Milos Kostov

Giant paraovarian cyst in a child complicated with torsion.

BACKGROUND A variety of benign cyst may occur in and around the ovary and broad ligament and may simulate serous cystadenomas. The majority of broad ligament and paraovarian epithelial tumors are serous neoplasms of low malignant potential and presented with a pelvic mass with or without ascites or pain, but without involvement of the ovary. Ovarian torsion and paraovarian serous cystadenoma are rarely reported. CASE REPORT We presented a case of giant paraovarian cyst in an 14-year-old girl, with characteristics of serous cystadenomas grossly and microscopically, and complicated with double adnexal torsion. A computed tomography scan showed large hypodense cystic mass (measuring 30 x 26 x 12 cm), occupying the whole abdominal cavity, with no adhesion to the surrounding organs. CONCLUSION Precise clinical data as well as pathological examinations based on immunohistochemical stainings were important in making the diagnosis. These rare cystic lesions of para/mesoovarian location in children and their unclear histogenesis might be a histopathological diagnostical problem.

Three cases of death caused by shots from blank cartridge.

The authors describe 3 cases of lethal injuries caused by 7.62 mm blank cartridge shots from military automatic rifle of domestic origin (AK 47, 7.62 mm). In 1 case, the cartridge was fired from a weapon that had been leaned on the head, with subsequent destruction of brain, and in other 2 cases, the weapon had been leaned on the chests, which led to destruction of heart parts. The injuries were caused by the action of striking wave of gunpowder explosion, the air blast type. The cases demonstrate that the gas pressure from the exploding propellant of blank cartridge is powerful enough to penetrate the thoracic wall and the skull.

Safety of simultaneous colon and liver resection for colorectal liver metastases

BACKGROUND/AIM Surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer (CRC) remains controversial. The aim of this study was to assess safety of simultaneous colon and liver rese cions and the direct effects of this type of treatment upon morbidity and mortality of the patients with synchronus hepatic metastases of CRC. METHODS Intraoperative and postoperative data of 31 patients with simultaneous liver and colorectal resection were compared with the data of 51 patients who had undergone colon and hepatic resection in the staging setting. Analized were demographic data, number of metastases, type of the liver resection, operation time, intraoperative blood loss, percentage of postoperative complications, morbidity and mortality and lenght of hospitalisation. RESULTS In the group of the patients operated simultaneously 5 hepatectomies, 3 sectionectomies, 2 trisegmentectomies, 3 bisegmentectomy, 6 segmentectomies, and 12 metastasectomies were combined with colon resection. In this group operation time (280 vs. 330 minutes) and in traoperative blood loss (450 vs. 820 ml) were lower than those in the two staged operation group. Postoperative complication rate was lower in the simultaneous group (19.35%o) than in the two-staged operation group (19.60%), without statistical significance. There was no hospital mortality in both groups. The patients having simultaneous resection required fewer days in the hospital (median 10.2 days) than the patients undergone operation in the two stage (18.34 days). CONCLUSION By avoiding a second laparotomy, overall operation time, blood loss, hospital stay and complication rate are reduced with no change in hospital mortality, so simultaneous colon and hepatic resection performed by the competent surgeons are safe and efficient for the treatment of synchronous colorectal liver metastases.

A rare case of retroperitoneal malignant Triton tumor invading renal vein and small intestine.

INTRODUCTION Malignant Triton tumor is a very rare malignant peripheral nerve sheath tumor with rhabdomyosarcomatous differentiation. Most of those tumors occur in patients with von Recklinghausens disease or as a late complication of irradiation and commonly seen in the head, neck, extremities and trunk. CASE REPORT We reported retroperitoneal malignant Triton tumor in a 57-year-old female patient. Skin lesions were not present, and there was no family history of neurofibromatosis or previous irradiation. The presented case is one of a few recorded in the specialized literature that occurs in the retroperitoneal space in sporadic form. In this case, tumor consisted of a multilobular mass was in close relation with the abdominal aorta and inferior vena cava and involved the renal vein with gross invasion of the small intestine. The patient underwent total resection of the tumor and left nefrectomy was performed. The small intestine 10 cm in length was also resected and end-to-end anastomosis was conducted. The postoperative course was uneventful and the patient was discharged from the hospital ten days after the surgery. CONCLUSION Diagnostically, it is crucial to recognize this uncommon histological variant because malignant Triton tumor has a worse prognosis than classic malignant peripheral nerve sheath tumor does. The use of the immunohistochemistry is essential in making the correct diagnosis. Only appropriate pathological evaluation supported by immunostaining with S-100 protein and desmin confirmed the diagnosis. Aggressive surgical management treatment improves the prognosis of such cases with adjuvant radiotherapy.

Dolichoectasia of Vertebrobasilar Arteries as a Cause of Hydrocephalus and Ischemic Cerebral Stroke

Introduction Dolichoectasia of vertebrobasilar artery is a rare vasculopathy, which is characterized by ectasia, elongation, and tortuosity of the basilar artery. Case Description A 85-year-old man was referred to the Clinic of Neurology with sudden-onset coma. A brain computed tomography scan showed remarkable fusiform dilatation with elongation of basilar artery, with compressive effect on brain stem. Autopsy confirmed existence of vertebrobasilar dolichoectasia, with organized old thrombus and partially with recent occlusive thrombosis. The histology and immunohistochemical staining were showing a loss of the elastic tissue with significant fibrosis in the tunica media and small groups of foam macrophages and cholesterol crystals in atherosclerotic plaque. Conclusions We presented a case of dolichoectasia of vertebrobasilar artery with an obstructive hydrocephalus, due to direct compression on pons and midbrain, which is an extremely rare entity. This case had been analyzed during the patients life through clinical, laboratory, and radiology examinations and after he died through autopsy.

Giant renal oncocytoma

BACKGROUND Renal onkocytoma is a distinctive benign tumor derived from epithelial cells of the distal renal tubules. These tumors are often clinically asymptomatic, diagnosed accidentally and difficult to distinguish from renal cell carcinoma. CASE REPORT We presented a giant renal onkocytoma in a man aged 64, without any signs or symptoms of the urogenital system disorder. The preoperative diagnosis described the tumor mass of the right kidney, size 16 x 14 cm, and indicated a malignant tumor of kidney. The patient underwent radical nephrectomy. The tumor was encapsulated at the intersection with the characteristic central hyaline scar. Microscopically, it was built of uniform polygonal cells with abundant eosinophilic cytoplasm. Immunohystochemiclly, tumor cells were immunoreactive to CK AE1/AE3 and CD 117, but showed negative immunoreactivity to CK 7, RCC marker and Vimentin. CONCLUSION Giant renal oncocytomas are rare tumors with benign clinical course. As a rule, they are discovered by accident. Clinical differentiation from malignant tumors of the kidney is not possible. They are treated surgically, mainly by radical nephrectomy. A definitive diagnosis is made only by histopathological examination of tumors using immunohistochemical marker panels.

Primary ovarian malignant melanoma

BACKGROUND Primary ovarian malignant melanoma is extremely rare. It usually appears in the wall of a dermoid cyst or is associated with another teratomatous component. Metastatic primary malignant melanoma to ovary from a primary melanoma elsewhere is well known and has been often reported especially in autopsy studies. CASE REPORT We presented a case of primary ovarian malignant melanoma in a 45-year old woman, with no evidence of extraovarian primary melanoma nor teratomatous component. The tumor was unilateral, macroscopically on section presented as solid mass, dark brown to black color. Microscopically, tumor cells showed positive immunohistochemical reaction for HMB-45, melan-A and S-100 protein, and negative immunoreactivity for estrogen and progesteron receptors. CONCLUSION Differentiate metastatic melanoma from rare primary ovarian malignant melanoma, in some of cases may be a histopathological diagnostic problem. Histopathological diagnosis of primary ovarian malignant melanoma should be confirmed by immunohistochemical analyses and detailed clinical search for an occult primary tumor.

Inflammatory myofibroblastic tumor of the larynx

BACKGROUND/AIM Inflammatory myofibroblastic tumor (IMT) of the larynx is a rare borderline lesion composed of myofibroblastic and inflammatory cells. CASE REPORT We presented a case of 77-year-old male with hoarseness for about three months. Laryngoscopy showed a polypoid tumor originated from the anterior commissure with glottic projection. Grossly, the tumor was 22 x 15 mm, whitish, oval nodus with firm consistency. Histologically, the lesion was composed of spindled to stellate cells arranged in a fascicular to storiform pattern and inflammatory cells: lymphocytes, histiocytes, plasma cells and neutrophils. The stroma was fibromyxoid and collagenous. Immunohistochemically, tumor cells showed strong positivity for actin and vimentin and negativity for cytokeratin, CD34, S100 and desmin. The proliferation (Ki67) was less than 10%. CONCLUSION Inflammatory myofibroblastic tumor may be mistaken as a malignancy and the differential diagnosis can be difficult without immunohistochemistry. It is critical to recognize this uncommon entity to avoid unnecessary aggressive treatment.