PG) has adopted the technique for nearly a decade and has also been involved in conducting a randomized controlled trial comparing the outcomes after SP and ECE. Through this article, the authors would like to share their technique and experience with ECE.

Solitary pulmonary capillary hemangioma: Clinicopathologic and radiologic characteristics of nine surgically resected cases

BackgroundSolitary pulmonary capillary hemangioma (SPCH) is an extraordinarily rare capillary derived mesenchymal neoplasm. Although routine morphology and immunohistochemistry are adequate for the diagnosis of classical SPCH in surgical specimens, true gross appearance identification of most tumor themselves and diagnosis for some exceptional cases are still very difficult. Furthermore, preoperative imaging and frozen diagnosis remain a challenge. MethodsWe reported nine original cases of solitary pulmonary capillary hemangioma and summarized the clinical characteristics of twenty-one reported lesions. Imaging materials were reviewed by the image experts of our hospital. Quick hematoxylin-eosin stained intraoperative frozen sections and routine histological diagnosis were re-confirmed by 3 specialist pathologists with at least 10 years of diagnostic experience in our department. Immunohistochemistry analysis was performed on formalin fixed archival tissue. The surgical methods, following up information and prognosis were retrospectively analyzed. ResultsIn imaging, three tumors showed solid nodules, three cases displayed mix ground glass nodules, two nodules were pure ground glass density, and one case was a cystic-solid mass. Macroscopically, solitary pulmonary capillary hemangiomas were ill-defined soft hemorrhagic lesion with pale yellow or dark brownish cut surface. Two cases had a clear boundary and seven lesions were poorly demarcated. Typical morphological features were densely proliferating thin-walled capillaries composing of single layer of flatten or cuboidal endothelial cells within the thickened alveolar septa. One case was mistaken for a histiocytogenic lesion during freezing. The cystic-solid lesion showed a hyperplasia capillary network along the submucosal interstitium of bronchioles. Immunohistochemically, tumor endothelial cells were positive for ERG, Fli-1, CD31, CD34 and Vimentin and negative for CK, α-SMA, TTF-1, HMB45, S-100 and CD68. Lobectomy was performed on seven cases, wedge resection and segmentectomy were proceeded in two patients respectively. Follow up information showed no evidence of complication or recurrence. ConclusionsSolitary pulmonary capillary hemangioma has special imaging and various histological features and must be distinguished from small benign lung lesions and preinvasive cancer. Although the prognosis of this tumor is good after surgical resection, the correct interpretation of the gross appearance and radiographic findings are still important. Choosing appropriate resection mode depends on accurate evaluation preoperative and intraoperative.

Bipedicled Mini V-Y Advancement Flap for Skin Defect of the Face

In young patients, even small circular facial defects after the excision of benign skin tumors present a reconstructive challenge. The usefulness of a V-Y advancement flap for reconstructing such defects is well documented. We refined this technique as a mini V-Y advancement flap consisting of two subcutaneous pedicles that vascularize the skin island via subdermal plexus lateral bridges. This technique was used for 21 middle-aged or younger patients with a small benign skin lesion. None of them experienced any postoperative complications. Aesthetically excellent results were found in all patients. This small advancement flap could be attempted as an alternative to fusiform excision of small skin lesions, particularly in younger patients.

Breast Lesion Excision System in the diagnosis and treatment of intraductal papillomas – A feasibility study

ObjectivesThis study aims to evaluate the feasibility of Breast Lesion Excision System (BLES) in the treatment of intraductal papillomas. Material and methodsAll patients with a needle biopsy –based suspicion of an intraductal papilloma who consequently underwent a BLES procedure at Helsinki University Hospital between 2011 and 2016 were included in this retrospective study. The purpose of the BLES procedure was either to excise the entire lesion or in few cases to achieve better sampling. ResultsIn total, 74 patients underwent 80 BLES procedures. Pathological diagnosis after the BLES biopsy confirmed an intraductal papilloma without atypia in 43 lesions, whereas 10 lesions were upgraded to high-risk lesions (HRL) with either atypical ductal hyperplasia or lobular carcinoma in situ. Five cases were upgraded to malignancy, two were invasive ductal carcinomas and three were ductal carcinoma in situ. Additionally, 18 lesions were diagnosed as other benign lesions. Four procedures failed. Complete excision with BLES was achieved in 19 out of 43 intraductal papillomas, 6 out of 10 HRL and two out of five malignant lesions. No major complications occurred. The BLES procedure was adequate in the management of the 71 breast lesions. ConclusionThe BLES procedure is an acceptable method for the management of small benign and high-risk breast lesions such as intraductal papillomas in selected patients. Thus, a great amount of diagnostic surgical biopsies can be avoided.

Giant Brunner's Gland Hamartoma of the Duodenal Bulb Presenting with Upper Gastrointestinal Bleeding and Obstruction.

Brunner’s gland hamartomas are small benign lesions that are most commonly found in the bulb of the duodenum. They are very uncommon, and most are found incidentally during upper gastrointestinal series or esophagogastroduodenoscopy. The lesions tend to be asymptomatic, but patients may present with symptoms of duodenal obstruction or hemorrhage secondary to ulceration. Histologically, a Brunner's gland hamartoma consists of the components of Brunner's gland cells, as well as glandular, adipose and muscle cells. In this study, we report the case of a 30-year-old man who presented with upper gastrointestinal bleeding and obstructive symptoms due to a giant Brunner's gland hamartoma in the duodenal bulb. The hamartoma was successfully removed by endoscopic resection. No significant complications were observed. Microscopically, the lesion was found to be entirely composed of variable Brunner's glands and adipocytes.

First manic episode in a patient with a frontal meningioma

IntroductionPsychiatric symptoms are common among brain tumor patients. Meningiomas are the most common benign brain tumors accounting for 13 to 26% of all intracranial tumors and might present exclusively with psychiatric symptoms. To diagnose a manic episode according to DSM-5 criteria the episode must not be attributable to the physiological effects of a substance or to another medical condition.Objectives/aimsDescribe a case of first manic episode with a frontal meningioma along with a brief review of available literature.MethodsThe case we report is based on information collected from interviews with the patient and the family members as well as from the clinical files. The literature review was performed using the PubMed database.ResultsWe describe the case of a 58-year-old woman presenting with symptoms of a first manic episode with psychotic features. There were no previous hypomanic or major depressive episodes. In order to exclude organic causes a brain CT scan was performed that revealed a possible frontal lesion. A brain MRI confirmed the presence of a frontal meningioma with an approximate diameter of 1.4 cm.ConclusionsThe majority of the cases described in the literature refer to large tumors presenting with major depressive symptoms. Given the absence of similar cases in the literature, it seems unlikely that such a small benign lesion may cause a manic episode with psychotic features. Nevertheless, we cannot exclude that possibility.Disclosure of interestThe authors have not supplied their declaration of competing interest.