Armand Asarian

Eccrine porocarcinoma of the lower extremity: A case report and review of literature

Eccrine porocarcinoma is a rare malignancy of the eccrine sweat gland. It is usually found frequently on the lower extremities, and it affects both sexes equally usually in the sixth to seventh decade. In our case, we present a 42-year-old male patient with a recurring exophytic tumor on the right lower extremity without local extension. The initial tumor was biopsied, excised and diagnosed as an eccrine poroma. The tumor then recurred 6 years later, was re-excised, reconstructed with a soleus muscle flap and diagnosed as an eccrine porocarcinoma.

Percutaneous endoscopic suturing: an effective treatment for gastrocutaneous fistula

BACKGROUND Development of persistent gastrocutaneous fistula and leakage after the removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping/suturing, electric and chemical cauterization, argon plasma coagulation, and fibrin sealant, have been used with variable success. Although surgical closure is the current treatment of choice, most of the elderly patients are poor surgical candidates because of multiple comorbid conditions. OBJECTIVE We describe a method of endoscopic suturing of a gastrocutaneous fistula that is a safe and cost-effective alternative to surgical closure. DESIGN Individual case. SETTING Community hospital. PATIENT One elderly patient. INTERVENTIONS By using a trocar, we placed multiple, long monofilament sutures from the skin around the gastrocutaneous fistula in criss-cross fashion. Gastric ends of these sutures were pulled from the stomach with a snare under endoscopic visualization. Suture knots were made at the gastric end of the sutures and then were pulled back from the cutaneous side. Multiple biopsy specimens were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at skin level to obliterate the fistula. RESULT Our procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within 7 days. The patient tolerated the optimal rate of enteral nutrition without further leakage. LIMITATION Only 1 patient. CONCLUSION We believe that this method of endoscopic suturing along with de-epithelialization of the fistula tract for persistent gastrocutaneous fistula is a safe and cost-effective alternative to surgical closure.

Duodenal web associated with malrotation and review of literature

Intestinal obstruction due to midgut malrotation in neonates is well known. The incidence of malrotation in newborns is around 1:500 and the symptomatic incidence is 1:6000 births. Duodenal web as a cause of intestinal obstruction is less common and is reported to be 1:10 000–1:40 000. Malrotation is known to be associated with other congenital obstructive anomalies including duodenal atresia, stenosis and duodenal web. But, intestinal obstruction due to malrotation associated with duodenal web has been reported only rarely with a few published cases in our literature review. We present a case of intestinal obstruction diagnosed in the prenatal period via sonogram. A plain X-ray of the abdomen after birth showed a distended duodenum with paucity of air distally suggesting duodenal obstruction. An exploratory laparotomy showed a duodenal web proximal to the sphincter of oddi. The patient also had an associated malrotation and underwent Ladds procedure and appendectomy. The post-operative period was uneventful.

Splenic injury from colonoscopy: a review and management guidelines.

Splenic injury is an uncommon complication of colonoscopy. Less than 100 cases are reported in the English language literature. The exact mechanism of injury to the spleen during colonoscopy is unknown; various authors propose several risk factors and possible mechanisms. Splenic injury can be graded or classified according to the extent of laceration and the severity of the resultant hematoma. The management options range from observation to emergency splenectomy. Computed tomography scan is the most important imaging modality to diagnose splenic injury. Early recognition and appropriate management is of paramount importance in the management of this condition. A high index of suspicion in a patient with persistent abdominal pain after colonoscopy is key especially when a perforated viscous is ruled out. This article outlines the clinical presentation of splenic injury after colonoscopy and delineates a management algorithm.

Ectopic Hepatic Tissue Presented as a Posterior Mediastinal Mass

We present a young patient with respiratory complaints that was found to have a mass in her right posterior mediastinum. The mass was diagnosed to be ectopic histologically unremarkable hepatic tissue. We have also reviewed several of the few intrathoracic ectopic liver cases in the literature, along with a brief discussion of the significance of such a finding.

Invasive ductal carcinoma of the breast with clear cell and pseudo-lactating changes

Invasive ductal carcinoma of the breast with clear cell changes is a very rare pathological entity. There are <150 cases of this breast cancer subtype reported in the literature. Clear cell carcinoma could be easily missed or under-diagnosed in a breast core biopsy specimen due to the fact that this subtype tends to show a papillary pattern with clear cell and pseudo-lactating changes, especially in young female patients. Normal breast tissue may possess clear cells as a consequence of the physiological changes of pregnancy, the clearing of the cytoplasm within myoepithelial cells, or the clearing of the cytoplasm in apocrine metaplasia. Owing to its aggressive clinical course, clear cell carcinoma must be differentiated from other subtypes of breast carcinoma. Special attention given to this rare subtype by pathologists and clinicians could avoid misdiagnosis and delay of treatment.

Left inguinal appendix in an HIV patient: A case report and review of literature

INTRODUCTION The presence of the appendix in an inguinal hernia sac is rare, with an estimated incidence of 0.51-1% of all inguinal hernias. An inguinal appendix is most commonly referred to as Amyands hernia. PRESENTATION OF CASE A 59-year-old HIV positive male presented to our center with a left painful inguinal mass. The preoperative diagnosis was a left inguinal hernia. Intraoperatively, the sac was found to contain a non inflamed appendix; the appendix was reduced back to the peritoneal cavity and the patient underwent a tension free prosthetic left inguinal hernia repair. DISCUSSION Most cases of inguinal appendices are right-sided and are diagnosed intraoperatively; left-sided cases as we encountered are rare and most likely the result of cecal mobility. Preoperative diagnosis of the entity is difficult and most cases are diagnosed intraoperatively. A CT scan is not necessary unless other pressing differentials need to be ruled out. Most authors agree that if the appendix is not inflamed, appendectomy, concurrently with herniorrhaphy, should not be performed to avoid perioperative septic complications. CONCLUSION Surgical management of inguinal appendices carries a risk of septic complications. This is especially pertinent to our case, considering the immunocompromised status of our patient. The decisions in the operating room were geared toward limiting septic potential.

Enhanced resting‐state dynamics of the hemoglobin signal as a novel biomarker for detection of breast cancer

PURPOSE The work presented here demonstrates an application of diffuse optical tomography (DOT) to the problem of breast-cancer diagnosis. The potential for using spatial and temporal variability measures of the hemoglobin signal to identify useful biomarkers was studied. METHODS DOT imaging data were collected using two instrumentation platforms the authors developed, which were suitable for exploring tissue dynamics while performing a simultaneous bilateral exam. For each component of the hemoglobin signal (e.g., total, oxygenated), the image time series was reduced to eight scalar metrics that were affected by one or more dynamic properties of the breast microvasculature (e.g., average amplitude, amplitude heterogeneity, strength of spatial coordination). Receiver-operator characteristic (ROC) analyses, comparing groups of subjects with breast cancer to various control groups (i.e., all noncancer subjects, only those with diagnosed benign breast pathology, and only those with no known breast pathology), were performed to evaluate the effect of cancer on the magnitudes of the metrics and of their interbreast differences and ratios. RESULTS For women with known breast cancer, simultaneous bilateral DOT breast measures reveal a marked increase in the resting-state amplitude of the vasomotor response in the hemoglobin signal for the affected breast, compared to the contralateral, noncancer breast. Reconstructed 3D spatial maps of observed dynamics also show that this behavior extends well beyond the tumor border. In an effort to identify biomarkers that have the potential to support clinical aims, a group of scalar quantities extracted from the time series measures was systematically examined. This analysis showed that many of the quantities obtained by computing paired responses from the bilateral scans (e.g., interbreast differences, ratios) reveal statistically significant differences between the cancer-positive and -negative subject groups, while the corresponding measures derived from individual breast scans do not. ROC analyses yield area-under-curve values in the 77%-87% range, depending on the metric, with sensitivity and specificity values ranging from 66% to 91%. An interesting result is the initially unexpected finding that the hemodynamic-image metrics are only weakly dependent on the tumor burden, implying that the DOT technique employed is sensitive to tumor-induced changes in the vascular dynamics of the surrounding breast tissue as well. Computational modeling studies serve to identify which properties of the vasomotor response (e.g., average amplitude, amplitude heterogeneity, and phase heterogeneity) principally determine the values of the metrics and their codependences. Findings from the modeling studies also serve to clarify the influence of spatial-response heterogeneity and of system-design limitations, and they reveal the impact that a complex dependence of metric values on the modeled behaviors has on the success in distinguishing between cancer-positive and -negative subjects. CONCLUSIONS The authors identified promising hemoglobin-based biomarkers for breast cancer from measures of the resting-state dynamics of the vascular bed. A notable feature of these biomarkers is that their spatial extent encompasses a large fraction of the breast volume, which is mainly independent of tumor size. Tumor-induced induction of nitric oxide synthesis, a well-established concomitant of many breast cancers, is offered as a plausible biological causal factor for the reported findings.

Splenic rupture and intracranial haemorrhage in a haemophilic neonate: Case report and literature review

Splenic rupture and intracranial haemorrhage are life-threatening conditions infrequently encountered in neonates without history of birth trauma. External manifestations of birth trauma; namely, capput succadeneum and cephalhematoma, when present raise suspicions for more serious intracranial or visceral damage. Rupture of normal spleen without an obvious source of trauma in haemophilic neonate is a rare event. The concurrence of both conditions and the unusual presentation make this case a rare one that is seldom encountered in the literature. Additionally, when splenic rupture occurs, the consensus is to employ all non-operative techniques aimed at salvaging the spleen, thus avoiding the immune-compromised state associated with splenectomy. However, in this case, we present a 3-day-old male with family history of haemophilia A, who was diagnosed with splenic rupture and bilateral subdural haematomas and underwent splenectomy, albeit with post-operative complications, in light of haemodynamic instability and high ongoing transfusion requirements.

Unusual complication of bladder prolapse with subsequent diagnosis of urothelial carcinoma leading to a necrotizing soft tissue infection after radical cystectomy

Abstract There is lack of information in the literature on long-term complications of suprapubic catheters. The most common complications include urinary tract infection, bladder calculi, urine leakage and neoplastic changes. We report a case of an unusual complication of bladder prolapse, with subsequent diagnosis of urothelial carcinoma, leading to a necrotizing soft tissue infection after a radical cystectomy in a patient with long-term catheterization and its management. Due to the rarity of this complication, its management has not been well studied. In this particular case, the logical indication was radical cystectomy due to the presence of bladder necrosis.