Report of two cases of fluorodeoxyglucose positron emission tomography/computed tomography appearance of hibernoma: A rare benign tumor

False-positive findings are commonly seen in positron emission tomography computed tomography imaging. One of the most common false positive finding is uptake of fluorodeoxyglucose in brown adipose tissue. Herein, we report two cases with incidentally detected hibernomas-a brown fat containing tumor with metabolic activity.

Development and validation of clinical diagnostic models for the probability of malignancy in solitary pulmonary nodules

BACKGROUND

It is critical to develop a non-invasive and accurate method for differentiating between malignant and benign solitary pulmonary nodules. In large sample studies, the effectiveness of the diagnostic prediction model as a tool of assessment of the probability of malignancy is still unclear. The establishment of a diagnostic model based on large samples is needed.

METHODS

In this study, 3358 patients diagnosed with a solitary pulmonary nodule between January 2005 and March 2013, were enrolled. All patients received surgery for pulmonary nodule resection. Clinical characters, preoperative biomarker results, and computed tomography scan findings were collected. All patients were randomly separated into a training set (n = 1679) and a test set (n = 1679); we used training sets to build a diagnostic model for the malignancy probability of pulmonary nodules, and applied the test set to validate our model, as well as other published diagnostic models.

RESULT

Logistic regression analysis identified 11 clinical characteristics as independent predictors of malignancy in patients with a solitary pulmonary nodule. The goodness-of-fit statistic for the model indicated that the observed proportion of malignancies did not differ from the predicted proportion (P = 0.571). The area under the curves of the receiver operator characteristic curve for our model in the training set was 0.935.

CONCLUSION

As the accuracy of the model was high, we suggest that the diagnostic model can be used as a tool to help guiding clinical decisions, when the clinician cannot make a definitive diagnosis of a solitary pulmonary nodule.

Peripheral lymphadenopathy: approach and diagnostic tools

Peripheral lymph nodes, located deep in the subcutaneous tissue, clean antigens from the extracellular fluid. Generally, a normal sized lymph node is less than one cm in diameter. Peripheral lymphadenopathy (LAP) is frequently due to a local or systemic, benign, self-limited, infectious disease. However, it could be a manifestation of underlying malignancy. Seventy-five percent of all LAPs are localized, with more than 50% being seen in the head and neck area. LAP may be localized or generalized. Cervical lymph nodes are involved more often than the other lymphatic regions. Generally, it is due to infections, but most of the supraclavicular lymphadenopathies are associated with malignancy. Based on different geographical areas, the etiology is various. For example, in tropical areas, tuberculosis (TB) is a main benign cause of LAP in adults and children. Complete history taking and physical examination are mandatory for diagnosis; however, laboratory tests, imaging diagnostic methods, and tissue samplings are the next steps. Tissue diagnosis by fine needle aspiration biopsy or excisional biopsy is the gold standard evaluation for LAP. We concluded that in patients with peripheral LAP, the patient's age and environmental exposures along with a careful history taking and physical examination can help the physician to request step by step further work-up when required, including laboratory tests, imaging modalities, and tissue diagnosis, to reach an appropriate diagnosis.

A prospective case controlled study of the short-term outcome following hemicolectomy for benign compared with malignant colonic polyps

AIM

The number of patients diagnosed with advanced colonic polyps has increased due to screening. The outcome of hemicolectomy for benign lesions is poorly documented. We present a case-matched study comparing the results of hemicolectomy for benign and malignant polyps performed in two institutions.

METHODS

Data for consecutive patients undergoing surgery for benign colonic polyps (BCPs) were prospectively collected in two hospitals. Each patient was matched for age, sex, ASA grade, site and type of resection (laparoscopic, open and converted) with two controls who underwent surgery for colon cancer (CC). The length of stay (LOS) and 30-day outcome were analysed adjusting for potential confounders. Multilevel linear and logistic regression analyses were performed.

RESULTS

Forty-six patients having hemicolectomy for BCP were matched with 81 patients with CC. The median size of BCP was 4 cm [interquartile range (IQR) 2.5-5.4 cm]. Patients with a BCP had a marginally longer LOS [median 5.5 (IQR 4-8) days and 5 (IQR 3-7) days (P = 0.04)]. Twenty-one (46%) of 46 patients with BCP had a postoperative complication compared with 25 (31%) of 81 CC patients (P = 0.12, OR = 2.11, 95% CI 0.82-5.41). Four (9%) of 46 patients with BCP underwent re-operation and a further three (7%) were readmitted compared with one (1%) and two (2%) of 81 patients with CC (P = 0.07 and 0.28). There was no mortality in either group.

CONCLUSION

Complications following hemicolectomy for BCP or CC are not significantly different. The results of the study provide further impetus to develop local full thickness colonic excision for benign colonic lesions as an alternative to major surgery.

Cough, exercise, and sex headaches

Cough, exercise, and sex headaches are underrecognized distinct but related syndromes, triggered by rapid rises in intra-abdominal pressure. All may occur as a manifestation of a possible underlying, symptomatic etiology, and additional diagnostics should typically be pursued to rule out serious causes. Cough headaches may be more common in certain subgroups or settings. Based on recent epidemiologic data, exercise-related headache may be more common than previously thought. There is no evidence that different pain types in sexual headaches are distinct from a pathophysiologic standpoint. Each of these headache syndromes is reported to be responsive to indomethacin.

Granulomatous inflammation and organizing pneumonia: Role of computed tomography-guided lung fine needle aspirations, touch preparations and core biopsies in the evaluation of common non-neoplastic diagnoses

Background:

Fine-needle aspirations (FNAs) and core biopsies (CBs), with or without touch preparations (TPs), are performed to characterize pulmonary lesions. Although a positive (P) or suspicious report is sufficient for further management, the significance of unsatisfactory (U), negative (N) and atypical (A) cytological diagnoses remains uncertain. The aims of the study were to correlate U, N and A cytological diagnoses with histological and/or clinical/radiological follow-up and evaluate the utility of FNAs, TPs and CBs.

Materials and Methods:

We performed a retrospective search and examined 30 consecutive computed tomography-guided transthoracic U, N and A lung FNAs (n = 23) and TPs (n = 7) with surgical pathology (SP) (n = 17) and/or clinical/radiological follow-up (n = 13) and compared them to 10 SP-confirmed P FNAs, which served as controls.

Results:

The 30 FNAs and TPs were from 29 patients. All 6 U specimens were scantly cellular. Granulomas, the most common specific benign cytological diagnosis, were evident in 8 (of 13) and 7 (of 11) N and A cytology cases, respectively. Histology corroborated the presence of granulomas identified on cytology. Organizing pneumonia was the second leading benign specific diagnosis (5/17), but it was rendered on histology (n = 5) and not FNAs or TPs. Evaluation of the A cases revealed that type II pneumocytes were the source of “atypical”, diagnoses often associated with granulomas or organizing pneumonia and lacked 3-D clusters evident in all P cases.

Discussion:

U, N and A FNAs and TPs lacked 3-D clusters seen in carcinomas and were negative on follow-up. Granulomas and organizing pneumonia were the most common specific benign diagnoses, but the latter was recognized on histology only. In the absence of a definitive FNA result at the time of on-site assessment, a CB with a TP containing type II pneumocytes increases the likelihood of a specific benign diagnosis.

Multiple trichoepitheliomas: A rare occurrence

Trichoepitelioma is an extremely rare cosmetically disfiguring condition usually affecting the females. Trichoepitheliomas are benign lesions seen on the face, which are thought to derive from the hair follicle. Malignant transformation to basal cell carcinoma is rare and occurs late in the course of the disease These lesions are often misinterpreted and diagnosed clinically as neurofibromatosis or histpathologically as basal cell carcinoma. We report a case of multiple trichoepithelioma occurring in a male patient. The patient presented with multiple dermatologic growths on the face with varied histopathological presentations which have been described in detail.

Radiotherapy and technetium-99m-labeled red blood cell scintigraphy for hemoptysis from chronic MRSA infection

AIM

To discuss the application of external beam radiotherapy (EBRT) and technetium-99m-labeled red blood cell scintigraphy (LRBCS) in life-threatening hemoptysis from a non-malignant condition.

MATERIALS AND METHODS

This case report presents a patient with persistent hemoptysis secondary to chronic Methicillin-resistant Staphylococcus aureus (MRSA) infection in whom conventional management failed to localize the site of pulmonary bleeding or to provide effective therapy.

RESULTS

EBRT was successfully given for life-threatening hemoptysis with improvement in quality of life for nearly 1 year. LRBCS was used to localize the source of further bleeding and facilitate targeted therapy.

CONCLUSION

EBRT can be an effective and well-tolerated modality in treating life-threatening hemoptysis refractory to conventional methods. LRBCS is a non-invasive diagnostic tool that can be used to detect the source of pulmonary bleeding.

Clinicopathological study and management of peripheral soft tissue tumours

BACKGROUND

Soft-tissue tumours comprise a large heterogeneous group of mesenchymal neoplasms that is classified according to their normal tissue counterpart. They are ubiquitous in nature and can pose a challenge in terms of diagnosis and therefore, in their management. Biopsy findings bear direct implications on the treatment outcomes.

AIMS

The current study was conducted to understand various modes of clinical presentation, diagnostic modalities and to correlate them with operative findings, to delineate the different treatment modalities for patients with soft tissue tumours. We also assessed the risk factors and complications associated with soft tissue tumours.

SETTING AND DESIGN

This was a prospective study conducted at a rural teaching hospital in India.

METHODS

Accurate history was elicited from patients with peripheral soft tissue tumours and a thorough physical examination was done. The patient demographics were noted. The clinical parameters assessed included location and size of swelling, any associated pain, neurovascular symptoms, presence of any deformity and medical risk factors. To diagnose the type of swelling, biopsy was done. All swellings were excised, and based on the diagnosis, additional therapeutic measures were employed. Post-operative complications and hospital stay were recorded.

RESULTS

A total of 74 patients were included in the study, with male to female ratio of 1:1 and average age of 37.96 years. All of them presented with a swelling. The lower extremities and trunk were the most common sites, with each comprising about 25%. The size of tumour varied from 2 to 10 cm in diameter. Seventy one were benign and three were malignant. About one third of patients complained of pain. Comorbid illnesses were present in three patients. For benign tumours, simple excision was done, while for the malignant ones, multimodal therapeutic approach was taken. Post-operatively, two patients developed skin ulceration over the tumour, and six had wound infection.

CONCLUSION

Most soft tissue tumours encountered in clinical practice are benign, of which lipoma is the commonest. While simple excision suffices for most benign tumours, a more aggressive treatment approach is required for their malignant counterparts.

Fascin expression in pleomorphic adenoma and mucoepidermoid carcinoma

BACKGROUND

Salivary gland tumors constitute an important part of oral and maxillofacial pathology. Pleomorphic adenoma (PA) and mucoepidermoid carcinoma (MEC) are the most common benign and malignant salivary gland tumors. Fascin is an actin-bundling protein that increases the motility of normal and transformed epithelial cells. The aims of the study were to determine the expression of fascin in these tumors and to determine its role in their progression.

MATERIALS AND METHODS

A total of 40 formalin-fixed, paraffin-embedded tissue blocks of PA, and 20 blocks of MEC were included in this study. Diagnostic confirmation was performed through examination of hematoxylin and eosin sections. Both tumors were immunohistochemically analyzed for the presence of fascin using Avidin-Biotin complex method and evaluated via light microscope by 2 independent observers. Statistical analysis was performed using Kruskal-Wallis and Chi-square tests with significant level of P < 0.05.

RESULTS

In both the tumors, the percentage of stained cells was significantly correlated with intensity of staining (P = 0.01 in PA and P = 0.00 in MEC). In PA, statistical analysis showed a significant direct correlation between percentage of stained cells and recurrence (P = 0.00).

CONCLUSION

Fascin might be a useful marker for recurrence of PAs and patients with high fascin expression in primary PA should be followed up periodically to detect potential recurrence as soon as possible.

A case of fibrous pseudotumor of the paratesticular region

A 78-year-old male patient presented with an inguinoscrotal nodule that had lasted for 3 years. The patient reported a past medical history of hydrocele formation. The final diagnosis was fibrous pseudotumor of the paratesticular region, which was based on a histopathological examination and immunohistochemical findings. The aim of this case report is to spread awareness and recognition of neoplastic and non-neoplastic entities that occur in the paratesticular region.

Unusual benign polypoid and papular neoplasms and tumor-like lesions of the vulva

We aimed to investigate the prevalence and spectrum of unusual benign neoplasms and tumor-like lesions presenting as vulvar polyps and papules, to study their clinical, pathologic, hormonal, and developmental features and whether they have important associations with other pathologic lesions or clinical diseases. We conducted a retrospective review study of 115 vulvar specimens over 7 years. Common lesions, for example, fibroepithelial polyps, skin tags, papillomas, abscesses, viral warts and common cysts, were excluded. We found 21 cases (18%) with uncommon benign vulvar lesions. They included 7 epithelial cysts, 3 vascular lesions, 3 glandular neoplasms, 3 endometrioses, 1 caruncle, 1 pilonidal sinus, 1 prolapsed urethra, 1 seborrheic keratosis, and 1 granular cell tumor. The age range was between 1 and 64 years with a mean age of 33 years. Most (86%) were 2.5 cm or less. Many were asymptomatic incidental pathologic findings that can be missed clinically. Nine cases have important clinical associations or coexisting incidental pathologic lesions. Some lesions demonstrated hormone receptors. Some were clinically confused with fibroepithelial polyps, abscesses, warts, melanocytic lesions, and tumors. In conclusion, although the vulva is a small compartment, its developmental and histologic complexity can result in a variety of unusual and rare benign polypoid and papular lesions, some unique to the vulva, which might present diagnostic challenges to the clinicians and pathologists. In addition, many bear controversy regarding their histogenesis and origin of development in the vulva.

Benign medullary fibroma of the kidney: a rare diagnostic dilemma

Renomedullary interstitial cell tumor or medullary fibroma, is a small tumor that commonly presents as an incidental finding, but in rare cases maybe large and symptomatic. Although it is a benign tumor, it is difficult to differentiate this lesion from other malignancies of the kidney on radiological basis and hence many patients undergo radical nephrectomy. We present a case of renal medullary fibroma and various nuances associated with radiological identification of this lesion and its management related dilemmas.

Managing adnexal masses: a medical quandary

INTRODUCTION

Management of Adnexal masses poses a double edged problem. There is a dilemma of performing extensive surgery in the form of staging laparotomy for a benign disease on one hand and the lurking fear of missing the diagnosis of malignancy on the other. Thus, it seems that it is important to establish risk profiles of all patients with adnexal masses so that they can reap the benefit of minimally invasive surgery wherever possible and be rightly subjected to staging laparotomy where indicated.

MATERIAL AND METHODS

This prospective study was carried out at a Tertiary care Hospital. 136 women with an adnexal mass on ultrasound which met the said criteria were enrolled into the study from January 2008 to July 2011. They were then taken up for laparoscopic management.

RESULTS

All but 2 cases were found to be benign (134/136) after the final histopathology report using the said criteria.

CONCLUSION

Hence, by using simple readily available investigations like ultrasound (pattern recognition approach, Tumour morphology and ascites) and CA-125, the nature of adnexal mass can be reliably predicted and these patients can be safely offered the benefits of laparoscopic surgery.

Surgical removal of an intravenous leiomyoma with intracardiac extension and pulmonary benign metastases

Intravenous leiomyomatosis (IVL) with right intracardiac extension or pulmonary benign metastases (PBM) is rare. We report a case of 51 year-old woman, who underwent successful extensive double stage surgical removal of the intracardiac IVL extension associated with a pulmonary limited resection where the cystic bullae and PBM were found, and a month later gynaecological operation. To our knowledge this is the first reported case of such a combination.

Non-surgical pneumoperitoneum after oro-genital intercourse

INTRODUCTION

In many cases, a pneumoperitoneum is due to air escaping from a perforated hollow viscus or surgical intervention but there are increasing reports of non-surgical causes.

PRESENTATION OF CASE

We report a case where a pneumoperitoneum was identified after oro-genital sexual intercourse.

DISCUSSION

There were nineteen reported cases of non-surgical pneumoperitoneum from gynaecologic causes up to May 2013. We report an additional case four hours after oro-genital intercourse. Close clinical observation and symptomatic treatment are usually all that is required but operative interventions should be considered if the patient develops abdominal pain, peritoneal signs, fever or leukocytosis during observation.

CONCLUSION

This adds to the world literature on non-surgical pneumoperitoneum from oro-genital intercourse. Clinicians should be aware of this condition and focus on medical-sexual history as this information could prevent a patient from being exposed to expensive diagnostics and invasive operative treatments. Patients should also be educated about the mechanisms to avoid future possible diagnostic dilemmas.

Cutaneous benign epithelioid peripheral nerve sheath tumour: a rare entity

Benign epithelioid peripheral nerve sheath tumor, a rare entity is an umbrella term describing benign, neural origin tumors with epithelioid morphology. Clinically indistinguishable from other benign cutaneous lesions, histopathology offers the only source of accurate diagnosis. Morphologic mimics include many benign and malignant soft tissue lesions. Besides a predominant epithelioid component, the lesion can also show a fair share of spindle cells. A circumscribed nodular tumour of low mitotic activity, it often exhibits areas resembling schwannoma or neurofibroma. An awareness of this entity and its varied morphological aspects helps to arrive at the correct diagnosis and hence avoid unnecessary extensive surgical procedures. This case presents features of this benign tumor which occurred in a 47 years old man.

Clinicopathologic evaluation of salivary gland neoplasms: a 38-year retrospective study in Iran

We present a 38-year retrospective study of 165 patients with salivary gland tumors that were diagnosed from 1971 to 2009 in the Department of Oral and Maxillofacial Pathology, Faculty of Dentistry, Mashhad, Iran. The histologic diagnoses were reevaluated according to the 2005 World Health Organization classification. A total of 165 tumors were identified in 79 male and 86 female patients. The mean age was 43.41 ± 18.59 for male patients and 40.06 ± 15.91 for female patients. Although benign salivary gland tumors are usually more common than the malignant counterpart in previous studies, neoplasms showed an almost equal frequency of benign and malignant tumors in the present study. The frequency of major salivary gland tumors was 15.8%, and that of minor salivary gland tumors was 83%. The mean age of patients with major salivary gland tumors (44.30 years) was slightly higher than patients with minor ones (41.15 years). Pleomorphic adenoma was the most common histologic type of benign tumor identified, whereas mucoepidermoid was the most common malignant tumor. In contrast to some previous studies that have been reported parotid gland as the most common site for salivary tumors, in the current study, the palate was the most frequent location for salivary gland tumors and tumors have a propensity to occur at the palate than any other sites. Therefore, any lesion arising from the palate should be considered as a possible salivary gland tumor.

Global N-acetylaspartate concentration in benign and non-benign multiple sclerosis patients of long disease duration

BACKGROUND AND OBJECTIVE

To examine whether clinically benign multiple sclerosis patients (BMS) show similar losses of their global N-acetylaspartate (NAA) neuronal marker relative to more clinically disabled patients of similar disease duration.

METHODS

The whole-brain NAA concentration (WBNAA) was acquired with whole-head non-localizing proton MR spectroscopy. Fractional brain parenchymal volume (fBPV), T2 and T1 lesion loads, were obtained from the MRI in: (i) 24 BMS patients: 23.1 ± 7.2 years disease duration, median Expanded Disability Status Scale (EDSS) score of 2.0 (range: 0-3); (ii) 26 non-benign MS patients (non-BMS), 24.5 ± 7.4 years disease duration, median EDSS of 4.0 (range: 3.5-6.5); (iii) 15 healthy controls.

RESULTS

Controls' 12.4 ± 2.3mM WBNAA was significantly higher than the BMS's and non-BMS's 10.5 ± 2.4 and 9.9 ± 2.1mM (both p<0.02), but the difference between the patients' groups was not (p>0.4). Likewise, the controls' 81.2 ± 4.5% fBPV exceeded the BMS and non-BMS's 77.0 ± 5.8% and 76.3 ± 8.6% (p<0.03), which were also not different from one another (p>0.7). BMS patients' T1-hypointense lesion load, 2.1 ± 2.2 cm(3), was not significantly different than the non-BMS's 4.1 ± 5.4 cm(3) (p>0.08) and T2-hyperintense loads: 6.0 ± 5.7 cm(3) and 8.7 ± 7.8 cm(3), were also not different (p>0.1).

CONCLUSIONS

WBNAA differentiates normal controls from MS patients but does not distinguish BMS from more disabled MS patients of similar disease duration. Nevertheless, all MS patients who remain RR for 15+ years suffered WBNAA loss similar to the average RR MS population at fourfold shorter disease duration suggesting relative global neuronal sparing or leveling-off of the neurodegeneration rate.

Anomalous origin of the right vertebral artery from the right common carotid artery associated with an aberrant right subclavian artery

Vertebral artery origin anomalies are typically incidental findings during angiography or post mortem examination. We present two cases of vertebral origin from the right common carotid artery in association with an aberrant right subclavian artery. We also review the embryonic development and the clinical significance of this anomaly.

Multi-session radiosurgery of benign intracranial tumors

Multi-session stereotactic radiosurgery (SRS) enables a high dose per fraction to be delivered to the tumor bed with rapid dose falloff that allows for sparing of critical structures, resulting in less radiation-associated toxicity. In this article, the authors review the basic concepts and techniques of multi-session SRS, indications for this technique, outcomes from single-session and multi-session SRS using 3 commonly treated benign intracranial tumors (meningiomas, vestibular schwannomas, pituitary adenomas), and discuss why multi-session SRS is an attractive approach for the treatment of these tumors.

Benign fibroushistiocytoma of the gingiva

Benign fibroushistiocytoma is a benign connective tissue tumor rarely seen affecting the head and neck region. These tumors were believed to be of histiocytic origin as they are comprised of cells, which showed spindled morphology and cells with a round histiocytic appearance. The current concept consents that the lesional cells rather represent a fibroblastic differentiation. Diagnosis of these tumors proves to be challenging even with the use of immunohistochemistry due to lack of any specific markers. Here, we describe a case which presented in the gingiva mimicking a reactive lesion, which in fact was a tumor.

Retrospective Analysis of Ossifying Fibroma of Jaw Bones Over a Period of 10 Years with Literature Review

OBJECTIVE

The purpose of this retrospective analysis is to document and discuss the features, treatment rendered and result of 25 histologically proven cases of ossifying fibromas of jaw bones operated by a single surgeon over a period of 10 years.

MATERIALS AND METHODS

The records of ossifying fibroma were obtained from the archives of Oral and Maxillofacial Surgery at Maulana Azad Institute of Dental Sciences (MAIDS) from 2001 to 2011. Only those cases were included in the study where definitive surgery was performed based on clinical, radiological & histopathological features.

RESULTS

Twenty-five patients were analyzed with a final diagnosis of ossifying fibroma comprising of 14 males (56 %) and 11 females (44 %). The age range was 11-45 years with a mean of 24.12 years. Mandible was involved in 72 % and maxilla in 28 % cases with a predominance of mandibular posterior [19 (76 %)] cases. The study showed similar findings in regard to clinical, radiographic & histological features of ossifying fibroma as compared to other studies. It also showed that the treatment rendered in the form of eneucleation, curettage or resection of the lesion depending on its stage and extent were adequate, as no recurrence has been reported till date.

CONCLUSION

Enucleation is preferred in small and well demarcated lesions. Curettage should be done in relatively large lesions with ill defined borders, not involving basal bone of mandible or cortical perforation. Resection should be reserved for aggressive and extensive cases with involvement of basal bone or perforation of cortices.

An extracranial invasive meningioma mimicking malignant bone tumor - "carpet meningioma"

Meningioma is a common benign intracranial neoplasm. The incidence of an extracranial extension to other sites is rare. Due to the neglected intracranial component, the chances of an under diagnosis or a misdiagnosis of the extracranial component is there, which may adversely affect the management and therefore, the prognosis. Here, we are reporting a case of a 39 years old male patient with a preoperative probable diagnosis of a malignant bone tumour which involved the skull bone, which was made, based on the imaging studies , which was histopathologically found to be an invasive meningioma with an extensive extracranial skull vault involvement and was confirmed by immunohistochemistry. We have proposed a term, "carpet meningioma" for this extracranial invasive meningioma, because it had covered the skull vault like a carpet. The follow up studies after 1 year have revealed no evidence of a recurrence.

Radiofrequency ablation of a large hepatic adenoma in a child

Hepatic adenomas are rare benign liver tumors seen most commonly in young women on oral contraceptives. Large hepatic adenomas are at risk of malignant transformation and require treatment in select patients, usually by surgical resection. Radiofrequency ablation (RFA) has become a widely used and accepted tool for the curative treatment of small primary hepatocellular carcinomas in adults; however, its use in the treatment of other liver lesions, such as hepatic adenoma, has only recently been described. Use of RFA for liver lesions in pediatric population remains novel. We present a case of large hepatic adenoma successfully treated with RFA in a child with chronic liver disease secondary to alpha-1-antitrypsin deficiency. RFA may be an attractive option in pediatric liver tumor management in selected cases because of its less invasive characteristics.

A huge primary ovarian leiomyoma with degenerative changes-an unusual

Primary ovarian leiomyoma is a rare benign tumour of the ovary, which is seen in women who are aged between 20 years to 65 years. Ovarian leiomyomas can be confused with other spindle cell tumours which display gross anatomical and histological similarities. A case of a primary leiomyoma of the ovary in a pre-menopausal female is being presented here, due to its huge size and unusual presentation.

The role of magnetic resonance imaging and positron emission tomography-computed tomography combined in differentiating benign from malignant lesions contributing to vertebral compression fractures

Background:

Obtaining tissue confirmation of the underlying pathology is the gold standard for establishing the etiology of nontraumatic vertebral compression fractures. However, newer investigative modalities such as the magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) combined potentially offer the ability to distinguish between benign and malignant lesions, thereby circumventing the need for invasive tissue diagnostic/biopsy procedures.

Methods:

Twenty-four patients with nontraumatic, spontaneous vertebral compression fractures were prospectively studied. After clinical evaluation, all patients underwent MRI (with/without contrast) focusing on the spinal lesion, followed by whole-body PET-CT. This was followed by fine needle aspiration cytology (FNAC) of the lesion to confirm the diagnosis. The sensitivity and specificity of MRI and PET-CT studies were calculated for benign vs. malignant lesions.

Results:

The sensitivity/specificity of MRI for benign lesions were 78.57%/90%, while the sensitivity/specificity values of PET-CT for benign disease were 92.8%/90% respectively. Alternatively, the sensitivity/specificity of MRI for malignant lesions were 90%/78.57%, while the sensitivity/specificity of PET-CT for malignant disease were 90%/92.8%, respectively. Furthermore, the sensitivity for diagnosing malignant lesions utilizing both studies together was 100%, but the algorithm was not specific. Additionally, the specificity for MRI and PET-CT combined was 100% for benign lesions. PET-CT also helped in monitoring responses to empirical antitubercular treatment (ATT) therapy. Of interest, FNAC was inconclusive in four cases in which PET-CT findings helped further in either obtaining a tissue diagnosis from another location or institution of empirical therapy in suspected cases of tuberculosis.

Conclusions:

The specificity for MRI and PET-CT combined was 100% for benign lesions. Unfortunately, the specificity for MRI and PET-CT combined was not 100% for malignant vertebral lesions, though it was sensitive. The PET-CT scan was an extremely useful tool when FNAC from the affected site proved inconclusive. It gave additional information regarding the overall extent of disease, while identifying other locations amenable to FNAC. Furthermore, in countries where tuberculosis is endemic, the empirical response to ATT therapy could be monitored utilizing PET-CT.

Laparoscopic excision of mesenteric cyst of sigmoid mesocolon

Mesenteric cysts are rare abdominal tumours. They are found in the mesentery of small bowel (66%) and mesentery of large intestine (33%), usually in the right colon. Very few cases have been reported of tumours found in mesentery of descending colon, sigmoid or rectum. Mesenteric cysts do not show classical clinical findings and are detected incidentally during imaging due to absent or non-specific clinical presentation or during management of one of their complications. Ultrasonography (USG)/computed tomography (CT)/ magnetic resonance imaging (MRI) are used in diagnosing mesenteric cyst but they cannot determine the origin of cyst. Laparoscopy not only helps in diagnosing the site and origin of the mesenteric cyst but also has a therapeutic role. Laparoscopic treatment of mesenteric cyst is a safe, preferred method of treatment and is a less-invasive surgical technique. Here, we present an unusual case of mesenteric cyst arising from the sigmoid mesocolon treated by laparoscopic excision.

Multicystic benign mesothelioma of the pelvic peritoneum presenting as acute abdominal pain in a young woman

Multicystic benign mesothelioma (MBM) of the peritoneum is a very rare condition. Since the first description of MBM in 1979, approximately 100 cases have been reported. This is a case report of MBM of the pelvic peritoneum presenting as acute abdominal pain in a young woman. Laparoscopy confirmed multiple grapelike clusters of cysts that originated in the peritoneum of the rectouterine pouch and histopathologic diagnosis was confirmed as MBM of the pelvic peritoneum. We hope to alert gynaecologists of the diagnostic and therapeutic approaches to MBM which can be accomplished by laparoscopy.

Benign triton tumor: a rare entity in head and neck region

Benign triton tumors (BTT) are very rare lesions composed of mature skeletal muscle and neural tissue. We report a case of a 14-year-old boy who presented with asymptomatic swelling of the chin over an 18-month duration which increased gradually to involve the left side of the lower lip. Clinically, a diagnosis of neurofibroma was made. Excisional biopsy confirmed the diagnosis of a BTT. Having an affinity for large nerve trunks like the brachial and sciatic, these tumors rarely occur in the head and neck region. When they do, they may involve the large central cranial nerve trunk and present as intracranial masses or involve the smaller peripheral nerve twigs and present as asymptomatic skin nodules, of which only four cases involving peripheral nerves are reported in the English literature. Here, we report the fifth documented case of a BTT involving the mental branch of the trigeminal nerve. A brief review of the literature is also provided.

Hepatocellular adenomas associated with hepatic granulomas: experience in five cases

We present five cases in whom two rare entities were simultaneously found within the liver, i.e. hepatocellular adenomas (HCAs) and granulomas. Coexistence of both entities confuses diagnosis. Our aim is to disclose the association between HCA and hepatic granulomas. Five patients presented with HCA for which they underwent resection. During laparotomy or at pathological examination, granulomas were found in tumorous and non-tumorous tissue. No specific cause for the granulomas was found. Immunohistochemistry showed overexpression of C-reactive protein and serum amyloid A in 4/5 patients, classifying these lesions as inflammatory HCA. HCA and especially the inflammatory subtype may cause formation of granulomas in (peri-)tumorous tissue as a local response to persistent inflammation and/or the presence of a tumor. Both HCA and hepatic granulomas have also been associated with oral contraceptive use. In conclusion, HCAs associated with hepatic granulomas derive from a local response to (inflammatory) HCA or neoplasm, chronic use of oral contraceptives, or a combination of these factors.

Epidemiology of musculoskeletal tumors in Shiraz, south of Iran

Background:

Musculoskeletal tumors are rare, but their descriptive data in any region are important to reduce mortality rate and improve their management.

Materials and Methods:

Retrospectively, 426 pathologic reports from 1997 to 2008 were reviewed in Shiraz University Orthopedic Hospitals which are the main referral centers for musculoskeletal tumors in south of Iran. We collected and analyzed data on age, gender, anatomical site, and histopathologic types of musculoskeletal tumors.

Results:

Of the 426 cases, 60.1% were men and 39.9% were women. The commonest malignant bone tumors were osteosarcoma (89; 50.6%), metastasis (30; 17.0%), Ewing's sarcoma (28; 15.9%), and chondrosarcoma (14; 8.0%). The most frequent benign bone tumors were osteochondroma (136; 63.9%), enchondroma (23; 10.8%), giant cell tumor (21; 9.9%), and osteoid osteoma (14; 6.6%). The femur was the most commonly involved site in musculoskeletal tumors. It was followed by the tibia in benign tumors and the humerus in malignant ones. Metastasis (28; 32.6%), soft tissue tumors (18; 20.9%), osteochondroma (10; 11.6%), and osteosarcoma (9; 10.5%) were the most diagnosed bone lesions in patients older than 40.

Conclusion:

There are no significant changes in epidemiology of musculoskeletal tumors in Shiraz, south of Iran, in comparison with other parts of the world.

Melanotic neuroectodermal tumor of infancy: A rare case report with differential diagnosis and review of the literature

Melanotic neuroectodermal tumor of infancy is a very rare benign but locally aggressive neoplasm of neural crest origin with a high recurrence rate. It usually affects infants of less than 1 year of age. Most commonly, the lesion affects the maxilla followed by skull, mandible, brain and other extracranial sites. We report an 11-month-old female baby with a similar tumor involving the anterior region of maxilla along with a brief review of the literature and differential diagnosis. A wide surgical excision was performed by an intraoral approach. A 2-year follow-up of the patient showed no recurrence.

Pathological fractures in children

Pathological fractures in children can occur as a result of a variety of conditions, ranging from metabolic diseases and infection to tumours. Fractures through benign and malignant bone tumours should be recognised and managed appropriately by the treating orthopaedic surgeon. The most common benign bone tumours that cause pathological fractures in children are unicameral bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological fractures through a primary bone malignancy are rare, these should be recognised quickly in order to achieve better outcomes. A thorough history, physical examination and review of plain radiographs are crucial to determine the cause and guide treatment. In most benign cases the fracture will heal and the lesion can be addressed at the time of the fracture, or after the fracture is healed. A step-wise and multidisciplinary approach is necessary in caring for paediatric patients with malignancies. Pathological fractures do not have to be treated by amputation; these fractures can heal and limb salvage can be performed when indicated.

Thyroid incidentaloma

Because of emerging investigation modalities many of the thyroid lesions are picked up and that poses a big dilemma about management of such lesions. Majority of these lesions especially in iodine-deficient regions, are not significant and may be only followed up without any active treatment but, sometimes the small lesions may be microcarcinoma. This article discusses about the reliability of clinical examination of neck for detection of such lesions, the controversy of such lesion being benign or malignant, and how to evaluate these lesions and the recommendation as per American Thyroid Association guidelines.

Association of alanine-valine manganese superoxide dismutase gene polymorphism and microheterogeneity manganese superoxide dismutase activity in breast cancer and benign breast tissue

PURPOSE

Although the etiology of breast cancer is multifactorial, oxidative stress plays an important role in carcinogenesis. In this study, manganese superoxide dismutase (MnSOD) gene polymorphism and activity were evaluated in benign and breast cancer tissue.

METHODS

One hundred and one females were enrolled in this study, 65 who were histopathologically diagnosed with breast cancer and 46 who were benign patients. MnSOD enzyme activity was determined using an indirect competitive inhibition assay and MnSOD gene polymorphism using poly merase chain reaction and agarose gel electrophoresis.

RESULTS

MnSOD enzymatic activity (79.83±42.14) was lower in breast cancer tissue compared to benign tumors (236.18±46.37). At the same time, MnSOD enzymatic activity among Ala/Val patients was significantly lower in breast cancer tissue (39.19±7.33) than in Val/Val malignant breast tumors tissue (96.9±22.9). MnSOD enzymatic activity was significantly lower in Val/Val cancer tissue (96.9±22.9) than in benign tissue (255.44±42.7).

CONCLUSION

Breast cancer tumors contain less MnSOD than benign breast samples. Patients with Ala/Val polymorphism had reduced MnSOD activity compared to patients with Val/Val breast cancer. Ala/Val gene polymorphism may be a risk factor associated with more advanced breast cancer stage. MnSOD gene polymorphism Ala/Val may be a risk factor associated with more advanced breast cancer stage, and reduction of MnSOD activity may be a mechanism of the progression of benign to malignant tumors. Further investigations are needed to evaluate the role of MnSOD in breast cancer progression.

Nodular fasciitis of the oro-facial region

Nodular fasciitis is a benign proliferative spindle-cell lesion that presents as a rapidly growing mass frequently being mistaken for a sarcoma. A rare presentation and treatment of nodular fasciitis in the cheek of an 8-year-old boy is described here. He came with a chief complaint of swelling in the left cheek since 1 month which rapidly increased to the size of a marble, over a period of 1 month. Surgical excision of the lesion was planned under general anesthesia following which the surgical site was closed with resorbable sutures. Based on the history, clinical picture, and histopathological examination, the lesion was diagnosed as nodular fasciitis. Although infrequent in both children and the oral mucosa, nodular fasciitis should be considered in the differential diagnosis of facial tumors in infants and young children.

Non malignant maxillary lesions: our experience

A wide variety of lesions occur in maxilla. Non specificity of clinical and radiological features makes diagnosis of these lesions a difficult task. We report six interesting cases of maxillary swelling among a total number of 37 such lesions of maxilla. These six cases are as follows two cases of central giant cell granuloma, two cases of fibrous dysplasia, one case of pigmented melanotic neuroectodermal tumor and one case of solitary myofibroma.

Unicameral bone cyst of the proximal tibia in a five year old girl

Unicameral bone cysts (UBCs) are benign, osteolytic lesions which are often asymptomatic and are commonly seen in the proximal of humerus and femur. The average age at diagnosis is 9-11 years and there is a male preponderance with a male-to-female ratio of approximately 2-2.5 to 1. We describe a case of 5-year-old girl who presented to orthopedic clinic with a 4-month history of painful limping. Plain radiography of the right knee demonstrated a well-defined lytic lesion in the proximal of the tibia. Open biopsy and then curettage and bone grafting with bone- substitute was performed. The diagnosis of this condition requires a high index of suspicion. This report demonstrates that all UBCs do not have the same clinical patterns and with adequate attention good results can be achieved.

Breast MR Imaging: What the Radiologist Needs to Know

Magnetic resonance imaging (MRI) of the breast is being performed more frequently to improve primary and recurrent tumor detection, characterization, and response to therapy. Sensitivity of this test approaches 90% and the specificity ranges from 37% to 100%. We present a concise tutorial for the general radiologist with a pictorial review of common lesions identified with breast MRI.

Immunophenotypic Characterization of Benign and Malignant Prostatic Lesions

BACKGROUND

Biopsy diagnosis is the gold standard for differentiating benign and malignant prostatic enlargements. This study was aimed at supplementing biopsy diagnosis with immunophenotypic characters of prostatic lesions.

METHODS

Twenty five cases each of nodular hyperplasia and adenocarcinoma prostate were compared for their morphologic appearances and immunophenotyping, by studying antibodies to prostate specific antigen (PSA), transglutaminase, chromogranin and high molecular weight keratin, proliferating cell nuclear antigen, cell death (apoptosis) and neovascularisation (CD 34).

RESULTS

Markers of differentiation (PSA and transglutaminase) aided recognition of higher-grade tumours. PSA negativity avoided metaplasia being overcalled as carcinoma. Loss of basal cells around malignant prostatic acini as determined by high molecular weight keratin (HMWK), was useful in foci of atypical small acinar proliferation and in prostatic intraepithelial neoplasia. Assessment of proliferation indices identified subsets of tumours, within conventional morphologic Gleason's grades, with a higher growth fraction. Cell death determination and study of tumour vessels did not offer any improvement on morphology.

CONCLUSION

Immunophenotypic assessment helps in refining morphologic diagnosis of prostatic lesions. Differentiation and proliferation markers objectively assess tumour characteristics with their biologic growth potential and are recommended for diagnostic use. They also help in assessement of response to therapy.

Ectomesenchymal chondromyxoid tumor: Review of literature and a report of a rare case

Ectomesenchymal chondromyxoid tumor (ECMT) is a rare benign intraoral tumor. Clinically, it presents as a slow growing, painless, firm, submucosal sweling exclusively occurring on the anterior dorsum of the tongue. Till date only 40 cases have been reported in literature. Histopathologically the tumor is characterized by a well circumscribed, lobular proliferation of round, polygonal, ovoid or fusiform cells in a net-like pattern in a myxoid to chondromyxoid background. Here, we present a rare case of ECMT occurring in a 7-year-old boy and throw some light on this distinct entity.

Laugier-hunziker syndrome: a rare cause of oral and acral pigmentation

Laugier–Hunziker syndrome (LHS) is an acquired, benign pigmentary skin condition involving oral cavity including lower lip in the form of brown black macules 1–5 mm in size, frequently associated with longitudinal melanonychia. There is no underlying systemic abnormality or malignant predisposition associated with LHS, and therefore the prognosis is good. Important differential diagnoses include Peutz Jeghers syndrome and Addison’s disease among other causes of oral and acral pigmentation. Treatment is sought mainly for cosmetic reasons and Q-switched Nd-Yag laser/ Q-switched alexandrite therapy and cryosurgery have been tried with varying success.

Differences in perioperative outcomes after laparoscopic management of benign and malignant adnexal masses

Objective

To compare the feasibility and safety of the laparoscopic management of adnexal masses appearing preoperatively benign with those suspicious for malignancy.

Methods

Retrospective study of 694 women that underwent laparoscopic management of an adnexal mass.

Results

Laparoscopic management of an adnexal mass was completed in 678 patients. Six hundred and thirty five patients had benign pathology (91.5%) and 53 (7.6%) had primary ovarian cancers. Sixteen patients (2.3%) were converted to laparotomy; there were 13 intraoperative (1.9%) and 16 postoperative complications (2.3%). Patients divided in 2 groups: benign and borderline/malignant tumors. Patients in the benign group had a higher incidence of ovarian cyst rupture (26% vs. 8.7%, p<0.05). Patients in the borderline/malignant group had a statistically significant higher conversion rate to laparotomy (0.9% vs. 16.9%, p<0.001), postoperative complications (1.9% vs. 12.2%, p<0.05), blood loss, operative time, and duration of hospital stay. The incidence of intraoperative complications was similar between the 2 groups.

Conclusion

Laparoscopic management of masses that are suspicious for malignancy or borderline pathology is associated with an increased risk in specific intra-operative and post-operative morbidities in comparison to benign masses. Surgeons should tailor the operative risks with their patients according to the preoperative likelihood of the mass being carcinoma or borderline malignancy.

Benign extracranial nerve sheath tumors of the skull base: postoperative morbidity and management

The purposes of this retrospective case series study were to examine the outcome of the operative treatment of extracranial nerve sheath tumors (NSTs) of the skull base and to learn the optimal management. The study was conducted at a university teaching hospital and a regional referral center. A total of 19 cases of benign extracranial NSTs of the skull base who presented to the otolaryngology department over a period of 10 years were studied regarding the clinical, radiological, and pathological features and the operative and postoperative management. In the majority, these tumors originated from cranial nerves; postoperative complications were frequent and depended on the nerve of origin. Postoperative nerve deficit was apparent in 10 cases, and a second operation was necessary in 8 cases. The greatest postoperative morbidity was associated with the parapharyngeal NSTs (i.e., dysphagia in 30%, dysphonia in 30%, and Horner's syndrome in 20% of cases). The conclusion from this study is that high postoperative morbidity resulting from surgery on skull base NSTs demands an integrated approach between the otolaryngologist, plastic surgeon, neurosurgeon, speech therapist, physiotherapist, dietician, and occupational therapist and a clear strategy of long-term follow-up.

Nodular fasciitis of the zygoma: A case report

Nodular fasciitis (NF), a benign proliferation of fibroblasts, commonly presents as a solitary, well-circumscribed, rapidly growing soft tissue mass. It is most commonly located in the upper extremities, particularly on the volar aspect of the elbow, and on the chest and trunk. In adults, NF is rarely found in the head and neck region. Although benign, it can often be confused with a more malignant process and therefore must be properly diagnosed histologically. The cause of NF is unknown but an association with trauma may be present. Treatment is most commonly by local surgical excision, and recurrence is rare. A case of NF over the zygoma in a 60-year-old man not associated with trauma is presented.

Benign fibroxanthoma of the mandible

Histiocytomas constitute a large group of tumors, the classification of which created a lot of confusion in the past. For this reason, various attempts were carried out during the last years so that a widely accepted classification system could be defined. Fibroxanthomas, according to contemporary data, are classified into benign histiocytomas and they are mostly located at the skin of extremities. They are rarely localized in the area of the head and neck, where they are found commonly in soft tissue. Fibroxanthomas located at the bones of oral and maxillofacial region are extremely rare. The purpose of this paper is to present a case of a fibroxanthoma located at the mandible as well as to analyze the histological findings of the lesion on which the diagnosis and differential diagnosis were based.

Epidemiology of benign eyelid lesions in patients presenting to a teaching hospital

PURPOSE

This study evaluates the relative frequency of benign eyelid lesions presented to a teaching hospital in Saudi population.

PATIENTS AND METHODS

Charts of patients with benign eyelid lesions were retrospectively reviewed from January 2003 to December 2008. Clinical details included demographic data, symptoms and signs, surgical findings, primary diagnosis, and indication for biopsy were analyzed in a histopathologically confirmed benign eyelid lesions. Eyelid lesions were arranged according to their order of frequencies.

RESULTS

A total of 222 biopsies were evaluated from 181 patients (male 39.2% and female 60.8%). The age of the patient at the time of biopsy ranged from 2 to 87 years old. The most common benign eyelid lesion encountered in our practice was sweat gland hidrocystoma followed by chalazion, skin tag, epidermal cyst, nevus, seborrheic keratosis, xanthelasma, and molluscum contagiosum respectively. Histopathological studies confirmed the clinical diagnosis in 95.9% (213/222) of specimens and was different from the clinical diagnosis in 4.1% (9/222) of the lesions which included seborrheic keratosis (n = 3), pilomatrixoma, steatocystoma, hemangioendothelioma, juvenile xanthogranuloma, calcinosis cutis, and syringocystadenoma papilliferum. No malignant lesion was labeled as benign.

CONCLUSION

Epidemiology of benign eyelid lesions in Saudi population is different from Far East or Western populations. Sweat gland hidrocystoma with classical clinical features and straightforward diagnosis is the most frequent lesion in our series which could be due to characteristic dry climate.

Imaging appearance of bone tumors of the maxillofacial region

This paper reviews the imaging appearance of benign and malignant bone tumors of the maxillofacial region. A benign bone tumor commonly appears as a well circumscribed lesion. The matrix of the tumor may be calcified or sclerotic. Malignancies often display aggressive characteristics such as cortical breakthrough, bone destruction, a permeative pattern and associated soft-tissue masses. Computed tomography scan is an excellent imaging modality for accurate localization of the lesion, characterization of the tumor matrix and detection of associated osseous changes such as bone remodeling, destruction or periosteal reaction. Magnetic resonance imaging is of limited value in the evaluation of maxillofacial bone tumors.

Peripheral osteoma of the maxillofacial region diagnosis and management: a study of 06 cases

BACKGROUND

Osteomas are benign neoplasm often associated with facial asymmetry, pain and surface ulceration. Peripheral osteomas are more common in the cranio-maxillofacial region. It is prevalent at younger age but maximum seen in the sixth decade, with a female to male ratio is 1:2. The aim of this study was to review the clinical presentations and management protocol of such lesions in cranio-maxillofacial region.

MATERIALS AND METHODS

The study was conducted at Command Military Dental Centre (EC) during May 2004 to May 2007. Six serving soldiers and their families (four males, two females), age group ranging between 13 and 56 years, mean age 34.5 years were recruited in this study. The tumors were excised using extra oral, intra oral and combined approaches; no complications were reported during post op period.

RESULTS

All the cases were operated under GA through extra oral, intra oral and combined approaches with satisfactory results. HPE report was benign in all our cases with no post operative complications reported during follow up.

CONCLUSION

Cranio-maxillofacial osteomas are exclusively benign tumors and not very common entities. Proper diagnosis and precision management alleviates symptoms without any post surgical complications. In our series of six cases the tumors were diagnosed and managed as per standard surgical protocol with excellent result.