David Manaouil

Reactive nodular fibrous pseudotumor of the gastrointestinal tract and mesentery.

To the Editor: We have read with interest the report of five cases of reactive nodular fibrous pseudotumor of the gastrointestinal tract and mesentery by Yantiss et al. We recently observed an additional example of this rare entity. A 32-year-old man who had a history of epigastric complaints for a few months experienced a recent exacerbation of abdominal pain with periumbilical and dorsal irradiation. The clinical examination and biochemical analysis were normal. The abdominal CT scan showed a round mass of the ascending colon lying close to the duodenum. Upper endoscopy disclosed a 5-mm fistulalike orifice in the lateral wall of the second duodenum. A right hemicolectomy with resection of the duodenal adherence was performed. The specimen revealed a 9-cm firm whitish nodular mass of the mesocolon with infiltration of the wall of the ascending colon (Fig. 1a). Upon examination, it appeared that the mass was surrounding a perforated duodenal diverticulum (Fig. 1a, b). On histologic examination, the unencapsulated tumor was paucicellular and composed of spindle cells with oval nuclei. No mitosis was observed. The cells were arranged in short fascicles and embedded in a hyalinized collagenous matrix. Keloid-like foci with thick bands of glassy collagen were seen (Fig. 2). Infiltration of the colonic muscularis propria by this paucicellular process was observed. It also surrounded a duodenal diverticulum lined by an ulcerated mucosa (Fig. 1b). The diverticular wall was inflamed and perforated, leading to the formation of an abscess surrounded by histiocytes (Fig. 2). On immunohistochemistry, the tumor cells were positive for vimentin (Immunotech, Marseille, France, 1/250), CD117 (Dako, Glostrup, Denmark, 1/50) (Fig. 3), and a few stained positive for actin (Dako, 1/200). Myofilaments were noted on ultrastructural analysis (Fig. 4). This new case of reactive nodular fibrous pseudotumor of the mesocolon, developing around an inflamed and perforated duodenal diverticulum, empha sizes the reactive nature of this rare lesion.

L’angiomyofibroblastome du tractus génital masculin: Étude anatomo-clinique et immunohistochimique de trois cas

Angiomyofibroblastoma of the male genital tract is a rare tumor with only 20 cases reported in the literature to date. We report three cases in males aged from 23 to 44 years. They presented with painless inguinal, scrotal and perineal masses, ranging from 3 to 8 cm in diameter. On microscopic examination the tumors were composed of small spindle cells without atypia in a fibrous and myxoid stroma. There were scattered mononuclear inflammatory cells around capillaries. Immunohistochemical studies showed positive staining of the tumor cells for vimentin, and weak reactivity for CD34, bcl-2, CD99, EMA and CD117. Some tumor cells expressed estrogen receptors in all three cases, and progesterone receptors in only one case. There was no recurrence with a follow-up ranging form 12 to 21 months. Angiomyofibroblastoma of the male genital tract is a benign often hormone-dependent tumor. Its histogenesis is still unclear. It has to be distinguished from aggressive angiomyxoma and myxofibrosarcoma.

Mise en cause du chirurgien : quelles sont les procédures ? Comment gérer une expertise ?

Resume Les chirurgiens sont particulierement exposes aux procedures de recherche en responsabilite et y sont statistiquement plusieurs fois confrontes lors de leur carriere. Le chirurgien, qu’il soit praticien hospitalier, medecin salarie du secteur prive, ou en exercice liberal, peut etre directement et personnellement mis en cause lors d’une procedure penale. Lorsque l’expertise est demandee par une juridiction civile, elle concerne les chirurgiens liberaux ou salaries du prive. L’expertise administrative concerne les chirurgiens hospitaliers du secteur public. Enfin, une nouvelle structure est apparue depuis la loi du 4 mars 2002 avec les commissions regionales de conciliation et d’indemnisation des accidents medicaux (CRCI) qui s’adressent a tous les types d’exercice. Il est indispensable que le praticien prepare l’expertise, (etude du dossier et de la litterature), afin de pouvoir justifier sa conduite diagnostique et therapeutique. Lors de l’expertise, le chirurgien peut se faire accompagner par un medecin conseil et/ou un avocat mandates par son assurance, mais ne doit pas se contenter de se faire representer par eux. La presence du chirurgien, qui a assure les soins, a l’expertise est indispensable car il est celui qui connait le mieux le dossier. Le chirurgien peut ainsi repondre de facon precise aux interrogations de l’expert. C’est par ailleurs un comportement responsable et respectueux vis-a-vis du patient ou de ses ayants droit en cas de deces.Surgeons are particularly exposed to lawsuits. Most will be threatened or confronted with litigation several times during their career. The surgeon can be held directly and personally liable during a penal procedure. Civil jurisdictions oversee expert evaluation in cases involving self-employed and salaried surgeons in private practice. An administrative structure for expert evaluation is set up for surgeons working in the public sector. The law of March 4, 2002 has set up a new structure with commissions for reconciliation and compensation of medical accidents (CRCI); these apply to all surgeons. It is essential that the practitioner prepare himself fully, studying both the patient dossier and the pertinent medical literature in order to participate in an expert evaluation under the best circumstances and to justify the diagnostic and therapeutic measures taken. The surgeon may be accompanied by legal counsel and an expert medical witness, but he should not abdicate all responsibility for testimony to them; he, as the treating physician, has the fullest knowledge of the medical case and can best respond to the experts interrogation. This behavior also demonstrates both responsibility and respect to the patient and his family.