Superficial Portion Research Articles

Role of intraoperative cranial ultrasonography in detection of residual brain lesions during surgery

BackgroundThe use of IOUS is increasingly common in recent neurosurgical practice. IOUS has become very valuable in neurosurgery. It plays a key role in the localization of space-occupying lesion location and decreasing operation time and hence improves both surgical efficiency and safety. Ultrasound is very useful in the determination of the lesion location, its most superficial portion, and in differentiation between solid tumors and cystic components.ResultsIntraoperative ultrasonography has a significant edge over the other intraoperative aids for image guidance in brain surgery, especially in terms of independence, cost, and adaptability to multiple different clinical scenarios. Ultrasound-based neuro-navigation is an easy-to-use, fast, and safe technique of real-time imaging for various neurosurgical procedures.ConclusionWe conclude that ultrasound-based neuro-navigation is an easy-to-use, fast, and safe technique of real-time imaging for various neurosurgical procedures.

Genomic progression for local invasion of cutaneous squamous cell carcinoma from the superficial to the deep portion.

Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer. While many treatments exist, our understanding of its genomic progression, especially from the epidermis to the deep dermis, remains limited. This study aims to identify genetic mutations associated with the progression of cSCC into the deep dermis, providing insights into its aggressive behavior and high-risk features. We performed high-depth whole-exome sequencing on 12 cSCC tissues, along with paired normal tissues from six patients, using microdissection techniques. The mutational analysis focused on identifying alterations enriched during cSCC progression. Gene Ontology enrichment analysis, immunohistochemical assays, and external single-cell RNA data were utilized for validation. A total of 8863 non-synonymous somatic mutations were identified in 4092 genes across the superficial and deep portions of cSCCs. Analysis of deep portion mutations revealed a significant correlation with gene ontology biological processes, particularly cell junction organization, and cell-cell adhesion. Clonal mutations in these processes were more prevalent in the deep portions, indicating their impact on the cSCC mutation landscape. Genetic evolution analysis identified 29 causal genes associated with dermal invasion in cSCC. We highlight somatic mutations in cSCC, revealing heterogeneity between superficial and deep regions. Altered genes in cell junction organization and cell-cell adhesion emerged as pivotal in dermal invasion. We identified 29 causal genes primarily in deep tumor regions. Our findings emphasize analyzing multiple tumor regions to capture varied mutational landscapes. These insights advance our understanding of cSCC progression, emphasizing genetic and cellular changes during tumor evolution.

Combined Direct and Indirect Revascularisation With Superficial Sparing of Temporalis Muscle in Moyamoya Disease: Operative Technique: 2-Dimensional Operative Video.

The primary objective of revascularization surgery for moyamoya disease (MMD) is to augment cerebral blood flow and prevent disease progression.1 There are several options for bypass surgery, including direct methods such as superficial temporal artery-middle cerebral artery anastomosis, indirect bypasses such as encephalomyosynangiosis, encephaloduroarteriosynangiosis or encephaloduroarteriomyosynangiosis, or combined procedures.2-5 In our institution, we undertake a combined approach involving multiple low-flow bypasses and a modified indirect bypass technique, with additional attention to achieving an optimal cosmetic result. Given that MMD often affects young patients, considering cosmesis as a significant factor in managing this condition should be standard practice. We present our modified operative technique of a combined approach to revascularization surgery in patients with MMD with particular emphasis on the indirect bypass procedure. The temporalis muscle is divided in two parts in the sagittal plane where the deeper portion is mobilized to perform an EMS, and the superficial portion is reattached to the bone flap to maintain cosmetic symmetry. A 23-year-old woman presented with a 6-month history of transient left-sided hemiparesis on a background of MMD (previous left-sided revascularization surgery). Subsequent imaging demonstrated worsening right internal carotid artery stenosis. The patient and her family were extensively counseled and decision to proceed with right-sided bypass surgery was undertaken (Video). The patient had an unremarkable postoperative course and was discharged home on day 14. Institutional review board approval was not required in our institution. The patient consented to the procedure and to the publication of his/her images.

Proposal for Manual Osteopathic Treatment of the Phrenic Nerve.

The article reviews the anatomical path of the phrenic nerve and its anastomoses, with the most up-to-date knowledge reported in the literature. We have briefly reviewed the possible phrenic dysfunctions, with the final aim of presenting an osteopathic manual approach for the treatment of the most superficial portion of the nerve, using a gentle technique. The approach we propose is, therefore, a theory based on clinical experience and the rationale that we can extrapolate from the literature. We hope that the article will be a stimulus for further experimental investigations using the technique illustrated in the article.To the authors' knowledge, this is the first article that takes into consideration the hypothesis of an osteopathic treatment with gentle techniques for the phrenic nerve.

Breast ultrasound: An opportunity to detect unsuspected pleural and pulmonary abnormalities.

While scanning women for breast US, is possible to observe changes in the appearance of the pleural line or in the most superficial portion of the lung. The objective of this single-center, prospective study was to determine the prevalence of a variety of pleural and pulmonary US findings during routine breast US. In this study, there were 200 women undergoing standard breast US examination. The presence of pleural and pulmonary abnormalities in these cases was recorded. Two off-site reviewers confirmed the presence of pleura and lung changes. There was no abnormal finding in 168 out of 200 cases (84%) while there were one or more abnormal findings in 32 cases (16%). Pleural effusion was observed in 0.5% of cases, thickening of the pleural line 5% of cases, irregularity of the pleural line in 6% of cases, increased number of vertical artifacts in 9% of cases, subpleural nodulations in 2% of cases, and lung consolidation in 0.5%. Pleural and lung changes are not uncommon during breast US. Operators performing breast US examinations should be aware of the possibility to identify unsuspected pleuro-pulmonary abnormalities.

Right Lower Sleeve Lobectomy: Detailed Technique and Perioperative Patient Management.

This report reviews our experience with right lower sleeve lobectomy and describes our technique and approach to perioperative patient management. We retrospectively reviewed 11 patients who underwent right lower sleeve lobectomy for lung cancer. Surgical techniques and perioperative management were also investigated. Bronchoplasty was performed using 4-0 absorbable monofilament sutures. The deepest portion was anastomosed using continuous sutures; interrupted sutures were used for the more superficial portions. The truncus intermedius and right middle lobe bronchus should be anastomosed in a natural position. Anastomosis patency was confirmed using intraoperative bronchoscopy. Separation of the right upper and middle lobes and pericardiotomy at the inferior edge of the superior pulmonary vein are useful for mobilizing the right middle lobe. Death during hospitalization and treatment-related death did not occur. One patient developed pneumonia, and another developed a bronchopleural fistula. We reported our technique of right lower sleeve lobectomy and our approach to perioperative patient management. Sharing knowledge is essential to completing this rare surgery.

Evaluation of Venous Structures that Are Involved in Transsylvian Approach Using 3D Rotational Venography.

In the transsylvian (TS) approach, as characterized by clipping surgery, the presurgical visualization of the superficial middle cerebral vein (SMCV) can help change the surgical approach to ensure safe microsurgery. Nevertheless, identifying preoperatively the venous structures that are involved in this approach is difficult. In this study, we investigated the venous structures that are involved in the TS approach using three-dimensional (3D) rotational venography (3D-RV) and evaluated the effectiveness of this method for presurgical simulation. Patients who underwent 3D-RV between August 2018 and June 2020 were involved in this retrospective study. The 3D-RV and partial maximum intensity projection images with a thickness of 5 mm were computationally reconstructed. The venous structures were subdivided into the following three portions according to the anatomic location: superficial, intermediate, and basal portions. In the superficial portion, predominant frontosylvian veins were observed on 31 (41%) sides, predominant temporosylvian veins on seven (9%) sides, and equivalent fronto- and temporosylvian veins on 28 (37%) sides. The veins in the intermediate (deep middle cerebral and uncal veins) and basal portions (frontobasal bridging veins) emptied into the SMCV on 57 (75%) and 34 (45%) sides, respectively. The 3D-RV images were highly representative of the venous structures observed during microsurgery. In this study, 3D-RV was utilized to capture the details of the venous structures from the superficial to the deep portions. Presurgical simulation of the venous structures that are involved in the TS approach using 3D-RV may increase the safety of microsurgical approaches.

Extensor Carpi Ulnaris “Turn Around” Ligamentoplasty For Distal Radioulnar Joint Instability

Extensor Carpi Ulnaris “Turn Around” Ligamentoplasty For Distal Radioulnar Joint Instability

Weave Technique for Reconstruction of Medial Collateral Ligament and Posterior Oblique Ligament: A Functional Percutaneous Approach Using Gracilis Tendon

Background: Injury to the medial collateral ligament (MCL) is common. MCL injuries, with impairment of its superficial portion, associated with the deep portion, lead to valgus instability and extrusion of the medial meniscus, resulting in instability and increased pressure in the medial compartment, with consequent damage to the cartilage. We can synthesize this set of structures as the medial meniscocapsular complex. Treating medial, superficial, and deep capsular meniscal complex together aims to restore the normal anatomy, stability, and function of the medial meniscus. Indications: • Anterior cruciate ligament with MCL grade III or MCL grade II • MCL grade III or grade II with clinical instability Technique Description: An arthroscopic examination was performed to assess the “floating meniscus” sign and to confirm a tear of the MCL. The gracilis tendon is harvested in a usual fashion, leaving its distal insertion pedicle fixed to the tibial bone. An incision over the medial epicondyle is made, and a 6-mm drill is used to create a 2.5-cm bone tunnel. The passage of the medial subfascial graft is made toward the medial epicondyle. At this point, its fixation is performed with an interference screw. After fixing the anterior arm, we will return with the free portion of the graft in the most posterior portion and also percutaneously. This posterior arm is biologically fixed, closing the sartorius fascia over the 2 arms of the reconstruction with periosteal stitches. Results: Reconstruction tests were performed on cadaver models, obtaining a graft tension without compromising the range of motion (ROM) and a good result in their final analysis. We ended up publishing our results in a clinical study, with good functional results in both the Lysholm and Tegner scores, at a follow-up of 2 years. Discussion/Conclusion: We present an arthroscopic-assisted technique for a medial, percutaneous, aesthetic, and extremely functional approach. A technical limitation of our procedure is the absence of a biomechanical test for the gracilis double reconstruction: a strong point is that we performed some reconstruction tests on cadaver models, obtained good visual results and graft tension without compromising the ROM, and performed a positive clinical study with a minimum follow-up of 2 years. In conclusion, a simple and inexpensive technique that uses known anatomic principles of graft placement, without compromising ROM was performed. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

ENPP1 downregulation and FGF23 upregulation in growth-related calcification of the tibial tuberosity in rats.

During tibial tuberosity growth, superficial and deep portions can be observed; however, the deep portion is not observed after the growth period, as it develops into bone tissues. Calcification in vivo is known to be constitutively suppressed by ectonucleotide pyrophosphatase/phosphodiesterase-1 (ENPP1) but promoted by tissue-nonspecific alkaline phosphatase (TNAP). FGF23 promotes calcification of enthesis. Gene expression of FGF23 increased rapidly at 13W in this study. Therefore, the tibial tuberosity is speculated to develop via Enpp1 downregulation and Tnap upregulation; however, the understanding of these processes remains unclear. Hence, in the present study, we aimed to explore the age-related structural changes and underlying gene expression changes in the tibial tuberosity of rats. Male Wistar rats were divided into three groups (3-, 7-, and 13-week-old; eight each). The tibial tuberosity superficial and deep portions were clearly observed in 3- and 7-week-old rats, but the presence of the deep portion was not confirmed in 13-week-old rats. The extracellular matrix of hypertrophic chondrocytes was calcified. Furthermore, the Enpp1 expression was the highest in 3-week-old rats and decreased with growth. The TNAP expression did not differ significantly among the groups. The deep portion area was significantly lower in 3-week-old rats than in 7-week-old rats. Generally, the extracellular matrix of the immature chondrocytes is not calcified. Therefore, we speculated that the cartilaginous tibial tuberosity calcifies and ossifies with growth. The Enpp1 expression decreased with growth, whereas the Tnap expression remained unchanged. Thus, we surmise that the tibial tuberosity calcifies with growth and that this process involves Enpp1 downregulation and FGF23 upregulation. As Osgood-Schlatter disease is closely related to the calcification of the tibial tuberosity, these findings may help clarify the pathogenesis of this disease.

Quantifying acute kidney injury in an Ischaemia-Reperfusion Injury mouse model using deep-learning-based semantic segmentation in histology.

This study focuses on ischaemia-reperfusion injury (IRI) in kidneys, a cause of acute kidney injury (AKI) and end-stage kidney disease (ESKD). Traditional kidney damage assessment methods are semi-quantitative and subjective. This study aims to use a convolutional neural network (CNN) to segment murine kidney structures after IRI, quantify damage via CNN-generated pathological measurements, and compare this to conventional scoring. The CNN was able to accurately segment the different pathological classes, such as Intratubular casts and Tubular necrosis, with an F1 score of over 0.75. Some classes, such as Glomeruli and Proximal tubules, had even higher statistical values with F1 scores over 0.90. The scoring generated based on the segmentation approach statistically correlated with the semiquantitative assessment (Spearman's rank correlation coefficient=0.94). The heatmap approach localised the intratubular necrosis mainly in the outer stripe of the outer medulla, while the tubular casts were also present in more superficial or deeper portions of the cortex and medullary areas. This study presents a CNN model capable of segmenting multiple classes of interest, including acute IRI-specific pathological changes, in a whole mouse kidney section and can provide insights into the distribution of pathological classes within the whole mouse kidney section.

Gene fusions in poroma, porocarcinoma and related adnexal skin tumours: An update.

Poroma is a benign sweat gland tumour showing morphological features recapitulating the superficial portion of the eccrine sweat coil. A subset of poromas may transform into porocarcinoma, its malignant counterpart. Poroma and porocarcinoma are characterised by recurrent gene fusions involving YAP1, a transcriptional co-activator, which is controlled by the Hippo signalling pathway. The fusion genes frequently involve MAML2 and NUTM1, which are also rearranged in other cutaneous and extracutaneous neoplasms. We aimed to review the clinical, morphological and molecular features of this category of adnexal neoplasms with a special focus upon emerging differential diagnoses, and discuss how their systematic molecular characterisation may contribute to a standardisation of diagnosis, more accurate classification and, ultimately, refinement of their prognosis and therapeutic modalities.

Partial ruptures of the distal triceps tendons show only slightly lower ultimate load to failure: a biomechanical study

ObjectivePartial ruptures of the distal triceps tendon are usually treated surgically from a size of > 50% tendon involvement. The aim of this study was to compare the ultimate load to failure of intact triceps tendons with partially ruptured tendons and describe the rupture mechanism.MethodsEighteen human fresh-frozen cadaveric elbow specimens were randomly assigned to two groups with either an intact distal triceps tendon or with a simulated partial rupture of 50% of the tendon. A continuous traction on the distal triceps tendon was applied to provoke a complete tendon rupture. The maximum required ultimate load to failure of the tendon in N was measured. In addition, video recordings of the ruptures of the intact tendons were performed and analysed by two independent investigators.ResultsA median ultimate load to failure of 1,390 N (range Q0.25—Q0.75, 954 – 2,360) was measured in intact distal triceps tendons. The median ultimate load to failure of the partially ruptured tendons was 1,330 N (range Q0.25—Q0.75, 1,130 – 1.470 N). The differences were not significant. All recorded ruptures began in the superficial tendon portion, and seven out of nine tendons in the lateral tendon portion.DiscussionPartial ruptures of the distal triceps tendon demonstrate a not statistically significant lower ultimate load to failure than intact tendons and typically occur in the superficial, lateral portion of the tendon. This finding can be helpful when deciding between surgical and conservative therapy for partial ruptures of the distal triceps tendon.

ORAL LICHEN PLANUS AND ORAL LICHENOID LESION: A CLINICOPATHOLOGICAL STUDY

Objective To reassess the cases diagnosed as oral lichen planus (OLP) and oral lichenoid lesion (OLL) and compare their sociodemographic and clinicopathological characteristics. Study Design Records and slides of 72 cases with diagnosis of OLP and OLL were evaluated and submitted to bivariate analysis. Results OLP prevailed (52.8%). Middle-aged, non-smoking white women with white lesions at multiple oral sites without symptomatology, were, clinically, the most affected for both lesions. In LPO, bilateral lesions showing intense lymphocytic infiltrate (IL) in band, well-defined and in the superficial portion of the connective tissue, with a hydropic degeneration of the basal layer, colloid bodies, parakeratin, hyperplastic epithelial crest, and absence of epithelial dysplasia, predominated. In OLL, isolated lesions presenting moderate to intense focal IL, with basal degeneration colloid bodies, hyperplastic epithelial crest, and epithelial dysplasia, were observed. OLP was associated with lesions that appeared bilaterally (p=0.001), well-defined IL, in band, and in the superficial portion of the connective tissue (p≤0.0001). OLL was associated with the presence of epithelial dysplasia and mild dysplasia (p≤0.0001). Conclusion Histopathology of the lichenoid IL and the presence of dysplasia alone are not sufficient for the differential diagnosis LPO and LLO; the association of clinical and follow-up data is essential. To reassess the cases diagnosed as oral lichen planus (OLP) and oral lichenoid lesion (OLL) and compare their sociodemographic and clinicopathological characteristics. Records and slides of 72 cases with diagnosis of OLP and OLL were evaluated and submitted to bivariate analysis. OLP prevailed (52.8%). Middle-aged, non-smoking white women with white lesions at multiple oral sites without symptomatology, were, clinically, the most affected for both lesions. In LPO, bilateral lesions showing intense lymphocytic infiltrate (IL) in band, well-defined and in the superficial portion of the connective tissue, with a hydropic degeneration of the basal layer, colloid bodies, parakeratin, hyperplastic epithelial crest, and absence of epithelial dysplasia, predominated. In OLL, isolated lesions presenting moderate to intense focal IL, with basal degeneration colloid bodies, hyperplastic epithelial crest, and epithelial dysplasia, were observed. OLP was associated with lesions that appeared bilaterally (p=0.001), well-defined IL, in band, and in the superficial portion of the connective tissue (p≤0.0001). OLL was associated with the presence of epithelial dysplasia and mild dysplasia (p≤0.0001). Histopathology of the lichenoid IL and the presence of dysplasia alone are not sufficient for the differential diagnosis LPO and LLO; the association of clinical and follow-up data is essential.

Role of Individualized Homoeopathic Medicine in Urticaria: A Case Report

Urticaria is a vascular reaction of the superficial portion of the dermis. It is characterized by appearance of erythematous, oedematous papules or plaques known as wheals. The present article is a case report of a 17-year-old male visited to the OPD of Swasthya Kalyan Homoeopathic Medical College and Research Centre with the complaint of eruptions (wheals) on left forearm. After complete case taking and thorough analysis and repertorization using synthesis repertory, Phosphorus 30C was selected and prescribed based on individualization. This article illustrates the beneficial effects of Homoeopathic medicine Phosphorus in the case of Urticaria.

Proposal for a novel classification of benign parotid tumors based on localization

ObjectivePostoperative facial nerve paralysis is the most problematic complication after surgical treatment of parotid tumors. Localization of tumors is highly relevant for the surgical approach, but existing classification systems do not focus on the association between localization and surgical technique. Therefore, we created a new localization-based classification system for benign parotid tumors and investigated the characteristics of tumors in each localization and the frequency of postoperative facial nerve paralysis by retrospectively applying the classification to previous cases. MethodsFirst, we defined 6 portions of the parotid gland (upper, U; lower, L; posterior, P; anterior, A; superficial, S; deep, D) by dividing the transverse plane into an upper and lower portion at the mandibular marginal branch, the longitudinal plane into a posterior and anterior portion at the midline of the parotid anteroposterior diameter, and the sagittal plane into a superficial and deep portion along the course of the facial nerve. Then, we defined 8 locations by combining the 6 portions in all possible ways (i.e., U-P-S, U-P-D, U-A-S, U-A-D, L-P-S, L-P-D, L-A-S, L-A-D). We used this classification to define the tumor localization in 948 patients who had undergone partial superficial parotidectomy for benign parotid tumors and then investigated the incidence, histopathological type, signs/symptoms, diagnosis, surgery, and complications in each area. ResultsPleomorphic adenomas comprised approximately 70% of tumors in the upper portion but only approximately 35% in the lower portion. The rate of postoperative facial nerve paralysis was significantly higher for tumors in deep locations than in superficial locations (33.9% vs 14.9%, respectively), and the odds ratios for postoperative facial nerve paralysis in the U-P-D and U-A-D locations were 7.6 and 4.8 compared to the L-P-S location. When maximum diameter, operation time, bleeding volume, sex (reference: female), and age were added as control variables, the odds ratios were 4.2 and 3.0. ConclusionDetermining tumor localization preoperatively with the new localization-based classification of parotid tumors is helpful not only for predicting the histopathological type but also for predicting surgical complications, particularly postoperative facial nerve paralysis.

Better Comprehension of Primary Pyogenic Spinal Infections.

To the Editor: Some years ago, childhood spondylodiscitis was used to describe a continuum of primary pyogenic spinal infections (PPSIs), from discitis to vertebral osteomyelitis, including spondylodiscitis with its occasional associated soft-tissue abscesses. The pathophysiology of PPSIs has, nevertheless, become clearer and less controversial. The theory suggesting that spondylodiscitis was a self-limiting inflammatory condition is now considered completely obsolete. A better understanding of pathophysiological processes has made it possible to differentiate forms of childhood PPSI according to patients’ ages, their immune system development, better knowledge of their bacterial etiology, and the vascularization of their vertebrae and disks. The different clinical forms of PPSI have now been categorized in various ways that physicians and pediatricians should know. The first classification is based on the child’s age and the development of their immune system, and it distinguishes three main clinical forms of childhood PPSI. The neonate form of spondylodiscitis generally affects infants under 6 months old and is recognized as the most severe manifestation of the disease: patients often present with septicemia and multiple infectious foci. Fortunately, this is the rarest form of the disease. The infantile form concerns children from 6 to 48 months old (a period during which maternally derived immunity decreases and stops), the age group representing 60%–80% of cases of childhood spondylodiscitis. Finally, in the third form, affecting children above 4 years old, patients are more prone to being febrile and appearing very ill. The second classification can be superimposed on the first and assigns each age group a bacterial probability of spondylodiscitis. Approximately 80% of spondylodiscitis cases in children younger than 6 months are due to S. aureus. For children from 6 to 48 months old, there are now robust arguments supporting the hypothesis that K. kingae should be considered the primary etiological pathogen for spondylodiscitis. The third form affects children older than 4 years of age, and S. aureus is the predominant pathogen. Finally, a third classification is based on the anatomical characteristics of the patient’s vertebral endplate and disk vascularization. Many studies have demonstrated that the vertebral endplates and the superficial portion of the disks share a common blood supply at birth that gradually regresses during infancy. In children, the metaphysis of the vertebral body has a rich blood flow, with an incomplete vascular ring ending at the pedicle’s base. Otherwise, it has been shown that several fine anastomotic branches exist between the upper and lower metaphyseal rings of two adjacent vertebrae, mostly present around the disk’s posterolateral region, providing its blood flow. It is also commonly accepted that infection starts under the vertebral endplates, that it subsequently and successively crosses both the vertebral endplate and the disk’s surface via those fine anastomotic branches, reaching the adjacent vertebral body and, lastly, the disk space between the two affected vertebral bodies. Interestingly, the blood vessels which cross the vertebral endplates evolve at around 7 or 8 years old. These anatomical observations lead to two conclusions. First, it becomes reasonable to think that pure discitis, as some authors have suggested, cannot occur. Secondly, it seems highly likely that children will tend to have spondylodiscitis before the age of 7 to 8 years old and, afterwards, that older children and adolescents are more likely to develop vertebral osteomyelitis, providing that the infection is not neglected. Unfortunately, these concepts do not yet appear in textbooks or university curricula, thus perpetuating enormous confusion about these infections.

Abstract 14256: Dual-Targeted NIRF Molecular Imaging Combined With Intravascular OCT for Inflammatory Micro-Calcification in the High-Risk Plaque

Background/Objectives: Micro-calcification is a major target for high-risk plaque but the mechanistic linkage with macrophage-driven inflammation remains questionable. To address this issue, we newly innovated dual-targeted multimodal imaging strategy for calcifying inflammatory activity by integration of intravascular OCT with near-infrared fluorescence (NIRF) molecular imaging. Methods/Results: We fully integrated dual-targeted NIRF molecular imaging with intravascular OCT. Novel NIRF emitting probe targeting micro-calcification was fabricated by chemically coupling alendronate and Cy5.5 to the ends of azide-PEG-NHS ester (Al-Cy5.5). Based on whole body biodistribution, OCT/dual-NIRF in vivo imaging of rabbit aortoiliac atheroma was acquired 48 hrs and 72 hrs after intravenous injection of Al-Cy5.5 (5.0 mg/kg) and macrophage mannose receptor targeted Cy7-emitting probe (7.5 mg/kg), respectively. NIRF signals of Cy5.5 and Cy7 were highly enhanced at the area of micro-calcification and macrophage accumulation within the plaque (Figure) (p<0.01). Fluorescence microscopy and immunostainings from the corresponding sections well corroborated the in vivo findings and concomitantly elevated dual-NIRF signals indicated the presence of calcifying inflammatory activity in atheroma. Intriguingly, osteogenic activity (TRAP stain) was closely interconnected with macrophages in superficial micro-calcification rather inner dense calcification (p<0.01). Conclusions: Our intravascular OCT/dual-NIRF imaging was feasible to simultaneously visualize micro-calcification, osteogenic activity and macrophages in the coronary-sized atheroma. This novel imaging strategy is expected to expand our pathophysiologic insight for the biological behavior of calcifying inflammatory activity existing on the superficial fibrous cap portion of high-risk plaques.

Necrolytic migratory erythema as a cutaneous manifestation of a pancreatic neuroendocrine tumor.

Glucagonoma syndrome is a rare entity defined by the existence of necrolytic migratory erythema (NME), elevated serum glucagon levels, and an underlying alpha-cell secreting tumor of the pancreas [ [1] John A.M. Schwartz R.A. Glucagonoma syndrome: a review and update on treatment. J Eur Acad Dermatology Venereol. 2016; 30: 2016-2022 Crossref PubMed Scopus (42) Google Scholar ]. We present the case of a female with clinical manifestations of this syndrome. In this paper, we describe the case of a 38-year-old woman referred to the dermatology department to investigate pruritic lesions located on the lower extremity, with subsequent extension to the axillae, groin, and intergluteal region, and pubis (Fig. 1). After several attempts, a skin biopsy specimen revealed histopathologic features suggestive of NME. Further evaluations revealed the presence of 8 centimeters nonmetastatic glucagonoma, located at the tail of the pancreas. 68Ga-DOTA TOC and an 18F-FDG PET identified a mild uptake of the lesion (Fig. 1). The glucagon level was >500 pg/mL. The patient was diagnosed with glucagonoma syndrome, and a caudal pancreatectomy was subsequently performed. Microscopy and the immunohistochemical study were consistent with a glucagonoma (Fig. 2). After surgery, the cutaneous manifestation was resolved, with normalization of glucagon levels. This uncommon case report adds information about an infrequent neuroendocrine tumor with cutaneous expression. Early recognition and diagnosis must support by radiological and nuclear medicine imaging tests [ [2] Jensen R.T. Cadiot G. Brandi M.L. et al. ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms: functional pancreatic endocrine tumor syndromes. Neuroendocrinology. 2012; 95: 98 Crossref PubMed Scopus (371) Google Scholar ]. Surgery is the initial treatment of choice. Fig. 2Skin biopsy revealing irregular acanthosis of the epidermis with loss of the stratum granulosum and edema of the superficial portion of the epidermis (A). Hematic extravasation and presence of abundant focal polynuclear cells alternating with areas of parakeratosis (B). Histological study reveals a nodular tumor of 8 × 4.5 × 3.5 cm, located in the tail of the pancreas with an intact capsular surface surrounded by adipose tissue (C). In the sections performed, a proliferation of neuroendocrine cells is identified, growing in an anastomosing, gyriform, pseudorosette trabecular pattern (D). Cells with ample eosinophilic cytoplasm and enlarged nuclei with central macronucleolus. Two mitoses are identified in 42 high magnification fields corresponding to less than one mitosis per 2 mm2 (E). Cells show intense positivity for chromogranin (F) and glucagon (G). View Large Image Figure Viewer Download Hi-res image

S2216 A Rare Case of Symptomatic Colonic Lymphangioma

Introduction: Lymphangiomas are benign lymphatic lesions, most frequently identified in the head and neck. Colonic lymphangiomas occur but are rare and represent less than 1% of all lymphatic malformations. These lesions are often asymptomatic and discovered incidentally during routine colonoscopy. We present a case of a symptomatic colonic lymphangioma manifesting as a large mass requiring surgical resection. Case Description/Methods: A 42-year-old male presented with the complaint of lower abdominal pain. Associated symptoms included nausea with no vomiting, and he denied family history of gastrointestinal malignancies. At presentation, vital signs were stable and abdominal exam was benign. Laboratory studies were unremarkable, but a Computed Tomography (CT) abdomen/pelvis with contrast revealed a 6.6 x 7 x 6.6 cm colonic mass near the hepatic flexure. Follow up colonoscopy demonstrated a large, subepithelial-appearing mass in the ascending colon protruding more than 90% into the lumen. Retroflexed view revealed 2 x 2 cm ulceration on the proximal aspect of the lesion. Serum tumor markers including CEA, CA 19-9, and CA 125 were all within normal limits and additional CT imaging revealed no metastatic lesions. Biopsies resulted back demonstrating superficial portions of colonic mucosa with mild focal inflammation. However, surgical evaluation was advised given the mass size and the patient thus underwent an elective laparoscopic right hemicolectomy. Tissue samples were sent for evaluation and revealed lymphangiomatosis/lymphatic malformation/cystic lymphangioma centered in the colonic submucosa with extension into the subserosal tissue. No cellular atypia or malignancy was identified, and 24 lymph nodes were benign. These pathology findings were confirmed by expert review at a tertiary center, where it was noted that this case also lacked features of congenital lymphangiectasia. During post-operative follow-up, the patient was reported to be progressing well (Figure). Discussion: Lymphangiomas have an incidence of less than 0.20% and intra-abdominal lymphangiomas represent only a fraction of cases. Although most colonic lymphangiomas are asymptomatic and identified incidentally, they can lead to an array of symptoms and severe complications such as obstruction, intussusception, and perforation requiring surgical intervention if large. Although colonic lymphangiomas are rare, it is important to be aware of their rising incidence to help facilitate accurate and timely diagnosis to prevent complications.Figure 1.: A. Colonoscopy. Submucosal mass in the ascending colon involving more than 90% of the circumference. Figure B. CT axial image. Mass in the ascending colon/hepatic flexure. Figure C. CT coronal image. Mass in the ascending colon/hepatic flexure. Figure D. CT sagittal image. Mass in the ascending colon/hepatic flexure.