Search

Despite formidable advances throughout surgical disciplines spanning decades, plastic surgeons, especially microsurgeons, have most certainly ignored the memo to sufficiently recognize the alarming prevalence of musculoskeletal disorders (MSDs), a consequence of anti-ergonomic postures assumed during intricate procedures (eg. microsurgery), capable of physical limitations which can lead to early retirement. Collective ignorance of the aforementioned predicament is reflected in the plastic surgery literature wherein epidemiologically rigorous studies remain non-existent. Anecdotal reports evidencing the crippling effect of anti-ergonomic postures along with rigorous operative practices in plastic surgery procedures that have exaggerated operative durations suggest increased predisposition to occupational disorders like cervical disk disease, distal interphalangeal arthrosis, ligamentous injury, pulmonary embolism secondary to deep vein thrombosis and tendinitis. Remarkably, evidence in the literature highlights the commencement of musculoskeletal discomfort as early as in residency, even though previous studies have documented 35.4 years as the initiation point of musculoskeletal symptoms.

Patient: Female, 43 Final Diagnosis: Metastatic breast cancer Symptoms: Breast lesion, breast tumor Medication: — Clinical Procedure: Chest wall reconstruction with a bilayered wound matrix mesh following toilet mastectomy Specialty: Surgery Objective: Unusual or unexpected effect of treatment Background: Breast cancer is still the most common malignancy in women. Though management of local disease has been thoroughly studied, management of metastatic breast cancer (MBC) is still under much debate. Modern diagnostic tools allow the detection of early metastatic disease, which may be more responsive to treatment than late metastatic disease. Source control of MBC by “toilet mastectomy” is being studied in many case reports and studies. Case Report: We present the case of a 43-year-old woman presenting with MBC and complaining of a recurrent breast fungating disease, aiming to highlight the importance of palliative surgical treatment in systemic breast malignancy and to report our experience with the effectiveness of the ‘Integra” mesh. Conclusions: Chest wall reconstruction using bilayered wound matrix mesh following “toilet mastectomy” offers excellent reconstructive results and local control of disease, and is a low-morbidity procedure.

Patient: Female, 58 Final Diagnosis: Metastasis of breast cancer to the sigmoid colon, appendix, and ovaries Symptoms: Abdominal pain Medication: — Clinical Procedure: Abdominal laparotomy Specialty: Surgery Objective: Unusual clinical course Background: Metastasis of breast cancer to the gastrointestinal (GI) tract is not common, however, invasive lobular carcinoma is more likely to metastasize to the GI tract than ductal carcinoma. The simultaneous metastasis of invasive lobular carcinoma to the GI tract and ovaries is an extremely uncommon presentation, which may mimic another rare entity that is peritoneal carcinomatosis secondary to breast cancer. Diagnosis of this entity is difficult as it can masquerade as a primary disease process instead of a secondary one. Treatment is even more difficult due to the sparsity of guidelines regarding this presentation. Case Report: A 58-year-old female with a history of invasive lobular carcinoma of the left breast treated 5 years prior to presentation with GI symptoms. Workup revealed a stenosis of the sigmoid colon; however, colonoscopy and biopsy did not show signs of malignancy. The patient was initially diagnosed with diverticulitis and given appropriate treatment which mildly improved her symptoms but did not eradicate them. Continued symptoms and failed attempts at diagnosis prompted the decision to perform an exploratory laparotomy which revealed metastasis of invasive lobular carcinoma to the sigmoid colon, appendix, and ovaries. Conclusions: GI metastasis of breast cancer is a difficult entity to diagnose and treat. Concomitant metastasis to the GI tract and genitourinary system is even more challenging to diagnose and treat. These variable metastasis presentations of breast cancer indicate a need for more specific modalities for follow-up of breast cancer patients especially those with the invasive lobular subtype which tends to metastasize to unusual distant sites and present years after diagnosis and treatment of the primary disease.

Em um ano marcado pela pandemia da Covid-19, em que o distanciamento social se tornou obrigatório, a edição do Programa Aproxime-se precisou ser adaptada ao modo remoto. Em parceria com a Pró-Reitoria de Extensão (ProEx) da Universidade Federal de Minas Gerais (UFMG), o projeto de extensão do Centro de Apoio à Educação a Distância (CAED) busca realçar a presença da Universidade nos polos de Educação a Distância (EaD), estendendo a participação às comunidades locais, seguindo os requisitos da Extensão Universitária. Este relato tem como objetivo apresentar um panorama da experiência da edição de 2020 do Programa Aproxime-se, bem como ressaltar a importância de sua execução em um contexto pandêmico, fornecendo, ainda, informações sobre práticas alternativas, transdisciplinares e interdisciplinares no campo da Extensão Universitária. Apresenta-se, para tal, a metodologia construída para esse ano e os frutos obtidos com as ações. Inúmeros foram os desafios, em grande medida, ocasionados e expandidos pela pandemia, mas a potencialidade da Extensão tornou viável a execução de um planejamento flexível, adequado às necessidades dos tempos atuais e em consonância com a tríade universitária: ensino, pesquisa e extensão.

Patient: Female, 30-year-old Final Diagnosis: Gastric ectopic pancreas Symptoms: — Medication: — Clinical Procedure: Laparscopic sleeve gastrectomy Specialty: Surgery Objective: Rare disease Background: Ectopic or heterotopic pancreas is relatively rare pathology described as pancreatic tissue lacking communication with the normal pancreas. Ectopic pancreatic tissue can be found along the gastrointestinal tract, with the most common location the stomach along the greater curvature. This congenital condition could be identified incidentally, or present with symptoms that range from pain and bleeding to obstruction and malignant transformation. Case Report: We report a case of a 30-year-old female, who underwent laparoscopic sleeve gastrectomy for morbid obesity of body mass index (BMI) of 46 kg/m2, and who was found to have a 3 cm submucosal mass at the lesser curvature while dividing the stomach. The sleeved stomach tube’s intraoperative gastroscopy showed a submucosal mass at the posterior stomach wall towards the lesser curvature, increasing the suspicion of gastrointestinal stromal tumor (GIST) tumor. The choice was to continue with a secure margin and conversion to roux-en-y gastric bypass with gastric tumor resection. It turned out that the final pathology was submucosal ectopic pancreas. Despite being a rare pathology, for any submucosal gastric mass, ectopic pancreas should be on the differential diagnosis list. During the sleeve surgery, the mass was found, and the approach was changed to intraoperatively subtotal gastrectomy and roux-en-y gastric bypass. Conclusions: Before any bariatric operation, even in asymptomatic young patients, it is worth doing routine upper endoscopy to prevent surprising intraoperative pathology.

Patient: Female, 78 Final Diagnosis: Gall bladder volvulus Symptoms: Abdominal pain Medication: — Clinical Procedure: Cholecystectomy Specialty: Surgery Objective: Rare disease Background: Gall bladder volvulus is a rare clinical entity, with only around 500 cases reported in the literature. It is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic pedicle, although cases of torsion of the gallbladder fundus itself have been reported. Case Report: A 78-year-old woman presented for severe right upper-quadrant abdominal pain that began acutely 3 days prior. Her pain was accompanied by nausea and vomiting. She also reported feeling chills. Abdominal X-ray revealed a 7-cm-diameter subhepatic opacity containing gas. Abdominal ultrasound and CT scan revealed a distended and displaced gallbladder located below the liver, in contact with the right kidney. Subsequently, open cholecystectomy was performed, and a distended, necrotic gallbladder was found twisted on its pedicle; thus, a gall bladder volvulus was diagnosed. Conclusions: In our patient, the classic patient characteristics of an elderly thin female with kyphosis were present. However, the rest of the presentation was not typical of gallbladder volvulus due to the patient’s delay in seeking treatment, and was representative of the necrotic phase of gallbladder torsion, in which the patient becomes ill-appearing, with fever and chills, with significant abdominal rigidity.

Background: Cystic hygromas, interchangeably named Lymphangiomas, are rare, congenital, benign lesions due to an abnormal lymphatic system development that tend to occur mostly in the head, neck, and oral cavity. Case Presentation: This is a case of 18 year old male patient Syrian, smoker, with a history of multiple cystic hygromas since birth along with a generous surgical history of multiple laparotomies for intrabadominal cystic excisions, splenectomy herniorrhaphies (bilateral inguinal hernias and 2 incisional hernias due to laparotomies) left orchieopexy then testiculectomy, scrotal skin graft , multiple abdominal radioguided cystic drainage and sclerotherapy; presented to our care center for fever, dry cough, pleuretic chest pain, and mild abdominal pain with watery diarrhea. Conclusion: Cystic Hygroma is still being considered as a rare entity and can virtually occur in the whole body sites mostly at head and neck regions as explained above. Challenges in this disease is by finding cases where the presence of such cystic lesions is in extremely rare and unusual sites as well as different treatment modalities and prognostics depending on the site and size of the detected cystic formations.

Patient: Female, 25 Final Diagnosis: Leo-ileo-cecal intussuception Symptoms: Abdominal pain Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare disease Background: Intussusception is defined as the penetration or telescoping of a segment of bowel into a more distal segment. Intussusception is a common cause of small bowel obstruction, especially in children. However, this finding is much less common in adults. Furthermore, when present in adults, intussusception is often found in association with some sort of organic mass, such as a tumor or pancreatic divisum that acts as a lead point, dragging the proximal segment into the distal one. The presence of an intussusception in an adult patient with no obvious lead point is very uncommon. Case report: Here we report a case of ileo-ileo-cecal double intussusception in an adult patient that yielded no lead point on surgical exploration. The patient was a 25-year-old female who presented with symptoms of obstruction and was diagnosed with the intussusception via computed tomography scan. Surgical resection of the bowel was necessary as reduction could not be accomplished. Conclusions: The finding of intussusception in an adult patient is far less common than in children, and even more rare when a lead point is not established. When surgery is required, a thorough exploration should be performed to search any signs of a potential lead point. Laparoscopy is usually preferred to laparotomy; however, in this case the degree of distention determined the surgical approach. Thus, due to severe distention, laparotomy was preferred.

Patient: Male, 57 Final Diagnosis: Perforated diverticuli Symptoms: Asymptomatic Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: Perforation of the colon is associated with high mortality and requires early diagnosis. However, the diagnosis of perforation from atypical causes can be a diagnostic challenge. This report is of a rare case of recurrent sigmoid colonic perforation in a patient with diverticular disease who did not present with an acute abdomen but who had pemphigus vulgaris treated with immunosuppressive therapy. Case Report: A 57-year-old man with pemphigus vulgaris was treated with steroids, non-steroidal anti-inflammatory drugs (NSAIDS), and azathioprine. He had episodes of abdominal bloating but denied any other symptoms. He was diagnosed with spontaneous sigmoid diverticular perforation without presenting with an acute abdomen. Conclusions: Diverticular perforation can be asymptomatic in patients on immunosuppressive therapy. Therefore, there should be a high index of suspicion for bowel perforation in patients with abdominal symptoms who are treated for skin diseases, such as pemphigus vulgaris, and are on steroids and other immunosuppressive treatments.

Patient: Male, 27 Final Diagnosis: Appendicitis Symptoms: Abdominal discomfort Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare disease Background: Left-sided acute appendicitis, although well described in the literature, is still an easily missed diagnosis. Midgut malrotation and situs inversus are 2 known leading conditions that contribute to misdiagnosis of appendicitis. Case Report: Here is the case of a 27-year-old male without any previous medical history, who presented with left lower quadrant tenderness and was misdiagnosed with gastroenteritis as an outpatient and sent home; the patient presented the next day to the emergency department where he was found to have acute appendicitis with situs inversus. He underwent laparoscopic appendectomy where a phlegmon was identified. Pathology came back as peri-appendiceal mucocele with no signs of malignancy. Conclusions: This case report aimed to revisit the idea of left-sided acute appendicitis and discuss the management of a perforated appendiceal mucocele contained by a phlegmon.

Patient: Female, 32 Final Diagnosis: Gastro bronichial fistula Symptoms: Dyspnea Medication: — Clinical Procedure: — Specialty: Surgery Objective: Unusual clinical course Background: Bariatric operations have been gaining more ground over the past decade. The most commonly used bariatric operation is the laparoscopic sleeve gastrectomy. A complication of laparoscopic sleeve gastrectomy is gastric leak; which can rarely cause a primary subphrenic abscess and a secondary diaphragm rupture that will lead eventually to a gastrobronchial fistula. Case Report: We present the case of a 32-year-old patient who started having symptoms suggestive of gastrobronchial fistula at 2 months following laparoscopic sleeve gastrectomy. Conclusions: The treatment of a gastrobronchial fistula is controversial as this complication is rarely covered in published studies. Our expert opinion for this patient case was to opt for a surgical approach seeing that the complexity and severity of the fistula had a low chance of subsiding after only conservative measures.

Patient: Male, 68 Final Diagnosis: Ruptured metastatic hepatic lesion from a jejunal GIST Symptoms: Abdominal discomfort • hypotension Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Gastrointestinal stromal tumors (GISTs) are rare gastrointestinal neoplasms. The spontaneous rupture of a jejunal GIST is very rare and spontaneous rupture of liver metastasis from an intestinal GIST is even rarer with only a few cases reported in the literature. Case Report: In this article, we reported a case of spontaneous rupture of a liver metastasis from a malignant jejunal GIST that presented with active tumoral bleeding, hypovolemic shock, and hemoperitoneum. The patient was successfully treated with arterial embolization of the tumor. Conclusions: In appropriately selected patients, arterial embolization appears to be an effective safe treatment for a GIST metastasis rupture.

Purpose: We aim to provide results of the real-world experience of a single center in Lebanon on the use of radioembolization to treat liver-only or liver-dominant tumors. Methods: This retrospective review included patients who were evaluated for radioembolization between January 2015 and June 2017 and who had a lung shunt fraction of 20% or less. Tumor responses were determined using the response evaluation criteria in solid tumors (RECIST). Results: Of the 23 Arab patients with a median age of 64 years (range, 36-87 years), eight had hepatocellular carcinoma, four had cholangiocarcinoma, and 11 had liver-only or liver-dominant metastases from other primary cancers. Most (n=17) had multifocal lesions, and 13 had a history of branched (n=8) or main (n=5) portal vein thrombosis. When appropriate, the gastroduodenal artery and middle hepatic artery were embolized for consolidation of radiotherapy; 18 patients required arterial coil occlusion, two had their cystic artery occluded, and one developed cholecystitis, which was successfully treated with antibiotics and supportive care. Another patient developed a post-radioembolization complication-a peptic ulcer unrelated to arterial reflux of microspheres because both the gastroduodenal and right gastric arteries were occluded. The median time to progression was seven months (range, 3-36 months), and median overall survival from radioembolization was 12 months (range, 3-40 months). Tumor responses included five complete responses, 13 partial responses, one stable disease, and four cases of progressive disease. Conclusion: Performing radioembolization in a non-referral, private center in Lebanon resulted in good patient outcomes with few complications.

BACKGROUND Hemorrhagic cholecystitis is an uncommon occurrence in the setting of gallbladder pathology. It is a rare complication of acute cholecystitis that may have a misleading presentation and workup, making it challenging to diagnose pre-operatively. CASE REPORT We report the case of a 43-year-old female who presented for severe epigastric pain with nausea and vomiting and whose imaging was in favor of acute cholecystitis. The patient was scheduled for laparoscopic cholecystectomy, during which she was found to have hemorrhagic cholecystitis, later confirmed by pathology. CONCLUSIONS Hemorrhagic cholecystitis is an uncommon diagnosis in patients presenting with abdominal pain. The case discussed hereafter was found to have hemorrhagic cholecystitis intra-operatively. Urgent cholecystectomy is crucial in the setting of hemorrhagic cholecystitis due to its possible fatality. This case emphasizes the importance of thinking of hemorrhagic cholecystitis in a patient presenting for what appears to be a severe acute cholecystitis.

Patient: Male, 73 Final Diagnosis: Leishmania Symptoms: Fever Medication: — Clinical Procedure: — Specialty: Oncology Objective: Unusual clinical course Background: Leishmaniasis is a parasitic infection spread by the bite of infected sand flies that are usually present in the Middle East, Africa, and some parts of Asia and Europe. Leishmaniasis manifests in 3 different forms: Visceral (also known as Kala Azar), which is the most serious type; cutaneous, which is the most common type; and mucocutaneous. The symptoms of this infection range from a silent infection to fever, enlargement of the liver and spleen, weight loss, and pancytopenia. Case Report: In this case report, we discuss a 73-year-old man known to have chronic lymphocytic leukemia (CLL), presenting with unremitting fever and who to our surprise was found to have Kala Azar. Conclusions: Early diagnosis and treatment are very important in treating visceral leishmaniasis. While the conventional treatment in immunocompromised patients is liposomal amphotericin B, our patient responded to corticosteroids.

Key Clinical Message Nutritional support and Antibiotics treatment can be used as conservative treatment for the resolution of gastro‐colic fistula after sleeve gastrectomy in stable patients specially to prevent cumbersome redo surgeries that have higher risks of complications particularly in patients with minimal financial means.

Highlights • Posterior reversible encephalopathy syndrome, syndrome characterized by headache, confusion, visual loss and seizures. • Mesenteric leiomyosarcoma causing Posterior reversible encephalopathy syndrome. • Symptoms disappearance after resection of the tumor, suggests a renin production cessation., Background Posterior reversible encephalopathy syndrome (PRES) is a syndrome characterized by headache, confusion, visual loss and seizures. Many factors influence the appearance of this syndrome, predominantly eclampsia, certain medical treatments and malignant hypertension. Diagnosed by typical transient lesions on magnetic resonance imaging. Case Report We present a case of mesenteric leiomyosarcoma in a 52 year old woman, who had severe headache, abdominal heaviness, and hypertension. Investigations revealed a mesenteric mass and a Posterior Reversible Encephalopathy Syndrome features on brain MRI, suggesting renin secretion by the tumor, causing the patient’s symptoms. Conclusion Patient’s symptoms disappeared after resection of the tumor, suggesting a renin production cessation.

Background Numerous studies have demonstrated that radioembolization of the liver with yttrium-90 microspheres provides a survival advantage for patients with unresectable primary or secondary tumors of the liver. The goal of this study was to provide results of the real-world experience of a single center in Lebanon with the use of radioembolization to treat liver-only or liver-dominant tumors. Methods Patients were included in this retrospective review if they were evaluated for radioembolization between January 2015 and June 2017 and had a lung shunt fraction of 20% or less. Tumor responses were determined using the Response Evaluation Criteria In Solid Tumors. Results Of the 23 patients treated with radioembolization, 8 had hepatocellular carcinoma, 4 had cholangiocellular carcinoma, and 11 had liver-only or liver-dominant metastases from other primary cancers. All were Middle Eastern, with a median age of 64 years (range 36-87 years), and 14 were men. A majority (n=19) had an initial tumor volume of 49% or less. Most (n=17) had multifocal lesions, and 8 had a history of branched or main portal vein thrombosis. Eighteen patients required arterial coil occlusion. Two patients had their cystic artery occluded, and one of these patients developed cholecystitis, which was successfully treated with antibiotics and supportive care. Only one other patient developed a postradioembolization complication, which was a peptic ulcer and was not thought to be due to arterial reflux of microspheres because both the gastroduodenal and right gastric arteries were occluded. Median time to progression was 7 months (range 3-36 months), and median overall survival from radioembolization was 12 months (range 3-40 months). Tumor responses include complete response for 5 patients and partial response for 13 patients. One patient had stable disease and 4 had progressive disease. Conclusion While avoiding prophylactic coiling, we had a positive experience with coiling of the gastroduodenal artery and middle hepatic artery for consolidation of radiotherapy. Performing radioembolization in a nonreferral, private center in Lebanon resulted in good patient outcomes with a low rate of complications.

Abdominal wall endometriosis is a rare condition that occurs after a cesarean section or pelvic surgery and it has an incidence of 0.03%-1.5% in women with previous cesarean delivery. The predominant clinical picture is cyclic pain. We report two cases of abdominal wall endometriosis. The first was a 36-year-old female patient who presented for recurrent cyclic abdominal pain and was found to have endometriosis near the cesarean scar. The second was a 40-year-old female who had the same clinical presentation and was found to have endometriosis away from the scar. These cases highlight the need to have a high index of suspicion when treating women with recurrent cyclic abdominal pain.

Summary:. Morel-Lavallée lesion (MLL) is a closed degloving soft-tissue injury that results in the accumulation of a hemolymphatic fluid between the skin/superficial fascia and the deep fascia. This is a rare injury that may be challenging to diagnose, and necessitates early identification and treatment to achieve the best outcomes. We report the case of a 45-year-old male patient who was referred to our institution for large wound closure after undergoing debridement of a misdiagnosed MLL that became complicated by infection and sepsis. The patient was retrospectively diagnosed with a Stage VI MLL and had to undergo 4 operations with skin grafting and vacuum-assisted closure therapy playing an essential role in achieving tissue closure. This case was presented as a reminder of this rare diagnosis, and the importance of considering it when faced with a patient presenting with a relevant clinical picture post trauma. An early diagnosis is important because early intervention can prevent complications and lead to better outcomes. The misdiagnosis in the case of our patient and delayed treatment led to an aggressive debridement with a large wound that was challenging to close.

Case series Patients: Male, 33 • Male, 18 • Male, 19 Final Diagnosis: Congenital band causing a small bowel obstruction Symptoms: Progressive abdominal pain that eventually becomes excessive Medication: — Clinical Procedure: Laparoscopic band removal Specialty: Surgery Objective: Rare disease Background: Among the causes of constipation are bands and adhesions that lead to obstructions at different points in the intestinal tract. These can occur as a consequence of healing following surgery or trauma. However, an entity known as congenital band exists where a band is present from birth. Here we report three such cases of adults with symptoms of intestinal obstruction, in whom a congenital band was discovered through exploratory laparoscopy. Case Reports: All three of these patients presented lacking a history of any abdominal trauma or previous abdominal surgeries, a fact that is often used to exclude an adhesion as a differential. All three recovered quickly and had relief of their symptoms following surgical intervention. Conclusions: Bands and adhesions are common surgical causes of small bowel obstruction, leading to symptoms such as nausea, vomiting, constipation, and obstipation. These bands almost always result from a prior abdominal surgery or from a recent abdominal trauma. The three cases presented here show a far more unusual picture of a band, one that is congenitally present, as there was an absence of such a history. This is significant because clinical suspicion of a band is often very low due to a lack of distinguishing clinical and diagnostic features, and when the past history is negative.

Key Clinical Message In any patient, the occurrence of postsplenectomy splenosis can complicate the planning of further surgeries. In our case, the gastric sleeve procedure was aborted, as it would have put the patient's life in danger. Therefore, only the gastric band was removed, eliminating future erosion.

O artigo trata da relação entre o Parque Estadual do Sumidouro - PES e os moradores do entorno. No passado, as principais atividades econômicas no entorno do PES eram as serrarias e pedreiras de Pedra Lagoa Santa e, atualmente, grande parte está interditada por falta de licença ambiental. O objetivo desse estudo foi analisar a existência de conflitos entre essa população e o PES, assim como o uso público do espaço do parque. A hipótese formulada é de que há uma relação negativa entre o PES e a população, na medida em que o fechamento das pedreiras ocorreu concomitantemente à implantação do parque. Foram realizadas três visitas ao PES para reconhecimento da área e coleta de dados, incluindo sete entrevistas qualitativas com moradores do entorno, moradores ligados à atividade de extração da pedra e trabalhadores do PES. A partir das entrevistas realizadas foi possível perceber que grande parte se mostrou insatisfeita com a falta de diálogo e que os entrevistados atribuem o fechamento das pedreiras à criação do PES. Constatou-se que os moradores têm dificuldade de compreender a relação entre as competências de cada órgão integrante da política ambiental, atribuindo erroneamente funções aos órgãos. A análise das entrevistas permitiu confirmar a hipótese do projeto, ou seja, há um conflito socioambiental no entorno do PES e isso tem relação com o fechamento das pedreiras. Para a minimização dos conflitos foram propostas medidas como: a criação de uma equipe para lidar com os conflitos, no cenário da Parceria Público Privada, e o desenvolvimento mais efetivo de uma educação ambiental voltada à comunidade, a fim de melhorar a relação entre o PES e os moradores do seu entorno.

Patient: Female, 34-year-old Final Diagnosis: Unicentric Castleman’s disease Symptoms: Hematuria Medication:— Clinical Procedure: Laparoscopic approach of a para-duodenal retroperitoneal mass Specialty: Surgery Objective: Rare disease Background: Castleman’s disease is a benign, lymphoproliferative disorder that is extremely uncommon. Multiple classifications have been described; however, the exact etiology remains unknown. Preoperative diagnosis is not common, as imaging cannot distinguish the disease from other processes, and biopsy is insufficient to provide the architecture of the mass, which is necessary for diagnosis. Unicentric retroperitoneal disease has been described, and management includes complete resection of the mass, which is usually curative. Case Report: A 34-year-old previously healthy woman presented with hematuria. Evaluation revelated a retroperitoneal mass that was abutting the duodenum and head of the pancreas. Biopsy failed to provide a diagnosis, so laparoscopic resection was performed. Postoperative diagnosis was consistent with unicentric Castleman’s disease. Conclusions: Castleman’s disease is an uncommon process, and one that is difficult to diagnose. Unicentric Castleman’s disease should always be a differential diagnosis of solitary retroperitoneal masses that are well-demarcated, as treatment can be curative with surgical resection.

BACKGROUND Duodenal and ampullary carcinoids are very rare tumors accounting respectively for 2% and 0.03% of all carcinoid tumors. Clinical findings vary according to the location of the tumor within the periampullary region; with epigastric pain being the most common presenting symptom in duodenal carcinoids and jaundice the most common clinical finding in ampullary carcinoids. Treatment options include pancreaticoduodenectomy, local excision, and endoscopic excision. CASE REPORT In this case report, we present a 60-year-old male who presented with a one-week history of intractable epigastric pain. He was diagnosed with duodenal periampullary carcinoid tumor and treated with local excision. CONCLUSIONS Although duodenal and ampullary carcinoid tumors may have different clinical presentations, as well as histochemistry characteristics and metastatic potential, they appear to benefit from the same surgical treatment.

Patient: Male, 73 Final Diagnosis: Foreign body causing recurrent diverticulitis Symptoms: Chronic abdominal pain Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Challenging differential diagnosis Background: Ingested foreign bodies (IFBs) are usually asymptomatic and are excreted uneventfully. IFBs become a major concern in elderly patients due to the increase number of diverticuloses where the foreign body can lodge and cause severe complications. Case Report: We report a case of an elderly patient who ingested a chicken bone that caused recurrent diverticulitis. Conclusions: The diagnosis of complicated IFB cases is challenging, requires physician clinical expertise, and must be considered in individuals at risk.

Patient: Male, 45 Final Diagnosis: Mesenteric fibromatosis Symptoms: — Medication: — Clinical Procedure: Surgical removal of the mesenteric fibromatosis Specialty: Surgery Objective: Rare disease Background: Mesenteric fibromatosis, also known as mesenteric desmoids, is part of the clinical-pathologic spectrum of deep fibromatosis, which encompasses a group of benign fibro-proliferative processes that are locally aggressive and have the capacity to infiltrate or recur without metastasis. Case Report: Case of a 45-year-old man, with a history of hypertension and lung fibrosis, presenting for a left abdominal mass, which was found incidentally during his lung fibrosis imaging. He complained of constipation due to pressure upon his bowel leading to difficulty in defecation. Conclusions: Although there are many overlapping criteria between gastrointestinal stromal tumors and mesenteric fibromatosis, making it difficult to discriminate between the two, there are differences that are unique to mesenteric fibromatosis that should be noticed during the diagnosis. In this case, mesenteric fibromatosis was unusual as it is not associated with Gardner’s syndrome, desmoid tumors, nor familial adenomatous polyposis, but was an incidental finding.

Background: Standard combination chemotherapy for advanced SCLC has not changed substantially in the last two decades. The challenge when identifying novel SCLC therapies is the prevalence of multiple inactivating mutations in tumor suppressor genes (TP53, PTEN, RB1) and gain-of-function oncogenic mutations (PI3K3CA, MYC family). BET bromodomain inhibitors such as OTX015 (OncoEthix SA) which binds to human bromodomain proteins BRD2/3/4, modulate the transcription of target genes via epigenetic mechanisms. OTX015 shows preclinical activity in hematologic and solid tumors and is currently in clinical development. Here we characterized the effects of OTX015 on a series of SCLC cell lines. Material and Methods: OTX015 growth inhibition 50% (GI50) values were determined with the MTT assay after 72 h exposure in four established SCLC cell lines (H82, H69, DMS79, DMS114). Protein levels were analyzed by Western Blot using commercial antibodies and RT-PCR was performed with Fast SYBR Green Master Mix on a StepOnePlus Real-Time PCR System at baseline, then 4 and 24 h post-treatment. For cell cycle analysis, cells were stained with propidium iodide and analyzed for DNA content with a FACScan flow cytometer. Results: DMS114 cells showed dose-dependent sensitivity to OTX015 [GI50 = 120 (84–172) nM], while H82, H69, DMS79 cells were resistant [GI50 >6 mM], although they overexpressed CMYC and/or NMYC proteins. While all four SCLC cell lines are KRAS wild-type and TP53 mutated, OTX015-resistant SCLC cell lines harbor a homozygous mutation in RB1, while DMS144 cells express RB1 wild-type. All cell lines exhibited similar basal mRNA levels of BRD2/3/4, CMYC, NMYC, HEXIM, BCL-2 and p21. Following OTX015 treatment at 500 nM, CMYC and NMYC mRNA levels were unchanged, while mRNA levels of HEXIM and genes coding for histones (HIST1H2BK, HIST2H2BJ) were upregulated in all four cell lines. In DMS114 cells, OTX015 caused cell cycle arrest in G1 in a timedependent manner, which may be explained by an upregulation at the protein level of the cell cycle inhibitor p27. Conclusion: Our findings suggest that the MYC family does not mediate OTX015 antitumor effects in SCLC cell lines. The presence of functional RB1 protein, controlling cell progression at G1, may explain the cytostatic effects of OTX015. Further studies investigating the therapeutic potential of OTX015 in SCLC are ongoing.