Acute upper gastrointestinal bleeding in southern Saudi Arabia

PATIENT: A 62-year-old former miner with silicosis of the lungs but otherwise in good general condition presented with a solid nodule in the nasal left lid area for a duration of three months. Because of a central ulceration the reference diagnosis was basalioma. The tumour infiltrated the nasal part of the upper and lower eyelid and the tear ducts so that these were unrinseable. Similar lesions have been present since two years in other skin regions. METHODS: Two cutaneous biopsies confirmed the diagnosis of a Mycosis fungoides without detectable expression of the CD30-antigen. Medical investigation finally revealed hepatosplenomegaly and cervical, inguinal and abdominal lymph node involvement. A lymph node biopsy three months after presentation again showed a T-cell-lymphoma which was CD30-positive now. THERAPY: Systemic polychemotherapy was started. The lid lesions completely resolved, and the tear ducts were rinseable again.     

Possible involvement of endothelial leukotrienes in acetylcholine-induced contraction in rabbit coronary artery

OBJECTIVE: To evaluate the symptoms, diagnostic procedures, and treatment by transduodenal excision, of tumours in the ampulla of Vater. DESIGN: Open study of consecutive patients. SETTING: University hospital, Denmark. SUBJECTS: Six patients with tumours in the ampulla of Vater. INTERVENTIONS: Ultrasonography, duodenoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic biopsy if tumour was visible at the papilla. Transduodenal excision of the ampulla and anastomoses of the common duct and pancreatic duct to the duodenum. MAIN OUTCOME MEASURES: Postoperative complications and survival. RESULTS: None of the tumours could be seen on ultrasonography. All the tumours were diagnosed on duodenoscopy with ERCP. The histopathological diagnoses of the endoscopic biopsy specimens were adenoma (n = 3), suspicion of adenocarcinoma (n = 2), and adenocarcinoma (n = 1). Curative resection by transduodenal excision of the ampulla of Vater was possible in all cases. Pathological examination of the surgical specimens showed three adenomas and three adenocarcinomas. One patient had a recurrence after 2.5 years and had a further resection. Three patients died after one, three, and nine years, respectively; two had no recurrence and one was suspected of having one. The other three patients were alive 8-20 months after the operation. CONCLUSION: The procedure is recommended for small and probably benign tumours and, when technically possible, in malignant tumours in patients at high operative risk. Close postoperative follow-up with duodenoscopy and ERCP is recommended.     

Partial simple vegetative crisis: importance of electroencephalographic findings

INTRODUCTION: 50% of the patients with cerebral tumours present with epileptic crises, which may be partial or generalized. The commonest partial crises have motor symptoms. These make up 30% of the simple partial crises. Partial simple crises with purely vegetative-type symptoms are very uncommon (less than 5%). They are considered to be caused by discharges in the internal regions of the temporal lobes, mainly in the limbic system. This means that it is very difficult to identify them using techniques of surface EEG. CLINICAL CASE: We describe the case of a patient with a cerebral tumour. The initial clinical features were short episodes of generalized coldness and sweating which had been present for the previous two weeks, without any other symptoms. During a routine EEG, focal critical paroxystic activity was recorded in the right temporal region. This coincided with a clinical episode similar to those described. CONCLUSIONS: The episodes were labelled partial simple vegetative crises. In this case the EEG was crucial for diagnosis and subsequently to recommend suitable treatment. However, difficulty in recording this type of crisis with a surface EEG makes correct diagnosis of these patients very difficult, since the epileptogenic focus is deeply situated.     

Use of the orbicularis muscle flap for complex lower lid problems: a 6-year analysis

There are several groups of patients seeking lower lid blepharoplasty who present with the potential for unsatisfactory postoperative results, such as those presenting with atonic eyelids, patients with severe blepharochalasis alone or with large fat bags, patients with festoons, those with abnormal anatomy, and patients with deformity due to prior surgery. The orbicularis muscle flap technique provides good results in patients with potentially problematic lower eyelids. Of 600 blepharoplasties, 8.5 percent underwent the orbicularis muscle flap procedure. Follow-up time was 1.3 years, and average patient age was 54 years. Details of this technique are described together with results, including illustrative photographs. Of 51 patients, 49 had excellent or acceptable results and 2 had unacceptable results, 1 of whom required a small correction. This method produces a "minilift" of the lower eyelid and upper cheek skin that cannot be achieved with the standard lower eyelid blepharoplasty as described to date.     

Unilateral eyelid swelling in naevus flammeus faciei. Problems in differential diagnosis of unilateral eyelid swelling

A 32-year-old white woman presented with persistent swelling of the right upper eyelid for diagnosis and therapy. History and physical examination revealed a faint nevus flammeus on the right side of her face and neck and bilateral blepharochalasis, both of which can produce unilateral periorbital swelling. A biopsy taken for histology was diagnostic in this case, since it showed lymphoedema secondary to lymphangiectasias associated with the patient's port-wine stain. Many other possible causes of unilateral lid swelling have to be considered and excluded before a definite diagnosis can be established. The differential diagnosis is discussed.     

Pseudo pectus excavatum (author''s transl)

Seventy seven angioleiomyomata from 75 patients, 19 males and 55 females, are reviewed. One patient had 2 lesions and another a local recurrence after surgical excision. Only 3 were less than 20 years old and most were beyond 30 (average age 47). Fifty four lesions were on the lower limbs, 4 on the head and legs), 9 on the upper limbs, 4 on the head and 1 on the trunk. The size of the lesions varied from a pepper grain to a pigeon egg but most were pea sized. The more significant symptom was pain, present in at least 58% of the lesions, and responsible for the diagnosis, often made, of neurofibroma, neuroma, glomus tumour and leiomyoma. Its intensity was variable and could be induced by mechanical or thermal stimuli or even arise spontaneously. Histologically the tumour was usually a deep dermal or hypodermal, well defined, ovoid or round shaped, compact nodule, composed of smooth muscle fibers often disposed around variously shaped vascular lumina. Clinical and histological similarities to glomus tumours as well as the occasional coexistence of both lesions point to a common origin from the myoarterial glomus or from a closely related arteriovenous anastomosis. The relevant features in our series are compared with those reported in the literature and their similarities and differences are discussed.     

"Big Smoke" has big risks: daily cigar use causes cancer, heart disease

BACKGROUND: To study the behaviour of recurrent benign parotid tumours, recurrence characteristics and problems faced with the removal of these lesions. METHODS: We reviewed the charts of the work of a single surgeon between 1971 and 1996. RESULTS: There were 24 patients (13 women, 11 men) with a mean age of 44 years at re-operation. Mean follow-up period was 10 years (range 1-22 years). There were 21 recurrent pleomorphic adenomas, two monomorphic adenomas and one patient with recurrent oncocytoma. Nine patients had solitary recurrence with a mean size of 14 mm, 15 patients had multiple recurrences with a mean size of 8 mm. There was malignant transformation of a previously benign lump in one patient. Three patients presented with a second or third recurrence. Overall facial nerve paralysis was 53% (38% temporary and 15% permanent). Frey's syndrome occurred in four patients (17%). CONCLUSIONS: Recurrent benign parotid tumours are uncommon if superficial parotidectomy (SP) is the performed initially; recurrence rates are between 0-4%. The recurrences are usually slow growing and require lengthy follow-up. Pre-operative diagnosis of a lump in the region of previous excision is useful in treatment planning. Malignant transformation in previous benign lump should be considered and fine needle aspiration biopsy may help in diagnosis. Facial nerve injury is more likely if the tumour is deep, in multiple sites or involves extensive scar tissue. Radiotherapy is controversial, it should be considered if there has been tumour spillage following re-operation.     

Adrenal gland myelolipoma. Report of a new case

OBJECTIVE: We report a new case of symptomatic myelolipoma of the adrenal gland. We analyse clinical, diagnostic, histopathologic and therapeutic aspects. METHOD AND RESULTS: Surgical excision was performed by lumbotomy. The patient was asymptomatic after surgery. DISCUSSION: Adrenal myelolipoma is norfunctioning benign tumour constituted by fat tissue and small islands of haemathopoyetic in a variable rate. The patients are usually asymptomatic. In symptomatic patients the most common symptoms are nonspecific abdominal pain, haematuria and hypertension. The diagnosis is achieved by ultrasound, CT and PAFF. The management is controversial: Surgical treatment or watching are options depending on the size and/or symptoms.     

A highly differentiated exocrine pancreatic tumour in a young boy

A primary pancreatic tumour in a 6-year-old boy was removed by radical excision. From both light and electron microscopic observations the tumour was considered to be of exocrine origin, with some differentiation towards acinar cells. Although the tumour was highly differentiated, it was regarded as probably malignant because of tumour growth into the surrounding fibrous capsule. The case is discussed in relation to earlier rare reports of pancreatic tumours in infants and children.     

Sacrococcygeal germ-cell tumours--the Red Cross War Memorial Children's Hospital experience, 1980-1996

OBJECTIVE: To document the experience of Red Cross War Memorial Children's Hospital in the treatment of sacrococcygeal germ-cell tumours. PATIENTS: Twenty-seven patients with sacrococcygeal germ-cell tumours were treated in our hospital from 1980 to 1996. DESIGN: A retrospective review of these patients' records was undertaken. RESULTS: There were 19 female and 8 male patients. Seventeen (63%) presented in the neonatal period, 13 on the first day of life. Complete surgical resection of the tumour was achieved in all patients with mature or immature teratomas (20 patients) and in 2 neonates with malignant tumours. The first of these 2 neonates, with a malignant teratoma, was not given chemotherapy and remains well 10 years later. The second, with a yolk-sac tumour, also received no initial chemotherapy. He relapsed at the age of 9 months and was successfully treated with repeat excision and chemotherapy. All 5 patients first diagnosed after the age of 1 year had malignant tumours. These patients had incomplete surgical resection (3) or biopsy only (2), and 3 were successfully treated with chemotherapy. One patient relapsed with yolksac tumour after initial complete resection of a mature teratoma. She was successfully treated with repeat surgery and chemotherapy.     

Carotid body tumor

INTRODUCTION: The carotid body tumour was first described by von Haller in 1743. The first two, unsuccessfully surgically treated carotid body tumours, were done by Reinger in 1880 (his patient died), and by Maydel in 1886 (his patient developed hemiplegia). Scudder made the first successful surgical removal of the carotid body tumour in 1903. Using data from the Cologne (Germany) Medline Research Centre, surgical treatment of carotid body tumour was not reported in Yugoslav medical literature. The aim of this study is to present 6 surgically treated carotid body tumours. MATERIAL AND METHODS: Over the period from 1982 to the end of 1996, 6 patients with carotid body tumours were operated on in the Centre of Vascular Surgery of the institute of Cardiovascular Diseases of the Clinical Centre of Serbia in Belgrade. Four of them were female and two male patients, average age 43.4 years. In all cases the tumour was an asymptomatic neck mass. Color-Duplex ultrasonography and selective carotid arteriography were used to establish the diagnosis in 5 cases. The pathohistological examination of all 6 patients revealed the benign character of tumors. Patient 1. A 52-year old man. The suspicion of symptomatic carotid artery aneurysm, was the indication for urgent operation. The intraoperative finding showed a carotid body tumour which compressed carotid arteries. The subadventitial removal of the tumour was done. The patient was followed for 14 years without signs of local recidivation. Patient 2. A 38-year old man. During the operation the tumour was removed subadventitially, without clamping or injuring the carotid arteries. The patient was followed for 8 years and 3 months, and there were no signs of local recidivation. Patient 3. A 48-year old woman. Intraoperative findings showed an infiltration of the carotid arteries and tumour was removed together with parts of internal and external carotid arteries. The internal carotid artery was reconstructed using saphenous vein graft. The follow-up period was 4 years and 6 months, without signs of local recidivation. Patient 4. A 61-year old woman was operated on (neck exploration) in other hospital 4 years before the admission to our Centre. During the primary operation, an internal carotid artery was ligated without neurological consequences. Also, histological examination was performed. We removed a tumour together with the ligated internal carotid artery without its reconstruction. Three years after the operation the patient was without signs of local recidivation. Patient 5. A 40-year old woman. After subadventitial surgical removal of the tumor without clamping or injuring the carotid arteries, the patient was followed-up for 2 years and 2 months, and was without signs of local recidivation. Patient 6. A 30-year old woman was operated on (neck exploration only) in other hospital two months before the admission to our Centre. Intraoperative findings showed tumour infiltration to the carotid arteries, and therefore, internal and external carotid arteries were removed together with the tumour. The internal carotid artery reconstruction was performed using aaphonous vein graft. The early postoperative period was unremarkable. However, 48 hours after the operation cerebrovascular insult developed with hemiplegia. There was no sign of graft thrombosis. The patient was followed-up for 2 years postoperatively. There were no signs of local recidivation. The same patient had also a small asymptomatic tumour at the other side of the carotid arteries. DISCUSSION: The carotid body tumour originates from the paraganglious tissue at the carotid artery bifurcation. There are angiomatous and adenomatous forms. All of our 6 cases had adenomatous form. It grows slowly, and can compress and/or infiltrate carotid arteries and nerves. Three of our 6 cases showed signs of carotid artery compression and 3 showed infiltration to the carotid arteries. Malignant alteration of this tumour is uncommon. (ABSTRACT T     

Acute renal failure due to oxalate ingestion

Analysis of the infiltrant tumours of the bladder diagnosed in our service between 1986-1996 both inclusive, with associated tumour of the upper tract during its evolution. From a total of 262 infiltrant transitional tumours of the bladder and 52 transitional tumours of the upper urinary tract, 8 patients were found to have both types of tumours in association, which accounted for 3.05% of all infiltrant vesical tumours. Mean age of our patients, all male, was 65. The pathological anatomy of the upper tract tumours was: 4 pT1 and 4 pT3. 75% presented relapsing tumours of the bladder, 50% had a background of bladder Cys, 87.5% were multifocal vesical tumours and 100% were larger than 3 cm. In addition, 62% cases were ipsilateral to the tumours of the upper urinary tract. It can therefore be concluded that for tumours of the bladder, multifocality, relapse, presence of vesical Cys and tumour size, are all concurring features when association of these two types of tumours occurs.     

The clinical and histological features of transitional cell carcinoma of the bladder with microcysts: analysis of 12 cases

OBJECTIVE: To describe the clinical course and histological features of transitional cell carcinoma (TCC) of the bladder with microcysts. PATIENTS AND METHODS: Among 940 patients with bladder TCC diagnosed at our institution during a 5 year period. 12 (1.2%; eight men and four women, mean age 71.1 years, range 52-85) were diagnosed histologically as having microcystic TCC. Sections of the tumours were stained with haematoxylin and eosin, periodic acid-Schiff and Alcian blue and clinical data obtained from the patients' records. RESULTS: Of the 12 patients with bladder TCC with microcysts, three had tumours confined to the epithelium, six had tumour invasion of the lamina propria and three had muscle invasion. One patient had low-grade TCC and 11 had high-grade TCC; six patients had a second primary tumour; three had a colon carcinoma, one a villous adenoma of the caecum, one a locally advanced carcinoma of the prostate and the last a squamous cell carcinoma of the uterine cervix. CONCLUSIONS: Microcystic TCC was associated with high-stage and high-grade bladder tumours and with other primary tumours, especially of the colon. Screening these patients for asymptomatic tumours of the colon is suggested.     

Treatment of chondrosarcoma. A retrospective study at the Norwegian Radium Hospital

The authors present a retrospective analysis of 59 chondrosarcoma patients treated at the Norwegian Radium Hospital during the period 1981 to 1993. 31 patients were admitted with untouched tumour, seven after fine needle cytology and 20 after open biopsy or partial excision. One patient had recurrent local disease. Only 20% of the tumours were of high grade malignancy. 51 patients were treated by surgery. Reconstructions were performed in 16 patients, using allografts or endoprostheses. Amputations were performed in six cases and wide excision in 12 cases. In these 18 patients local recurrence appeared in one case, and two developed lung metastases. Only one of the 18 patients operated by amputation or wide excision has since died from chondrosarcoma. Marginal excisions were performed in 26 cases. Nine of these patients developed a local recurrence, five developed metastases and three have died. Six patients had partial excisions. Postoperative radiotherapy was given to one patient only. Five of the six are alive. In one case, the quality of the margins could not be evaluated. A total of 45 of the 51 patients treated for the primary tumour by surgery are alive. The median observation time is four years. Treatment of nonmetastatic chondrosarcoma should be surgical. Chondrosarcoma patients show wider variations in age, localization of tumour and tumour growth rate than patients with other bone sarcomas. Although wide excisions provide the best local control of any grade of malignancy, the mutilation or risk involved may be so great that some patients may benefit from marginal or even partial excision.     

Fibrous pleural tumour producing 171 litres of transudate

Localized fibrous tumours of the pleura (or localized benign mesothelioma) are rare, and in most cases, asymptomatic. This report describes a 48 yr old female with a right-sided fibrous pleural tumour, which produced 171 L of transudate before a correct diagnosis was reached. The tumour was surgically removed and the transudation stopped immediately.     

Evaluation of levator muscle integrity in ptosis with levator force measurement

PURPOSE: To determine the efficacy of the force the levator muscle can generate as a diagnostic tool for ascertaining the cause of ptosis. METHODS: A total of 187 patients with ptosis were evaluated clinically, their levator force was measured, and each ptotic eyelid subsequently had surgical correction. At each step, patients received a diagnosis of congenital or acquired (history- dependent) aponeurotic, myogenic, neurogenic, or mechanical ptosis. To measure the levator force, a clamp placed on the upper eyelid lashes was attached to a force transducer. The maximum force generated on upgaze was recorded as the levator force. Data from healthy subjects were used to determine whether each levator muscle of the ptotic eyelids produced normal or less than normal force. The correct diagnosis was considered to be the diagnosis based on the findings at the time of surgery. The diagnosis of each patient with ptosis determined by eyelid excursion, eyelid excursion plus examination, levator force, and the levator force plus examination results were compared with the correct diagnosis. RESULTS: Eyelid excursion predicted the correct diagnosis 78.2% of the time. When eyelid excursion was combined with the examination results, the diagnosis was correct 84.0% of the time. Levator force predicted the correct diagnosis 95.2% of the time. When levator force was combined with the examination, the diagnosis was correct 97.9% of the time. CONCLUSION: Diagnosis of the cause of ptosis based on levator force measurement is significantly more accurate than when the diagnosis is based on eyelid excursion, even when information obtained on examination also is considered. Levator force measurement should be an integral part of ptosis evaluation.     

Adult colloid milium of the eyelid

PURPOSE: To report a patient with bilateral upper and lower eyelid margin nodules that proved to be adult colloid milium. METHODS: After clinical study, biopsy specimens were obtained and analyzed histologically and ultrastructurally. RESULTS: Adult colloid milium can be diagnosed by clinicopathologic correlation. CONCLUSION: Adult colloid milium should be included in the differential diagnosis of eyelid margin nodules.     

Spontaneous rupture of renal tumours: the role of imaging in diagnosis and management

This study aimed to evaluate whether patients presenting with spontaneous haemorrhage from renal tumours could be accurately diagnosed and initially managed conservatively, and evaluate the role of imaging in guiding the timing and type of subsequent operation. The clinical features, imaging findings and management of seven patients presenting with spontaneous rupture of renal tumour over a 5-year period were reviewed. The information from various imaging studies was evaluated in relation to the subsequent course of intervention. The tumours consisted of six angiomyolipomas and one renal cell carcinoma. In all cases, imaging studies were diagnostic, with computed tomography being the most useful single modality. Emergency surgery was required in one patient for evacuation of suspected infected haematoma and wedge excision of angiomyolipoma. Three elective nephrectomies were performed, while three other patients with ruptured angiomyolipoma were treated conservatively and remained well, without any intervention. In conclusion, patients presenting with spontaneous rupture of renal tumour can be managed conservatively initially. Imaging facilitates accurate pre-operative diagnosis, which was angiomyolipoma in all but one patient in this series. The subsequent intervention can be tailored according to the lesion type and the anticipated risk of re-haemorrhage.     

Acute on-chronic middle ear disease

OBJECTIVE: To emphasise the value of computed tomography even in the absence of symptoms in a case of penetrating injury of the upper eyelid. METHODS: Case report. RESULTS: Although clinically asymptomatic, penetration of upper eyelid was associated with intracranial penetration that left a track in the brain parenchyma. CONCLUSIONS: Computed tomography of orbit and brain is an important investigation, even in seemingly trivial eyelid injury, to reveal the full extent of the damage.