Metanephric adenoma diagnosed on biopsy in an infant: a case report

BACKGROUND

Metanephric adenoma is a rare benign renal tumor of the kidney, uncommonly observed in children. It is often misdiagnosed preoperatively as a malignant neoplasm, leading to an unnecessary nephrectomy. The challenge is to make the right diagnosis preoperatively and therefore manage it with conservative surgery. We report a case of a child with metanephric adenoma who underwent nephron-sparing surgery.

CASE PRESENTATION

A renal tumor was discovered fortuitously in an 18-month-old Caucasian girl with several congenital malformations. Investigations showed a 28 × 27 × 27 mm left renal mass centrally located, well defined, nonvascularized, with no calcifications and which compressed the adjacent renal tissue. Furthermore, there were no signs of metastasis. The decision of a multidisciplinary meeting was to perform a computed tomography (CT)-scan-guided biopsy. Histologic examination concluded it was a metanephric adenoma. We performed a left open partial nephrectomy via a flank retroperitoneal incision. The final histopathological examination confirmed the diagnosis. The postoperative course was uneventful.

CONCLUSION

Preoperative diagnosis of metanephric adenoma is challenging. Because of the high probability of unnecessary radical nephrectomy, preoperative biopsy can be safe and determining to guide a more conservative approach so nephron-sparing surgery can be performed.

Intraperitoneal Rupture of Liver Hydatid Cyst in Children

The article's abstract is not available.

[Ureterocele associated with simplex ureter in children: clinical and therapeutic features]

L´urétérocèle est une dilatation pseudo-kystique de l´uretère terminal sous muqueux. C´est une uropathie malformative rare surtout si elle survient sur un uretère simplex. Il s´agit d´une étude rétrospective menée sur dix ans, de 12 dossiers de malades colligés au Service de Chirurgie Pédiatrique de l´Hôpital Fattouma Bourguiba de Monastir entre 2006 et 2016. L´âge moyen de nos malades est de 2,7 ans avec des limites allant de 7 jours à 11 ans, le sex-ratio est de 1. Le tableau clinique a été dominé par la fièvre en rapport avec une infection urinaire haute. Le diagnostic a été posé essentiellement par l´échographie rénale et vésicale, l´urographie intraveineuse (UIV) et l´uréthro-cystographie rétrograde (UCR). L´urétérocèle était unilatéral dans 10 cas et bilatérale dans 2 cas soit un total de 14 cas d´urétérocèles. Tous ont été sur uretère simplex et ont été opérées par voie endoscopique. Aucun incident peropératoire n´a été noté. Les suites opératoires étaient simples. Une amélioration clinique et radiologique a été obtenue dans tous les cas. L´urétérocèle sur uretère simplex est une malformation urinaire très rare. Non diagnostiquée à temps, elle peut retentir sur le haut appareil. Le traitement endoscopique est une alternative séduisante avec des résultats satisfaisants.

Promising proteins detected by Western blot from Echinococcus granulosus protoscoleces for predicting early post-surgical outcomes in CE-affected Tunisian children

BACKGROUND

Cystic echinococcosis (CE) affects predominantly young patients in highly endemic areas. Improved serological methods are needed for the follow-up of CE cases, especially given the high rates of post-surgical relapse that require detection as soon as possible.

METHODS

We designed a study to investigate the value of antigenic proteins extracted from Echinococcus granulosus (E. granulosus) protoscoleces, and of recombinant B2t and 2B2t proteins, for assessing the efficacy of surgical treatment carried out on CE-affected children. This study was performed on 278 plasma samples collected from 59 Tunisian children surgically treated for CE and monitored for 3 years post-surgery. The patients were classified according to post-surgical outcomes into a "non-relapsed" (NRCE) and a "relapsed" (RCE) group. We performed in-house ELISAs to measure anti-B2t and anti-2B2t IgG and immunoblotting for the detection of IgG against SDS-PAGE-resolved E. granulosus protoscoleces-specific antigens. The Wilcoxon test was applied to assess anti-B2t and anti-2B2t IgG levels. We applied the Cochran Q test to compare the distribution of immunoblotting antigenic bands between 1-month and 1-year post-surgery.

RESULTS

The probability of being "relapse-free" when a decrease in antibody titers occurred between 1 month and 1 year post-surgery was 81% and 75%, respectively, for anti-B2t and anti-2B2t IgG. We identified five protoscolex protein bands of 20, 26/27, 30, 40 and 46 kDa as highly immunoreactive by immunoblot for both RCE and NRCE patients at 1 month post-surgery, and significantly lower immunoreactivity after 1 year (p < 10^-4) for NRCE compared to RCE patients. The proteins at 26/27 and 40 kDa displayed the best performance in predicting the outcome, with an 84% probability of being relapse-free when the reactivity against the 40 kDa antigen, the doublet at 26/27 kDa, or both was absent or disappeared between 1 month and 1 year post-surgery, and a 93% probability of being relapsed when both bands remained reactive or increased in intensity between the two time points.

CONCLUSIONS

The B2t protein could be useful for the prediction of CE early post-surgical outcomes. The proteins of E. granulosus protoscoleces, especially the doublet P26/27 and P40, could be promising predictive biomarkers for the post-surgical follow-up of CE cases as well.

Capitonnage seems better in childhood pulmonary hydatid cyst surgery

BACKGROUND

Pulmonary hydatid disease remains an important healthcare problem. Conservative operative interventions including cystotomy or cystotomy with capitonnage are the two commonly used techniques. However, there is no scientific consensus over selection of these operative interventions.

AIM

The aim of this study is to compare these two methods: capitonnage and uncapitonnage in the surgery of childhood pulmonary hydatid cyst in regard to the postoperative period.

METHODS

This is a retrospective analysis of 136 patients operated for pulmonary hydatid disease between January 2010 and July 2017 according to two techniques. Group A was cystotomy with capitonnage (n = 76), and group B was cystotomy alone (n = 60). We compared the postoperative outcomes.

RESULTS

Our data showed pneumothorax(PNO) and emphysema were seen in 30% of Group B and only in 13.2% in Group A, and the persistence of residual cavity in 23.3% in Group B and 7.9% in Group A (p = 0.014). We have not seen any case of recurrence with capitonnage.

CONCLUSION

We conclude that capitonnage appears to prevent PNO and emphysema formation and a remaining residual cavity in the long term with a significant difference. And it prevents prolonged postoperative air leak and hospitalization with a slightly nonsignificant difference. It is difficult to say with absolute certainty that the noncapitonnage group is inferior to the capitonnage group, since several factors can influence the evolution.

TYPE OF STUDY

Clinical research article Level of evidence III.

Asymptomatic perforated gastric duplication clogged by omentum, anorectal malformation and agenesis of the corpus callosum: A rare combination

Gastric duplication cysts are uncommon congenital anomaly and its association with other malformations is rarely reported. Many theories exist for the development of these lesions. This case report describes coincidental detection of perforated gastric duplication clogged by the omentum associated with anorectal malformation and agenesis of the corpus callosum.

Congenital Complete Esophageal Diaphragm: A Rare Variant of Esophageal Stenosis

Congenital esophageal web is a rare disorder that presents a diagnostic and management challenge. In a female infant born at 31 weeks of gestation, significant secretions and respiratory distress were noted at birth. Chest X-ray demonstrated the nasogastric tube in the esogastric junction with no distal bowel gas. Esophagogram showed a congenital web near the esogastric junction. An endoscopic examination under general anesthesia showed a complete, thick membrane on the distal esophageal lumen. Endoscopic incision and cauterization of the web through the midline were performed, improving the clinical symptoms and esophageal stenosis.

Mesenteric cyst in infancy: presentation and management

Mesenteric cysts are documented as a rare entity in pediatric population. They are considered as benign intra-abdominal tumors with an unknown etiology. Symptoms are not specific and knowledge of such condition is essential in order to establish a proper management. We report three pediatrics cases of mesenteric cysts managed between 2000 and 2009 in the pediatric surgery Department of Monastir College Hospital. We described the clinical, radiological and operative findings. Two males and a female were managed (age range: 10 days-5years, mean age: 6,3years). Two patients were presented with an intestinal obstruction. A preoperative diagnosis was made basing on imaging. Thus, abdominal ultrasonography was performed in all of our reported cases and showed a cystic mass in all cases. The cystic nature of the mass, its margins and its extension were better described on tomographic images. The mesenteric cyst was completely and successfully removed in all cases. The histopathological report confirmed the diagnosis and showed a multiloculated cyst with columnar mesothelial lining, without any defined muscular layer or cellular atypia and without any evidence of malignancy. The children were evaluated post-operatively with a mean follow-up of 2 years and a half. No recurrence was noted in our patients during the follow-up period. It is known that clinical features are not specific of such anomaly but once the diagnosis is made, the complete surgical removal of the cyst remains the treatment of choice with excellent outcomes.

Right Congenital Diaphragmatic Hernia Associated With Hepatic Pulmonary Fusion: A Case Report

We present a case of male newborn presented with respiratory distress at 21 hours of life. The patient was operated for right congenital diaphragmatic hernia (CDH). Hepatic pulmonary fusion (HPF) was found at surgery.

Neurological complications in insufficiency fractures of the sacrum. Three case-reports

Three cases of nerve root compromise in elderly women with insufficiency fractures of the sacrum are reported. Neurological compromise is generally felt to be exceedingly rare in this setting. A review of 493 cases of sacral insufficiency fractures reported in the literature suggested an incidence of about 2%. The true incidence is probably higher since many case-reports provided only scant information on symptoms; furthermore, sphincter dysfunction and lower limb paresthesia were the most common symptoms and can readily be overlooked or misinterpreted in elderly patients with multiple health problems. The neurological manifestations were delayed in some cases. A full recovery was the rule. The characteristics of the sacral fracture were not consistently related with the risk of neurological compromise. In most cases there was no displacement and in many the foramina were not involved. The pathophysiology of the neurological manifestations remains unclear. We suggest that patients with sacral insufficiency fractures should be carefully monitored for neurological manifestations.

Hormone receptors in rapidly progressing breast cancer

Biopsy specimens from 85 Tunisian breast cancer patients were compared with those of 95 American breast cancer patients for estrogen receptor (ER) and progesterone receptor (PR) levels. Tunisian patients with rapidly progressing breast cancer (RPBC) had lower ER levels than American patients or Tunisian patients without evidence of RPBC. Lower ER levels in the earliest stage of RPBC, which presents without inflammatory signs, supported epidemiologic and pathologic studies indicating that rapid growth as reported by the patient is an important aspect of RPBC. Low ER levels were generally found in young, premenopausal Tunisian women with advanced RPBC; multivariate analyses suggest that age was the most important correlating factor. In the Tunisian patients, ER levels showed a direct correlation with response to therapy. No consistent relationship between American and Tunisian patients or subgroups was observed for PR levels. These results indicate the need for reevaluating the routine use of oophorectomy in RPBC.

Histopathological features of rapidly progressing breast carcinoma in Tunisia: a study of 94 cases

The histological features of 94 cases of carcinoma of the breast seen in Tunisia were recorded and subsequently correlated with the clinical classification of the patients in terms of poussée évolutive (PEV) categories. Histological features analyzed in the breast tissues and skin included tumor type, nuclear grade, number of mitoses, involvement of the dermis, cutaneous inflammatory infiltrate and edema. Twenty-eight percent of the cases in which the skin was examined showed tumor emboli in the lymphatics of the dermis. The frequency of cutaneous permeation correlated with the PEV categories. The percentage of cases with nuclear grade 3 was higher for the group with rapid progression of the disease (PEV 1,2,3) than for the cases belonging to the PEV-0 category (90% versus 64.2%). The present study demonstrates that a large proportion of breast carcinoma patients in Tunisia suffer from "inflammatory carcinoma of the breast".

Preliminary results of primary systemic chemotherapy in association with surgery or radiotherapy in rapidly progressing breast cancer

112 Tunisian patients with rapidly progressing breast cancer (RPBC) were entered into a clinical trial evaluating combination chemotherapy as a primary form of treatment before surgery or radiotherapy. Three cycles of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) were administered at monthly intervals; patients were then randomized to surgery or radiotherapy to control the primary tumour, and 12 more cycles of CMF followed local/regional therapy. RPBC was sensitive to CMF; after only 3 cycles, 11% of evaluable patients showed complete remission and 78% had at least 25% diminution in tumour size. The disease-free interval (DFI) was substantially greater in this series than in a previously reported series treated by surgery and/or radiotherapy alone. No difference in DFI was found between patients randomized to receive surgery and those randomized to receive radiotherapy. Postmenopausal patients responded to CMF as well as premenopausal patients. Combination chemotherapy appears to play an important role in the control of RPBC, an aggressive malignancy often resembling inflammatory breast cancer.

Epidemiologic features of rapidly progressing breast cancer in Tunisia

A form of breast cancer characterized by rapid disease progression, inflammation, and edema is found in approximately 55% of the breast cancer patients presenting at the Institute Salah Azaiz, Tunis (Tunisia). In 581 patients seen between January 1, 1969, and December 31, 1974, we examined age, place of residence, reproductive history, delay in seeking treatment, and blood gropu as potential risk factors to determine the distinction between the rapidly progressing disease and the less aggressive form. Rural residence, blood type A, and recent pregnancy are risk factors among premenopausal women, but older age, rural residence, blood type A, late menarche, and delay in diagnosis are associated with postmenopausal rapidly progressing breast cancer. The most significant risk factors were rural residence and blood type A. Rapidly progressing breast cancer was diagnosed in two of every three breast cancer patients coming from a rural environment. Forty-three percent of 203 patients with rapid disease progression were blood type A, a significantly higher percentage than the 33% found in the general Tunisian population and the breast cancer patients without evidence of rapidly progressive disease. We observed that the risk factors for disease progression were quite different from those reported to influence the incidence of breast cancer.

Epidemiologic features of rapidly progressing breast cancer in Tunisia

A form of breast cancer characterized by rapid disease progression, inflammation, and edema is found in approximately 55% of the breast cancer patients presenting at the Institute Salah Azaiz, Tunis (Tunisia). In 581 patients seen between January 1, 1969, and December 31, 1974, we examined age, place of residence, reproductive history, delay in seeking treatment, and blood gropu as potential risk factors to determine the distinction between the rapidly progressing disease and the less aggressive form. Rural residence, blood type A, and recent pregnancy are risk factors among premenopausal women, but older age, rural residence, blood type A, late menarche, and delay in diagnosis are associated with postmenopausal rapidly progressing breast cancer. The most significant risk factors were rural residence and blood type A. Rapidly progressing breast cancer was diagnosed in two of every three breast cancer patients coming from a rural environment. Forty-three percent of 203 patients with rapid disease progression were blood type A, a significantly higher percentage than the 33% found in the general Tunisian population and the breast cancer patients without evidence of rapidly progressive disease. We observed that the risk factors for disease progression were quite different from those reported to influence the incidence of breast cancer.

Rapidly progressing breast cancer (poussée évolutive) in Tunisia: studies on delayed hypersensitivity

Delayed hypersensitivity reactions to a battery of antigens were measured in 145 Tunisian breast cancer patients to determine whether an immunologic mechanism could be detected which might explain the high frequency (60%) of the rapidly progressing form in Tunisian breast cancer patients. Although a greater proportion (30%) of patients with rapily progressing breast cancer reacted to extracts of a breast tumor antigen (2937) than patients without PEV (9%), no significnat difference between PEV and non-PEV patients could be found in reactivity to DNCB, standard microbial antigens, or extracts from tissue culture cell lines. Rapidly progressing breast cancer in Tunisia is not associated with an impairment of delayed hypersensitivity.

Clinical and prognostic features of a rapidly progressing breast cancer in Tunisia

Clinical and radiographic examination of 581 patients with histologically verified breast cancer has permitted us to define a subgroup having a significantly poorer prognosis than other patients. Their condition, called "poussée évolutive" (rapidly progressing), is characterized by rapid tumor growth and/or inflammation adjacent to the tumor. Statistical analysis of the survival of M0 patients (412 of the 581) shows that the diagnosis of "poussée évolutive" provides prognostic information beyond that given by T and N classifications and after delay between initial symptoms and diagnosis have been considered. Six years of clinical experience with this condition are discussed.

Clinical and prognostic features of a rapidly progressing breast cancer in Tunisia

Clinical and radiographic examination of 581 patients with histologically verified breast cancer has permitted us to define a subgroup having a significantly poorer prognosis than other patients. Their condition, called "poussée évolutive" (rapidly progressing), is characterized by rapid tumor growth and/or inflammation adjacent to the tumor. Statistical analysis of the survival of M0 patients (412 of the 581) shows that the diagnosis of "poussée évolutive" provides prognostic information beyond that given by T and N classifications and after delay between initial symptoms and diagnosis have been considered. Six years of clinical experience with this condition are discussed.