Huseyin Eken

Bone Marrow Metaplasia in Multinodular Goiter With Primary Hyperparathyroidism

M ultinodular goiter (MNG) constitutes a mixed group of nodular entities. Structural and functional heterogeneity is the most characteristic feature of MNG and may exhibit degenerative alterations such as hemorrhagic and cystic changes, fibrosis, squamous metaplasia and calcification. Rarely, osseous metaplasia, mature bone formation and bone marrow metaplasia have been reported in thyroid tissue. However, according to our literature search, mature bone formation and bone marrow metaplasia in thyroid tissue with primary hyperparathyroidism (PHPT) have not been reported previously. We report a patient with bone marrow metaplasia in the thyroid tissue and PHPT. A 57-year-old white female patient was admitted to the general surgery department for swelling in the neck (over 5 years) and constipation lasting 3 months. On physical examination, a grade 2 goiter was palpated; there was no other pathology in the physical examination. The patient had a history of hyperparathyroidism (parathyroid hormone: 199; normal range: 11–54 pg/mL) and hypercalcemia (Ca: 11.7; normal range: 8.5–10.5 mg/dL). The common blood count and peripheral blood smear were within the normal ranges. The thyroid stimulating hormone and thyroid hormones were also within the normal ranges. On thyroid ultrasonography, a 21 3 14 mm solid nodule in the left lobe of the thyroid in an inferior location, with a peripheral hypoechoic area, was detected. In the middle of the same lobe, there was a calcified nodule (7 mm in diameter), and near the right thyroid lobe in the posteroinferior area, a 15 3 5-mm hypoechogenic lobulated solid nodule, similar to parathyroid adenoma in the sonographic view, was seen. In parathyroid scintigraphy, minimally focused activity retention in the right inferior lobe of the thyroid was detected, which could be a parathyroid adenoma. Because of a prediagnosis of MNG and parathyroid adenoma, a left thyroidectomy and parathyroid adenoma resection of the right inferior location of the right thyroid lobe, by frozen section, was performed. Based on the results of the frozen section, which were similar to the parathyroid adenoma, the operation was ended. On the 1st postoperative day, the patient had a PTH of 18 and Ca of 9.9. In the macroscopic view, a 4 3 3.5 3 2 cm-sized, 12-g weight, claret red–colored, localized, elastic-hard stiffness thyroid tissue was detected. In the cross-sectional view, a 1.5-cm-diameter claret red nodule and, near it, a 0.8-cm-diameter hard calcified region were seen. After decalcification of the tissue, localized degenerated hyalinizing areas and, near them, hypocellular bone marrow and lamellar bone trabeculae were seen (Figures 1 and 2). This was reported as an MNG consisting of bone marrow metaplasia. The frozen section material included parathyroid tissue of 13 0.53 0.4 cm in size, 0.7 g in weight, encapsulated and pink beige color. Using the light microscope, chief cells that compressed the normal parathyroid tissue were seen and described as an adenoma. There was no complaint from the patient during the postoperative follow-up time. Thyroid nodules are a common occurrence in clinical practice. The incidence of thyroid nodules has been on the rise in recent decades, mainly because of the wider use of imaging instruments. The incidence of nodular goiter in the general adult population is 3% to 5% clinically, about 50% discovered at autopsy, whereas it is nearly 100% in the endemic areas. Clinically, most patients are euthyroid and their clinical importance is primarily to exclude a malignancy. Thyroid nodules may undergo a broad spectrum of degenerative changes, such as infarction, hemorrhage or fibrosis, which are associated with calcification or even ossification. Osseous metaplasia, in contrast to calcification, is a rare event in any organ or tissue, and the detection of mature bone formation in a thyroid nodule is extremely rare. Osseous metaplasia could be seen secondary to ischemia, necrosis or inflammation in the tumor or surrounding tissue. Some studies have shown that bone formation might occur as a result of local or systemic inflammation. Additionally, there are studies reporting that hypercalcemia levels are closely associated with bone formation. PHPT is characterized by the autonomous production of PTH, in which there is hypercalcemia or normal to high serum FIGURE 1. Histopathologic view.

Gossypiboma Mimicking a Mesenchymal Tumor: A Report of a Rare Case.

Patient: Female, 62 Final Diagnosis: Gossypiboma Symptoms: Abdominal discomfort Medication: — Clinical Procedure: Surgery Specialty: Surgery Objective: Challenging differential diagnosis Background: Gossypiboma is the term for a surgical complication resulting from foreign materials such as a surgical sponge or gauze that was accidentally left inside a patient’s body. Case Report: Here, we report the case of a 62-year-old woman with gossypiboma. She underwent surgery due to an abdominal mass that was preoperatively considered a tumor. Intra-postoperatively, it was diagnosed as gossypiboma. Conclusions: For the prevention of gossypiboma during the pre-operative and post-operative periods, counting sponges and surgical equipment must be done very carefully. If there is any doubt postoperatively, direct abdominal imaging may be helpful.

Incarceration of the hepatic lobe in incisional hernia: A case report

Introduction Incisional hernias are abnormal peritoneal outward pouch-like protrusions that develop due to defects that arise as a result of the disruption of the fascias continuity after abdominal surgery. Presentation of case A 77-year-old female patient presented to the emergency department of our hospital with complaints of abdominal swelling, abdominal pain, nausea and vomiting. The patient was recommended for surgery. It was decided that the primary fascia closure and onlay patch was the most appropriate approach. Discussion When the defect in the abdominal wall grows, the functionality of the related abdominal wall is disrupted thereby eliminating the dynamic structure of the abdominal wall. Incisional hernias lead to a significant number of job losses and morbidity and negatively affect quality of life. Moreover, the formations in the hernia pouch might lead to higher risk of strangulation and dysfunction. Conclusion Subcutaneous herniation of the left lobe of the liver passing through the abdominal wall is a very rare condition.

A giant ancient schwannoma mimicking an adnexal mass: Case report.

Introduction:Ancient schwannoma is a rare tumor of the peripheral nerve sheath. As degenerative properties are defined histologically, it can be wrongly interpreted as malignant. Case presentation:The case presented here is of a giant ancient schwannoma with a pelvic retroperitoneal location, which was mimicking an adnexal mass. Conclusion:In the rarely seen cases in the retroperitoneum, it may reach very large dimensions.

A Rare Case of Isolated Cystic Hydatid of Thyroid Gland.

AbstractHydatid cysts are most frequently localized within the liver and lungs, although they can also be found in highly vascularized tissues such as the brain, muscle, heart, pancreas, adrenal, and thyroid glands.A 65-year-old female patient was admitted to our clinic with complaints of a progressively growing mass that was compressing the surrounding tissues and causing respiratory distress. The pathological result was obtained as cytic hydatid.In patients with diagnosed hydatid cysts in the liver, systemic evaluation is necessary to rule out involvement of other organs. Among patients presenting with growths located in the neck, primary hydatid cyst of the thyroid gland must be considered in endemic regions.

Bogota Bag Use in Planned Re-Laparotomies

Background Planned re-laparotomies are a series of surgical interventions that are rarely used and have a high mortality rate. The aim of this study was to investigate the factors affecting mortality and the effectiveness of the use of the Bogota bag for temporary closure of the abdomen in patients for whom re-laparotomy was planned. Material/Methods A retrospective examination was made of data of patients in whom a Bogota bag was used in planned re-laparotomies for various reasons in the General Surgery Department of Suleyman Demirel University Medical Faculty between June 2008 and April 2014. Results Bogota bags were used in a total of 38 patients, comprising 23 (60.5%) males and 15 (39.5%) females, with a mean age of 58.94±17.89 years. The mean period of hospitalization was 14.5 days (range, 1–143 days) and the mean number of operations during that time was 3 (range, 1–11). The mean duration of intensive care unit stay was 6 days (range, 1–143 days). Malignancy was determined in 8 patients (21.1%). Indications were intra-abdominal sepsis in 23 patients (60.5%), mesenteric vascular disease in 10 patients (26.3%), and packing was required in 5 patients (13.2%). Mortality developed in 25 patients (65.8%). A significant relationship was determined between mortality and a diagnosis of mesenteric artery ischemia (p: 0.035). The mortality rate was 56% (n: 13) in patients diagnosed with intra-abdominal sepsis. A relationship was determined between mortality and age (p: 0.015), duration of hospital stay (p: 0.007), need for cardiac inotrope (p: 0.01), and need for mechanical ventilation (p: 0.01). The mean Apache II score was 26.4±5 for patients who died and 15.8±5.2 for surviving patients (p<0.001). In 5 (38.4%) of the 13 surviving patients, primary repair was applied to the abdomen, and in the remaining 8 patients abdominal wall repair was performed using dual mesh. Conclusions In patients in whom a Bogota bag was used, which is a cheap and easy method for temporary closure of the abdomen, the high mortality rates seen are related to diagnosis, Apache II score, age, and organ failure.

Rare tumors of the gallbladder: Clear cell carcinoma

Highlights • Our goal in presenting this case was to emphasize the importance of taking an accurate medical history in patients with clear cell carcinoma, a rarely seen gallbladder cancer.

The effect of metyrosine on oxidative gastric damage induced by ischemia/reperfusion in rats. Biochemical and histopathological evaluation

PURPOSE To investigate the effect of metyrosine against I/R induced gastric damage in rats. METHODS Eighteen albino Wistar male rats were divided into groups; gastric I/R (GIR), 50 mg/kg metyrosine+gastric I/R (MGIR), and sham (SG) groups. 50 mg/kg metyrosine was given to the MGIR group, and distilled water was given to the GIR and SG groups by the oral gavage. After 30 minutes, 25 mg/kg thiopental sodium was injected intraperitoneally. Ischemia was achieved for 1 hour by clamping the celiac artery of the MGIR and GIR groups, then reperfusion was achieved for 3 hours. After that, animals were killed with 50 mg/kg thiopental. Biochemical and histopathological examinations performed on the gastric tissues. RESULTS Metyrosine decreased the MDA and MPO and the increased the tGSH and SOD. In addition, it reduced inflammation by suppressing the decrease of COX-1 and the increase of COX-2. Histopathologically, metyrosine decreased symptoms caused by I/R such as mucosal necrosis, hemorrhage, edema, PMNL infiltration, and dilated congested blood vessels. CONCLUSIONS Metyrosine prevented the I/R induced oxidative stress in the gastric tissue. Metyrosine may be beneficial for gastric I/R injury.

Necl 4 and RNAse 5 Are Important Biomarkers for Gastric and Colon Adenocarcinomas

Background There is a need to identify new prognostic factors that may be used in addition to the known risk factors in gastrointestinal adenocarcinomas. In this study, we aimed to determine the expression of Necl 4 and RNase 5 biomarkers in gastric and colon adenocarcinomas, as well as the prognostic efficacy of these biomarkers in gastric and colon adenocarcinomas. Material/Methods Ninety-two cases resected due to stomach and colon adenocarcinoma were included in the study. The expression of Necl 4 and RNase 5 biomarkers was evaluated by immunohistochemical staining of the stomach and colon normal mucosa and adenocarcinoma areas. Results In colon adenocarcinomas, there was a significant association between Necl 4 and lymphovascular invasion, vascular invasion, and perineural invasion (p<0.05). There was a significant association between RNase 5 and histological differentiation in colon adenocarcinomas (p<0.05). There was no association between RNase 5 and Necl 4 in gastric or colon adenocarcinomas. Conclusions Necl 4 may have prognostic value in colon adenocarcinomas, but it is difficult to ascertain in gastric adenocarcinomas.

Auto‐Amputation of the Breast; a Rare Case Caused by Invasive Ductal Carcinoma

L aboratory and radiological examinations performed following admission of 73 year-old woman with dyspnea for emergency room; due to detection of pleural effusion at left thorax, she was hospitalized by department of Thorax surgery for further investigation and treatment. During detailed examination of the patient, due to presence of a wide scar tissue that retracts surrounding tissues at right breast and there was no history of any previous surgery for this region (mastectomy etc.) and exposure to burns or chemicals, and general surgery consultation was requested. On her physical examination, it was observed that right breast was absent and a hard mass resembling a scar tissue with diameter of about 15 cm in that region (Fig. 1). On axillary examination, palpable lymph nodes whose diameter was reaching up to 3 cm were palpated. No noticeable feature was present in patient’s family history and background. It was learned that it took 3 years of this mass to appear as scar-like and during that period the patient who was aware of this situation avoided from examination. The result of incisional biopsy taken from the tissue in structure of hypertrophic scar was observed as invasive ductal carcinoma. In videoendoscopic examination of thorax performed aimed at left thorax; in the pleural biopsy taken due to observation of pleural involvement with malignant appearance, invasion of invasive ductal carcinoma was observed. During the same session, pleurodesis was performed to the patient. Patient was evaluated with computerized tomography of thorax (Fig. 2) and magnetic resonance imaging of the breast (Fig. 3). The patient at which “amputated breast cancer showing contralateral involvement that was invaded the thoracic wall and the pleura” was evaluated by Committee of oncological cases of our hospital and accepted as unresectable, she was referred to the oncological treatment. Now, the oncological follow-up and treatment of the patient is ongoing. Although several cases in the literature with spontaneous amputation of any organ are detected, cases of auto-amputation belonging to the breast are uncommon. First, two cases in Israel, in Africa, and India and finally from Turkey have been reported. Such a rare situation which is neglected by the patient until it reaches the stage of amputation can be correlated with lack of awareness of regular control and examination in developing countries.