Bocio multinodular ectópico submandibular: a propósito de un caso y revisión de la literatura / Submandibular ectopic multinodular goiter: case report and literature review

Resumen El tiroides ectópico es una alteración congénita infrecuente que presenta una prevalencia entre 1/100.000-1/300.000. En el 90% de los casos se encuentra en la línea media cervical, siendo los casos de tiroides ectópico cervical lateral muy infrecuentes. Presentamos el caso de una paciente de 44 años que consultó por presentar una tumoración submandibular izquierda de más de seis meses de evolución. Las pruebas de imagen (ecografía, tomografía computarizada y gammagrafía) sugirieron un bocio ectópico multinodular; la punción aspiración con aguja fina (PAAF) informó de tejido tiroideo sin atipias (Bethesda II) y el estudio sanguíneo de hormonas tiroideas fue normal, orientando finalmente el caso como un bocio multinodular ectópico submandibular eutiroideo. Ante la ausencia de síntomas y signos sugerentes de malignidad, en conjunto con una PAAF con características de benignidad, se decidió realizar seguimiento. En el momento que presentó clínica por efecto masa se decidió realizar la exéresis de la lesión, que confirmó el diagnóstico de bocio multinodular ectópico. Los casos descritos en la literatura de bocio multinodular ectópico submandibular como único tejido tiroideo funcionante son excepcionales. El tiroides ectópico se debe considerar en el diagnóstico diferencial de una masa submandibular. Aunque actualmente no existe un consenso en relación con el manejo de dicha patología, el crecimiento de la masa puede contribuir a la decisión de una exéresis completa del tiroides ectópico, aun tratándose del único tejido tiroideo funcionante.

Abstract Ectopic thyroid is an uncommon congenital disorder with a prevalence between 1/100,000-1/300,000. In 90% of cases, it is placed in cervical midline, being the cases of lateral cervical ectopic thyroid very infrequent. We present the case of a 44-year-old female patient who had a left submandibular mass during more than six months. Imaging tests (ultrasound, computed tomography and scintigraphy) suggested a multinodular ectopic goiter; fine needle aspiration (FNA) reported thyroid tissue without atypia (Bethesda II) and the thyroid hormone blood tests were normal, finally orienting the case as a euthyroid submandibular ectopic multinodular goiter. In the absence of symptoms and signs suggestive of malignancy, together with an FNA with benign characteristics, it was decided to follow up. When the patient presented clinical symptoms due to mass effect, it was decided to perform excision of the lesion, which confirmed the diagnosis of ectopic multinodular goiter. There are very few cases described in the literature of submandibular ectopic multinodular goiter as the only functioning thyroid tissue. Ectopic thyroid should be considered in the differential diagnosis of a submandibular mass. Although there is currently no consensus on the management of this pathology, the growth of the mass may contribute to the decision of a complete excision of the ectopic thyroid, even if it is the only functioning thyroid tissue.

Intrapancreatic accessory spleen / Baço acessório intrapancreático

ABSTRACT An asymptomatic 79-year-old woman, with incidental finding on abdominal ultrasound of a solid nodule in the tail of the pancreas. Magnetic resonance imaging showed a 12mm solid tumor. The suggested diagnosis was pancreatic neuroendocrine tumor. The pathological examination showed an intrapancreatic splenic tissue. This is a rare ectopic location of spleen tissue and it should be considered in the differential diagnosis of pancreatic solid tumors.

RESUMO Mulher de 79 anos, com achado incidental em ultrassonografia de abdome de lesão sólida em cauda de pâncreas. Em ressonância magnética, foi confirmada lesão de 12mm. Foi aventada a hipótese diagnóstica de tumor neuroendócrino não secretor, sendo realizada pancreatectomia distal laparoscópica. Em estudo anatomopatológico, diagnosticou-se tecido esplênico, configurando baço acessório intrapancreático. Este tipo de manifestação topográfica de baço é rara, mas deve fazer parte dos diagnósticos diferenciais em tumores sólidos do pâncreas.

Ectopic salivary gland tissue in palatine tonsil: a case report and review of literature

A case of ectopic salivary gland tissue in a routine tonsillectomy specimen is reported and the literature is reviewed. Tonsillectomy specimens are routinely sent for histopathologic evaluation to assess the nature of inflammatory process as well as to exclude occult malignancy. A tonsillectomy specimen from a young woman who underwent surgery for recurrent attacks of tonsillitis in the previous six months was received at the histopathology laboratory of Gulf Medical College Hospital, Ajman. Routine microscopic examination revealed tonsilar tissue with chronic inflammation and lobules of mucous secreting salivary acini with ducts adjacent to the surface squamous epithelium of the tonsilar tissue

Coristoma pancreático en la vesícula biliar / Heterotopic pancreas found in the gallbladder: report of one case

We report a 54 years old woman presenting with pain in the right upper abdominal quadrant. An abdominal ultrasound showed multiple gallbladder stones. The patient was operated with the diagnosis of cholelithiasis. During the pathological study of the excised gallbladder a 0.9 cm diameter yellowish nodule was found, that corresponded to heterotopic pancreatic tissue.

La heterotopía pancreática corresponde a la presencia de tejido pancreático fuera de su localización habitual, que carece de continuidad anatómica y vascular con el páncreas normal; el 85 por ciento a 90 por ciento de los casos reportados comprometen estómago, duodeno o yeyuno, mientras que la localización en vesícula biliar es infrecuente y corresponde tan sólo al 1 por ciento de ellas. Esta entidad es generalmente asintomática y en la mayoría de los casos su diagnóstico constituye un hallazgo incidental durante el examen anatomo-patológico de la pieza quirúrgica. Se presenta el caso de una mujer de 54 años sometida a colecistectomía abierta electiva con el diagnóstico de colecistolitiasis. El examen anatomo-patológico de la pieza operatoria, junto con diagnosticar la colecistitis crónica litiásica, describe la presencia de tejido pancreático heterotópico en el espesor de la pared y a nivel del cuello de la vesícula biliar compuesto por acinos y conductos pancreáticos.

Proliferation and cell death in an experimental model of brain tissue heterotopia in the lung / Proliferação e morte celular na heterotopia encefálica experimental

PURPOSE: To investigate the proliferation and neuronal death in brain tissue heterotopia in the lung in an experimental model during both fetal and neonatal periods. METHODS: Twenty four pregnant female Swiss mice were used to induce brain tissue heterotopia on the 15th gestational day. Briefly, the brain of one fetus of each dam was extracted, disaggregated and injected into the right hemithorax of siblings. Six of these fetuses with pulmonary brain tissue implantation (PBI) were collected on the 18th gestational day (group E18) and six other on the 8th postnatal day (group P8). Immunohistochemical staining for PCNA and Bcl2 were used to assess proliferation and cell death. RESULTS: PCNA Labelling Index (LI) in heterotopic brain tissue was greater in fetal than postnatal period (E18 > P8) (p<0.05) and the immunostaining with Bcl2 antibody did not show difference. CONCLUSION: Cell proliferation is maintained in brain tissue heterotopia, although apoptosis is also observed.

OBJETIVO: Investigar a proliferação e morte neuronal na heterotopia encefálica pulmonar em modelo experimental durante o período fetal e neonatal. MÉTODOS: Foram utilizados 24 camundongos Swiss fêmeas prenhes para induzir a heterotopia encefálica no pulmão. O tecido encefálico de um feto de cada fêmea prenha foi removido, picotado e injetado no pulmão dos irmãos. Seis fetos com Implantação Encefálica Pulmonar (IEP) foram coletados no 18º dia gestacional (grupo E18) e seis outros fetos no 8º dia pós-natal (grupo P8). Foi realizada a reação Imuno-histoquímica para PCNA e Bcl2 para analisar a proliferação e morte celular. RESULTADOS: O índice de marcação (IM) para PCNA era maior no período fetal quando comparado com o período pós-natal (E8 > P18) (p<0,05) e a imunomarcação para o anticorpo Bcl2 não apresentou diferença. CONCLUSÃO: A proliferação celular foi mantida no tecido heterotópico encefálico, embora a apoptose também foi observada.

Ectopic breast carcinoma

A 47-year-old premenopausal woman had a swelling in right axilla which had been diagnosed as "ectopic breast tissue" with an incisional biopsy. A subcutaneous nodule appeared two years ago. The ectopic breast containing the mass was excised with axillary dissection. It was an invasive ductal carcinoma and metastasis was detected in one lymph node. She received local radiotherapy after 6 cycles of chemotherapy and has now been taking hormonotherapy. Ectopic breast tissue has potential for malignant transformation. As its carcinoma has a worse prognosis and a higher incidence of metastasis because of delayed diagnosis, prophylactic excision may be recommended

Coristoma pancreático en la vesícula biliar: Reporte de dos casos / Pancreatic choristoma in the gallbladder: Report of two cases

Pancreatic choristoma is the ocurrence of normal pancreatic tissue in an abnormal location without any anatomic continuity with the main body of the gland. Although heterotopia is uncommon in the gallbladder and biliary tract, anecdotic cases of gastric mucosa, liver, adrenal gland and pancreas among other tissues have been described. We report an eight year-old male and a 22 year-old female, electively operated for symptomatic cholelithiasis. On pathology, a nodule identified as a pancreatic endocrine and exocrine choristoma, was found in the gallbladder wall of both patients. We employed immunohistochemistry to characterize this choristoma. Tubular and epithelial structures were immunoreactive to cytokeratins 7, 8, 18, 19 and 20 and to CA19-9. Exocrine activity was documented by immunoreactivity to al-antitrypsin and al-chemotrypsin. Other immunohistochemical markers such as insulin and somatostatin were positive identifying endocrine activity.

Coristoma hepático en la pared de la vesícula biliar: report of one case / Hepatic choristoma in the gallbladder wall

El tejido hepático heterotópico es una condición poco común que se identifica con mayor frecuencia durante la exploración quirúrgica del abdomen por otras indicaciones. Describimos un caso de tejido hepático heterotópico localizado en la pared externa de la vesícula biliar de un paciente masculino de 47 años de edad, en el cual se realizó una colecistectomía laparoscópica porcolelitiasis sintomática. El reporte histopatológico informa de cambios crónicos en la pared vesicular y leve infiltrado linfocitario difuso en el corion de la mucosa y muscularis mucosae sin compromiso inflamatorio o infiltración por otros tejidos. El nodulo hepático compromete solo la serosa y mide 12x8x6 mm, la arquitectura es típica del parénquima hepático con su arquitectura lobulillar conservada y leve hiperemia centrolobulillar difusa. Aún cuando el coristoma hepático de nuestro paciente constituye un hallazgo inesperado, es importante destacar las implicaciones patológicas de este tejido y el potencial de malignidad asociado al mismo.

Ectopic and extranumerary parathyroid glands location in patients with hyperparathyroidism secondary to end stage renal disease

Supranumerary or ectopic parathyroid glands are the main cause of persistent hyperparathyroidism (HPT) in patients with end stage renal disease (ESRD) submitted to parathyroidectomy (PTx). PURPOSE: To evaluate the prevalence and location of parathyroid glands in these patients. METHODS: Thirty-five patients with ESRD and severe secondary hyperparathyroidism (HPT2) had been submitted to total PTx at HUCFF from December 2001 to July 2005. Surgery was always performed by the same surgeon, who described in details the location of the glands. RESULTS: Sixteen patients (45.7 percent) had ectopic glands, which were also extranumerary in five of them (14.3 percent). The most common locations were the thyroid parenchyma (33.3 percent), thyroid-thymus conduit (18.5 percent), and thymus (14.8 percent). Before PTx, the sensibility of ultrasonography and scintigraphy with technetium-99m Sestamibi was low (48.3 percent and 35.3 percent, respectively). Moreover, 51.4 percent of the nodules found at US were thyroid nodules. However, 99mTc-Sestamibi was useful to identify ectopic glands in those two patients with persistent HPT after PTx. CONCLUSION: The presence of extranumerary and ectopic parathyroid glands in HPT2 is sufficiently important to justify their exhaustive search. As the preoperative image exams present low sensibility to locate them, it is necessary to develop an exploratory routine embracing the most common sites of location.

A principal causa cirúrgica de persistência da doença após paratireoidectomia no hiperparatireoidismo secundário à insuficiência renal crônica (HPT2) é a existência de paratireóides supranumerárias e/ou ectópicas. OBJETIVO: Avaliar o número, prevalência de ectopia e localizações mais comuns das paratireóides nestes pacientes. MÉTODOS: Acompanhamos prospectivamente pacientes com HPT2, submetidos à paratireoidectomia no HUCFF, entre dezembro/2001 e julho/2005. Todos foram operados pelo mesmo cirurgião, que descreveu detalhadamente a localização das paratireóides encontradas. RESULTADOS: Foram avaliados 35 pacientes: em cinco (14,3 por cento) foi encontrada uma quinta glândula, supranumerária; dezesseis (45,7 por cento) possuíam glândulas ectópicas; as localizações mais comuns foram parênquima intratireoidiano (33,3 por cento), trajeto conduto tireotímico (18,5 por cento) e timo (14,8 por cento). As principais glândulas ausentes na presença de ectopia foram as inferiores esquerdas (29,6 por cento) e direitas (25,9 por cento). A sensibilidade da ultra-sonografia e da cintigrafia com sestamibi na detecção dos nódulos foi baixa (48,3 por cento e 35,3 por cento, respectivamente). Além disso, 51,4 por cento das ultra-sonografias mostraram incidentalomas tireoidianos. CONCLUSÃO: A presença de paratireóides supranumerárias e ectópicas no HPT2 é suficientemente relevante para justificar sua procura exaustiva. Como os exames de imagem pré-operatórios contribuem muito pouco para localizá-los, é necessário que se desenvolva uma rotina de exploração abrangendo as localizações mais comuns.

Gastric heterotopia together with squamous metaplasia in the gallbladder / Heterotopía gástrica y metaplasia escamosa en la vesícula biliar

Heterotopic gastric mucosa in the gallbladder is extremely unusual. In this study, we aimed to report a case of gastric heterotopia together with squamous metaplasia in the gallbladder of a 47-year-old female patient who experienced an intensive abdominal pain. He was admitted to the hospital for clinical treatment without any improvement. Ultrasonography showed a stone located in the gallbladder neck and dilatation of intrahepatic bile ducts, both hepatic ducts and common hepatic duct. Laparoscopic cholecystectomy was performed. In the microscopical examination, the epithelium of the gallbladder revealed an unspecified chronic cholecystitis. Besides, at the level of the gallbladder body, a heterotopic gastric mucosa contain chief, parietal and mucosal cells with cystic glands and squamous metaplasia was found. Actually the patient is in long-time follow-up, asymptomatic. We also review 96 other reports of HGM in the gallbladder in the international medical literature from 1934. As heterotopic tissue may promote carcinogenesis of the gallbladder, close attention should be paid to any occurrence of such lesions in this anatomical region. It appears that laparoscopic cholecystectomy may be unavoidable for patients affected by heterotopic gastric mucosa at the present time and care must be taken when a diagnosis is made based on intraoperative frozen sections.

La heterotopía de la mucosa gástrica (HGM) en vesícula biliar es extremadamente rara. En este estudio, reportamos un caso de heterotopía gástrica junto con metaplasia escamosa en vesícula biliar de un paciente femenino de 47 años que experimentó un dolor abdominal intenso. Lo admitieron al hospital para el tratamiento clínico sin ninguna mejoría. Ultrasonografía demostró un cálculo situado en el cuello de la vesícula y dilatación de conductos biliares intrahepáticos, los conductos hepáticos y conducto hepático común. Se realizó la colecistectomía por vía laparoscópica. En el exámen microscópico el epitelio reveló una colecistitis crónica inespecífica. Además, en el nivel del cuerpo de la vesícula biliar fue hallada una mucosa gástrica heterotópica con células principales, parietales, células mucosas con las glándulas enquistadas y metaplasia escamosa. El paciente está en el seguimiento a largo plazo, asintomático. Revisamos 96 informes de HGM en vesícula biliar en la literatura médica internacional a partir de 1934. El tejido heterotópico puede promover la carcinogénesis de la vesícula biliar, por lo cual se debe prestar atención a cualquier ocurrencia de tales lesiones en esta región anatómica. La colecistectomía laparoscópica puede ser inevitable para los pacientes afectados por la mucosa gástrica heterotópica actualmente y todo cuidado debe ser tomado cuando se hace un diagnóstico por secciones congeladas intraoperatorias.

Ectopic adrenal tissue in the spermatic cord in pediatric patients: surgical implications

OBJECTIVE: To study the incidence and relevance of ectopic adrenal tissue in pediatric patients who underwent groin surgical explorations. MATERIALS AND METHODS: We studied 1120 patients with groin surgical explorations during a period of 8 consecutive years. PatientsÆ clinical data and histological findings were analyzed. RESULTS: We found ectopic adrenal tissue in 13 patients in 1120 groin surgical exploration (1.16 percent). Of the 13 cases, 5 were diagnosed as having undescended testes, 6 inguinal hernia and 2 communicating hydrocele. Median age at diagnosis was 5.6 years. Histological sections showed adrenal cortical tissue with no medulla present. CONCLUSION: Based on the clinical implications of those adrenal rests it is mandatory the removal of this ectopic tissue whenever encountered during surgical interventions in the groin region in children.

Surgical correction of corneal dermoid in a dog

A five-month-old female Shih-tzu puppy was presented for repair of congenital choristoma in left eye. The patient was suffered from chronic epiphora and ocular discharge during 3 months. On ophthalmic examination, left eye revealed hyperemia in conjunctiva of the temporal canthus due to choristoma with hair. At surgery, the choristoma invaded by stromal layer of the cornea, and extended to limbus and conjunctiva. Based on the anatomical location and histopathological features of the removed tissue, the choristoma was diagnosed as corneal dermoid.

Lingual thyroid causing dysphonia: case report

CONTEXTO: Tireóide lingual é uma entidade rara, devida a falha na migração da glândula em sua fase embriogênica. A presença da glândula tireóide na base da língua pode acarretar sérios problemas aos pacientes, como disfagia e disfonia, obstrução de vias aéreas superiores e até hemorragia, em qualquer fase da vida. RELATO DE CASO: Apresentamos um caso de tireóide lingual em paciente de 41 anos de idade, discutindo-se a embriogênese, diagnóstico e conduta adequada para tratamento. Elementos para o diagnóstico e avaliação terapêutica são descritos com especial atenção aos achados clínicos, testes laboratoriais, além de metodologia de imagem como medicina nuclear e tomografia computadorizada, realizados para confirmação diagnóstica e planejamento da melhor conduta operatória. A excisão cirúrgica da tireóide ectópica é reservada para casos de aumento glandular, que podem resultar em disfunção das vias aéreas superiores (disfonia ou disfagia), além de hemorragia recorrente.

Posterior mediastinal gastroenteric cyst in neonate

Posterior mediastinal enteric cysts are infrequently reported. They are mostly asymptomatic 1. The incidence of gastroenteric cysts presenting during immediate neonatal period is rare. Alimentary tract duplications are other rare congenital anomalies and are commonly seen in relation to the ileum. However, the high incidence of associated thoracic or cervical vertebral anomalies with foregut cysts provide an early clue to the diagnosis 2. A detailed timely antenatal scan can increase the awareness regarding such rare condition and help in diagnosis and better outcome. The purpose of this case report is to highlight the clinical diagnosis and management of a neonate with posterior mediastinal gastroenteric cyst

Heterotopía pancreática: un caso de localización duodenal y coledociana / Heterotopic pancreas: a case of duodenal and common bile duct site

Se describe un caso de heterotopia pancreática de localización duodenal y coledociana en un paciente en el que realizó una colecistectomía electiva por vía tradicional por colecistolitiasis. Durante el transcurso de la cirugía constatamos una dilatación de la vía biliar extrahepática. Por ello, se realizó una colangiografía intraoperatoria, que permitió verificar la existencia de una masa ocupante a nivel de colédoco distal. Se decidió entonces la exploración de la vía biliar para resecar la lesión. El estudio histológico del espécimen fue concluyente de tejido heterotópico pancreático. Después de este procedimiento, se decidió explorar la región de la papila, hecho que significo realizar una duodenotomía longitudinal. Así, se logró observar una masa nodular de un cm de diámetro en la porción medial, que protruía hacia la mucosa duodenal. Se practicó una esfinterotomía y resección de la masa, cuya biopsia contemporánea fue informada como tejido pancreático, compatible con heterotopia. Al mes después de la cirugía se realizó una colangiografía de control a través de la sonda de Kehr, con un paso normal del medio de contraste al duodeno. El curso postoperatorio fue correcto. El control ambulatorio, con un seguimiento de 10 meses, el paciente se encuentra en buenas condiciones

Tumores parafaríngeos en niños: descripción de dos casos clínicos / Parapharyngeal tumors in pediatrics: 2 clinical cases

Se presentan dos casos clínicos de tumores parafaríngeos de niños tratados en el Servicio de ORL del Hospital Regional Valdivia. El primero corresponde a un coristoma que histológicamente constituye tejido neuroglial maduro el cual fue tratado con cirugía exclusiva. El segundo caso es un Rabdomiosarcoma embrionario que fue sometido a una resección con quimioterapia y radioterapia según protocolo y a una cirugía de rescate por una recidiva local. Se revisa la literatura con especial énfasis a la anatomía, técnica quirúgica e histología de los tumores que afectan el espacio parafaríngeo

Dermolipomas / Dermolipomas

Los dermolipomas son coristomas congénitos compuestos de tejido adiposo y tejido conectivo denso, localizados por lo general en la región superotemporal del fórnix, cerca de la glándula lagrimal y el músculo recto externo. Histopatológicamente están contorneados por un epitelio escamoso estratificado que puede estar queratinizado o no. Los giagnósticos diferenciales incluyen: dermoide epibulbar, quiste de la glándula lagrimal, prolpso de la grasa orbitaria, linfangioma y linfoma. El tratamiento, por lo general, es observación; la cirugía puede ser indicada para impedir el crecimiento, por cosmesis o por irritación conjuntival