A case report of a rare intramuscular granular cell tumor.

BACKGROUND: Granular cell tumors (GCTs) were firstly described by Weber in 1854 and 70 years later by Abrikossoff and classified as benign tumors. Originally considered muscle tumors, they have been identified as neural lesions, due to their close association with nerve and to their immunohystochemical characteristics. GCTs are uncommon tumors and they may arise in any part of the body; they have been mainly observed in tongue, chest wall and upper extremities; less frequent sites are larynx, gastrointestinal tract, breast, pituitary stalk and the female anogenital region. Here we report a case of GCT showing an uncommon localization such as the upper third of the right rectus muscle of the abdominal wall. CASE PRESENTATION: A 45 year-old woman of Caucasian origin presented to the surgeon with a 6-month history of light pain in the upper third of the abdominal wall. Radiological exams (Ultrasonography, Computed Tomography and Contrast magnetic resonance imaging) showed a localized in the right rectus abdominis muscle. After excision, histological and immunohystochemical analysis, with the support of electron microscopy, allowed making diagnosis of granular cell tumor. DISCUSSION: After fist description by Abrikosoff in 1926 of GCT like mesenchymal tumor of unknown origin, in recent years immunohystochemical techniques definitely demonstrated the histogenetic derivation of GCT from Schwann cells. Granular cell tumors are rare, small, slow-growing, solitary and painless subcutaneous nodules which behave in a benign fashion, but can have a tendency to recur; in rare cases they can metastasize, when they became malignant; there are some clinical and histological criteria to suspect the malignance of this tumor. CONCLUSION: It is important that clinicians, radiologists and pathologists are aware of the clinical presentation and histopathology of GCT for appropriate management, counselling and follow-up. In our case we had a complete radiological, morphological and immunohystochemical characterization of the lesion and a definitive diagnosis of benignity confirmed by electron microscopy.

[Day-surgery as a factor in reducing hospital stay]. / La day-surgery come fattore di riduzione della durata della degenza.

The authors analyse the factors that have conditioned the early development of day-surgery in Italy and enumerate its fields of application. They outline the history of day-surgery and report the results of studies, citing laws, documents, rules and guidelines governing its application in Italy today. They also analyse the reasons why a more widespread use of day-surgery is proving difficult in Italy. They consider the surgeon's liability and briefly report the results of day-surgery activity at the "G. Martino" Polyclinic Endocrine General Surgery Unit in Messina, consisting in over 3000 operations since 1987. In conclusion, they consider the undoubted advantages of day-surgery for selected operations and stress that it is an effective alternative in comparison with the traditional hospital stay, according to the new philosophy inspiring modern medical care, namely, that of "operating better, in the patient's interest, at lower cost, and quickly".

[Ileal leiomyosarcoma presenting with an episode of acute massive intestinal bleeding]. / Leiomiosarcoma ileale manifestatosi con episodio di enterorragia acuta massiva.

The aim of this article was to present a case of gastrointestinal stromal tumour (GIST) presenting with acute intestinal bleeding. The Authors outline the histogenetic, clinical, diagnostic and prognostic profile of this pathology. Technical progress in immuno-histochemical and ultrastructural diagnostics has made possible to go beyond the old definition of gastrointestinal stromal tumours and identify several subgroups of such tumours on the basis of nervous and/or muscular phenotypic differentiation. The histopathological and structural variety of GIST accounts for their different clinical manifestations and variable and unpredictable biological behaviour. Histological criteria are by no means of absolute value: tumours considered benign on the basis of histology may present a malignant behaviour in the course of time, with the development of metastases and recurrences. In this regard, a number of predictive malignancy indices have been identified such as the patient's age, tumour size, presence of haemorrhage and necrotic areas, high mitotic index (> 5 mitoses/50 HFP), and kit-gene mutations. The Authors stress the diagnostic importance of 99m Tc-RBC scintigraphy in the case reported and agree with the literature as to the appropriate therapy, consisting in intestinal resection. The therapy of active GIST is essentially surgical and consists in resection of the intestinal tract affected by the tumour: lymphadenectomy must be performed only in case of need, because GIST metastasis preferably via the blood stream. As far as therapy is concerned, the demonstration of kit-gene mutation, expressed by the more aggressive forms, has made it possible to produce an inhibitor of protein tyrosine kinase Ber-Abl, which causes selective inhibition of cellular proliferation both in vitro and in vivo and induces apoptosis of Ber-Abl positive cell lines.

[Haemorrhagic complications in thyroid surgery. Control of bleeding from retroneural vessels using collagen and thrombin gelatine granules]. / Complicanze emorragiche in ch irurgila tiroldea. Impiego di granuli di gelatina di collageno e trombina.

They conclude that numerous factors contribute towards causing haemorragic complications, such as the technique used for haemostasis, the drainage, and the haemorragic risk factors presented by the individual patient. Prevention of bleeding, however, will depend essentially on the surgeon's experience and the precautions he takes. Of particular interest is the use of FloSeal (collagen and thrombin gelatine) to treat bleeding from retroneural arterial vessels, wich has often been seen to pose a serious problem for the surgeon. The results obtained in the case series described confirm the validity of this haemostatic sealant (arrest of bleeding in 100% of treated patients).

[Complications of open prosthetic surgery for large incisional hernias]. / Le complicanze della chirurgia protesica "open" dei grandi laparoceli.

The authors examine the complications of open prosthetic surgery for incisional hernias and analyse them from different points of view. The case series includes, over a period of 16 years, 492 hernioplasties for incisional hernias and 160 (32.5%) for large incisional hernias. The authors stress that the best results have been achieved by the retromuscular placement of prostheses. They conclude that while, on the one hand, the successful use of prosthetic material has marked the end of the inoperability of this pathology, such procedures are closely associated with the development of complications, which were unknown in the pre-prosthetic era and are sometimes very serious and linked to the site of the prosthesis and to the kind of material used.

[Iatrogenic injuries to the colon]. / Le lesioni iatrogene del colon.

The authors examine a number of aetiological, diagnostic and therapeutic aspects of iatrogenic injuries to the colon on the basis of an analysis of their own experience and a review of the literature. They highlight the low incidence of this kind of injury, which accounts for only 0.3% of all visceral injuries. Endoscopy and laparoscopic surgery are the most important causes of iatrogenic injuries to the colon. The authors conclude that these injuries are less serious and have a better prognosis than other kinds of colon perforations, because the colon is "clean" and it is possible to obtain an early diagnosis. Exceptions are lesions that occur in the course of a barium enema since these are associated with a high mortality rate which in some series may be as high as 100% of cases owing to the high toxicity of the barium contrast medium.

Effects of thyroidectomy alone or followed by radioiodine ablation of thyroid remnants on the outcome of graves' ophthalmopathy.

Fifty-five patients with Graves' disease (GD) and mild to moderate Graves' ophthalmopathy (GO) underwent near-total thyroidectomy (Tx). In 16 patients this was followed by a standard ablative dose of (131)I because of the hystologic evidence of differentiated thyroid carcinoma. We retrospectively evaluated whether or not GO activity could be affected by thyroid surgery alone or followed by complete ablation of thyroid tissue. Accordingly, on the basis of clinical activity score (CAS) values prior to thyroidectomy, we identified two groups: group A with active GO (CAS > or = 3; n = 31) and group B with inactive GO (CAS < or = 2; n = 24). CAS values were then recorded at 6, 12, and 24 months after surgery/(131)I ablation. Over the course of the follow-up period, GO became inactive in approximately 70% of group A patients (CAS 4.2 +/- 0.8 at baseline, 2.1 +/- 2.0 at 24 months, p < 0.0001) and became active in 37.5% patients from group B. When we examined GO activity according to the type of treatment used (Tx or Tx and (131)I), the prevalence of inactive GO both short- and long-term, was significantly higher in the group of patients who underwent Tx and (131)I ablation. Therefore, this seems to be a more effective means of inducing and maintaining inactive GO.

[Pancreatic echinococcosis. Report of a clinical case and review of the literature]. / Echinococcosi pancreatica. Descrizione di un caso clinico e revisione della letteratura.

We report a case of a suppurative hydatid cyst of the pancreas treated surgically (internal drainage on Roux "Y" loop). Follow-up at 6 months revealed no evidence of the cyst. We emphasise the low incidence of the disease in a pancreatic site (02-2% in the literature). This was the first case in our experience despite the fact that Sicily is an area in which the parasite is endemic. We also emphasise the preoperative diagnostic difficulties: ultrasonography and computed tomography yielded very images very similar to those of a pseudocyst or cystic carcinoma. In most cases, in fact, as in the one reported here, the condition is diagnosed during surgery.

Transclavicular access as an adjunct to standard cervical incision in the treatment of mediastinal goitre.

There are cases in which resection of cervico-mediastinal goitres requires additional thoracic access as an adjunct to standard transverse cervicotomy, and typically this takes the form of sternotomy or thoracotomy. The authors propose transclavicular access as an alternative to thoracotomy or sternotomy access for the removal of such goitres. This technical variant is performed by means of resection of the middle third of the clavicle and extraperiosteal disarticulation. They report a case of cervicomediastinal or "plunged" goitre associated with mediastinal metastasis from a follicular thyroid carcinoma in a 77-year-old woman, in whom this technical variant was used. They conclude by stressing the greater effectiveness, ease of execution and relatively limited "aggressiveness" of the technique in comparison with other ways of reaching the mediastinum. The variant proves effective in solving a number of technical, functional and aesthetic problems.