The insulinoma as a diagnostically and therapeutically challenging neoplasm

Introduction and purpose An insulinoma is the most common neuroendocrine tumor of a pancreas. This tumor produces insulin, which in excess causes hypoglycemic attacks, provoked by hunger or physical effort. Delays in diagnostic processes of the insulinoma are associated with the misattribution of symptoms to cardiac, psychiatric or neurological disorders. Thus, the suitable diagnostic procedures play a significant role as they ensure quick introduction of treatment. The purpose of this work is to evaluate advances in demanding diagnostically and therapeutically insulinoma. A brief description of the state of knowledge The used method was a literature review. The basic and the most common method of treating the insulinoma is a surgery. Due to this, finding precise location of the tumor preoperatively is crucial. In the diagnostics of the insulinoma both basic CT and MRI contrast enhanced and an endoscopic ultrasound, a selective arterial calcium stimulation test and the latest molecular imaging are used. In treatment process not only traditional surgical excisions were performed, but also laparoscopic and robotic surgeries turned out to be success. Conclusions Summing up, the insulinoma is a neoplasm with a wide range of therapeutic and diagnostic solutions, thanks to the progress that has been made in recent years. Although there are many difficulties on a diagnostic path of the insulinoma, new solutions and appropriate aproach make this process easier. Nevertheless, doctor’s diagnostic vigilance is essential, because consideration in the differential diagnosis the insulinoma is an essential step and without this step any further actions can be taken.

623 Completed Audit Cycle of Indications for Excision of Fibroadenomas At A University Hospital

Aim This audit looked at indications for excisions of fibroadenomas one year on from the first audit cycle and following intervention of presentation and teaching at local departmental meeting. This audit was motivated by a drive to reduce operations on benign breast conditions including fibroadenoma excisions. ABS (Association of Breast Surgery) guidelines advise excision for fibroepithelial lesions (B3) on biopsy, pain and increasing size. Local consensus is excision of fibroadenomas over 30mm on ultrasound. Method Patients who underwent surgical excisions of fibroadenomas over 6 months at one hospital were analysed for size on ultrasound, biopsy histology and reason for excision, and compared to previous audit results over 24 months. Results Over 6 months, 18 patients underwent excisions. Histology specimens showed 13/18 were fibroadenomas, 4/18 benign phyllodes and 1/18 other benign conditions. This was similar to the previous audit, although there was an increase in the rate of benign phyllodes. Pre-operatively, 11/18 of patients met the ABS criteria for excision (7/11 were B3 lesions, 3/11 for increasing size and 1/11 pain). 11/18 patients met the local criteria. 2/18 patients met neither criteria. This had improved compared to the first audit cycle. Conclusions 88.9% of patients met ABS or local criteria, compared to 83.7% previously, and so this had improved following intervention. One outcome from the first audit cycle was patients need greater reassurance about the benign nature of fibroadenomas to avoid unnecessary morbidity due to surgical procedures, and this appears to have improved on re-audit. Both patients not meeting criteria had histology showing fibroadenomas.

Concurrent Adjacent Merkel Cell Carcinoma and Chronic Lymphocytic Leukemia without Simultaneous Merkel Cell Polyomavirus Detection: A Case Series

Background: The association between Merkel cell carcinoma (MCC) and chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL) is well established in the literature. A majority of MCCs are known to be associated with Merkel cell carcinoma polyomavirus (MCPyV), which is postulated to be a possible causative agent linking these two entities. We aim to identify the presence of MCPyV in patients with concurrent adjacent MCC and CLL/SLL. Methods: Archived pathology materials of three cutaneous or surgical excisions with concurrent MCC and CLL/SLL were reviewed. Additional 12-µm sections from paraffin-embedded tissue of these resections were matched with original hematoxylin and eosin-stained slides and used to extract foci from each tumor separately. DNA was extracted from these tissues, and polymerase chain reaction (PCR), utilizing a primer set within a highly conserved “small T” viral DNA region, was done to detect MCPyV. Results: Out of 140 cases of cutaneous or surgical excisions with MCC identified in our electronic medical records (EMR), three had coexisting neighboring CLL/SLL in the same resection specimen. In one case out of three, MCPyV was detected in MCC but not in CLL/SLL. The remaining two cases showed no detection of MCPyV in either MCC or CLL/SLL. Conclusion: MCPyV was not concurrently associated with adjacent MCC and CLL/SLL, indicating that it is not driving simultaneous tumorigenesis, at least in a subset of these cases.

Deep Dermatophytosis

Deep dermatophytosis is a rare fungal infection described for the first time by Hadida and Schousboe. It is a chronic dermatophytic infection of the skin and viscera, mainly described in the Maghreb where it has an autosomal recessive transmission. Immunological studies have revealed a deficiency of cellular immunity leading to dermatophytes tolerance. Commonly, first lesions begin in childhood. Both superficial and deep dermatophytic lesions are possible. A 17 years old male patient with a history of chronic generalized pruritic erythematous-squamous lesions presented for subcutaneous abscesses of scalp and trunk. He underwent multiple antibiotic courses and surgical excisions with persistent relapses. Trichophyton rubrum was identified in skin biopsy and all samples sites. It was found no immunodeficiency within the limits of the blood tests conducted. Search for CARD9 protein deficiency was positive. Treatment based on Terbinafine and surgical drainage with mid improvement

Public perceptions on pathology: a fundamental change is required

Pathology has been mostly invisible for the public. The missing recognition affects the pathologists’ reputation, and efforts with recruitment and advocacy. Our survey with 387 respondents confirms that the public knowledge on the role of the pathologists has not improved despite campaigns and advocacy efforts. Pathology was identified as a medical specialty by 79.1% of the respondents. Only 34.8% assumed that it takes more than 8 years of post-high school training to become a pathologist. Most commonly, another medical specialist was identified as the ultimate diagnostician on Pap tests (gynaecologist), breast biopsies or malignant surgical excisions (oncologist), gastrointestinal biopsies (gastroenterologist) or prostate biopsies (urologist). The experience gained by undergoing these procedures had minimal impact on understanding the pathologists’ role, since they were identified as ultimate diagnosis makers by the minority of these patients (13.8%–36.4%). The integration of pathologist–interactions into patient care may be a potential solution with benefits beyond improved perceptions.

Primary vaginal leiomyosarcoma: case report of a rare gynaecological malignancy and diagnostic challenge in a resource-constraint setting

ABSTRACT Primary vaginal leiomyosarcoma (VLMS) is an extremely rare variant of primary vaginal cancers with very poor prognosis irrespective of the stage at presentation and the type of treatment received. It is easily recurrent and has a high propensity for haematogenous spread especially to the lungs. We present the case of a 34-year-old Para 1 + 1 (1 alive) woman with recurrent vaginal mass of 8 years duration after two surgical excisions without histological evaluation. She had examination under anaesthesia and a wide local excision of the vaginal mass. Histological examination of the mass revealed poorly differentiated VLMS with positive surgical margins and she was commenced on adjuvant chemo-radiation. Histological evaluation remains the hallmark for diagnosing rare malignancies like VLMS, which unfortunately is not a standard practice in some resource-constraint settings.

Anaesthetic Management of Emergency Tracheostomy in a Three Years Old Child with Recurrent Laryngeal Papillomatosis: A Case Report

Juvenile onset recurrent laryngeal papillomatosis is a condition which requires multiple surgical excisions to maintain airway patency. However, if neglected may lead to airway compromise requiring emergency tracheostomy and anaesthetic management in such paediatric case is challenging. Awake tracheostomy is difficult and risky in children who are usually restless and uncooperative. Also induction of anaesthesia by intravenous or inhalational route pose a threat to the loss of airway muscle tone & patency. We present here a three years old child with recurrent laryngeal papillomatosis who landed up with emergency tracheostomy for severe stridor where the passage of even the smallest size endotracheal tube would not be possible however emergency tracheostomy could be safely done by inhalational induction maintaining spontaneous ventilation. Such paediatric case where even endotracheal tube could not be passed has been rarely reported. Also literature on anaesthetic management of paediatric emergency tracheostomy is sparse.