Successful Surgical Resection Research Articles

Identifying functional cortical plasticity after spinal tumour resection using navigated transcranial magnetic stimulation.

Our aim was to investigate the effectiveness of navigated transcranial magnetic stimulation (nTMS) brain mapping to characterise preoperative motor impairment caused by an intradural extramedullary (IDEM) tumour and postoperative cortical functional reorganisation. Preoperative and 1-year follow-up clinical, radiological and nTMS data from a case of thoracic spinal meningioma that underwent surgical resection of the lesion were collected and compared. A 67-year-old patient presented with severe progressive thoracic myelopathy (hypertonic paraparesis, clonus, insensate urinary retention) secondary to an IDEM tumour. Initial nTMS assessment showed bilateral upper limb representation with no positive responses for both lower limbs. He underwent successful surgical resection for his IDEM (meningioma WHO grade 1). At 1-year follow-up, the patient's gait was improved and his bladder function normalised. nTMS documented positive responses for both upper and lower limbs and a decrease in the area (right side: 1.01 vs 0.39cm2; left side: 1.92 vs 0.81cm2) and volume (right side: 344.2 vs 42.4uVcm2; left side: 467.1 vs 119uVcm2) of cortical activation for both upper limbs, suggesting a functional reorganisation of the motor areas after tumour resection. nTMS motor mapping and derived metrics can characterise preoperative motor deficit and cortical plasticity during follow-up after IDEM resection.

A rare case of pheochromocytoma in a pregnant woman presenting with chest pain: extraordinary management

BackgroundPheochromocytoma is rare in pregnant women. It presents as diverse symptoms, including hypertension and sweating. The symptoms of pregnant women with pheochromocytoma and comorbid hypertension often mimic the clinical manifestations of preeclampsia, and these women are often misdiagnosed with preeclampsia.Case presentationIn this case, a pregnant woman presented with chest pain as the primary symptom, and a diagnosis of pheochromocytoma was considered after ruling out myocardial ischemia and aortic dissection with the relevant diagnostic tools. This patient then underwent successful surgical resection using a nontraditional management approach, which resulted in a positive clinical outcome.ConclusionsIt is essential to consider pheochromocytoma as a potential cause of chest pain and myocardial infarction-like electrocardiographic changes in pregnant women, even if they do not have a history of hypertension.

Surgical strategy for intravenous leiomyomatosis spreading from uterine to the right atrium presenting with recurrent syncope.

Uterine leiomyoma invading internal iliac vein and consequently disseminating into the right atrium is an extremely rare condition, and surgical strategy is controversial. Here, we reported a specific case with successful surgical resection through one-stage total hysterectomy, bilateral oophorectomy, and the intracardiovascular lesion. This procedure would be an optimal choice for uterine leiomyoma invading inferior vena cava and spreading to right atrium.

Mediastinal Thymic Cyst in Adults: A Rare Case Report

Thymic cysts are rare, benign lesions located in the cervico-thoracic region, often incidentally discovered. The only curative treatment is complete surgical excision, which eliminates symptoms, prevents complications, and provides a definitive diagnosis through histopathological examination, typically revealing the presence of Hassall's corpuscles. Minimally invasive approaches are preferable. We present the case of a 40-year-old patient with an anterior mediastinal cystic mass that underwent successful complete surgical resection. The histopathological examination confirmed a diagnosis of benign unilocular thymic cyst, resulting in favorable clinical and radiological outcomes.

Magnetic resonance imaging-guided intracranial resection of glioblastoma tumors in patient-derived orthotopic xenografts leads to clinically relevant tumor recurrence

BackgroundPreclinical in vivo cancer models are essential tools for investigating tumor progression and response to treatment prior to clinical trials. Although treatment modalities are regularly assessed in mice upon tumor growth in vivo, surgical resection remains challenging, particularly in the orthotopic site. Here, we report a successful surgical resection of glioblastoma (GBM) in patient-derived orthotopic xenografts (PDOXs).MethodsWe derived a cohort of 46 GBM PDOX models that faithfully recapitulate human disease in mice. We assessed the detection and quantification of intracranial tumors using magnetic resonance imaging (MRI).To evaluate feasibility of surgical resection in PDOXs, we selected two models representing histopathological features of GBM tumors, including diffuse growth into the mouse brain. Surgical resection in the mouse brains was performed based on MRI-guided coordinates. Survival study followed by MRI and immunohistochemistry-based evaluation of recurrent tumors allowed for assessment of clinically relevant parameters.ResultsWe demonstrate the utility of MRI for the noninvasive assessment of in vivo tumor growth, preoperative programming of resection coordinates and follow-up of tumor recurrence. We report tumor detection by MRI in 90% of GBM PDOX models (36/40), of which 55% (22/40) can be reliably quantified during tumor growth. We show that a surgical resection protocol in mice carrying diffuse primary GBM tumors in the brain leads to clinically relevant outcomes. Similar to neurosurgery in patients, we achieved a near total to complete extent of tumor resection, and mice with resected tumors presented significantly increased survival. The remaining unresected GBM cells that invaded the normal mouse brain prior to surgery regrew tumors with similar histopathological features and tumor microenvironments to the primary tumors.ConclusionsOur data positions GBM PDOXs developed in mouse brains as a valuable preclinical model for conducting therapeutic studies that involve surgical tumor resection. The high detectability of tumors by MRI across a substantial number of PDOX models in mice will allow for scalability of our approach toward specific tumor types for efficacy studies in precision medicine-oriented approaches. Additionally, these models hold promise for the development of enhanced image-guided surgery protocols.

Successful Surgical Resection of an Ependymal Cyst in the Fourth Ventricle of a Dog.

Ependymal cysts represent congenital brain malformations rarely described in human medicine, where surgical resection is the treatment of choice. In veterinary medicine, only three cases have been previously reported, with one partially resected with surgery. A 6 yr old entire male American Staffordshire terrier was referred with a 4 mo history of incoordination and collapsing episodes with extensor rigidity. Neurological examination localized the lesion to the left central vestibular system and cerebellum. A brain computed tomography scan showed a hypoattenuating lesion with peripheral contrast enhancement in the fourth ventricle consistent with a cyst and secondary hydrocephalus. Treatment with prednisone was initiated, but despite an initial improvement, neurologic signs recurred and a suboccipital craniectomy to remove the cyst was performed. The cyst was first drained, and the capsule was carefully resected. The histopathological evaluation revealed a simple cubic to cylindrical epithelium with apical cilia and loose surrounding fibrillar tissue consistent with an intraventricular ependymal cyst. Four and a half years after surgery, the dog only shows short episodes of balance loss when turning abruptly but is otherwise neurologically normal. To the authors' knowledge, this is the first reported ependymal cyst in the fourth ventricle of a dog with successful surgical resection.

Isolated Giant Scrotal Lymphoedema From Filariasis in a Nigerian Male: A Case Report

Isolated lymphoedema of the scrotum is rare. In sub-Saharan Africa, the infective cause is commonly due to lymphatic filariasis, a neglected tropical disease commonly caused by Wuchereria bancrofti. The swelling of the affected skin and soft tissues results from impaired lymphatic drainage of the affected area due to the chronic inflammatory response to the dead and dying filaria worms in the lymphatic vessels. We describe the case of a 38-year-old man who presented with isolated scrotal lymphoedema secondary to W. bancrofti infection. The patient, in addition to cyclical anti-filarial medical treatment, had successful surgical resection of redundant and fibrous scrotal tissue resulting in overall improvement in his quality of life.

Lipid profiling of electrosurgical vapors for real-time assistance of soft tissue sarcoma resection.

Soft tissue sarcomas (STS) constitute a heterogeneous group of rare tumor entities. Treatment relies on challenging patient-tailored surgical resection. Real-time intraoperative lipid profiling of electrosurgical vapors by rapid evaporative ionization mass spectrometry (REIMS) may aid in achieving successful surgical R0 resection (i.e., microscopically negative-tumor margin resection). Here, we evaluate the ex vivo accuracy of REIMS to discriminate and identify various STS from normal surrounding tissue. Twenty-seven patients undergoing surgery for STS at Maastricht University Medical Center+ were included in the study. Samples of resected STS specimens were collected and analyzed ex vivo using REIMS. Electrosurgical cauterization of tumor and surrounding was generated successively in both cut and coagulation modes. Resected specimens were subsequently processed for gold standard histopathological review. Multivariate statistical analysis (principal component analysis-linear discriminant analysis) and leave-one patient-out cross-validation were employed to compare the classifications predicted by REIMS lipid profiles to the pathology classifications. Electrosurgical vapors produced during sarcoma resection were analyzed in vivo using REIMS. In total, 1200 histopathologically-validated ex vivo REIMS lipid profiles were generated from 27 patients. Ex vivo REIMS lipid profiles classified STS and normal tissues with 95.5% accuracy. STS, adipose and muscle tissues were classified with 98.3% accuracy. Well-differentiated liposarcomas and adipose tissues could not be discriminated based on their respective lipid profiles. Distinction of leiomyosarcomas from other STS could be achieved with 96.6% accuracy. In vivo REIMS analyses generated intense mass spectrometric signals. Lipid profiling by REIMS is able to discriminate and identify STS with high accuracy and therefore constitutes a potential asset to improve surgical resection of STS in the future.

An unusual location of newborn huge dermoid cyst: a case report and literature review

BackgroundDermoid cysts are benign germ cell tumors with ectodermal and mesodermal components. It is a slow-growing lesion that commonly arises in the midline of the head and neck. The last location represented 7%, and the periorbital region was the most frequently arising area. True lateral neck dermoid cysts are rare. We present an unusual location of a dermoid cyst in a newborn.Case presentationWe report an unusual location of a 10-day newborn giant dermoid cyst with multiple implantation sites, namely the shoulder, scapula, cervical, temporal, and occipital scalp. Successful surgical resection was achieved, and the patient was discharged after the removal of the stitches.ConclusionDermoid cysts are unusual neoplasms with rare diagnoses at birth, but often in childhood. Concomitant implantation locations on the shoulder, neck, temporal, and occipital scalps are rare.

Inflammation in the tumor-adjacent lung as a predictor of clinical outcome in lung adenocarcinoma

Approximately 30% of early-stage lung adenocarcinoma patients present with disease progression after successful surgical resection. Despite efforts of mapping the genetic landscape, there has been limited success in discovering predictive biomarkers of disease outcomes. Here we performed a systematic multi-omic assessment of 143 tumors and matched tumor-adjacent, histologically-normal lung tissue with long-term patient follow-up. Through histologic, mutational, and transcriptomic profiling of tumor and adjacent-normal tissue, we identified an inflammatory gene signature in tumor-adjacent tissue as the strongest clinical predictor of disease progression. Single-cell transcriptomic analysis demonstrated the progression-associated inflammatory signature was expressed in both immune and non-immune cells, and cell type-specific profiling in monocytes further improved outcome predictions. Additional analyses of tumor-adjacent transcriptomic data from The Cancer Genome Atlas validated the association of the inflammatory signature with worse outcomes across cancers. Collectively, our study suggests that molecular profiling of tumor-adjacent tissue can identify patients at high risk for disease progression.

Abstract 18453: Giant Right Atrial Lipoma Inducing Atrial Flutter and Tachycardia-Mediated Cardiomyopathy: The Value of Multimodality Cardiac Imaging

Case Presentation: A 60-year-old male who presented with progressive dyspnea on exertion and atrial flutter with rapid ventricular response. His TTE showed a large (5.1 x 3.9 cm) right atrial (RA) mass occupying 80% of a severely dilated RA attached to the lateral wall (Fig A) and severe global LV hypokinesis with an ejection fraction of 20 - 25%. A TEE was then performed to further characterize this mass and showed a large (6.3 x 5.5 x 3.7 cm), heterogeneously echoreflectant, bi-lobed, and partially mobile RA mass attached to the lateral wall (Fig B,C) just below the superior vena cava and extending near the tricuspid valve annulus with sparing of the leaflets and only mild tricuspid regurgitation. At last, a chest CT scan showed a large (5.5 x 4.5 x 3.3 cm) mass which was tissue characterized as RA lipoma (Fig D). Therefore, patient underwent an uncomplicated surgical resection of the mass with partial removal of RA free wall (Fig D,E) repaired with a pericardial patch. Pathology confirmed a RA lipoma. Patient’s atrial flutter was then ablated, and patient was discharged home in stable condition. Discussion: This case illustrates an unreported cavitary giant RA lipoma inducing atrial flutter and tachycardia-mediated cardiomyopathy and emphasizes the importance of multimodality cardiac imaging in its diagnosis and management. Cardiac lipomas are rare benign tumors usually of small size and therefore mostly incidentally detected. They can rarely lead to embolization, conduction abnormalities, and flow obstruction requiring surgical resection. In this patient, pre-operative echocardiography and CT imaging were critical in the assessment of the tumor size, tissue characterization, location, motion, relation or extension to other cardiac structures, and obstruction or dysfunction of heart valves. Pre-and-intraoperative echocardiography were also essential in planning and performing the successful surgical resection of the RA lipoma.

Undifferentiated Pancreatic Carcinoma with Osteoclast-like Giant Cells: A Case Report

Undifferentiated pancreatic carcinoma with osteoclast-like giant cells (UC-OGC) is uncommon, accounting for only 1% of all pancreatic carcinomas. We report a case of a 39-year-old man with undifferentiated pancreatic carcinoma with osteoclast-like giant cells who underwent successful surgical resection and chemotherapy.

Giant intrathoracic cystic schwannoma resected by video-assisted thoracoscopic surgery.

Schwannoma is a benign tumour originating from the Schwann cells. Patients can remain asymptomatic, as the onset of symptoms usually depends on the compressive effect on adjacent organs; dimensional and morphological variability increase the time for the diagnosis. We report the case of a successful surgical resection, performed by video-assisted thoracoscopic surgery (VATS), on a patient with radiological evidence of a massive cystic intrathoracic neoformation, histologically revealed to be a peculiar Schwannoma.

THU027 Challenges In The Management Of Extreme Hyperglycemia In An Acromegalic Patient

Abstract Disclosure: M. Sonbol: None. M. Novitskaya: None. J. Monye: None. S. Jafri: None. E. Japp: None. Introduction: Hyperglycemia in acromegalic patients presents a unique challenge given the disruption GH has on glucose homeostasis. Chronic hypersecretion of GH causes severe insulin resistance which can progress to uncontrolled DM. We describe a patient with acromegaly requiring >180 units/day of insulin in the perioperative period while awaiting transsphenoidal surgery. Clinical Case: A 49-year-old female with HTN and recent diagnosis of uncontrolled type 2 DM presented with several months of blurry vision and headaches. She had several prior admissions for hyperglycemia and DKA (with normal C-peptide, and negative GAD-65 and islet cell autoantibodies) despite compliance with insulin therapy. Her HbA1c was 12.2% on 2 units/kg TDD of insulin. Imaging was significant for a sellar/suprasellar solid mass with cystic components measuring 8.3 x 6.3 x 7.8 cm encasing bilateral internal carotid arteries, encroaching the left orbital apex, and applying mass effect on bilateral frontal lobes, and right temporal lobe and midbrain. Labwork was significant for IGF-1 1083 ng/mL (n<238), and GH of 96.4 ng/mL (n<8). FSH and LH were suppressed, with otherwise normal pituitary hormone levels. Interestingly, the patient did not exhibit classic clinical features of acromegaly such as macroglossia, enlarged digits or coarse facial features. Transsphenoidal biopsy demonstrated mature PIT-1 lineage NET with expression of GH and PRL. Given the significant tumor mass effect, she was placed on dexamethasone 4 mg q12h. Preoperatively, her blood glucose worsened and reached 500 mg/dL despite >180 units of insulin/day on a subcutaneous insulin regimen. Glycemic management was escalated with addition of regular insulin gtt up to 25 units/hr to achieve target blood glucose of 140-180 mg/dL. After successful surgical resection of the tumor, HbA1c decreased to 7.7% on 1.3 units/kg TDD of insulin, metformin and empagliflozin at eight weeks postoperatively. Clinical Lessons: Unusual presentations of rapidly increasing insulin requirements in newly diagnosed DM should raise clinical suspicion for secondary causes such as acromegaly. The degree of insulin resistance is often out of proportion to the patient’s body habitus given the GH-mediated lipodystrophy and adipose tissue dysfunction. In this case, the patient’s insulin requirement was 2 units/kg TDD of insulin, with her BMI being only 22.14 kg/m2. Given the need for semi-urgent surgery due to the tumor’s mass effect, SSA therapy or GH-receptor antagonist was not initiated, and insulin therapy was the mainstay for preoperative glucose management. In severe cases of acromegaly-related hyperglycemia, subcutaneous insulin alone may not be sufficient for adequate glucose control, especially in the setting of preoperative steroids, and large doses of IV insulin may be needed to reach inpatient glucose goals. Presentation: Thursday, June 15, 2023

Multiple, Extensive Cardiac and Pulmonary Hydatid Cysts Managed by a Single-stage Surgical Removal: A Case Report

Background: Echinococcosis is a zoonotic infection that is characterised clinically by the development of hydatid cysts in different organs, mainly the liver and lungs. Cardiac involvement is rare but can lead to serious and fatal complications. Case Report: We report a rare challenging case of multiple, extensive cardiac and pulmonary Echinococcal cysts that were treated by successful single-stage surgical resection via median sternotomy without additional thoracic incisions. Conclusion: This article highlights the rare presentation of multiple, extensive cardiac and pulmonary Echinococcal cysts and how to overcome diagnostic challenges in the era of modern diagnostic imaging. Surgical removal remains the mainstay treatment, and a single-stage surgical approach is feasible in capable centres. Perioperative chemotherapy with Albendazole and the intraoperative use of scolicidal agents improved immediate surgical outcomes, although long-term effects could not be established in this case due to loss of follow-up.

Cardiac masses and the role of imaging in their diagnostic

Abstract Objectives Myxomas are the most common primary tumors of the adult heart and should be considered in the differential diagnosis of intracavitary cardiac masses, along with thrombi and vegetations. Methods We report a case of a 64-year-old obese, hypertensive woman, who presented with dyspnea on moderate exertion as well as fatigue. The patient was admitted to our hospital after the discovery on transthoracic echocardiography of an intracardiac mass, which was highly suggestive for a left atrial myxoma. Results On admission, the patient presents no abnormalities on physical exam, with blood tests showing only slight deviations in the lipid profile. The ECG presents a normal sinus rhythm of 80/min with two premature ventricular contractions and a premature atrial contraction. Transthoracic echocardiography revealed the presence of a well-defined, pediculated, left atrial mass attached to the interatrial septum, measuring 25/17 mm, with no apparent interference in mitral valve motion. We supplemented our investigations with the use of transesophageal echocardiography which further defined the dimensions and location of the tumor, while also showing the presence of an atrial septal aneurysm associated to two small atrial septal defects measuring 6 mm and 7 mm respectively, with a left to right shunt. Cardiac CT examination confirmed the benign aspect of the mass and offered important anatomical elements, useful in preoperative planning. The patient was, therefore, admitted to our Cardiovascular Surgery department, where a successful surgical resection of the tumor was performed, without any local or systemic complications. The differential diagnosis of this mass included intracavitary thrombi, vegetations, as well as other histological subtypes of benign or malignant tumors, while the presence of an atrial septal defect, which represents a possible source of paradoxical emboli, provided an additional challenge. Conclusions This complicated case stands out due to its particular echocardiographic appearance and emphasizes the importance of a comprehensive evaluation in both the differential diagnosis and preoperative assessment.

Diagnostic Value of Four-Dimensional Dynamic Computed Tomography for Primary Hyperparathyroidism in Patients with Low Baseline Parathyroid Hormone Levels.

Low baseline levels of parathyroid hormone (PTH) are associated with a higher rate of multiglandular disease, lower localization rates of preoperative imaging modalities, and a higher rate of unsuccessful minimally invasive parathyroidectomies. The objective of this study is to assess the diagnostic value of four-dimensional dynamic computed tomography (4D-CT) in localizing primary hyperparathyroidism (pHPT) in patients with low baseline PTH levels, compared to patients with high baseline PTH levels. Patients with pHPT who received a 4D-CT scan as part of their standard diagnostic evaluation were divided into two groups based on the following criteria: (1) preoperative PTH levels less than 100 pg/mL and (2) patients with preoperative PTH levels greater than 100 pg/mL. All patients underwent parathyroidectomy based on 4D-CT findings, with intraoperative parathyroid hormone monitoring. The lesion-based sensitivity of 4D-CT was 88% in patients with low baseline PTH levels and 94.7% in patients with high baseline PTH levels (p = 0.33). However, the success rate of image-guided resection based on 4D-CT findings was 71.4% in the low baseline PTH group compared to 90.6% in the high baseline PTH group (p = 0.06). Our study demonstrated that 4D-CT has a high lesion-based sensitivity in patients with pHPT and low baseline PTH levels but led to a relatively low rate of successful image-guided resection in patients with low baseline PTH levels. Therefore, it is important to exercise increased caution during 4D-CT-guided surgical exploration of patients with low baseline PTH levels to ensure successful surgical resection of all parathyroid lesions.

Successful treatment of severe subaortic stenosis with left ventricular dysfunction in children

Link of Video Abstract: https://youtu.be/tHcMqNHfLyYBackground: Subaortic stenosis (SAS) is the second most common form of left ventricular outflow obstruction, accounting for 14% of LVOT obstruction in the general population. This obstruction is in the area of the heart under the aortic valve. While only a few cases have been reported in pediatrics, SAS is a gradually progressive disorder rarely seen at birth and infancy. This case study aims to evaluate the successful treatment of severe SAS with left ventricular dysfunction in children Case Presentation: We present the case of an 8-year-old boy who presented with shortness of breath on exertion and diaphoresis 3 months ago. Transthoracic echocardiography revealed severe aortic stenosis (PG 69.86 mmHg) with discrete tissue in the anterior LVOT and left ventricular systolic function decreased (EF Teich 29.44%), with global hypokinetic. Transesophageal echocardiography (TEE) results in severe subvalvular AS with a fixed subaortic membrane (PG 51.16 mmHg; Stenotic area 0.1 cm2), anterior to the aortic valve 1 cm long. There was mild mitral regurgitation and moderate tricuspid regurgitation. The patient then undergoes successful medical treatment and surgical subaortic membrane resection with tricuspid repair. After one year's operation, the patient remained stable, in good condition and free of symptoms. Conclusion: Subaortic stenosis is a gradually progressive disorder and could develop into heart failure with significant left ventricular dysfunction. Monitoring is an important aspect, given the nature of disease progression. Successful management of a patient with subaortic stenosis involves a multidisciplinary approach, including an early diagnosis, a comprehensive understanding of cardiac pathophysiology, risk factors of recurrence, optimal medical management and surgical strategy.

Complex arteriovenous malformation of the corpus callosum: Surgical nuances

Introduction: Arteriovenous malformations of the corpus callosum (CC-AVMs) are rare and challenging lesions, accounting for 8–9% of all cerebral AVMs. They are associated with a high risk of recurrent hemorrhage and historically were considered inoperable. This case report describes the successful surgical resection of a high-grade CC-AVM following failed stereotactic radiosurgery. Case Description: A 19-year-old female with an anterior CC-AVM presented with seizures despite being on triple anti-epileptics. The patient had previously undergone conservative management for an intraventricular hemorrhage and stereotactic radiosurgery for the AVM. Pre-operative imaging revealed a 5 cm CC-AVM located at the genu and rostrum of the corpus callosum with intraventricular extension into the third ventricle. The AVM was classified as grade 4 according to the Spetzler-Martin grading system and grade 6 according to the supplementary grading system. The lesion was exposed through the anterior interhemispheric trans-callosal approach, and microsurgical nidal dissection was performed. The large draining vein was identified, coagulated, disconnected, and resected along with the nidus. The total operative time was 12.5 h. Postoperatively, the patient had no neurological deficits and was discharged on day 10. Complete resection was confirmed on postoperative magnetic resonance imaging, and the patient remained seizure-free at the 18-month follow-up visit. Conclusion: This case report demonstrates the feasibility of complete surgical resection for high-grade CC-AVMs that have failed non-surgical therapy. Careful surgical planning and technique can lead to favorable outcomes in these challenging cases.

Successful radical surgical resection of a giant neurofibroma.

Large neurofibromas often cause significant patient morbidity and present a unique challenge to dermatologists and surgeons. Radical resection offers the lowest rate of recurrence but is not often pursued due to the high risk of intraoperative hemorrhage and difficulty in repairing large defects. Subtotal resection and debulking are more frequently performed, leading to higher rates of recurrence. This case highlights a particularly large neurofibroma and demonstrates how surgical techniques like preoperative embolization and advancement flaps can improve outcomes in the radical resection of large neurofibromas.