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BACKGROUND Giant ovarian cysts (≥ 15 cm in diameter) are rare. The size limit of cysts and the methodology for a safe and successful minimally invasive surgery has not been established. Here we report a case of a large 10-kg multi-locular ovarian mass, which was successfully laparoscopically removed: Our aim was to innovate the surgical practice in this field by providing a safe, effective, and minimally invasive management method for such complex and rare cases. CASE SUMMARY A 49-year-old nulliparous woman presented with abdominal distension, lasting from six Mo prior to admission; she reported worsening abdominal pain, abdominal swelling, and mild dyspnea. Imaging showed a presumed benign multi-locular (> 10 locules) left ovarian cyst that measured about 30 cm in diameter. Based on the IOTA-ADNEX model the mass had a 27.5% risk of being a borderline or malignant tumor. The patient was successfully treated via a direct laparoscopic approach with salpingo-oophorectomy, followed by the external drainage of the cyst. Tumor spillage was successfully avoided during this procedure. The final volume of the drained mucinous content was 8950 L; the cyst wall, extracted through the minilaparotomy, weighed about 1200 g. The pathologic gross examination revealed a 24 cm × 15 cm × 10 cm mass; the histologic examination diagnosed a mucinous cystoadenoma. To our knowledge, this is the first case of a giant multi-locular ovarian cyst treated with a direct laparoscopy with salpingo-oophorectomy followed by external decompression. CONCLUSION Choosing the appropriate technique and surgeon skill are necessary for a safe and effective minimally-invasive approach of unique cases involving giant ovarian cysts.

Background Abdominal wall tumors are rare and include heterogeneous diseases. Among them, desmoid tumors are the most frequent and are often diagnosed in young women during or early after pregnancy; inflammatory response after trauma or microtrauma, such as after cesarean section, may favor their growth. Results A 37-year-old woman presented with a progressive mass in the abdominal wall after a cesarean section. Positron emission tomography imaging confirmed a positive mass with a high maximum standardized uptake value; a biopsy suggested a myofibroblastic tumor. With continued tumor growth and worsening symptoms, the mass resembled a desmoid tumor; therefore, we proceed with its resection. The final diagnosis was foreign body granuloma as a reaction to the spillage of meconium and keratinous material in the amniotic fluid during cesarean section. Conclusions The present case provides information on an abdominal wall foreign body granuloma arisen from meconium and vernix caseosa after cesarean section, which presented an atypical clinical picture, mimicking a desmoid, thus requiring a careful diagnostic and treatment approach.

Background.Patients presenting with stage IV breast cancer might benefit by removal of the primary tumor. We report our experience with CT-guided cryoablation of the primary tumor, with the aim of evaluating its role in this subgroup of patients.Patients and Methods.Data of 35 patients with mean age of 58 years with breast cancer at stage IV submitted to CT-guided cryoablation of the primary tumor between 2010 and 2016 were prospectively evaluated. All patients, except three, were preoperatively and postoperatively evaluated with breast MRI to assess the extent of tumor necrosis. Retreatment was performed in case of incomplete ablation.Results.Mean tumor size was 3.02 ± 1.4 cm. Six patients had multicentric disease. Complete tumor necrosis was 85.7% and 100% at 2-month and 6-month follow-up, respectively, as 5 patients with tumors > 3 cm required a redo cryoablation. No patient developed major complications. Minor side effects occurred in 30 patients (82%). All patients were discharged the same day of the procedure. During a mean follow-up of 46 months (range 3–84), 7 patients (20%) experienced local recurrences that were treated with redo cryoablation, and 7 (20%) died for disease progression.Conclusions.Our results suggest that cryoablation of the primary tumor is safe and effective in the treatment of patients presenting with stage IV breast cancer.

Purpose: To retrospectively evaluate the feasibility and efficacy of computed tomography (CT)-guided radiofrequency thermal ablation (RFA) in reducing the pain in patients with painful pelvic recurrence of rectal cancer ineligible for surgical resection. Material and methods: Twelve consecutive patients (10 men and 2 women; mean age 67 ± 10 years) with painful pelvic recurrence of rectal cancer underwent CT-guided RFA treatments under conscious sedation. At baseline, in all patients pelvic-sacral pain was classified as severe by Visual Analog Scale (VAS; VAS score ≥75 mm). The tumor density and carcinoembryionic antigen (CEA) serum level averages were 46 ± 7 HU and 15.7 ± 9.3 ng/mL, respectively. Clinical outcome was evaluated by VAS with a mean follow-up period of 23 months. Results: All RFA sessions were completed and well tolerated. Morbidity consisted of recto-vesical fistula (8 %) and rectal abscess (8 %). 1 month after RFA procedure, complete lack of enhancement was obtained in 7 cases (58 %). A significant difference in HU and CEA serum level averages between baseline and 1 month post-RFA was revealed (p

To evaluate the feasibility and effectiveness of computed tomography (CT)-guided percutaneous screw fixation plus cementoplasty (PSFPC), for either treatment of painful metastatic fractures or prevention of pathological fractures, in patients who are not candidates for surgical stabilization. Twenty-seven patients with 34 metastatic bone lesions underwent CT-guided PSFPC. Bone metastases were located in the vertebral column, femur, and pelvis. The primary end point was the evaluation of feasibility and complications of the procedure, in addition to the length of hospital stay. Pain severity was estimated before treatment and 1 and 6 months after the procedure using the visual analog scale (VAS). Functional outcome was assessed by improved patient walking ability. All sessions were completed and well tolerated. There were no complications related to either incorrect positioning of the screws during bone fixation or leakage of cement. All patients were able to walk within 6 h after the procedure and the average length of hospital stay was 2 days. The mean VAS score decreased from 7.1 (range, 4–9) before treatment to 1.6 (range, 0–6), 1 month after treatment, and to 1.4 (range 0–6) 6 months after treatment. Neither loosening of the screws nor additional bone fractures occurred during a median follow-up of 6 months. Our results suggest that PSFPC might be a safe and effective procedure that allows the stabilization of the fracture and the prevention of pathological fractures with significant pain relief and good recovery of walking ability, although further studies are required to confirm this preliminary experience.

Uterine leiomyosarcoma (LMS) in some cases may disseminate through the abdominal cavity, without extra-abdominal spreading, determining a condition of abdominal sarcomatosis, which represents a peculiar situation. Only radical surgical removal offers a chance of long-term survival in such cases of LMS. Here we describe a case of diffuse abdominal sarcomatosis from uterine LMS in a 51-year-old perimenopausal woman who underwent laparoscopic radical hysterectomy, bilateral salpingo-oophorectomy, total pelvic peritonectomy, pelvic lymphadenectomy to the mesenteric inferior artery, and omentectomy. Then, given the high probability of disease recurrence, the patient underwent a close follow-up consisting of positron emission tomography (PET)/computed tomography every 3 months and diagnostic (and if necessary operative) laparoscopy every 6 months. To date, the patient had 11 laparoscopies; 5 of them were preceded by a PET indicative of the presence of disease with high metabolic activity, which was confirmed at surgery and each time completely removed laparoscopically with no evidence of residual disease. To date, 5 years from diagnosis the patient is alive and continues her follow-up. Our report brings to light the ability of laparoscopic surgery to obtain disease control in a case of LMS with abdominal dissemination. Moreover, laparoscopic surgery, as demonstrated in our case, may have an important role in the close follow-up of the disease and allow a timely and early radical surgical approach of relapses before they become extremely large and difficult to remove radically.

The optimal management of local recurrences after primary resection of pancreatic cancer still remains to be clarified. A 58-year old woman developed an isolated recurrence of pancreatic cancer six year after distal pancreatectomy. Re-resection was attempted but the lesion was deemed unresectable at surgery. Then chemotherapy was administrated without obtaining a reduction of the tumor size nor an improvement of the patient’s symptoms. Thus the patient underwent percutaneous cryoablation under computed tomography (CT)-guidance obtaining tumor necrosis and a significant improvement in the quality of life. A CT scan one month later showed a stable lesion with no contrast enhancement. While the use of percutaneous cryoblation has widened its applications in patients with unresectable pancreatic cancer, it has never been described for the treatment of local pancreatic cancer recurrence after primary resection. Percutaneous cryoablation deserves further studies in the multimodality treatment of local recurrence after primary pancreatic surgery.

INTRODUCTION:The aim of this report is to evaluate feasibility, safety and activity of a new procedure of computed tomography (CT) - guided percutaneous screw fixation (PSF) plus cementoplasty for treatment of mielomatous osteolytic lesions with refractory pain and fracture or to prevent impending pathological fractures. The association of scew fixation with cementoplasty allows, compared to cementoplasty alone, a better augmentation of the bone and reduces the risk of cement leakage through a selective injection of the of polymethylmethacrylate (especially in case of lytic lesion of vertebral pedicle). METHODS: From September 2014 to May 2016 thirteen (13) consecutive patients (eight men and five women, median age 67 years, range 48-78 years) with Multiple Myeloma who had developed painful and symptomatic bone lytic lesions in the pelvis and vertebrae were submitted to the procedure (three patients underwent multiple interventions). This consisted of PSF followed by percutaneous bone-cement injection with an solution of polymethylmethacrylate (PMMA) in eighteen sessions. The procedures were performed into the thoracic vertebrae (three interventions), lumbar vertebrae (nine interventions), pelvis (five interventions, bilateral in one instance) and into a paravertebral mass which involved the fifth and sixth thoracic vertebrae. For the osteosynthesis we used cannulated screws with lateral holes, that allow to selectively inject the cement through the screw avoiding undesired leakage. After the screw insertion, to obtain a better augmentation of the bone, from 8 to 22 ml of PMMA in all the lesions. In two cases, before the PSF and PMMA injection, in order to reduce the volume of the tumor a radiofrequency ablation was performed. All the procedures were performed using local anesthesia, conscious sedation in all patients and antibiotic prophylaxis with ceftriaxone 2 gr i.v. Pain was measured by visual analogue scale (range 0-10), mobility by functional mobility score system with a range from 1 (normal mobility) to 4 (bedridden). Statistical analysis was performed using the test of Wilcoxon. RESULTS:Technical success was achivied in all patients. The CT scan acquired immediately after the procedure didn't demonstrate any complications such as leakage of cement or incorrect positioning of the screws or undesired burning during thermal ablation. No additional bone fractures occurred during a median follow-up of 19 months (range 3-23 months). Pain relief occurred in all the patients within one month. Median VAS score was 7 (range 4-9), 3 (range1-4) and 1 (range 1-2) before, at one and six months after procedure respectively (p Only three patients needed opioid therapy after the procedure. CONCLUSION:The PSF plus cemetoplasty of the pelvis and vertebrae is safe and effective in patients affected by myelomatous localizzations. The procedure is minimally invasive and allows to stabilize the fracture and prevent pathological fractures with significant pain relief and good recovery of walking ability. Further controlled studies with large series of patients are warranted to confirm these preliminary results. Disclosures No relevant conflicts of interest to declare.

Purpose To retrospectively evaluate the feasibility, safety, and effectiveness of computed tomography (CT)–guided percutaneous microwave ablation (MWA) in patients with bone metastases. Materials and Methods Twenty-one patients with metastatic bone lesions were treated in 18 MWA sessions. In patients whose lesions contained fractures, or who had a high risk for fracture (48%; n = 10), MWA was followed by cementoplasty with polymethylmethacrylate injection. The positioning of the MWA antenna into the tumor was guided by CT. Treatments were performed under conscious sedation. All patients underwent clinical (self-reported Brief Pain Inventory [BPI]; scale from 0 to 10) and radiologic evaluation at baseline and 1 month after the procedure. The reported results are data from baseline to a follow-up period of 3 months. Results There were no complications. A reduction of pain and improvement in quality of life was observed in all patients as measured by BPI score. On average, the mean BPI score during the 3-month follow-up period was reduced by 92% (41%–100%). Thirteen of 18 patients (72%) were symptom-free, four patients (22%) were still symptomatic but with 85% lower average BPI scores (41%–95%), and one patient (6%) experienced a recurrence of symptoms. Conclusions Preliminary results suggest that MWA of bone metastases is a well tolerated, safe, and effective procedure. However, its efficacy still remains to be determined by medium- and long-term studies.

Effective management of wound healing is a considerable challenge for clinicians. Patients underlying condition, accurate assessment of the wound and exudates, as well as selection of an appropriate dressing is all important factors for success. A variety of dressings are available to the clinician for the management of exudates. Hydrofiber dressings are a relatively new concept, and can be very cost effective because they can be worn for several days at a time. This report will review clinical evidences on the use of Hydrofiber dressing for the management of epithelial lesions, deal with current knowledge on the mechanism of action of this compound towards the epithelial wound healing process, immunological aspects and will also discuss relevant patents.