Surgical considerations in the resection of solitary fibrous tumors of the pleura.

Solitary fibrous tumors (SFTs) are rare mesenchymal pleural neoplasms with an overall good prognosis and low recurrence rate if completely resected and if degree of differentiation is favorable. Within the last decade, advances in research have led to more reliable methods of differentiating SFTs from other soft tissue tumors. Historically, several markers were used to distinguish SFTs from similar tumors, but these markers had poor specificity. Recent evidence showed NAB2-STAT6 fusion gene to be a distinct feature of SFTs with 100% specificity and sensitivity. Surgical resection, with an emphasis on obtaining negative margins, is the mainstay of treatment for SFTs. Preoperative planning with detailed imaging is imperative to delineate the extent of disease and vascular supply. One important radiologic distinction to aid delineation of a pleural-based tumor compared to a pulmonary parenchymal-based tumor is the angle that the tumor forms with the chest wall, which is obtuse for a pleural-based tumor, and acute for tumors of the lung parenchyma. Often, preoperative tissue diagnosis is not available, and surgery is both diagnostic and curative. Intraoperatively, emphasis should be on complete resection with negative margins. SFTs are resected via several approaches: thoracotomy, sternotomy with the option of hemi-clamshell extension, video-assisted thoracoscopic surgery, and robotic approach, which is increasingly being used and is our preference. We recommend a minimally invasive approach for most lesions, and have resected SFTs of the pleura that are up to 12 cm with the robotic approach. However, the current literature often cites 5 cm as the cut off for an open thoracotomy. Nevertheless, even with larger tumors, a minimally invasive robotic approach is our preference and practice. For giant SFTs (> 20 cm), an open approach may be preferable. Multiple thoracotomies and rib resection may be required to gain adequate exposure and ensure complete resection in these tumors. However, it is noteworthy that most of these tumors have a soft consistency and thus, once bagged, can easily be removed minimally invasively, and thus minimally invasive approach should not be completely ruled out. Recurrence in SFTs usually results from incomplete resection and redo surgery may portend a favorable prognosis.

Superior mesenteric artery thrombosis in a patient with COVID-19 pneumonia and Clostridium Difficle.

COVID-19, a novel respiratory viral illness, has spread globally and led to over 111 million cases worldwide. Most commonly, patients present with respiratory symptoms, and those with increased severity progress to acute hypoxic respiratory failure. Additionally, a portion of patients are noted to have coagulopathy and are considered to be at an increased risk for thromboembolic events. In this article, we present a unique case of a patient with severe abdominal pain in the setting of COVID-19 pneumonia and community acquired Clostridium difficile, found to have superior mesenteric artery thrombosis requiring exploratory laparotomy, thrombectomy and small bowel resection.

Primary small bowel adenocarcinoma with loss of nuclear expression of PMS2 after resection of mucinous cholangiocarcinoma.

Mucinous cholangiocarcinoma is an extremely rare form of intrahepatic cholangiocarcinoma that has been characterized by rapid growth, widespread metastasis and poor prognosis. These tumors have been shown to be a part of the Lynch syndrome tumor spectrum, however, the role of DNA mismatch repair (MMR) deficiency in their development is poorly understood. We present the case of a 74-year-old male with cholangiocarcinoma, who underwent Roux-en-Y hepaticojejunostomy and extended left hepatectomy and was diagnosed with a primary small bowel adenocarcinoma 2 years later. Immunohistochemistry testing for mismatch repair proteins was significant for the loss of nuclear expression of PMS2. Taken together, the cause of both the mucinous cholangiocarcinoma and primary small bowel adenocarcinoma with PMS2 loss in the patient presented here is likely genetic, suggestive of a cancer syndrome.

Erratum to: Hepatocellular carcinoma with extrahepatic blood supply from right renal artery.

[This corrects the article DOI: 10.1093/jscr/rjab391.].

Hepatocellular carcinoma with extrahepatic blood supply from right renal artery.

Extrahepatic blood supply is seen in around 17-27% of hepatocellular carcinoma lesions. Evidence suggests that this extrahepatic supply most commonly originates from a right intercostal artery (70-83%) followed by left intercostal, omental and right renal arteries. Thus a comprehensive knowledge of variations in standard vascular anatomy and cognisance of factors influencing or predicting extrahepatic blood supply in HCC is instrumental in ensuring the success of surgical and interventional procedures. We present the unusual case of a 66-year-old male with HCC in Segment I of the liver with aberrant blood supply from the right renal artery in the absence of any risk factors for extrahepatic circulation. He successfully underwent transarterial chemoembolization. There was no evidence of residual disease on repeat imaging.

Laparoscopic repair of incarcerated transverse colon internal hernia in a patient with Crohn's disease.

Internal hernia is a rare cause of bowel obstruction in patients with no prior surgical history. Laparoscopic repair of a transverse bowel herniation through the foramen of Winslow is the rarest type of internal hernia, with only two case reports published in the literature. In a patient with a history with Crohn's disease and no prior surgical history, presenting with signs of bowel obstruction, and no inflammatory symptoms, internal hernia should be suspected as one of the causes. Minimally invasive laparoscopic repair is a feasible safe option in those patients, allowing patients to go home the next day postoperatively.

ASSESSING THE KNOWLEDGE, ATTITUDES AND PRACTICES OF SCHOOL TEACHERS REGARDING DYSLEXIA, ATTENTION-DEFICIT/ HYPERACTIVITY AND AUTISTIC SPECTRUM DISORDERS IN KARACHI, PAKISTAN.

BACKGROUND: Learning impairments in children consist of a spectrum of disorders that are under diagnosed in Pakistan. Most learning disorders have long term consequences for a child and early detection is thus imperative. Teachers may be able to play a key role in such identification. The objective of our study was to survey knowledge, attitudes and practices of school teachers regarding dyslexia, Attention-deficit/hyperactivity disorder (ADHD) and autistic spectrum disorder, and assess their ability to identify learning disabilities. METHODS: A cross-sectional study was conducted with 233 primary school teachers from Karachi using a self-administered questionnaire. RESULTS: Mean scores for the knowledge test and the ability to identify learning- impaired children were 58.8% and 53.3%, respectively. Better qualified teachers scored significantly more on the knowledge and ability to identify learning impairments sections. Most teachers believed that these students should study in mainstream schools with special educators. Majority of the teachers belonged to schools where children with learning disabilities were detected using teachers' judgment. Most teachers manage these children by involving them in discussions, seating them at the front of the class, and giving them extra time. CONCLUSION: Knowledge about learning disabilities is very low amongst school teachers, which may limit their ability to identify learning impairments.