Chien-Long Kuo

Large Epidermoid Cyst of the Breast: Report of a Case

Epidermoid cysts are located mainly in the subcutaneous layer of the trunk and are often small and asymptomatic. When they develop in the breast parenchyma they are a rare benign condition, yet have the potential for malignancy. We report on a 39 year-old female who presented with a large protruding lump from her left breast. The mass grew up to more than 10 cm in diameter during the period of five years. Enlarged left axillary lymph nodes were noted also. A malignant tumor was suspected based on the imaging and clinical features. She underwent tumor excision and an epidermoid cyst was confirmed by histopathologic assessment. We collected the breast images, the surgical specimen photographs and reviewed the literature. To the best of our knowledge, the cyst reported here is the largest of the epidermoid cysts arising within the breast that have been reported. Although at times, the epidermoid cyst is difficult to distinguish from a malignant tumor, surgical excision is justified because of its potential for malignancy.

Gallium scanning in pulmonary alveolar proteinosis: a rare case report.

A 48-year-old woman was seen with progressive shortness of breath, cough with greenish sputum, generalized malaise and weight loss for 2 months. There was leukocytosis, but she was afebrile. Chest radiography revealed bilateral alveolar infiltrates. Ga-67 scintigraphy showed increased uptake in the lungs. High resolution computed tomography (HRCT) of the chest suggested the presence of pulmonary alveolar proteinosis (PAP). The histopathologic diagnosis was PAP. PAP is a rare disease associated with lipid accumulation and macrophage dysfunction. The use of Ga-67 scintigraphy in the diagnosis of PAP was unusual. The case report alerts us that PAP is rare but shows increased Ga-67 accumulation in the lungs.

Effect of Minimally Invasive Surgical Training Center on Laparoscopic Surgery: Observation from Preliminary Results for Primary Stomach GastroIntestinal Stromal Tumor in a Health Care System

Gastrointestinal stromal tumors (GISTs), are different from other mesenchymal tumors by immunohistochemistric biomarkers and are often encountered in the alimentary tract and less commonly originating from omentum, mesentery and peritoneum. They usually present as subepithelial tumors in the gastrointestinal tract or intraabdominal masses with malignant potential. The tumors might cause symptoms such as pain, intraluminal or extraluminal GI tract bleeding and obstruction but might also present as incidental findings. Gastroscopy, Ultrasonography and CT scan are employed for preoperative evaluation. The surgical principles are to excise the tumor with safe margin microscopically. Minimally invasive procedures are revolutionary innovation in surgery. Asian Institute of TeleSurgery training center is established in mid Taiwan in 2008 with the cooperation between Show Chwan Health Care System and European Institute of TeleSurgery in Strasbourg, France. We retrospectively reviewed 24 primary stomach GISTs operated at our institution in the past four years. The patients were divided into laparoscopy group (18 patients) and laparotomy group (6 patients) depending on the main surgical methods. The patients’ age, gender, hospital stay, operative time, blood loss, tumor size and complication rate were used for stastical analysis. There were significant differencesin tumor size and blood loss between the two groups with a p value of less than 0.05. In the past 4 years, 75% of primary gastric GISTs in our hospital were managed by laparoscopic surgery. Our experience showed that laparoscopic surgery is feasible for primary stomach GISTs in selective cases.

A False Negative Non-Morphine-Augmented Hepatobiliary Scan in a Patient with Empyematous Calculous Cholecystitis

False-negative results of hepatobiliary scans for the diagnosis of acute calculous cholecystitis are rare. We report a 60-year-old male case in which the diagnosis was suggested by typical clinical presentation (RUQ pain, fever and leukocytosis) and abdominal sonography (distension and mild thickened wall of the gallbladder with gallbladder stone), but a false negative (superscript 99m)Tc- DISIDA non-morphine-augmented hepatobiliary scan (visualization of the gall bladder since the 30(superscript th) mm imaging). The final diagnosis was empyematous calculous cholecystitis. This case report concludes that caution has to be taken in interpreting hepatobiliary scans, although the false-negative rate is very low.

Pseudoaneurysm of the Cystic Artery with Hemobilia: Report of a Case

Pseudoaneurysm of the cystic artery is a rare cause of hemobilia, with only twelve cases having been reported in the English literature. We report a case of pseudoaneurysm of cystic artery in a 70-year-old Taiwanese man. He suffered from epigastric pain, GI bleeding, jaundice and abnormal liver function. Duodenoscopy demostrated bleeding from papilla of Vater. We diagnosed hemobilia due to the pseudoaneurysm of the cystic artery after selective hepatic angiography. Furthermore, we successfully controlled bleeding by embolization of the cystic artery with microcoil. He received cholecystectomy, and pathologically, the gall bladder showed acute calculous cholecystitis with pseudoaneurysm formation. This case emphasizes the importance of including hemobilia in the differential diagnosis of upper GI bleeding. Selective hepatic angiography is the diagnostic modality of choice. Furthermore, transcatheter embolization should be attempted because it permits the delay of surgical intervention in unstable and critical patients with shock or sepsis.