When an old pigmented lesion becomes serious: the problematic diagnosis of low-grade skin malignancies – Bednar tumor with fibrosarcomatous transformation

Bednar tumor is a rare cutaneous neoplasm, regarded as a variant of dermatofibrosarcoma protuberans with melanotic colonization and it usually affects young and middle-aged adults or children. This lesion is considered a low-grade malignant tumor, which can be associated with multiple local recurrences after surgical excision. Although a rare phenomenon, these lesions may undergo fibrosarcomatous transformation, which implies a poorer prognosis of the disease, as the tumor has a more locally aggressive behavior and patients might also develop distant metastases. We present the case of a 53-year-old female patient, with no significant medical history, who presented with a subcutaneous nodule on her upper back, for which a wide surgical excision was performed. The gross examination of the specimen showed a solitary protuberant grey-white nodule with a bluish shade and flecked with pigment. The microscopic examination revealed a malignant proliferation with a predominantly fascicular growth pattern, composed of spindle cells with highly pleomorphic nuclei and high mitotic rate, as well as the presence of dendritic cells with abundant melanin. Upon immunohistochemical analysis, the proliferation showed negative staining for CD 34 and AE 1/3, whereas the scattered dendritic cells stained positive with S100 protein. Ki 67 was positive in 15% of the tumor cells and the absence of p53 expression was noted. Thus, the diagnosis of Bednar tumor with fibrosarcomatous transformation was established. The aim of this paper was to gain further knowledge about the histopathological and immunohistochemical features, as well as about the treatment of Bednar tumor, especially considering its rarity.

Multimodal analgesia in primary bone tumors

Introduction: A worrying increase in the number of bone tumors that appear at younger ages justifies the efforts aimed at optimizing perioperative management practices in orthopedic tumor surgery. Pain control is critical in the prognosis and postoperative outcome of these procedures. Material and methods: Our study included a group of 11 patients diagnosed with bone malignancies. These patients were hospitalized in the Orthopedic Clinic of the University Emergency Hospital Bucharest. Under our supervision, they underwent surgical treatment of the tumor under combined general anesthesia and epidural anesthesia for the pelvic limb, and general anesthesia only for the upper limb. We performed perioperative pain management with multimodal analgesia (continuous epidural analgesia with ropivacaine 0,2% and fentanyl 2 mcg/ml in association with systemic analgesics). Following this procedure, we measured the intensity of the postoperative pain at intervals of 48 hours and one week after surgery and compared with preoperative pain intensity using the visual analogue pain scale (VAS). Results: Multimodal analgesia (epidural analgesia associated with systemic analgesics – paracetamol, COX2 inhibitor, gabapentinoids) was performed well in the postoperative pain of the tumor prosthesis, with a significant decrease in VAS from a mean value of 7.63 preoperatively to an average of 3 in the first 48 hours postoperatively. After the removal of the epidural catheter, which also coincided with patient mobilization, the level of pain registered a slight increase to a mean value of 3.23. Conclusions: Multimodal analgesia is currently considered the gold standard in perioperative pain management. The use of multimodal analgesia during perioperative period in patients with bone tumors has been shown to decrease the length of hospital stay, improve surgical outcome, reduce the number of systemic complications, and improve the long-term prognosis of the patient. Efficacy of analgesia correlates with tumor site and vascularization.

Current review of surgical management options for total knee arthroplasty in the rheumatoid knee

Rheumatoid arthritis (RA) represents a condition that can erode cartilage and damage joints, leading to inflammation and loss of movement, characterized by inflammatory synovitis. While the widespread use of potent disease-modifying medications has increased opportunities for RA patients, orthopedic surgery and complete joint arthroplasty remain an important option in end-stage joint treatment. The knee is one of the most frequently affected joints in chronic rheumatoid arthritis patients. The severity of RA ranges from a moderate illness to a serious, rapidly progressing, destructive version, gradually leading to incessant pain and joint deformity. Despite recent advances in biological agents and therapeutic modalities in the field of rheumatology, certain patients with RA, who ultimately undergo joint surgery, tend to experience progressive joint damage. Though, TKA can be performed in these patients, increased complications and poorer outcomes may result after total knee arthroplasty, because of the particularities given by RA. They are associated with extended operating time, specifically resulting in increased infection, blood loss and deep vein thrombosis. However, because RA patients present additional risk factors for complications, certain critical preoperative examination and surgical aspects need to be considered in order to maximize TKA outcomes in this subgroup of patients.

Non-operative management of blunt splenic injuries beyond safety conditions A short narrative review

Although the introduction of specific guidelines regarding the acute management of trauma patients have resolved many inconsistencies in the acute treatment pathways, grey areas are still preventing consensus and unitary standards of care. The treatment of splenic injuries has seen a notable shift from splenectomy only in the early 20th century to mainly non-operative contemporary approaches. However, there is no current agreement on the optimum timing of switching from conservative to operative decisions, raising the legitimate question of whether some patients are put at risk by waiting too much or other patients are deprived of a necessary organ by not waiting enough. This paper focuses on the non-operative paradigms of blunt splenic injuries and their immediate and long-term clinical implications presented as a short narrative review. It presents the historical perspective on the treatment of splenic injuries, the role of surgery and selective angioembolisation and their repercussions on the immunological functions of the spleen.

Malignant granular cell tumor of the arm – case report

Granular cell tumor (GCT) is a rare form of soft tissue cancer that is usually benign. Its malignant evolution is encountered in less than 2% of cases, having a more rapid and unfavorable evolution. Clinical presentation betraying malignant features could be increased tumor size, rapid growth, deep localization, and female gender. This paper presents the case of a 52-year-old patient with a hard, rapidly evolving tumor in the left arm. The diagnosis of granular cell tumor was made based on histopathological examination using the Fanburg and Smith criteria to differentiate the formation as malignant, but with certainty this was subsequently confirmed by the existence of a metastasis. Surgical excision was performed and the evolution was favorable. Evolution and treatment differ depending on the benign or malignant form, but surgical treatment with wide local excision is recommended. This may be followed by chemotherapy or radiotherapy, and follow-up of patients for the rest of their lives is mandatory.

A rare case of knee joint mucormycosis with pathological fracture after COVID-19 infection

Mucormycosis is a fungal infection that generally occurs in patients with some degree of immunosuppression, such as patients with malignancies, diabetes, HIV infection, or patients who require the administration of immunosuppressive drugs. The final diagnosis is established by collecting some tissue from the infectious process and isolating the fungus using lab cultures. The treatment of mucormycosis is complex and consists of trying to reduce risk factors, rigorous surgical debridement, and specific antifungal treatment. We present the case of a 54-year-old male patient with a background of SARS-COV2 infection (moderate form), that started 3 months prior to presentation to our hospital, initially treated at home. The patient presented to the Orthopaedics Department of the University Emergency Hospital of Bucharest with pain and total functional impotence in his left knee as a result of a trauma that occurred about 2 months before the presentation to the hospital, at that moment with progressive worsening of the symptoms. Clinical and imaging examination established the diagnosis of pathological supra-intercondylar fracture of the left femur. The purpose of this case report is to present the risk of infection with an opportunistic agent as a result of immunosuppression induced by COVID-19 or its treatment with immunosuppressive agents necessary to combat the inflammatory process. The patient presented with a moderate form of COVID-19 treated at home with nonsteroidal anti-inflammatory drugs and antibiotics to prevent a bacterial superinfection. Mucormycosis remained a challenging situation for the physician, regardless of his medical specialty, both in terms of diagnosis and treatment. In this case, COVID-19 is one of the risk factors that contributed to the appearance of mucormycosis.

Posterior interosseous nerve entrapment by intramuscular lipoma arising from the supinator muscle - a case report

Background: Lipomas are benign, slow-growing tumors frequently subcutaneous and asymptomatic, intramuscular lipoma constituting a rare subtype. However, a lipoma occurring nearby the proximal radius may cause posterior interosseous nerve (PIN) entrapment. Case presentation: We described an uncommon case of a 45-year-old-man with a history of progressive, painless proximal right (dominant) forearm swelling for 4 months associated with PIN entrapment syndrome, presenting as fingers extension weakness. Intramuscular lipoma was observed in the supinator muscle in the magnetic resonance imaging (MRI). Lipoma surgical excision and release of the PIN through proximal forearm direct anterior approach was performed. Results: The histopathological examination confirmed the diagnosis of benign intramuscular lipoma. The follow-up of the patient showed full recovery within three months postoperatively. Discussion: Intramuscular lipoma is rare; however, it could originate from supinator muscle in the forearm, presenting with vague pain and could lead to compression of nearby neurovascular structures such as the PIN. Clinical evaluation and imaging studies, especially MRI, are crucial for diagnosis. If neural compression is evident, surgical resection is mandatory. Conclusion: Intramuscular lipoma entrapping PIN is rare and requires early clinical diagnosis confirmed by imaging and neurophysiological studies, surgical excision being the method of choice for optimum functional outcomes.

Ruptures of mesentery- a silent posttraumatic injury (Case Report)

The mechanism of mesenteric injury in blunt abdominal trauma involves compression and deceleration forces which result in a spectrum of injuries that range from contusions to tearing of the bowel wall, tearing of the mesentery, and loss of vascular supply. Hemoperitoneum is a major sign of severity in abdominal trauma, which, in most cases, requires emergency surgery.Our patient showed that the diagnosis of mesenteric injury should be considered even in patients who sustain only minor abdominal trauma. In this case the patient’s symptoms were suggestive only for the orthopedic lesion and not for the hemoperitoneum.Trans-scapho-lunate dislocation fracture is a rare lesion that may go unnoticed at initial assessment in a polytraumatized patient. A delay in the diagnosis and treatment of a scaphoid fracture may alter the prognosis after consolidation.

A case report of blunt liver trauma in times of COVID-19 pandemic

The liver is one of the most affected organs in abdominal trauma mostly because of its considerable dimensions, the fragility of the liver parenchyma.We present the case of a 29-year-old patient who sustained an abdominal trauma after an accidental fall from a 3 m height. The patient tested positive at RT-PCR for SARS-CoV-2 at admission, without any symptoms of viral infection. The emergency CT scan revealed a blunt liver trauma with an expanding hematoma (grade III). The patient was initially hemodynamically stable but shortly after admission became unstable and required surgical treatment that initially consisted of damage control and liver packing. Reintervention was decided 36 hours later, after reevaluation unpacking and hepatorrhaphy were done. The postoperative evolution was uneventful. The case indicated the importance of continuous monitoring of the traumatic patient. In liver trauma, hemodynamic instability guarantees an emergency laparotomy. The time of operations in trauma patients with SARS-CoV-2 must be reduced to the maximum both as an objective of damage control and also to minimize the risk of contagion.