Splenoportal-mesenteric axis thrombosis and splenic artery occlusion as initial presentations of COVID-19 disease

OBJECTIVE

Although pulmonary involvement represents the primary and most characteristic presentation of Sars-Cov-2 infection, due to its innate tropism for endothelium, it is also associated with systemic pro-coagulative changes and thromboses. This paper describes a COVID-19 atypical presentation with massive thrombotic occlusion of the splenoportal-mesenteric axis and the splenic artery in the absence of clinical or radiological manifestation of pulmonary involvement.

PATIENTS AND METHODS

Female patient, with no history of disease, trauma or fever in the last 30 days, was admitted to ER for persistent left subcostal pain. Laboratory exams, including inflammation, coagulation markers and Sars-CoV-2 serology, were requested. Whole-body CT with contrast media injection was performed.

RESULTS

Laboratory exams showed elevated reactive C-protein, bilirubin, γ-GT and D-dimer. Whole-body CT showed: splenic artery occlusion, thrombosis of splenic, mesenteric and portal veins with portal intra-hepatic branches ectasia, juxta-hilar portal cavernomatosis of probable acute onset (absence of signs of chronic hepatopathy and of varices), a hypodense area in the spleen indicating ischemic parenchymal suffering. The patient resulted positive for Sars-CoV-2 IgG, thus in the absence of typical clinics or pulmonary parenchymal abnormality at chest CT.

CONCLUSIONS

A case of acute venous thrombosis and arterial occlusion as primary manifestations of COVID-19.

Sentinel Lymphadenectomy in Cutaneous Melanoma

Aims and Background

In the last ten years validation of the sentinel lymph node (SLN) concept has led to modification of the surgical approach for patients with intermediate-risk cutaneous melanoma.

Methods and Study Design

Forty-eight patients affected by cutaneous melanoma with a Breslow thickness between 0.65 and 4 mm were enrolled in the study. Approximately 2 mCi of radiotracer and 1 mL of vital blue dye were injected in each patient around the site of the primary lesion. Lymphoscintigraphy was performed until the lymphatic basin and the respective SLN were localized. The whole surgical procedure consisted of enlargement of the surgical margins followed by localization and excision of the SLN(s) by using both radiotracer and vital dye. Whenever the SLN proved to be histologically positive for metastasis, complete regional lymphadenectomy was performed.

Results

Within 15 minutes of radiotracer administration the lymphatic basin was localized in all 48 patients by lymphoscintigraphy. Vital dye and radiotracer successfully allowed SLN localization and excision in 46 of 48 patients (97%); in one case the SLN was detected by radiotracer alone. The SLN proved to be metastatic in six (13%) of 46 evaluable patients; interestingly, in three of them the presence of metastatic cells was revealed only by immunohistochemistry. All patients with tumor-positive SLNs had primary lesions with a Breslow thickness = 2 mm.

Conclusions

Sentinel lymphadenectomy is able to identify lymph node involvement in patients with cutaneous melanoma with a Breslow thickness >1 mm, thus avoiding the risks associated with radical regional lymphadenectomy. Lymphoscintigraphy proved to be an important tool to obtain correct preoperative localization of the drainage basin, especially for melanomas located on the face and trunk.

[Intraoperative radiolocalization of intraductal breast carcinoma: sentinel lymph node evaluation]

Sentinel lymph node biopsy and intraoperatory radiolocalization (RLI) are fast becoming the standard surgical treatment for invasive breast cancer. Actually, it seems, they have the same rule in "high risk" DCIS of the breast.

[Chronic periaortitis]

The authors, o the basis of a retrospective analysis of a series of 13 cases of chronic periaortitis, after a review of the literature about the subject, discuss about the most recent theories about pathogenesis, pathological anatomy, diagnosis and treatment of this condition. At first the authors stress the importance of adopting the term chronic periaortitis to describe any idiopathic fibrotic retroperitoneal process, as a consequence of the well established relationship between the atherosclerotic abdominal aorta an the development of this condition. Histological, immunohistochemical and immunological studies, consented to clarify the pathogenesis o the lesion. CT or MRI currently makes the diagnosis but histological confirmation is desiderable. Surgical therapy plays still a fundamental role in the management of chronic periaortitis, but the use of immunosuppressive drugs is to be considered extremely promising.

Preservation and peeling of the inferior mesenteric artery in the anterior resection for complicated diverticular disease

The authors, on the basis of 3 cases of complicated diverticular disease, discuss the indications to surgery, considering the advantages and disadvantages of the various surgical techniques and examining in particular the rules for a correct operation with resection and primary or secondary anastomosis. As they performed a rectosigmoidectomy with primary high colorectal anastomosis, they report the reasons why they adopted the preservation and peeling of the inferior mesenteric artery (IMA).

[Ambulatory surgery of varices: our experience]

The Authors, on the basis of their experience with 196 patients aged from 18 to 45, affected by relapsing varicose veins, stress the advantages of the outpatient treatment according to Muller's technique. For these lesions excellent aesthetic and functional results, easy surgical technique, low incidence of complications, prompt resumption to work were registered.

[Role of total thyroidectomy in benign multinodular benign goiter]

The Authors report a review of the Literature and their personal series to evaluate the role of total thyroidectomy in the surgical management of non-toxic multinodular goiter. On the basis of the data obtained, the Authors consider total thyroidectomy the therapy of choice for this pathology.

[Gardner syndrome: diagnostic, clinical and genetic questions in the light of 2 case reports]

The authors on the base of two cases of Gardner's syndrome recently observed, proceed to a wide review of literature on this subject so as to stress the peculiar aspects of this syndrome, so complex and uncommon. The greatest emphasis is given to the role of genetics as regarding to diagnosis and screening programs, as well as to the more recent acquisitions about diagnosis, therapy and follow up of risk lesions, such as colorectal and duodenal adenomas, as well as of intrabdominal desmoid tumours, which, although not histologically malignant, may often influence prognosis negatively, because of their remarkable local invasiveness and tendency to recurrence.

[Subtotal colectomy with ceco-rectal anastomosis]

A case of subtotal colectomy cecoproctostomy for multiple lesions of the colon is introduced. This procedure has advantages over ileoproctostomy because it spares the terminal ileum, ileocecal junction and cecum. Due to the high incidence of bowel movements after the ileoproctostomy operation, the authors recommend cecoproctostomy as a valid choice in a selectioned group of patients with multiple or extended lesions that spares cecum and rectum.

[A case of ileocecocolic intussusception from cecal carcinoma]

The authors present a case of ileocecocolic intussusception by carcinoma of the caecum. They stress the most peculiar aspects of this condition: rare etiology; complete invagination of caecum appendix and ileum; typical clinical presentation characterized by variable dimensions of the mass and symptoms not ascribing to occlusion, no lesions at endoscopy; evidence of a typical "target mass" visualized at T.C.

[Squamous carcinoma of the anal canal and its variations. Personal experience and review of the literature]

Six cases of anal canal squamous carcinoma are presented. The authors precise the present view about pathological, epidemiological, clinical and therapeutical aspects of these lesions. They stress, also, the primary role of embryology and anatomy in the oncogenesis of such tumours; the importance to single out specific population at risk, absolutely different from the typical one for rectal adenocarcinoma and the role of chemoradiation therapy as treatment of choice of these neoplasms. Particular importance is given to modern histologic and histogenetic classification of these tumours, stressing the difficulties to distinguish the various histologic types.

[Perianal Paget's disease: clinical observation and review of the literature]

The authors present a case of PPD, stressing the importance to distinguish "true" PPD from pagetoid spread, for correct diagnosis and appropriate treatment. This distinction is possible by using immunohistochemical stains, with particular regarding Ab-GCDFP-15, considered specific marker for Paget's cell.

[Anorectal neuroendocrine carcinoma: observations on a case and review of the literature]

Carcinoid tumours of the anorectum are rare (0.7% of malignant rectal tumours). Because of this rarity several aspects of the management of these tumours remain controversial. Diagnosis may be delayed because of failure to recognize their morphological characteristics and histological appearance may not reflect their biological behaviour. Immunocytochemistry for neuroendocrine-cells are essential to identify different types of carcinoid tumours and to do differential diagnosis from other malignant tumours. All that allow an exact therapeutic approach to these tumours. The tumours less than cm 1 in diameter can be safely treated by local excision; the tumours more than cm 1 in diameter are treated by radical surgery (AAP).

[Tietze's syndrome: importance of differential diagnosis and role of CT]

A case of Tietze's syndrome is reported. A 55-year-old woman had experienced left anterior chest pain and tender swelling of the left second costosternal junction for one month. CT showed a focal enlargement of the left second costal cartilage with partial calcification. Six months later a complete recovery was registered and a second CT scan was negative. These clinical and CT findings are consistent with Tietze's syndrome.

[Ovarian endometriosis involving the intestine with "ab ++estrinseco" stenosis of the sigmoid]

The Authors report a case of ovarian endometriosis causing an "Ab extrinseco" sigmoid stenosis. The histogenesis as well as different possibilities of treatment, i.e. medical and surgical, are discussed.

[The colorectal adenoma-carcinoma sequence: the limits between polypectomy and intestinal resection]

According to a clinic case, the authors pointed out the role of histological diagnosis in the therapeutic approach of large intestinal adenomas. In order to identify those lesions which can metastasize, having exceeded the muscularis mucosae and having invaded the submucosa, rigorous histological standards must be performed. Intestinal resection versus polypectomy is determined only according to the involvement or not of the muscularis mucosae.

[Bilateral carcinoma of the breast: treatment and prevention, Review of the literature]

Authors analyze 256 patients admitted in III Clinica Chirurgica of University of Rome "La Sapienza" for breast cancer, from 1982 to 1992; 16 of them had later developed another neoplasm in the opposite breast. After a retrospective study of the clinical history of all patients they came to the conclusion that bilateral neoplasm frequency is similar to that reported in world literature (1-18%) (23, 9, 2). Moreover, are analyzed the primary risk factors for a bilateral carcinoma, and they consider the utility of the prophylactic surgical treatment of the opposite breast.

[Juvenile vascular pathology due to homocystinuria. A clinical case report]

The authors report a case of juvenile vasculopathy in a homocystinuria patient. They point out that thromboembolism may be the only symptomatic expression of this genetically determined metabolic disease. Diagnostic approach and surgical therapy of the vascular lesions as well as medical therapy to prevent further complications are analysed. The opportunity to perform clinical tests for the diagnosis of homocystinuria in all those young patients presenting vascular lesions without other risk factors is finally stressed.

[Bilateral breast tumors]

From a retrospective analysis of 181 cases observed in a ten-year period (1980-1990), the authors registered a frequency of bilateral breast cancer comparable to that reported in the literature (1-12%). Early diagnosis is the only factor able to modify positively the prognosis, through an accurate follow up, based on blood and X-ray tests (low-density mammography).