Recurrence of gigantic overhanging bleb post excision: a case report.

Purpose: To report the case of an extremely large overhanging bleb, extending from superior fornix to limbus, in a 57-year-old poorly controlled diabetic, six years after trabeculectomy for an uncontrolled primary open angle glaucoma (POAG) with recurrence, months after complete excision. Methods: An overhanging bleb is defined as a filtering cicatrix which has been massaged downward over the cornea by eyelid action. It has been linked to anti-metabolite use during glaucoma filtering surgery. Despite being functional, these blebs result in patient discomfort ranging from foreign body sensation and lacrimation to dysphotopsia. A 57-year-old male presented with complaints of reduced vision, foreign body sensation, watering, and difficulty in eye closure in the left eye (OS) for past 6 months. He had undergone trabeculectomy with mitomycin C 6 years ago for advanced primary open-angle glaucoma with no follow-up beyond the initial one 4 weeks post-surgery. Results: At presentation, he had a giant multi-loculated, cystic filtering bleb (15 mm x 8 mm x 4-5 mm), which was carefully excised. Amniotic membrane was used as an anti-fibrotic as well to cover the defect. Seven months after surgery, there was recurrence of this overhanging cystic bleb when it was again excised with debulking of the conjunctiva done and cryotherapy applied to its margins. Conclusion: Although multiloculated cystic overhanging blebs have been documented before, such a large (posterior extent till fornix), thick-walled multiloculated bleb with histopathological evidence of chronic inflammatory process has not been reported prior.

A rare case of extraskeletal mesenchymal chondrosarcoma with dedifferentiation arising from the buccal space in a young male.

Extraskeletal mesenchymal chondrosarcoma (EMCS) is a rare and aggressive pathological variant of chondrosarcoma arising from soft tissues of mainly the extremities, meninges/dura, trunk, and orbits. EMCS comprises only 2 % of all soft tissue sarcomas and only 6 % of them arise from soft tissue in the head and neck region. It usually affects in the second and third decade of life and is common in women. It runs a very rapid clinical course with distant metastases and has poor prognosis and survival rates. Histologically it has a dimorphic presentation of small round mesenchymal cells interspersed with foci of cartilaginous differentiation. Radiographically it appears as a soft tissue lobulated mass with various patterns of calcification. This is the first case of primary and recurrent EMCS originating in the buccal space with unusual features of dedifferentiation. The diagnostic challenges in this case were the inconclusive FNAC results, lack of radiographic evidence of characteristic calcifications and presence of areas of myxoid material and dedifferentiation on histopathology. The clinical, cytological, histological, immunohistochemical, radiographic, PET-CT findings and management with review of literature is presented. The diagnostic and management pitfalls of this extremely rare tumor are also discussed.

Comparative yield of fine needle aspiration cytology, ampullary biopsy, and needle knife assisted biopsy in the diagnosis of nonulcerated periampullary tumors.

AIM: Periampullary tumors (PAT) are defined as tumors arising within 2 cm of the major duodenal papilla. Studies on yield of preoperative biopsy for nonulcerated PAT are scarce. Needle knife papillotomy-assisted biopsy (NKAB) may sample the deeper tissues and thereby increase the histologic yield. We aimed to compare the diagnostic yield of fine needle aspiration cytology (FNAC), surface ampullary biopsy, and NKAB in nonulcerated PAT. METHODS: Patients with suspected PAT based on clinical, biochemical, and radiologic investigations were evaluated. Patients with smooth ampullary bulge on side viewing endoscopy (SVE) were included, while those with gastric outlet obstruction or obvious ulceration of ampulla on SVE were excluded. RESULTS: Twenty-five of 78 patients with PAT met the inclusion criteria. The median (range) age was 60 (43-75) years, and 13 were male. Serum CA 19.9 was 466 (2-9372) U/mL. Histopathological positivity rate for surface biopsy, FNAC, and NKAB was 10 (40 % and 95 % CI: 21.8 % to 61.1 %), 12 (48 % and 95 % CI: 28.3 % to 68.2 %), and 21 (84 % and 95 % CI: 63.1 % to 94.7 %), respectively. Diagnostic yield of NKAB was significantly better than surface biopsy (p = 0.001) and FNAC (p = 0.007). None of the patients subjected to NKAB had any complications other than self-limited minor ooze. CONCLUSION: NKAB was superior to surface biopsy or FNAC to establish preoperative tissue diagnosis of nonulcerated PAT. NKAB is safe and simple in expert hands and may be recommended as standard procedure to obtain histological specimen in these patients.

Nodules in antrum after variceal eradication a new finding in patients with portal hypertension.

Portal hypertension is known to cause esophageal varices, gastric varices and portal hypertensive gastropathy (PHG). The prevalence of gastric varices and PHG is known to increase after eradication of esophageal varices. PHG includes the presence of a mucosal mosaic pattern, cherry red spots, and/or black-brown spots and gastric vascular ectasia (GAVE). Patients with portal hypertension in whom esophageal varices were eradicated were on follow up endoscopy for detection of recurrence of esophageal varices. Their status of PHG was assessed and patients antral nodules were enrolled. Twenty patients with antral nodules were identified over one year. Fifteen out of 20 patients had cirrhosis as etiology of portal hypertension, three had non-cirrhotic portal hypertension and two had extra-hepatic portal vein thrombosis. GAVE was seen more commonly (n=8, 40%) in patients with PHG with nodules. PHG with antral nodules is a novel endoscopic finding present both in cirrhotic and non-cirrhotic portal hypertension with unknown pathogenesis, and is seen more commonly in patients with eradicated varices who are on long-term follow up.

Unusual widespread metastatic presentation of mixed medullary-follicular thyroid carcinoma.

Mixed medullary-follicular thyroid carcinoma (MMFTC) is a rare tumor with a metastatic behavior that has not been fully appreciated. Scintigraphy and radioiodine entrapment propensity of its metastases remains largely undescribed. The authors present a case of MMFTC with widespread bone and soft-tissue metastases, where every known site of metastases concentrated radioiodine intensely. The patient responded well to radioiodine therapy. The report suggests that the tumor may have a propensity to metastasize to the skeleton, and the metastases retain the ability to accumulate radioiodine.