A low grade osteosarcoma of the colon.

BACKGROUND: Soft-tissue osteosarcomas are very rare. Only three cases of extraskeletal osteosarcoma have been reported arising in colon and we report the first well differentiated one. PATIENTS AND METHODS: A 58-year-old woman was admitted to our hospital with a history of pain and swelling in lower right abdomen for the last 3 months. Routine laboratory tests and tumor markers (CEA, CA19-9, AFP) were all normal, as well as colonoscopy. CT-scan revealed large partly calcificated mass connected to the ascending colon without significant imbibition of contrast. Because of the size of the tumor, open surgery was indicated. An exploratory laparotomy followed by right hemicolectomy with anastomosis was performed according to oncological principles. RESULTS: Surgery and pathology confirmed the presence of 13 cm large soft tissue tumor connected to the colon by vascular pedicle. Histopathology showed spindle cells with minimal cellular atypia and focal osteoid production which lead to diagnosis of low grade osteosarcoma. Immunohistochemicaly, neoplastic cells were positive for alpha smooth muscle actin, caldesmon and desmin, but are negative for S100, CD34, CD117, DOG1, BCL-2, epithelial membrane antigen, and beta-catenin. CONCLUSION: Postoperative course went uneventful and adjuvant chemotherapy was not recommended. At 6-months follow-up there was no sign of recurrent tumor.

Language recovery after acute intracerebral hematoma in temporoparietal region.

Arteriovenous malformations are the most common cause of spontaneous intracerebral hemorrhages in older children. Intracerebral hematoma can cause serious lasting neurologic, cognitive, and language deficits, or even possible death. We present the case of a 16-year-old boy who had language impairments after suffering a large hemorrhagic stroke in the left temporoparietal region. All language components, verbal and nonverbal communication, reading, and writing, were found to be affected. These impairments were expected as they are characteristic of the location of the hematoma. After a year of speech language rehabilitation, there was an almost complete recovery of language skills. Quick diagnosis and adequate therapeutic interventions are important to diminish the influence of intracerebral hemorrhage on cognitive and language functions in children.

First quadricuspid aortic valve to be reported in Croatia.

Quadricuspid aortic valve is a rare congenital malformation of the aortic valve. Even in the era of a transthoracic and transesophageal ultrasound the occurrence is sometimes missed. Aortic incompetence occurs usually in 5th or 6th decade of life requiring surgical intervention. We report on a 70-year-old woman who presented with exertional dyspnea. In a diagnostic setting transthoracic ultrasound, helical computed tomography scan of the chest and coronary angiography including aortography were performed. Unusual aortic valve anatomy was not described as it was not expected. Finally, the diagnosis of this congenital malformation was established intraoperatively.

Criteria and procedures for breast conserving surgery.

AIM: Emphasizing circumstances that determine increasingly popular surgical approach of breast conserving surgery (BCS), used in lower grade breast tumors, while maintaining survival that is found when more radical procedures are used. PATIENTS AND METHODS: Several leading oncological protocols in the world are compared, using PubMed database, and our own experience. Data gathered are compared to conclusions of Consensus Conference on Breast Conservation (Milan, 2005). Furthermore, surgical contraindications found in our everyday work are considered, having in mind satisfactory cosmetic outcome, as well as keeping the 1 cm border of "clear" edges. Such more practical problems of edge detection can compromise BCS results. RESULTS: After observing several relevant protocols, we found very high frequency of mastectomy vs. BCS, despite the fact that stage of disease was low. We also found only 20% of absolute contraindications for BCS. Most frequent contraindication for BCS was multicentricity of the tumor (with micro calcifications), especially in ductal in situ carcinoma. CONCLUSION: BCS followed by radiation therapy with tumor-free edges is standard procedure in treatment of T1 and small T2 breast cancers. This approach implies higher risk of local recurrence (LR), although local recurrence is low (1% per year), with rates of survival similar to radical procedures.

Calcium at the carotid siphon as an indicator of internal carotid artery stenosis.

OBJECTIVES: Carotid siphon calcification is often visible on unenhanced head CT (UCT), but the relation to proximal carotid artery stenosis (CAS) is unclear. We investigated the association of carotid siphon calcification with the presence of CAS. METHODS: This IRB-waived retrospective study included 160 consecutive patients suspected of stroke (age 64 ± 14 years, 63 female) who underwent head UCT and CTA of the head and neck. CAS was rated on CTA as not present or present with non-significant (<50 %), moderate (50-69 %) or significant (≥70 %) stenosis. Presence, shape (on UCT) and volume (on CTA) of carotid siphon calcifications were related to CAS. RESULTS: Carotid siphon calcification was absent in 41 % of patients and bilateral in 94 % of those with calcifications. Presence, shape and volume of calcification resulted in odds ratios for having significant CAS of 10.1, 3.9 and 8.4, with 95 % CIs of 1.3-79.6, 1.1-14.1 and 2.6-26.8, respectively. Corresponding NPVs were 0.98, 0.98 and 0.96, while PPVs were 0.14, 0.07 and 0.29, respectively. CONCLUSION: Absence of calcification in the carotid artery siphon on UCT has high negative predictive value for carotid artery stenosis in patients with suspected stroke. However, siphon calcification is not a reliable indicator of significant carotid artery stenosis. KEY POINTS: • Many stroke patients do not have calcification in the carotid artery siphon. • Carotid stenosis ≥50 % is unlikely in stroke patients without siphon calcification. • Carotid siphon calcium is a poor indicator of significant carotid artery stenosis.

The effect of epineurotomy on the median nerve volume after the carpal tunnel release: a prospective randomised double-blind controlled trial.

PURPOSE: The purpose of this study was to evaluate the effects of epineurotomy on the post-surgical median nerve volume and clinical outcomes in carpal tunnel syndrome (CTS) patients with a prominent nerve narrowing. METHODS: This was a prospective, randomised, double-blind controlled trial. Patients (n = 50) were randomised (1:1) to open-field surgical carpal tunnel release followed by a longitudinal epineurotomy of the nerve (test), or to open-field release without epineurotomy (control). RESULTS: The nerve volume was slightly larger in the test group 90 days post-surgery (by 10.5 %, p = 0.157) but not 180 days post-surgery. No relevant electropyhsiological or clinical difference between groups and no effect of the nerve volume was observed. The subjective pain reduction was slightly more prominent in the control group at 180 days. Larger post-surgical nerve volume was associated with lower pain, but only in the control group. CONCLUSIONS: Even in selected CTS patients, longitudinal epineurotomy confers no benefit regarding the nerve volume or clinical outcomes over a simple carpal tunnel release.

Arthroscopic decompression of suprapatellar cyst: case report.

Bursae around the knee reduce friction between moving structures. When involution of suprapatellar septum fails to occur ("complete septum"), then suprapatellar bursa may stay completely separated from the knee joint cavity to form a cystic cavity. In the case of the increased volume, suprapatellar bursitis can cause painful suprapatellar swelling. The aim is to point to the possibility of arthroscopic decompression of suprapatellar cyst. In the case presented, the indication for knee arthroscopy was based on clinical examination, ultrasonography and magnetic resonance studies. The preoperative diagnosis was verified intra-operatively, and intra-articular cyst decompression was performed by arthroscopy. At the final examination 8 months postoperatively, the patient still had no pain, swelling and had full range of motion. This minimally invasive operative procedure resulted in a satisfactory anatomic and functional outcome. In this case report, we present a patient with suprapatellar cyst submitted to arthroscopic cyst decompression.

[Osteochondral fracture of the patella after acute dislocation]. / Kostano-hrskavicni prijelom ivera kao posljedica akutne luksacije.

Acute patellar dislocation is a common injury in young athletes, which occurs due to inappropriate biomechanical relations and anatomic deviations in the area of knee joint. In these unfavorable conditions, abrupt and vigorous strain of the quadriceps muscle of the thigh may result in lateral patellar dislocation. A case is presented of a young male athlete with acute patellar dislocation and consequential osteochondral fracture. Although x-ray showed normal knee finding, typical history, clinical examination and magnetic resonance image of the knee indicated arthroscopy, which confirmed the diagnosis ofpatellar dislocation. The osteochondral fragment was found and fastened by screws, thus reconstructing the articular surface of the patella. Medial patellar stabilizers were strengthened and lateral stabilizers loosened, thus re-establishing its anatomic slide way. On second-look operation, the screws were removed. In this case, good anatomic and functional outcome was achieved by timely operative treatment, joint surface reconstruction and rehabilitation.

Fournier gangrene: our approach and patients.

AIM: This retrospective analysis presents our experience in treating Fournier gangrene (FG) and aims to bring in focus diagnostic and therapeutic problems as well as early and aggressive treatment. PATIENTS AND METHODS: A total of 16 male patients were included in the study. The gastrointestinal form was seen in 5 and the urogenital form in 11 patients. The subjects ranged in age from 39 to 74 years (average 61) for the urogenital, and from 48 to 72 (average 58) for the gastrointestinal form. Other conditions were seen in 9 patients (diabetes mellitus was most common). Most patients were infected with several bacteria. We performed colostomy in 1 patient, orchidectomy in 2 patients, cystostomy in 2 patients and penis amputation in 1 patient. Ultrasound-guided biopsy or aspiration, and CT was also used. Aggressive surgical necrectomy and aggressive antimicrobial therapy was used. RESULTS: Treatment was successful in 14 of 16 patients (87.5%). The length of hospitalization was 19-58 days (average 48) for the urogenital form and 24-56 days (average 41) for the gastrointestinal form. Mortality was 12.5%. A lethal outcome was recorded in two patients infected with methicillin-resistant Staphylococcus aureus. The average time between onset and hospitalization was 3-11 days (5 on average) for urogenital FG and 4-10 days (average 6) for gastrointestinal FG. Treatment was significantly longer in patients with a comorbidity, such as diabetes or liver cirrhosis due to alcohol abuse. CONCLUSION: Early diagnosis as well as intensive and aggressive treatment are key to successful treatment of FG. Comorbidity increases length of therapy and lowers the chance for recovery. Disease can be seen again several years after the initial outburst.

Microdochectomy in the management of pathologic nipple discharge.

BACKGROUND: There is a debate in the literature whether a pathologic nipple discharge is a distinct sign of breast carcinoma. Our own results obtained by the use of microdochectomy as a minimally invasive operative procedure in 184 patients with pathologic nipple discharge were analysed. The aim of this retrospective 20-year study was to assess the efficacy of microdochectomy in detecting early stages of intraductal breast carcinoma. PATIENTS AND METHODS: The study included data on 184 patients aged 24-77 years (median 46.6) divided into two groups of premenopausal (n = 123) and postmenopausal (n = 61) women. There were 139 patients with unilateral single-duct sanguinolent discharge and 45 patients with other types of nipple discharge. The operative procedure consisted of the discharging duct excision by use of a guide probe, preceded by cytology and ductography studies. RESULTS: Histopathology of the excised ducts revealed only three carcinomas in premenopausal women and ten carcinomas in postmenopausal women. In a total of 13 carcinomas, there were 4 ductal carcinomas in situ, detected in patients aged 41-72 (median 66) years. Twelve carcinomas were associated with sanguinolent nipple discharge. Papilloma was the most common histology finding (56.5%). CONCLUSION: Results of the study suggested mainly the association of sanguinolent single-duct nipple discharge and papilloma, whereas the rate of malignancies detected (7.0%) was consistent with literature reports. Microdochectomy proved to be a highly efficient operative method free from any impairment of the breast integrity. Conservative treatment with close clinical monitoring of the patient with cytology and ultrasonographic assessment might be possible in selected cases.

[Ileus caused by metastasis of cutaneous malignant melanoma: case report]. / Ileus izazvan metastazom koznog malignog melanoma: prikaz bolesnika.

In this case report we describe rare metastatic appearance of cutaneous malignant melanoma ( MM) in small intestine followed by clinical appearance of acute surgical abdomen. A 42-year old women operated in our hospital in April 2009. due to unusual naevus on her right arm. Pathologicaly it was MM grossly 1.5 cm, microscopically Breslow 11 mm, Clark's level IV (T4), number of mitosis 1.4 per mm2, without ulcerations. She was sent to continue treatment at the National Referal Center for Melanoma in KB "S. milosrdnice" Zagreb, Croatia. A month later wider excision (3 cm free margin) and sentinel lymph node biopsy (SLNB) was made there followed by axillary lymphadenectomy due to positive axillary finding. She received six cycles of chemotherapy. She arrived in our hospital in May 2010, under clinical picture of small intestine ileus and acute surgical abdomen. After preparation she was operated the same day. The cause of ileus was metastasis of MM in the small interstine. We made intestinal resection with termino-terminal anastomosis. The patient was released to home care ten days after operation without any complication. This case report demonstrates rarely described case of MM metastasis in the small intestine found causing ileus.

Phyllodes tumors of the breast diagnostic and therapeutic dilemmas.

BACKGROUND: This article compares experiences in the diagnosis and treatment of phyllodes tumors from 2 regional institutions with the relevant literature. PATIENTS AND METHODS: From 1991 to 2005, 2,848 breast cancer patients were treated in our institutions, 36 (1.44%) for phyllodes tumors. The average tumor size was 5.1 cm (range 1.4-19.6). Triple assessment was the standard diagnostic algorithm. Wide excision with tumor-free margins was carried out in 29 (80.5%) cases and mastectomy in 7 (19.4%) cases. Axillary lymphadenectomy was performed in patients with positive lymph nodes. RESULTS: Histology showed the phyllodes tumors to be benign in 27 (75.0%), malignant in 6 (16.6%), and borderline in 3 (8.3%) cases. Follow-up was from 5 months to 16 years. In this period, recurrences of 3 (8.3%) malignant and 2 (5.6%) benign phyllodes tumors were diagnosed and treated. 10 (27.7%) patients treated with wide local excision showed deformities in the form of scarring. The steroid receptor status was of no prognostic value in our patients, and chemotherapy was used in only 1 (2.7%) patient. 5-year survival was 86.2%. CONCLUSION: Our study shows that tumor size, margin infiltration, mitotic activity and degree of cellular atypia are important prognostic factors. Problems in diagnosing this condition arise from its similarity to fibroadenoma. Although wide local excision is usually the treatment of choice, tumor recurrence is common. Axillary lymphadenectomy in malignant phyllodes tumors is, in our opinion, still controversial.

[Posterior horn cyst of the medial meniscus]. / Cista straznjeg roga medijalnog meniskusa.

We will present a rare case of a large symptomatic cyst of the medial meniscus, conjoined with a horizontal tear of a posterior meniscal horn. After clinical, radiological and ultrasound examination, a diagnosis was confirmed with MRI examination of the knee. Literature supports surgical therapy, which includes complete arthroscopic technique, meniscectomy and decompression of the cyst. In our case, it showed that arthroscopic partial meniscectomy and opened cystectomy were the efficient way of treatment.

Met-enkephalin effects on histamine-induced bronchoconstriction in guinea pigs.

We investigated the effects of the neuropeptide met-enkephalin on histamine-induced bronhoconstriction in an experimental model of asthma. Classic Konzett and Rössler's method of whole body plethysmography modified by Gjuris, was applied in the study. This method represents a standard experimental model of bronchoconstriction, suitable for the evaluation of peptide effects on the histamine-induced bronchoconstriction. The results of the measurements implicate a dose-related modulatory effect of met-enkephalin on the bronchoconstrictor action of histamine. Met-enkephalin doses of 1 mg/kg and 10 mg/kg, respectively, caused statistically significant reduction of the histamine-induced bronchoconstriction. Estimated ED50 dose was 0.235 mg/kg. Further studies are needed to define practical and therapeutical use of the presented observations in respiratory pharmacology.