Primary adrenal mantle cell lymphoma mimicking a non-functional retroperitoneal paraganglioma.

Key Clinical Message: Patients presenting with abdominal pain and retroperitoneal mass in radiographic images may be in the early stages of primary adrenal mantle cell lymphoma, which requires histological studies for a definite diagnosis. Abstract: This report presents a 37-year-old woman complaining of ambiguous abdominal pain, with imaging findings revealing a retroperitoneal abdominal mass on the left side of the aorta, and a possible diagnosis of non-functional retroperitoneal paraganglioma. Total laparoscopic excision was performed. Surprisingly, histological examinations revealed features in favor of mantle cell lymphoma.

Effectiveness of the oral Clonidine as a pre-anesthetic medicine for thyroidectomy surgery; A randomized clinical trial.

Introduction: Hemodynamic disturbance is a common problem in patients undergoing thyroid surgery. It may be due to episodic increases in thyroid hormones (thyroid storm) or stimulation of the carotid sinus baroreflex. The aim of the present study was to investigate effectiveness of the pre-operative oral Clonidine on reducing these hemodynamic changes during total thyroidectomy surgery. Methods: In a prospective, randomized, double-blind study, 80 patients scheduled for elective total thyroidectomy were randomized to receive either 0.2 mg Clonidine (n=40) or a matched placebo (n=40) orally sixty minutes before entering the operating room. Hemodynamic variables, the duration of surgery, estimated amount of blood loss and the dose of administered remifentanil were recorded for further analysis. Results: Oral Clonidine was found to be significantly better in maintaining stable hemodynamics compared to the control group. Also, In the Clonidine group, the estimated amount of blood loss (110.4±10 ml vs. 182.2±11.4 mL, P=0.04), duration of the surgery (78.26±55.2 min vs. 105.16±61.75 min, P=0.027) and administered dose of remifentanil (26.67±6.6 µg vs. 216.2±14.8 µg, P=0.01) were also significantly lower than the control group. Conclusion: Pre-operative administration of 0.2 mg oral Clonidine in patients undergoing total thyroidectomy results in improved perioperative hemodynamic stability and reduced response to perioperative stress.

Exosomes carrying immune checkpoints, a promising therapeutic approach in cancer treatment.

Exosomes are a subgroup of extracellular vesicles generated by distinct cells. Tumor-derived extracellular vesicles convey immunological checkpoint molecules. TEXs as critical mediators in tumor development, metastasis, and immune escape have recently become the focus of scientific research. Exosomes are involved in the regulation of the immune system. Exosomes interact with target cells in the tumor microenvironment, changing their function based on the cargo they contain. Exosomal immune checkpoints might be exploited to track tumor immune evasion, treatment response, and patient prognosis while enhancing tumor cell proliferation and spread. This review focuses on tumor-derived exosomes, their immunosuppressive effects in mice models, and their role in cancer immunotherapy. Exosomes are being studied as possible cancer vaccines, with numerous uses in tumor immunotherapy. Exosomes can carry chemotherapeutics, siRNA, and monoclonal antibodies. Exosomes produced by macrophages might be used to treat cancer. These and other clinical consequences provide new doors for cancer treatment.

Comparison of the Therapeutic Effects of a Pigtail Catheter and Chest Tube in the Treatment of Spontaneous Pneumothorax: A Randomized Clinical Trial Study.

OBJECTIVE: The purpose of this study was to compare the therapeutic effects of a pigtail catheter with a chest tube in the management of patients with spontaneous pneumothorax (SP). MATERIAL AND METHODS: A randomized controlled trial study was performed on patients with SP from August 2016 to December 2017 at Imam Reza Hospital, Tabriz, Iran. Forty-four patients were randomly assigned into 2 groups: group A with a 14-Fr pigtail catheter and group B using a 28-Fr chest tube. Two patients were excluded from the study. RESULTS: Forty-two patients participated in the study with 21 patients in each group. There were no significant differences between the groups in the patients' baseline data. The success rate was higher in patients with pigtail catheters (85.7%) than in patients with chest tubes (76.2%). However, the difference was not significant (P = .43). The procedure time was significantly shorter in the pigtail group compared to the chest tube group (P < .01). According to the visual analog scale (VAS), patients with pigtail catheters experienced milder pain during tube insertion than patients with chest tubes (P = .02). However, the pain score at the insertion site was not significantly different between the 2 groups for the first 2 days after the procedure. Patients with pigtail catheters experienced significantly less pain than patients with chest tubes during removal of the tube (P < .01). Also, there was no significant difference between the pain experienced by the 2 groups at the time of hospital discharge (P = .19). Analgesic drug usage was lower in patients with pigtail catheters compared to patients with chest tubes (P < .01). There was a trend toward lower median hospital stays demonstrated by patients with pigtail catheters compared to patients with chest tubes (P = .2). CONCLUSION: Pigtail catheters might be as effective as chest tubes for treating patients with SP in terms of lung re-expansion.

Comparison of end-to-side hand-sewn and side-to-side stapled cervical esophagogastric anastomosis in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy: an Iranian retrospective cohort study.

BACKGROUND: Controversies in terms of efficacy and postoperative advantages surround stapled esophagogastric anastomosis compared with the hand-sewn technique as a treatment for patients with esophageal cancer. The purpose of this study was to compare the clinical outcomes of hand-sewn end-to-side esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis after esophagectomy for the aforementioned patients. METHODS: This retrospective cohort study involved examining the medical records of 433 patients who underwent transhiatal esophagectomy for esophageal cancer from March 2010 to March 2016. All the patients were operated using end-to-side hand-sewn esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis. 409 of the patients received a year's worth of follow-up evaluations. All the cases were revisited in 2 weeks as well as in four, eight, and 12 months after surgery. The patients were assessed in terms of postoperative outcomes, including reflux symptoms, anastomotic leakage and stricture, and the need for anastomotic dilatation. RESULTS: Hand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (8 cases or 5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02). CONCLUSION: Side-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy.

Preoperative Vitamin D Supplementation in Patients With Vitamin D Deficiency Undergoing Total Thyroidectomy.

BACKGROUND: Transient hypocalcemia due to parathyroid gland or vessel manipulation is a common complication following thyroidectomy. Considering the role of 25-hydroxyvitamin D (25(OH)D) in calcium hemostasis, this study aimed to evaluate the effect of preoperative vitamin D supplementation on hypocalcemia incidence in thyroidectomy patients. METHODS: In this randomized clinical trial, 100 patients scheduled for total thyroidectomy and suffering from preoperative moderate or severe vitamin D deficiency were enrolled. Patients were randomly allocated to either study or control groups using the sealed envelope method. Patients in the study group received vitamin D3 50,000-unit pearl weekly for 4 weeks prior to the operation. The control group received placebo. Total and ionized serum calcium levels were checked before surgery, the day after surgery, and 2 weeks postoperatively. RESULTS: No significant difference was observed in terms of demographic data. During serial total calcium checks (5 episodes), total calcium levels changed significantly in patients who had received vitamin D supplements compared to the control group (P = 0.043). Symptomatic hypocalcemia incidence was significantly lower in patients supplemented with 25-hydroxyvitamin D (25(OH)D) (P = 0.04). Also, the requirement for intravenous calcium administration in order to treat the hypocalcemia symptoms was significantly lower in the study in comparison to the control group (P = 0.03). CONCLUSIONS: Vitamin D supplementation in patients with vitamin D deficiency might lead to a lower incidence of early-onset symptomatic hypocalcemia; hence, requiring less calcium supplementation for the management of hypocalcemia.

The Role of Immunohistochemistry Studies in Distinguishing Malignant Mesothelioma from Metastatic Lung Carcinoma in Malignant Pleural Effusion.

BACKGROUND AND OBJECTIVE: Early diagnosis of malignant pleural mesothelioma (MPM) is the key point of its treatment. The main problem is the precise diagnosis of mesothelioma and its differentiation from metastatic lung adenocarcinoma. Mesothelioma exhibits complex immunohistochemical characteristics. The aim of this study was to study hybrid immunohistochemistry in the differential diagnosis of primary malignant pleural effusion from metastatic pulmonary cancers. MATERIAL AND METHODS: Twenty tissue samples in paraffin blocks from the pathology department of Imam Reza Hospital in Tabriz whose pathology reports cited mesothelioma or metastatic lung adenocarcinomas, were included in the studies. These tissues were deemed appropriate for IHC in terms of tissue quality and quantity. They were studied and evaluated for pathological markers. RESULTS: In patients with adenocarcinoma CK7 in 100% of patients (13 patients), TTF1 in 61.5% of patients (8 patients) and CEA in 53.8% of patients (7 patients) were positive, but HBME1 and Calretinin were negative for all patients. In patients with mesothelioma, HBME1 and Calretinin were positive in 100% of patients (7 patients) and TTF1, CEA and CK7 were negative. CONCLUSION: The results of this study showed that CEA, CK7, TTF1, Calretinin and HBME1 are suitable criteria for differentiating between metastatic lung adenocarcinoma and mesothelioma, and can differentiate the mesothelioma and adenocarcinoma with high accuracy.

Randomized controlled trial on the comparison of chest tube drainage and needle aspiration in the treatment of primary spontaneous pneumothorax.

OBJECTIVES: To evaluate the efficacy of the chest tube drainage (CTD) and the needle aspiration (NA) in the treatment of primary Spontaneous pneumothorax (SP). METHODS: In a randomized controlled trial, seventy patients suffering SP were divided equally into two subgroups, as follows: (A) CTD and (B) NA. The immediate and one-week rate of the treatments was the primary endpoints. Postoperative complications, length of hospital stay and incidence of pneumothorax recurrence during one-year follow up were also recorded. RESULTS: The immediate success of treatment was 68.5% and 54.2% of patients in CTD and NA groups, respectively that showed no significant difference between study groups (P: 0.16). The complete lung expansion after one week observed in 32 (91.4%) of NA group and 33 (94.2%) patients in CTD group (P: 0.5). Pneumothorax recurrence was detected in 13 patients (4 in NA and 9 in CTD group) (P: 0.11). Mean pain intensity was significantly lower in the NA group at the first hour after the procedure, the first postoperative day and the first week after the intervention (P< 0.001). CONCLUSION: Needle aspiration (NA) can be applied as a first step treatment in patients with primary SP, considering its advantages.

Comparing postoperative complication of LigaSure Small Jaw instrument with clamp and tie method in thyroidectomy patients: a randomized controlled trial [IRCT2014010516077N1].

BACKGROUND: LigaSure® Small Jaw (LSJ) has been recently introduced as an energy-based vessel sealing device, which has provided better intraoperative and postoperative outcomes in thyroidectomies, compared to conventional technique. In the current study, we aimed to examine the efficiency of hand-sewn and LSJ thyroidectomy, based on operation time and perioperative complications. METHODS: All patients with the diagnosis of multinodular goiter, thyroid cancers, retrosternal goiter and other indications for thyroid surgeries, enrolled. Of 550 patients, 261 patients randomly assigned to the conventional group (A) and 274 patients to LigaSure Small Jaw group (B). Study groups compared concerning operative time, recurrent laryngeal nerve (RLN) injury, hypocalcemia, and postoperative complications. RESULTS: There was no significant difference regarding demographic data between groups A and B. During total thyroidectomy, intraoperative blood loss was 64.42 ± 20.72 ml and 49.64 ± 17.92 ml in groups A and B, respectively (P 0.043). Operative time was significantly lower in LSJ group compared to the conventional group in total and subtotal thyroidectomy (P 0.002; P 0.001). Three patients who underwent conventional total thyroidectomy had RLN palsy. However, there was no significant difference between techniques regarding RLN injury (P 0.134). Postoperative total and ionized serum calcium levels decreased compared to preoperative levels in both conventional and LSJ technique; however, changes in total and ionized serum calcium were more severe in patients with conventional thyroidectomy (total calcium, P < 0.0001) (ionized calcium, P 0.005). CONCLUSION: The LigaSure Small Jaw device decreases operative time and intraoperative bleeding compared to conventional technique. Besides, changes in total and ionized calcium levels in patients with LSJ thyroidectomy are subtle compared to HS technique. TRIAL REGISTRATION: Registered in Iranian Registry of Clinical Trials ( www.irct.com ), trial registration: IRCT2014010516077N1, Registered: 23 May 2014).

Predisposing factors for seroma formation in patients undergoing thyroidectomy: Cross-sectional study.

INTRODUCTION: Seroma is defined as collection of fluid within the surgical site during postoperative period that causes several complications. Recognition of predisposing risk factors can lead to avoid seroma formation after thyroidectomy. MATERIALS AND METHODS: A cross-sectional study was carried out during a 3-year period and 678 patients were enrolled the study. We recorded demographic data, past medical history and the type of thyroidectomy were for all patients. We measured total and ionized serum calcium and albumin level in all patients before surgery and a day after it. All patients underwent total or subtotal thyroidectomy and if needed central neck dissection was performed subsequently. Patients underwent serial aspiration If they had seroma formation. RESULTS: The overall post-thyroidectomy seroma incidence was 2.2%. There was no statistically significant correlation while evaluating gender, age and body mass index with post-operative seroma formation. However, seroma formation was significantly higher in patients underwent total thyroidectomy (P = 0.041). The results of postoperative laboratory tests showed a significant lower level of ionized calcium in patients with seroma formation (P < 0.0001). Logistic regression showed statistically significant value for variables including age, BMI and decreased ionized calcium level, in developing of seroma. CONCLUSION: We showed that Seroma formation was lower during thyroidectomy via electrical vessel sealing system in comparison with previous studies. In our study, older age, greater body mass index and decreased ionized calcium level were predictors of seroma formation.

Axillary Lymph Node Metastasis in Medullary Thyroid Carcinoma: A Case Report.

INTRODUCTION: Medullary thyroid cancer (MTC) is an uncommon neoplasm originating from parafollicular C cells. Distant metastasis in MTC, such as axillary node involvement, is extremely rare. CASE REPORT: The present study describes a known case of MTC with axillary lymph node metastasis in a 31-year-old woman. In 2010, she underwent total thyroidectomy and right-sided modified radical neck dissection. In May 2015, she was referred with a 3-month history of a mass in the left axilla. Fine needle aspiration cytology (FNAC) confirmed MTC in the axillary nodes. Left axillary lymph node dissection was performed and postoperative histopathology revealed metastatic medullary thyroid carcinoma in prepared specimens. CONCLUSION: MTC with axillary lymph node metastasis is a rare condition which has been reported in previous studies to impair patient prognosis. However, in the current case, the patient had no other MTC-related complications subsequent to final lymphadenectomy.

Combination of intracostal sutures with muscle flap to decrease post thoracotomy pain: A single blinded randomized clinical trial.

OBJECTIVE: To assess the efficacy of intercostal nerve protection by intercostal muscle (ICM) flap in post-thoracotomy pain improvement compared to intracostal suturing. METHODS: In a randomized controlled trial, ninety-four patients undergoing posterolateral thoracotomy surgery were divided into two subgroups. Intracostal sutures in isolation and in combination with ICM flap techniques were used for thoracotomy closure in both groups. Numeric Pain Scale and Visual Pain Scale as pain scores were assessed on the first, second, third, fourth, fifth, sixth and seventh postoperative days and follow-up visits during the 2nd week, 1st, 2nd, 4th and 6th months after thoracotomy. RESULTS: Out of 94 patients, 58 were male and 36 were females. While the mean age of patients in intracostal group was 45.3 ± 17.6 years, it was 47.4 ± 16.1 years in intracostal plus ICM flap group. The mean operation time for the first group was 191.0 ± 74.7 minutes, while it was 219.3 ± 68.8 minutes in the second (p>0.05). Numeric rating score and visual pain scale did not demonstrate any significant difference in pain severity on postoperative days and follow-up visits between both groups (p>0.05). Although the trend of pain reduction was significant in each group (p<0.001), the difference was not statistically significant (p>0.001). CONCLUSION: Intracostal sutures in combination with muscle flap did not reduce postoperative pain in thoracotomy compared with intracostal sutures alone in thoracotomy closure.

An unusual salvage technique for posterior tracheal membranous laceration associated with transhiatal esophagectomy: A transcervical-transsternal approach.

Various surgical approaches may be employed for esophageal resection. Major airway injuries due to transhiatal esophagectomy include vertical tears in the membranous trachea. Tracheal injury is an uncommon but potentially fatal complication. This article describes the technique to repair the posterior membranous tracheal tear, extended just over the carina through a transcervical-transsternal approach, thereby avoiding a second thoracotomy. Six patients with posterior membranous tracheal injury underwent this procedure. The laceration ranged from 3 cm to 5 cm in length. Four patients had received neoadjuvant chemoradiation. The management of tracheal laceration added approximately 60 minutes to the total operation time. There was no mortality related to tracheal injury. Patients were followed up for 6 months after surgery, and both posterior tracheal wall and transverse tracheotomy remained intact without stenosis. The transcervical-transsternal approach decreases the need of thoracotomy and its complications in patients with tracheal laceration in any stage, even in cases of an extended tear down to the carina.

RET Gene Analysis in Patients with Medullary Thyroid Carcinoma.

BACKGROUND: Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor from the para follicular C cells of the thyroid gland. It occurs either sporadically or as part of an inherited syndrome. It is caused by an autosomal dominant mutation in the RET (Rearranged during Transfection) proto-oncogene. METHODS: The studied population consisted of 47 patients diagnosed with MTC in a specific population of northwest Iran along with their three children. Blood samples were collected from all subjects, genomic DNA was extracted and RET exons 10, 11, 13, 14, 15, and 16 were analyzed using PCR and direct sequencing. RESULTS: 32 missense mutations were identified in exons 10 (6.25%) and 11 (84.4%). Moreover, two novel mutations in codon 595 in exon 10 (E595D and E595A) and a new mutation in codon 689 exon 11 (S689T) were detected, and a new nucleotide change was found in exon 11 (T675T). Four different polymorphisms were also identified in exons 11, 13, 14, and 15. Based on our data, the frequency profile of RET mutations in the Azari population of Iran with MTC is 61.7%. The most frequent mutation in our population was C364G, whereas in most populations it is C634R. CONCLUSIONS: These results underline the importance of the genetic background of family members of any patient with MTC.

Pectus excavatum repair using Prolene polypropylene mesh.

OBJECTIVE: We aimed to assess the clinical outcomes of our surgical technique for repair of pectus excavatum using Prolene polypropylene mesh. METHODS: Among 29 patients with pectus excavatum, the major complaint was cosmetic dissatisfaction, and the main symptom was exercise dyspnea in 15 patients. The Haller index used to assess pectus excavatum severity; it was significant in 22 patients. In all patients, a 2-layer sheet of Prolene polypropylene mesh was placed behind the sternum. RESULTS: No serious complication was observed postoperatively, and all patients were satisfied with the cosmetic result. Mitral valve prolapse improved in all cases after 3 months. Spirometry revealed improved pulmonary function after surgery. CONCLUSION: With due attention to the advantages of Prolene polypropylene mesh, such as remaining permanently in place, adapting to various stresses encountered in the body, resisting degradation by tissue enzymes, and trimming without unraveling, we concluded that this mesh is suitable for use as posterior sternal support in pectus excavatum patients.

A huge lymphangioma mimicking pleural effusion with extension to both chest cavities: a case report and review of literature.

Mediastinal lymphangioma is primarily a benign lesion and the majority of the cases are found incidentally. These lesions account for approximately 1% of all mediastinal tumors. Here we present a giant mediastinal cystic mass in a 35-year-old female who was presented with severe respiratory distress. On the plain chest radiography and CT scan, a massive left pleural effusion with large parasternal and mediastinal lymphadenopathy was seen. Thoracentesis was performed and 400 cm³ of clear fluid was drained from the left hemithorax. However, a subsequent CT scan with contrast and the same technique 40 days later showed a large cystic mass in the mediastinum protruding to the right and left hemi thoraces. The giant cystic mass was resected via right and left anterior thoracotomies. Histopathological examination revealed a diagnosis of lymphangioma. The patient has been alive and without tumor recurrence and has been followed for 2 years.

Mucinous adenocarcinoma of trachea: a rare case of primary tracheal tumor.

A primary tracheal tumor is not common, but adenocarcinoma is particularly rare. We describe a case of primary tracheal mucinous adenocarcinoma misdiagnosed as asthma in a 17-year-old girl. Computed tomography revealed an intraluminal partially obstructing mass in the mid portion of the trachea. A sleeve resection of the involved trachea with primary anastomosis was performed, followed by adjuvant radiotherapy. After 23 months of follow-up, there has been no recurrence.