Giant Ossified Clival Chondrosarcoma Resection: 2-Dimensional Operative Video

Chondrosarcomas are a spectrum of tumors with variable clinical behavior, histologically classified as grades I, II, and III.1 Maximal surgical resection with adjuvant radiation is the gold standard for grade III malignant tumors.2,3 Lower-grade skull base chondrosarcomas have a slow progressive local growth pattern with an overall benign profile.1,4 In these grade I and II tumors, radical resection can be sufficient in achieving long-term control of the disease without the need for adjuvant therapy, thus avoiding the long-term side effects of irradiation in relatively young patients.4,5 As a slow-growing tumor, skull base chondrosarcoma might reach a giant size with progressive neurological deficits prior to diagnosis. In these cases, to achieve maximal resection, skull base approaches tailored to the patient's anatomy are essential.4,6 Cranial approach is frequently needed due to the calcified nature of part of the tumor that is not amenable to resection through the endonasal approach. The endoscope is extremely helpful combined with the microscopic resection. We demonstrate these techniques through in the surgery of a 39-yr-old female who presented with progressive neurological deficits from a giant ossified chondrosarcoma and underwent a combined petrosal approach for the resection of her tumor. A postoperative small enhancement remained stable on the 4-yr follow-up exam. The pathology confirmed grade II chondrosarcoma, with the patient recovering from her neurological deficit except the third nerve. The patient consented to the surgery and publication of images. Image at 1:36 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, ©LWW, 1998.

The evolutionary biomechanics of locomotor function in giant land animals

ABSTRACT Giant land vertebrates have evolved more than 30 times, notably in dinosaurs and mammals. The evolutionary and biomechanical perspectives considered here unify data from extant and extinct species, assessing current theory regarding how the locomotor biomechanics of giants has evolved. In terrestrial tetrapods, isometric and allometric scaling patterns of bones are evident throughout evolutionary history, reflecting general trends and lineage-specific divergences as animals evolve giant size. Added to data on the scaling of other supportive tissues and neuromuscular control, these patterns illuminate how lineages of giant tetrapods each evolved into robust forms adapted to the constraints of gigantism, but with some morphological variation. Insights from scaling of the leverage of limbs and trends in maximal speed reinforce the idea that, beyond 100–300 kg of body mass, tetrapods reduce their locomotor abilities, and eventually may lose entire behaviours such as galloping or even running. Compared with prehistory, extant megafaunas are depauperate in diversity and morphological disparity; therefore, turning to the fossil record can tell us more about the evolutionary biomechanics of giant tetrapods. Interspecific variation and uncertainty about unknown aspects of form and function in living and extinct taxa still render it impossible to use first principles of theoretical biomechanics to tightly bound the limits of gigantism. Yet sauropod dinosaurs demonstrate that >50 tonne masses repeatedly evolved, with body plans quite different from those of mammalian giants. Considering the largest bipedal dinosaurs, and the disparity in locomotor function of modern megafauna, this shows that even in terrestrial giants there is flexibility allowing divergent locomotor specialisations.

Medial Acoustic Tumors: Special Considerations: 2-Dimensional Operative Video

Medial acoustic tumors are a rare distinct type of vestibular schwannoma having distinguished clinical and radiological features.1 Originating medially in the cerebellopontine angle without extending into the lateral internal auditory meatus, they are frequently giant in size at presentation in younger patients with a relatively preserved hearing, while they have other neurological deficits from cerebellar or brainstem compression and associated hydrocephalus. Imaging typically shows a cystic tumor with local mass effect and an internal auditory canal filled with cerebrospinal fluid.1,2 Surgical resection of theses schwannoma is particularly challenging not only due to their size and hypervascularity, but also given their particular arachnoidal rearrangement inducing marked adherence to the brainstem and facial nerve.2 The treatment is surgical resection, despite, however, their giant size hearing preservation should be sought and is attainable.1–5 Transmastoid approach with squeletonization and reflection of the transverse sigmoid sinus provides lateral exposure avoiding cerebellar retraction.6 In this report, we demonstrate the specific surgical considerations applied to the resection of a giant medial acoustic tumor in a 40-yr-old patient presenting with ataxia, vertigo, facial paresthesia, and intact hearing. The patient agreed to the surgery and photography. Image at 1:44 © Ossama Al-Mefty, used with permission; Image at 8:21 from Dunn et al,2 used with permission from JNSPG.

Left Hemicolectomy for Intussusception of the Transverse Colon Caused by a Giant Benign Lipoma

Colocolonic intussusception, caused by submucosal lipomas, is extremely rare. These benign soft tissue tumours comprise mature adipocytes of mesenchymal origin. While the majority of patients with lipomas remain asymptomatic, large or giant size lipomas (>4 cm) have been shown to cause debilitating abdominal pain, alternating bowel pattern, and anaemia secondary to gastrointestinal blood loss. This necessitates intervention in the form of surgical resection or endoscopic removal. However, once lipomas increase beyond 2 cm in size there is a significant risk of complications with an endoscopic approach, and open surgery or laparoscopic resection with bowel re-anastomosis is warranted. In this case put forth, the patient underwent a successful transverse colectomy and primary anastomosis.

Case Report: Totally Laparoscopic Resection of Retroperitoneal Paraganglioma Masquerading as a Duodenal Gastrointestinal Stromal Tumor

Introduction: Retroperitoneal paraganglioma (RPGL) is a rare clinical tumor derived from the retroperitoneal sympathetic paraganglion tissue. Since RPGLs are locate deeply and have no specific symptoms and imaging manifestations at the early stage, which easily causes missed diagnosis or misdiagnosis. In addition, reports on totally laparoscopic resection of RPGLs are scarce due to their close proximity to large vessels, giant size, uncertain location, and unknown malignant status.Case Presentation: We present here the case of totally laparoscopic resection of a 6.4 × 5.4 cm RPGL that was discovered during a workup for discomfort and upper abdominal pain in a 68-year-old female patient, mimicking a gastrointestinal stromal tumor (GIST) of the duodenum, Which was confirmed as a RPGL based on the histopathological and immunohistochemical findings.Conclusions: RPGL is a rare tumor, and the transperitoneal laparoscopic approach for the RPGL is a safe, applicable method with less trauma and quick recovery, which is worth clinical popularizing and application. Moreover, the survival prognosis of RPGL patients are related to metastasis, and lifelong follow-up should be emphasized.

Giant Calculus with More than 100 Small Calculi in Choledochal Cysts

Giant biliary calculus in the common bile duct (CBD) is rare. Giant calculus of choledochal cyst (CC) is even rarer, and no case of giant calculus of CC with more than 100 calculi has been reported in the indexed literature. We present the case of a 8.0 × 4.5 × 4.0 cm sized giant calculus with >100 small calculi in type IVa CCs with heterotopic pancreas in a 45-year-old male, which is a surprisingly rare occurrence. Magnetic resonance cholangiopancreatography showed multifocal irregular dilatation of intrahepatic biliary radicles with multiple filling defects with a giant calculus in CC with cholelithiasis. The case was successfully managed with open cholecystectomy and choledochotomy with retrieval of 1 giant and more than 100 small calculi with excision of CC with Roux-en-Y hepaticojejunostomy. Histopathological examination (HPE) showed inflamed CC identified with focal areas of surface ulceration with increased fibrosis areas in the wall and few pancreatic acini. A bile duct calculus is defined as “giant” when the size is 5 cm or more. Stone formation within is the most frequent complication of CC. Most intracystic calculi have been described as soft, earthy, and pigmented in appearance, supporting bile stasis as a primary etiologic factor. The only treatment for giant calculus of CBD or CC is surgical. Endoscopic treatment is mostly unsuccessful and open surgery is the treatment of choice due to giant size, increased load of calculus, and presence of calculi in the left and right hepatic ducts.

A LARGE SCALP MYXOID NEUROFIBROMA AN UNUSUAL PRESENTATION IN A MIDDLE- AGED PATIENT: A RARE CASE REPORT

The transformed cells in a neoplasm, whether benign or malignant, often resemble each other, as though all had been derived from a single progenitor, consistent with the monoclonal origin of the tumor. Myxoid neurobroma (MN) is a benign tumor of perineural origin, which is demonstrated by positive immunohistochemical staining for S100 protein. The most common locations are the face, shoulder, anus, periungual, and feet. To our knowledge, this is the first report of an MN in the scalp, which is a very rare location that has been reported earlier. The differential diagnosis of the tumor at this location MN should be kept in mind. This 56 years old male who presented with a large swelling in the scalp (occipital region) which extended to the nape of nack for last 3 years which is gradually increasing in size along with heaviness, intermittent severe pain in the head. Clinically (25x20) cm size swelling in the occipital area and extending to the nape of the neck. The swelling is nontender. It is ovoid in shape . Soft cystic in consistency, the surface is smooth, margins are well dened, the mobility is absent. Fluctuation test is negative but the swelling is brilliantly transilluminant. CONCLUSION: We report this case because of the rarity of both the tumor and its scalp location and also a giant size and to provide a review of the literature. This case study illustrates that any slowly progressing swelling in an unusual location should have been properly investigated and complete surgical excision is the preferred choice of treatment for future recurrence. The MN should be included in the differential diagnosis of tumors at this location.

A giant left ventricular pseudoaneurysm diagnosed after double-valve replacement

A diagnostic coronary catheter injury to the subaortic region in a 41-year-old woman with rheumatic heart disease led to a pseudoaneurysm that later caused extrinsic left coronary compression. She subsequently underwent double-valve replacement, overlooking the pseudoaneurysm that enlarged to a giant size three months later following thrombolysis for mitral prosthesis thrombosis. A thrombolysis-induced large intracerebral hemorrhage posed a significant risk for reoperation, and mechanical prosthetic valves in the aortic and mitral positions allowed a catheter option only, through percutaneous transapical access. Interventional closure of the pseudoaneurysm is discussed in this unique report.

THE TRADITION OF WRITING MUṢḤĀF AL-QUR'ĀN AKBĀR IN MUṢḤĀF AL-QUR'ĀN SCIENCES EDUCATION FOUNDATION (YPIIQ) WONOSOBO

The aim of this article is to describe the writing of Muṣḥāf al-Qur'ān Sciences Education Foundation (YPIIQ) Wonosobo still written by hand in this sophisticated era. The type of this research uses the field research by a qualitative method approach which finds out the phenomenon and analyse the existing data. The process of collecting data uses interview, observation and documentation techniques, and it has found some interesting things. Firstly, the emergence of the tradition of writing Muṣḥāf by hand and giant size departing from KH. Muntaha's idea, he is the caretaker of the Al-Asy'ariyyah Taḥfῑż al-Qur’ān Islamic Boarding School, Kalibeber, Mojotengah, Wonosobo, Central of Java. The devotion of KH. Muntaha Al-Hafidz to al-Qur'ān made him to finally realise the grand Qur'ān writing project. KH. Muntaha al-Hafidz also wants to continue writing Al-Qur’ān that had been written by his grandfather, namely KH. Abdurrahim (1860-1916 AD). Secondly, before writing, there are certain provisions that must be carried out by writers namely they must be in a sacred condition when writing the muṣḥāf, do the sunnah prayers of two raka'at and write it accompanied by fasting except several days that are forbidden to fast. Thirdly, the strong factor that encourages the tradition of writing muṣḥāf at the Qur’ān Sciences Education Foundation (YPIIQ) Wonosobo is still being carried out till now because of devotion to teachers and wants to always glorify the muṣḥāf.