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We present a case of a large full thickness abdominal wall defect following excision of a huge basal cell carcinoma, uniquely reconstructed with a sandwich omental flap, vicryl/prolene (vypro II) mesh and split thickness skin graft.
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Juvenile xanthogranulomatosis (JXG) is a rare benign condition, which usually presents with characteristic skin lesions and can be diagnosed clinically. However, systemic JXG may involve a wide range of extracutaneous sites and may pose a diagnostic dilemma for the clinician, radiologist, and pathologist. In particular it may simulate malignancy. Here, we report a case of systemic JXG within the abdominal wall musculature and lungs, which imitated a sarcoma with pulmonary metastases on computerized tomography. To the best of our knowledge, this is the first such reported case. In particular, systemic disease presenting without skin lesions is unusual.
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Intra-abdominal lymphangiomas are rare benign tumours that can cause various symptoms, mainly during childhood. They are diagnosed by ultrasonography, CT scanning or at laparotomy; ultrasonographic examination often shows a voluminous tumoral cystic formation with septa. The location of the cyst may be determined either by ultrasonography alone or by CT scanning. The definitive histological diagnosis is confirmed by immunohistochemical staining techniques. Rarely intra-abdominal lymphangiomas can occur in the abdominal wall. Complete resection is the treatment of choice. The case of a 2-year-old-boy with a large lymphangioma involving the lower half of the abdominal wall is reported. The patient underwent the complete removal of lymphangioma with good cosmetic result.
BACKGROUND: The tensor fascia lata is a versatile flap with many uses in reconstructive plastic surgery. As a pedicled flap its reach to the lower abdomen and groin made it an attractive option for reconstructing soft tissue defects after tumor ablation. However, debate exists on the safe dimension of the flap, as distal tip necrosis is common. Also, the adequacy of the fascia lata as a sole substitute for abdominal wall muscles has been disputable. The aim of the current study is to report our experience and clinical observations with this flap in reconstructing those challenging defects and to discuss the possible options to minimize the latter disputable issues. PATIENTS AND METHODS: From April 2001 to April 2004, 12 pedicled TFL flaps were used to reconstruct 5 central abdominal wall full thickness defects and 6 groin soft tissue defects following tumor resection. In one case, bilateral flaps were used to reconstruct a large central abdominal wall defect. There were 4 males and 7 females. Their age ranged from 19 to 60. From the abdominal wall defects group, all repairs were enforced primarily with a prolene mesh except for one patient who was the first in this study. Patients presenting with groin defects required coverage of exposed vessels following tumor resection. All patients in the current study underwent immediate reconstruction. RESULTS: The resulting soft tissue defects in this study were due to resection of 4 abdominal wall desmoid tumors, a colonic carcinoma infiltrating the abdominal wall, 4 primary groin soft tissue sarcomas, a metastatic SCC of the leg to groin nodes, and a primary SCC of the groin. The size of the flaps used ranged from 20 x 10 cm to 31 x 18 cm. All flaps survived. However, distal flap necrosis occurred in 4 cases. Three of those cases developed in flaps reconstructing abdominal wall defects, and one case developed in a flap used to cover a groin defect. In the former 3 cases, the flap was simply transposed without complete islanding of the flap. In the latter case, a very large flap was harvested beyond the safe limits with its distal edge just above the knee. In addition, wound dehiscence of the flap occurred in 2 other cases from the groin 132 group. Nevertheless, all the wounds healed spontaneously with repeated dressings. Out of the 5 cases that underwent abdominal wall reconstruction, one case developed ventral hernia, in which bilateral TFL flaps were used without mesh enforcement. There was minimal donor site morbidity in the form of partial skin graft loss in 2 cases. The average follow up period in this study ranged from 6 months to 2 years. Only one patient died of distant metastasis of a SCC of the groin skin, 8 months postoperatively and another 2 patients with abdominal desmoid tumors developed local recurrence. CONCLUSION: The tensor fascia lata flap is a reliable and a versatile flap, with minimal donor site morbidity. Problems with the flap's vascularity of its distal part should not be encountered, if the flap is harvested within the safe limits and properly designed and the edges comfortably insetted to the defect. A pedicled flap would be appropriate for lower abdominal wall defects, and is better islanded to achieve extra mobilization and allow a tension free closure, while for groin defects, simple flap transposition should be enough. Nevertheless, reconstruction for full thickness abdominal wall defects by this flap is a static reconstruction. We therefore strongly recommend enforcing the repair with a synthetic mesh primarily to minimize the incidence of ventral hernia. However, further studies with larger number of cases are needed to confirm this observation.
A series of 286 patients receiving surgical treatment for ovarian tumors at Song-klanagarind Hospital between January 1987 and June 1990 were reviewed. The most frequent diagnoses by age group were: cancer in 53 per cent of women > or = 50 yrs of age, endometrioma in 63 per cent of women 31-49 yrs of age and benign cystic teratoma in 49 per cent of women < or = 30 yrs of age. Mucinous ovarian tumors were the most common type of epithelial neoplasms. Abdominal pain was the symptom most frequently experienced in patients with benign ovarian tumors. The 95 per cent confidence interval for finding malignancy in women > or = 50 yrs, ascites > 500 ml and size of ovarian tumor > 10 cm was 47-99 per cent.
An ectopic, so-called wandering spleen is an uncommon occurrence. We present the case of a young woman who presented with abdominal pain and was found to have an enlarged spleen, located in the lower abdomen and pelvis. The possibility of lymphoma was entertained because of concomitant findings of thrombocytopenia and a possible mesenteric mass. The mass was subsequently found at laparotomy to be the tail of the malpositioned pancreas, and the thrombocytopenia resolved with splenectomy. Review of the literature indicates that lymphoma is an uncommon finding in wandering spleens, that wandering spleens are enlarged in most cases, and that thrombocytopenia, while uncommon, can be seen, in particular when associated with torsion of an elongated splenic pedicle.
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RATIONALE AND OBJECTIVES: The diagnostic potential of tumor microvasculatures with the monochromatic synchrotron radiation microangiography (MSRA) system was examined in an experimental model using athymic nude rats. MATERIALS AND METHODS: In the lower abdominal wall in athymic nude rats (male, 120-150 g, 6 weeks old), 1 x 10(7) cells of N-nitrosomethylurea-induced rat mammary adenocarcinoma was transplanted to prepare a lower abdominal wall tumor transplanted model. A microcatheter was inserted in the abdominal aorta in a rat under anesthesia, and microangiographic images of the normal inferior epigastric artery and vein were obtained using an MSRA system. Changes in the tumor microvasculatures were observed using an MSRA system on the day 7 (n = 3), day 14 (n = 3), day 21 (n = 3), and day 28 (n = 3) after transplant. In addition, we measured the microvessel density (MVD) with a computer using the binarization method. These results were compared among the histologic MVDs. RESULTS: The microvasculatures of tumors measuring 20-30 microm were observable by the MSRA system in the transplanted tumor model using the inferior epigastric artery and vein as the feeding vessels. The tumor microvasculatures were observed for 7-28 days after transplantation. The tumor MVD obtained by the binarization method increased as the tumor volume increased. When histologic MVD was compared with the fixed quantitative results of angiographic MVD, a significant correlation (r = 0.933, P <.01) was observed. CONCLUSION: These preliminary investigations indicate that MSRA proved to be suitable for quantification and appears to be a simple method for clearly imaging tumor microvasculatures.
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The granular cell tumor is an uncommon tumor that usually appears as a solitary small nodular growth and runs a benign course. It occurs widely throughout the body, but is rarely described in the abdominal wall. The authors report a case of malignant granular cell tumor which was arising in anterior abdominal wall of a 67-year-old woman. Malignant variant is rare and the abdominal wall site is extremely uncommon. Regarding this clinical case and the literature the authors purpose to review the criteria of malignancy.
RATIONALE AND OBJECTIVES: To evaluate the diagnostic value of breath-hold contrast-enhanced 3D magnetic resonance angiography (MRA) for assessment of the visceral abdominal arteries and veins in patients with suspected abdominal neoplasms. METHODS: Twenty-one patients underwent MR imaging on a 1.5 T unit using a body phased-array coil. MRA was performed with a 3D-FLASH sequence (TR 3.8 ms, TE 1.3 ms, flip angle 25 degrees, acquisition time 20 seconds), 8 to 12 seconds after an intravenous bolus injection of Gd-DTPA. The acquisition delay between the arterial and the portal venous phase was 12 seconds. The image quality and the degree of vascular involvement were evaluated using coronal source images and maximum intensity projection reconstructions. Diagnosis was confirmed by surgery/histology. RESULTS: Image quality was optimal in more than 85% of the patients (19/21 arterial phase and 17/21 portal venous phase). MRA correctly predicted vascular status in 20 of 21 patients (95%), with complete concordance between MRA results and surgical findings. In one patient with chronic pancreatitis, MRA demonstrated a false-positive finding that could not be confirmed surgically. CONCLUSIONS. Breath-hold contrast-enhanced 3D-MRA is a valuable technique for assessing visceral abdominal arteries and veins.
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INTRODUCTION: Desmoid tumors are very rare mesenchymal tumors with a partially aggressive growth pattern and high relapse rates. Without metastases, they are classified as semi-malignant tumours. The treatment of this neoplasia is discussed controversially. Up to now, there exists no broad consensus on the treatment regimes. Traditionally, the primary radical surgical resection is often preferred. This might be combined with an (neo-)adjuvant radiation therapy. Recently an increasing importance of radiotherapy has been described. Several studies favour radiotherapy as the single form of treatment. Furthermore several medication regimes have been described in the literature. CASE REPORTS: We report the follow-up of 4 patients who were treated for desmoid tumours. In 2 cases surgery was the primary treatment. After R0-resection and adjuvant radiation therapy, one of the patients developed 7 relapses. In another patient, 5 relapses were observed after surgical therapy. DISCUSSION: Therapeutic guidelines with broad acceptance do not exist up to now due to missing data of prospective studies with sufficient case numbers. In our opinion wide surgical resection should be performed in primary occurring cases with resectable tumours. On account of the previous experiences, it can be concluded that therapy of primary non respectable or recurrent desmoid tumours is not only a domain of a surgical approach. At present an adequate treatment should be planned interdisciplinary by surgeons, radiation therapists and oncologists. For generally accepted guidelines for this rare disease, general therapeutic options based on prospectively randomised studies have to be elaborated.
Stoma site metastasis of gastric adenocarcinoma was documented 37 d after partial gastrectomy with gastrostomy tube placement, and 22 d after tube removal. The tube was placed through grossly normal tissue but histopathologic examination revealed neoplasia at the surgical margins and concurrent lymphatic metastasis. Stoma site metastases may be due to direct tumor seeding or hemolymphatic spread.
Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. We describe here for the first time a patient with a huge GIST of the abdominal wall without any relation to the gastrointestinal tract, omentum, or mesentery. With regard to the size of 24 cm and a low mitotic index, this GIST is considered an intermediate risk for metastasis. Radical surgical resection was performed with negative pathologic resection margins. The classic immunohistochemical phenotype of the tumor described facilitates the differential diagnosis to exclude abdominal desmoid tumor and solitary fibrous tumor (SFT). In the case of metastasis, therapeutic nihilism no longer seems justified with the availability of imatinib, a tyrosine kinase inhibitor, which shows encouraging results in the therapy of metastatic GIST.
INTRODUCTION: Desmoid tumors are a clinical problem in 12 to 15 percent of patients with familial adenomatous polyposis. There is no predictably effective treatment for intra-abdominal desmoid tumors, which sometimes cause significant complications by their effects on the ureters or bowel. The relative rarity and the clinical heterogeneity of intra-abdominal desmoid tumors make randomized studies difficult to do. In this article a staging system is proposed to make multi-institutional studies easier. METHODS: Intra-abdominal desmoid tumors can be staged according to their size, clinical presentation and growth pattern. CONCLUSION: A way of staging intra-abdominal desmoid tumors is proposed to facilitate stratification by disease severity during collaborative studies of various treatments.