Carcinosarcoma of the colon with extensive and extraordinary metastases detected on F-FDG18PET/CT: A case report.

Introduction: Sarcomatoid carcinomas or carcinosarcomas are rare tumors with a double component, carcinomatous and sarcomatous. They most commonly arise from the head, neck, respiratory system and female genital tract. To the best of our knowledge, only thirty two cases of colorectal involvement have been reported in the medical litterature. Case report: We report a case of sarcomatoid carcinoma of the colon in a 58 year old woman with unusual sites of metastasis revealed by a whole body 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), who presented with right iliac fossa pain. Physical examination revealed only tenderness of the right iliac fossa. A right hemi-colectomy was performed. The immunohistochemical study of the surgical specimen revealed 2 cellular contingents, one carcinomatous and the other sarcomatous, leading to the diagnosis of carcinosarcoma. The evolution was rapidly unfavourable, with death occurring 4 months after the initial surgery. Discussion: Colorectal carcinosarcomas are very rare and aggressive tumors with high metastatic potential commonly in the liver, lymph nodes, and peritoneum. In our case, we order a FDG-PET/CT that revealed intriguing pattern of metastasis. Conclusion: The purpose of presenting this case report is to raise awareness among clinicians to consider this clinical entity as a differential diagnosis of colorectal tumors and order more often FDG-PET/CT for a good clinical staging.

Adult Intussusception: An Uncommon Condition and Challenging Management.

INTRODUCTION: Intussusception is a rare condition in adults. A pathological lesion is usually found with a significant percentage of malignancy. The optimal treatment is still not universally clear. METHODS: This is a retrospective review of adult patients with a diagnosis of intestinal intussusception and surgically treated at our institution from January 2009 to December 2018. Clinical, operative, and histological details were collected and analyzed. RESULTS: A total of 26 cases, 16 males and 10 females, were diagnosed with surgically proven intussusception during the 10-year period. The mean age was 45 years (range 21-70). Using ultrasound and/or computed tomography as imaging study, the preoperative diagnosis was made in 21/26 (81%) patients. Five intussusceptions were discovered only upon exploratory laparotomy for intestinal obstruction. There were 19 (73%) cases of enteric and 7 (27%) cases of colonic intussusceptions. All patients underwent surgical exploration. Intestinal resection with immediate anastomosis was the technique of choice for most patients. A single patient underwent stoma for peritonitis secondary to intestinal perforation. An organic cause has been systematically revealed, and no idiopathic intussusception was detected. Etiology was malignant in 9 (35%) cases. CONCLUSION: Adult intussusception should be considered in any patient with subacute abdominal pain. Considering the high rate of malignancy, intestinal resection without attempting reduction is highly recommended for colonic intussusceptions. However, a more selective approach can be adopted for enteric intussusceptions.

Abdominal wall schwannoma: a case report.

Schwannomas or neurilemmomas are benign and slow-growing tumors that arise exclusively from Schwann cells in peripheral nerve sheaths. These neoplasms theoretically can occur anywhere in the body, but they most frequently affect extremities, as well as head and neck region. However, their presentation in the abdominal wall is extremely rare and only few cases have been reported in the literature. Subcutaneous lesions may be asymptomatic and only incidentally discovered upon physical examination or imaging. However, occasionally they induce mass effects on surrounding large nerves. We present the case of a 34-year-old man with abdominal wall pain localized in the right iliac fossa and palpable subcutaneous mass. Ultrasound and CT scan revealed a solid well-defined mass of the abdominal wall. Following surgical excision under general anesthesia, histological examination was consistent with the diagnosis of benign schwannoma.

Liver trauma: What current management?

BACKGROUND: The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years. METHODS: The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed. RESULTS: The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group. CONCLUSIONS: Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.

[A rare case of spontaneous massive pneumoperitoneum]. / Un cas rare de pneumopéritoine spontané massif: à propos d'une Observation.

Spontaneous pneumoperitoneum is a rare disorder characterized by the presence of free air in the peritoneal cavity, in the absence of any obvious cause. We here report the case of a patient with massive pneumoperitoneum, detected by scan, in whom clinical, biological, radiological and laparoscopic examinations showed no detectable etiology. This case study describes a clinical entity rarely seen in our practice constituting a real diagnostic trap; accurate knowledge about the disease would avoid unnecessary and especially aggressive laparotomies revealing no signs of perforation. The laparoscopy seems to be a minimally invasive surgical procedure for doubtful cases allowing visual diagnosis by eliminating hollow organ perforation.

Metachronous pancreatic metastases from renal cell carcinoma: is there a place of Active-Surveillance before deferred deliberately Molecular Target Agent?

BACKGROUND: Metastatic renal cell cancer is a heterogeneous disease due to its diverse morphological features, the prognostic categories based on clinical criteria. Sometimes indolent course without any significant symptoms can be differentiated before the introduction of novel targeted agents. This observation led to interest in a strategy of deferring systemic therapy in the era of effective systemic therapies. CASE PRESENTATION: We report of a 78-year-old Moroccan man with pancreatic metastasis from renal cell carcinoma which occurred 14 years from right nephrectomy. Indolent disease based on body computed tomography imaging with 4 years follow-up was recognized. Active surveillance with deferred antiangiogenic multikinase inhibitor at disease progression was proposed. Nowadays, the patient is under oncological follow-up, he is in a good state of health, and he is disease-free for 48 months from the diagnosis of the tumor and for 20 months from the start of the treatment with Sunitinib CONCLUSIONS: Active surveillance before target therapy may be a suitable approach to ensure long progression-free survival with minimal side-effects and better quality of life in asymptomatic, low-volume, metastatic disease. Further prospective studies with biomarker validation are required to define the patients most likely to benefit from this approach.

Extra-Gastrointestinal Stromal Tumor of the Greater Omentum: Unusual Case Report.

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract, originating from the interstitial cells of Cajal and most frequently expressing CD-117, a C-kit proto-oncogene, which can be detected immunohistochemically. Extra-gastrointestinal stromal tumors are neoplasms with similar immunohistological features arising outside the gastrointestinal tract with no connection to the gastric or intestinal wall.We report the case of a 61-year-old Moroccan man who presented with chronic abdominal pain along with progressive abdominal distension for the past last year. The clinical examination demonstrated a large abdominal mass and an abdominal computed tomography scan revealed a voluminous intraperitoneal mass measuring 30 cm in its greatest diameter. At laparotomy, this mass seemed to be arising from the greater omentum without continuity to the gastrointestinal tract. The mass was completely removed with clear margins and pathological examination was suggestive for high-risk gastrointestinal stromal tumor of the greater omentum. Due to the aggressive nature of this patient's tumor, he was assigned to receive imatinib as adjuvant chemotherapy for 3 years. He remains alive without any sign of recurrence after 4 years of follow-up.Extra-gastrointestinal stromal tumors of the greater omentum can grow slowly and remain clinically silent despite the large size of the tumor. Complete surgical resection is the only effective treatment approach. Nevertheless, adjuvant therapy following resection with imatinib has become a standard of care in cases of high risk disease.

Analysis of prognostic factors affecting mortality in Fournier's gangrene: A study of 72 cases.

INTRODUCTION: Fournier's gangrene is a rapidly progressing necrotizing fasciitis of the perineum and genital area associated with a high mortality rate. We presented our experience in managing this entity and identified prognostic factors affecting mortality. METHODS: We carried out a retrospective study of 72 patients treated for Fournier's gangrene at our institution between January 2005 and December 2014. Patients were divided into survivors and non-survivors and potential prognostic factors were analyzed. RESULTS: Of the 72 patients, 64 were males (89%) and 8 females (11%), with a mean age of 51 years. The most common predisposing factor was diabetes mellitus (38%). The mortality rate was 17% (12 patients died). Statistically significant differences were not found in age, gender, and predisposing factors, except in heart disease (p = 0.038). Individual laboratory parameters significantly correlating with mortality included hemoglobin (p = 0.023), hematocrit (p = 0.019), serum urea (p = 0.009), creatinine (p = 0.042), and potassium (p = 0.026). Severe sepsis on admission and the extent of affected surface area also predicted higher mortality. Others factors, such as duration of symptoms before admission, number of surgical debridement, diverting colostomy and length of hospital stay, did not show significant differences. The median Fournier's Gangrene Severity Index (FGSI) was significantly higher in non-survivors (p = 0.002). CONCLUSION: Fournier's gangrene is a severe surgical emergency requiring early diagnosis and aggressive therapy. Identification of prognostic factors is essential to establish an optimal treatment and to improve outcome. The FGSI is a simple and valid method for predicting disease severity and patient survival.

Giant adrenal hemangioma: Unusual cause of huge abdominal mass.

Adrenal hemangioma is an extremely rare benign and non-functioning neoplasm of the adrenal gland. We report a case of a 71-year-old woman admitted for intermittent abdominal pain and abdominal distension associated with vomiting and chronic constipation for 5 years. Physical examination revealed a large abdominal mass. Both computed tomography scan and magnetic resonance imaging suggested hemangioma in the right lobe of the liver. Laboratory examinations and tumour markers were within normal limits, except for hypochromic microcytic anemia. The mass was removed intact by conventional surgery and histopathology revealed a cavernous hemangioma of the adrenal gland with no signs of malignancy. Surgical resection was curative, with no recurrence at the 2-year follow-up.

An unusual localization of retroperitoneal paraganglioma: a case report.

Paragangliomas are rare tumors arising from extra-adrenal chromaffine tissues. The diagnosis of non-functional retroperitoneal paraganglioma and its surgical management can be difficult. We report a case of a retroperitoneal paragangliomaof an unusual localization that renders the surgery more challenging. A 40 year-old woman presented to our department with a four-month history of upper quadrant pain with no vomiting, no fever, nor jaundice. Physical examination was normal. Ultrasonography showed a retro duodenal homogenous mass and computed tomographyscan showed a well-circumscribed round mass of heterogeneous density, which was in close contact with the aorta and the left kidney vein. Laboratory tests were normal. The patient underwent surgical management. The surgical exploration found a retroperitoneal tumor that was encapsulated and showing intimate contact with the abdominal aorta. We performed a complete resection of the tumor. Histological examination of the surgical specimen revealed a paraganglioma. The post operative course was uneventful. Paragangliomas are rare tumors. They can be asymptomatic for a long time and thus be diagnosed at late stage. A follow-up of patients is then essential. Surgical treatment is the only radical treatment and should be performed even in paragangliomas in close contact with the great vessels.

Giant inguinoscrotal hernia containing intestinal segments and urinary bladder successfully repaired by simple hernioplasty technique: a case report.

INTRODUCTION: Giant inguinoscrotal hernias are extremely rare nowadays, but they may still be encountered after years or even decades of neglect. Such hernias containing both bowel loops and urinary bladder have not been reported in the medical literature to date, to the best of our knowledge. CASE PRESENTATION: We report a case of a 65-year-old Moroccan man who presented with giant right-sided and long-standing inguinoscrotal hernia with compromised quality of life due to walking difficulties and sexual discomfort. Computed tomography revealed a voluminous hernia sac containing small and large bowel loops, greater omentum, and urinary bladder. Surgical repair was done through the classical inguinal incision using the Lichtenstein tension-free hernioplasty technique. No debulking or abdominal enlargement procedure had to be performed, apart from a partial omentectomy. CONCLUSIONS: Giant inguinoscrotal hernia containing intestinal segments and urinary bladder is a challenging surgical disease. A Lichtenstein tension-free technique seems to be the best surgical procedure for both the patient and the operating surgeon. It should be used whenever possible in such cases.

Long-standing insulinoma: two case reports and review of the literature.

BACKGROUND: Insulinomas are rare pancreatic endocrine tumors. Most are benign and solitary. However, the nonspecific symptoms and small size of these tumors led to difficulties of diagnosis and localization. CASE PRESENTATION: We present two Arab patients with pancreatic long-standing insulinoma. Both patients presented episodic hypoglycemic symptoms respectively during 10 and 2 years. Biochemical and morphological workup detected localized pancreatic insulinoma. Open procedure surgery was done for the two patients and insulinomas were successfully removed by enucleation. CONCLUSION: Insulinoma remains a diagnostic challenge to practitioners. Diagnosis of suspected cases is easily confirmed by standard endocrine tests, especially the supervised fasting test. Accurate preoperative localization is essential for more effective and safest surgery.

Perineal approach for surgical treatment in a patient with retro-rectal tumor: a case report and review of the literature.

BACKGROUND: Retrorectal tumors in adults are very rare and little known condition. These tumors, often misdiagnosed or mistreated, should be completely excised because of the potential for malignancy or infection. A suitable operative approach is the key to the successful surgical management. CASE PRESENTATION: We report the case of a 45-year-old Arab male who presented with chronic pelvic pain accompanied by straining to defecate and dysuria. The clinical examination showed a painless mass in the left perineal area. Pelvic magnetic resonance imaging and computed tomography scan demonstrated a huge and well-limited pelvic mass causing displacement and compression of the rectum and bladder. Although the large size of the mass (>7 cm in the greater diameter), it was successfully and completely excised through only perineal approach without undertaking coccygectomy or sacrectomy. The histopathological study revealed a low-grade leiomyosarcoma. The patient is currently in 4-years follow-up with no signs of recurrence or metastasis. CONCLUSION: Even large retro-rectal tumors may be successfully excised by the perineal approach especially in carefully selected patients, but require extensive knowledge of pelvic anatomy and expertise in pelvic surgery.

Intestinal intussusception in a young women: unusual cause and specific management.

BACKGROUND: Intussusception in adults is a rare cause of abdominal pain that is often associated with organic pathology. We describe a case of ileocolic intussusception revealing a cecal adenocarcinoma in a young woman successfully managed by laparoscopic-assisted surgery adhering to oncological principles. CASE PRESENTATION: A 30-year-old woman with a family history of colon adenocarcinoma in a young brother presented to our emergency department with a 2-month history of intermittent colicky abdominal pain accompanied by nausea and vomiting. Physical examination showed a palpable mass in the right lower quadrant of the abdomen. Computed tomography showed a 3-layered structure giving the characteristic target-shaped appearance in the ascending colon, highly suggestive for an ileocolic intussusception associated with right colic parietal thickening and an adjacent lymphadenopathy. Patient was planned for laparoscopic exploration and eventually definitive surgery. Intra-operatively, we found an ileocolic intussusception with thickening of the colic wall and slight proximal intestinal dilation. Multiple lymphadenopathies along the ileocecal artery were observed. Laparoscopic right hemicolectomy was performed following strict oncologic principles with "en bloc resection" and lymphadenectomy given the risk of an underlying malignancy. Considering this risk, previous reduction of the invaginated segments was not attempted and primary extracorporeal anastomosis was performed using manual sutures. Macroscopic examination of the resected specimen revealed a tumor mass of the caecal wall .The histological analysis identified a moderately differentiated tubular adenocarcinoma invading the serosa (T3) without permeation of the lymphatic or venous capillaries. No lymphatic metastasis of 28 nodes removed was seen. Postoperative course was uneventful and patient was discharged 5 days after surgery. Postoperative chest, abdomen, and pelvis CT scan were normal. Therefore, tumor is classified as stage II A (T3N0 M0).There was loss of MLH2 and MSH6 protein expression on immunohistochemistry findings reflecting a microsatellite instability phenotype, and the patient was followed up without adjuvant chemotherapy. CONCLUSION: Ileocolic intussusception rarely revealed a cancer in young adults. Laparoscopic surgery has a special interest in the diagnosis and treatment in this pathology. Oncogenetic consultation should be required in malignant lesion.