George T. Drugas

Management of gastrointestinal lymphoma

Despite numerous effective chemotherapeutic regimens developed to treat non-Hodgkin’s lymphoma (NHL), it remains the sixth most common cause of cancerassociated deaths in the United States. Estimates from the American Cancer Society project that about 53,000 new cases of NHL will be diagnosed in the United States in 2002 and approximately half of those afflicted will die of their disease. The incidence of NHL has increased greatly since the early 1980s, in large part from increased HIV disease, though ubiquitous environmental and toxic exposures have also been implicated. NHL is more common in men (M/F ratio 1.5/1). The incidence of NHL in younger white men (ages 18 to 45) has stabilized since 1997 but might be increasing in both women and African Americans. Extranodal lymphoma, or lymphoma arising within solid organs, occurs in up to 40% of all cases. The gastrointestinal (GI) tract is the most frequently involved extranodal site, accounting for up to half of all extranodal cases. Lymphomas can involve any part of the GI tract from oral cavity to rectum. Surgical resection can play an important role in the diagnosis and treatment of NHL involving the GI tract. The surgeon should maintain a high index of suspicion for GI lymphomas and appreciate the critical role surgery might play in obtaining an accurate diagnosis and successfully managing these malignancies. This article reviews GI lymphomas with particular emphasis on the role of surgery as part of a multidisciplinary approach to the diagnosis and management of NHL.

Isolated torsion of the fallopian tube in a menarchal 11-year-old girl.

Isolated torsion of the fallopian tube is a rare cause of an acute lower abdominopelvic pain in adolescent females that is difficult to recognize preoperatively. This is a case report of an 11-year-old girl who presented with a right lower quadrant abdominal pain, nausea, and vomiting secondary to isolated torsion of the right fallopian tube 2 days after the onset of her first menses. In this report, the patients clinical course is discussed with special emphasis on diagnostic imaging and management strategy of adnexal torsion in pubertal and adolescent girls.

Too attractive: the growing problem of magnet ingestions in children.

Background Small, powerful magnets are increasingly available in toys and other products and pose a health risk. Small spherical neodymium magnets marketed since 2008 are of particular concern. Objective The objective of this study was to determine the incidence, characteristics, and management of single and multiple-magnet ingestions over time. Methods Magnet ingestion cases at a tertiary children’s hospital were identified using radiology reports from June 2002 to December 2012. Cases were verified by chart and imaging review. Relative risk regressions were used to determine changes in the incidence of ingestions and interventions over time. Results Of 56 cases of magnet ingestion, 98% occurred in 2006 or later, and 57% involved multiple magnets. Median age was 8 years (range, 0–18 years). Overall, 21% of single and 88% of multiple ingestions had 2 or more imaging series obtained, whereas no single and 56.3% of multiple ingestions required intervention (25.0% endoscopy, 18.8% surgery, 12.5% both). Magnet ingestions increased in 2010 to 2012 compared with 2007 to 2009 (relative risk, 1.9; 95% confidence interval, 1.2–3.0). Small, spherical magnets likely from magnet sets comprised 27% of ingestions, all ingested 2010 or later: 86% involved multiple magnets, 50% of which required intervention. Excluding these cases, ingestions of other magnets did not increase in 2010 to 2012 compared with 2007 to 2009 (relative risk, 0.94; 95% confidence interval, 0.6–1.4). Conclusions The incidence of pediatric magnet ingestions and subsequent interventions has increased over time. Multiple-magnet ingestions result in high utilization of radiological imaging and surgical interventions. Recent increases parallel the increased availability of small, spherical magnet sets. Young and at-risk children should not have access to these and other small magnets. Improved regulation and magnet safety standards are needed.

Simultaneous gastric and small intestinal trichobezoars.

Bezoars are conglomerates of food or fiber in the alimentary tract of humans and certain animals, mainly ruminants. A trichobezoar represents a mass of accumulated hair. Trichobezoars may present as an isolated gastric mass, as an extension into the small intestine, or as an independent fragmented mass in the small intestine. The presence of discrete coexisting gastric and ileal trichobezoars has been reported only rarely in the literature. This is a case report of a 9-year-old girl presenting with small-bowel obstruction secondary to synchronous trichobezoars in the stomach and ileum. The case highlights the role of imaging and importance of complete evaluation of the gastrointestinal tract at the time of surgical evacuation.

Rhabdomyosarcoma of the clitoris

A healthy 2-year-old girl presented with a firm, mobile suprapubic mass that had been increasing in size over 8 months. Pelvic US revealed a 3.2-cm ovoid complex mass in the subcutaneous space overriding the mons pubis containing cystic and solid components (Fig. 1). Contrastenhanced CT revealed a solid, homogeneously enhancing soft-tissue mass in the subcutaneous tissues extending into the mons pubis and clitoris (Fig. 2). Histology demonstrat-

Mesenchymal hamartoma of the chest wall

A 33-week gestational male infant with mild respiratory distress after triplet birth was found on physical examination to have a firm, fixed 2-cm mass arising from the lateral right chest wall. Chest x-ray confirmed a spherical soft tissue mass distorting the right fourth and fifth ribs (A). Fine needle biopsy was consistent with a benign chest wall hamartoma (mesenchymoma). The child was treated expectantly until four months of age, when rapid enlargement of the lesion prompted CT examination. CT evaluation revealed progressive destruction of the right third, fourth, and fifth ribs with leftward mediastinal displacement by the mass (B). Heterogeneous areas within the lesion were consistent with hemorrhage and likely accounted for the rapid expansion of the mass seen clinically. The infant had primary resection of the lesion with Gore-Tex (WL Gore & Assoc, Flagstaff, AZ) patch reconstruction of the chest wall. The recovery period was uneventful. Histologic examination showed a benign mesenchymoma with no evidence for malignancy. The characteristic elements of this benign tumor are primitiveappearing mesenchymal cells, stromal elements, and cartilage. Hypercellular cartilage with enchondral ossification at its periphery is present (C1). Woven bone with a suggestion of osteoblastic rimming appears to arise from the primitive mesenchymal cells (C2). In the upper left corner and center of the slide is a dense cellular mixture of primitive mesenchymal cells, osteoclasts, and vascular spaces. At 1-year followup, the child is asymptomatic with a normal chest CT.

Temporary occlusion of the gastroesophageal junction: a modified technique for stabilization of the neonate with esophageal atresia and tracheoesophageal fistula requiring mechanical ventilation

Management of newborn infants with esophageal atresia and tracheoesophageal fistula that require mechanical ventilation is challenging. Without rapid control of the fistula, these patients develop profound respiratory failure and massive distention of the gastrointestinal tract. We present the case of a newborn who upon intubation exhibited respiratory failure and cardiovascular collapse, and in whom traditional intra-operative techniques to gain control of the tracheoesophageal fistula were unsuccessful. We describe a technique that temporarily occludes the gastroesophageal junction, and allows for stabilization of the neonate and definitive repair of the tracheoesophageal fistula.