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Journal of Medical Case Reports Feb 2020Papillary breast lesions may be benign, atypical, and malignant lesions. Pathological and clinical differentiation of breast papillomas can be a challenge. Unlike...
BACKGROUND
Papillary breast lesions may be benign, atypical, and malignant lesions. Pathological and clinical differentiation of breast papillomas can be a challenge. Unlike malignant lesions, benign breast papillomas are not classically associated with lymph node and distant metastasis. We report a unique case of a recurrent, benign breast papilloma presenting as an aggressive malignant tumor.
CASE PRESENTATION
Our patient was a 56-year-old postmenopausal African American woman who was followed in the breast clinic with a long history of multiple breast papillomas. She underwent multiple resections over the course of 7-9 years. After being lost to follow-up for 2 years, she once again presented with a slowly enlarging left breast mass. Subsequent imaging revealed a predominantly cystic mass in the left breast, as well as a suspicious hypermetabolic internal mammary node and a hypermetabolic nodule in the pretracheal space. Biopsy of the internal mammary node demonstrated papillary neoplasm with benign morphology and immunostains positive for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2/Neu. Due to the clinical picture concerning for malignancy, the patient was then started on endocrine therapy with palbociclib and letrozole before surgery. She then underwent simple mastectomy and sentinel lymph node dissection with negative nodes and pathology once again revealing benign papillary neoplasm. She underwent adjuvant chest wall radiation for 6 weeks and received letrozole following completion of her radiation therapy. She was without evidence of disease 30 months after surgery.
CONCLUSIONS
We present an unusual case of multiple recurrent peripheral papillomas with entirely benign histologic features exhibiting malignant behavior over a protracted period of many years, with an invasion of pectoralis musculature and possibly internal mammary and mediastinal nodes. Her treatment course included multiple surgeries (ultimately mastectomy), radiation therapy, and endocrine therapy.
Topics: Antineoplastic Agents; Breast Neoplasms; Female; Humans; Letrozole; Lymph Node Excision; Magnetic Resonance Imaging; Mastectomy; Middle Aged; Neoplasm Recurrence, Local; Papilloma, Intraductal; Radiotherapy; Tomography, X-Ray Computed
PubMed: 32070435
DOI: 10.1186/s13256-020-2354-7 -
Clinical Medicine Insights. Ear, Nose... 2019Deep neck spaces are regions of loose connective tissue filling areas between the 3 layers of deep cervical fascia, namely, superficial, middle, and deep layers. The...
Deep neck spaces are regions of loose connective tissue filling areas between the 3 layers of deep cervical fascia, namely, superficial, middle, and deep layers. The superficial layer is the investing layer, The pretracheal layer is the intermediate layer and the prevertebral layer is the deepest layer. Deep neck space infection (DNI) is defined as an infection in the potential spaces and actual fascial planes of the neck. Once the natural resistance of fascial planes is overcome, spread of infection occurs along communicating fascial boundaries. More recent trends include the increasing prevalence of resistant bacterial strains, a decline in DNIs caused by pharyngitis or tonsillitis, and a relative increase in DNIs of odontogenic origin. Most DNIs are polymicrobial. Only 5% are purely aerobic and 25% with isolated anaerobes. The epidemiology of DNIs needs to be monitored for changing trends and the impact of underlying host immunity and developing microbial multidrug resistance is established. Surveillance at laboratory level should include mandatory susceptibility testing of all empiric antibiotics against microbes commonly identified in adult DNI microscopy, culture, and sensitivity (MC&S) specimens. The role of susceptibility testing of microbes not commonly identified in adult DNI MC&S specimens needs further review, on a clinical case-by-case basis.
PubMed: 31496858
DOI: 10.1177/1179550619871274 -
Mediastinum (Hong Kong, China) 2019Surgical techniques remain the gold standard to diagnose and staging lung and pleural tumours. Non-invasive techniques have become more accurate but actually they are...
Surgical techniques remain the gold standard to diagnose and staging lung and pleural tumours. Non-invasive techniques have become more accurate but actually they are not enough to plan and evaluating prognosis of lung and pleural tumours. In some cases, we need to explore the pleural cavity and the mediastinal lymph node status to confirm or rule out tumour dissemination. The combination of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy through a single transcervical incision allows the surgeon to widen the range of the exploration and to improve the staging for lung and pleural cancers. VAMLA allows to perform a complete lymphadenectomy of the subcarinal space, the right and pretracheal areas. We consider sampling more safety on the left side to avoid left recurrent nerve injuries. Once this mediastinal tissue is removed, the right mediastinal pleura can be identified and incised. Once mediastinal pleura is opened, a 5 mm 30º thoracoscope is inserted through the video- mediastinoscope into the pleural cavity. It allows to obtain samples of parietal or visceral pleural, pleural fluid or lung nodules if present. In case of left-sided thoracoscopy the access to the left pleural cavity is anterior to the aortic arch as for extended cervical mediastinoscopy. The combination of VAMLA and thoracoscopy is useful to explore the mediastinum and the pleural space from a single incision and in the same surgical setting through the transcervical approach.
PubMed: 35118249
DOI: 10.21037/med.2019.05.02 -
Multimedia Manual of Cardiothoracic... Jan 2018Surgical staging of lung and pleural cancers is crucial for planning treatment and assessing prognosis. In some cases, we need to explore both the mediastinum and the...
Surgical staging of lung and pleural cancers is crucial for planning treatment and assessing prognosis. In some cases, we need to explore both the mediastinum and the pleural cavity to confirm or rule out tumor dissemination. The combination of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy through a single transcervical incision allows the surgeon to widen the range of the exploration and improve the staging for lung and pleural cancers. VAMLA consists of complete removal of the mediastinal fat and lymph nodes of the subcarinal space, the right paratracheal and pretracheal areas, and the left paratracheal space. Once this mediastinal tissue is removed, the right mediastinal pleura can be identified and incised. A 30o thoracoscope is then inserted through the video-mediastinoscope into the pleural cavity to obtain samples of pleural fluid and biopsies of the parietal pleura and lung nodules, if present. In the case of left-sided thoracoscopy the access route to the left pleural cavity is anterior to the aortic arch, as for extended cervical mediastinoscopy. The combination of VAMLA and thoracoscopy is useful for exploring the mediastinum and the pleural space from a single incision and in the same surgical setting as the transcervical approach.
Topics: Biopsy; Humans; Lung Neoplasms; Lymph Node Excision; Lymph Nodes; Mediastinoscopy; Mediastinum; Neoplasm Staging; Pleural Cavity; Pleural Neoplasms; Thoracic Surgery, Video-Assisted; Thoracoscopy; Video-Assisted Surgery
PubMed: 29384599
DOI: 10.1510/mmcts.2018.004 -
The American Journal of Emergency... Oct 2017Pneumomediastinum is a rare complication of facial fractures, always persuading the physicians to search for other and potentially more serious injuries such as...
Pneumomediastinum is a rare complication of facial fractures, always persuading the physicians to search for other and potentially more serious injuries such as esophageal or tracheal rupture. A 75-year old man presented to the Emergency Department (ED) reporting an accidental fall while walking on the road. He did not report loss of consciousness (LOS), was not taking anticoagulant drugs, did not report chest, abdomen or limb trauma. On physical examination he only showed swelling of nose and right orbit. The patient underwent a Computed Tomography (CT) scan of head and facial bones, showing a complex fracture involving right nasal bone, ethmoid, right orbital lateral wall, and right maxillary sinus lateral wall. No intracranial lesions were found. Due to the finding of subcutaneous emphysema in the right cheek, the scan was extended to the whole neck and chest. The exam showed a massive pneumomediastinum, extending till the diaphragmatic hiatus. The patient thus underwent bronchoscopy and esophagogastroscopy, but no further lesions could be found. Antibiotics therapy was then administered, and was discharged in good conditions after a five-days observation. In our patient, air had probably escaped into the pharyngo-maxillary space from the right maxillary sinus and tracked into both the retropharyngeal space and, for contiguity, into the pre-tracheal space. As our case report shows, if the airway is secure, the pneumomediastinum does not necessarily require treatment other than clinical observation and management of the fracture. If no other injuries are present, resolution of the pneumomediastinum may be expected without further medical interventions.
Topics: Aged; Diagnosis, Differential; Humans; Male; Mediastinal Emphysema; Orbital Fractures; Tomography, X-Ray Computed
PubMed: 28734704
DOI: 10.1016/j.ajem.2017.07.059 -
Ear, Nose, & Throat Journal Jun 2017Idiopathic pretracheal deep neck space infection is an extremely rare condition with potentially devastating complications. We present a series of 3 cases of pretracheal...
Idiopathic pretracheal deep neck space infection is an extremely rare condition with potentially devastating complications. We present a series of 3 cases of pretracheal deep neck space infection that arose in the absence of trauma or a congenital lesion and that exhibited mediastinal spread. To the best of our knowledge, these cases represent the first reported series of this rare condition to be published in the English-language literature. All cultures grew Streptococcus milleri, and all patients had a favorable outcome. A high index of suspicion for a deep neck space infection is warranted in view of the devastating complications of this condition. Computed tomography is the investigation of choice. Treatment with intravenous antibiotics and surgical drainage, particularly when mediastinitis is present, is recommended. This rare presentation warrants a thorough investigation to identify the source of infection.
Topics: Administration, Intravenous; Adult; Anti-Bacterial Agents; Drainage; Female; Humans; Male; Mediastinitis; Microbial Sensitivity Tests; Middle Aged; Neck; Neck Dissection; Soft Tissue Infections; Streptococcal Infections; Streptococcus milleri Group; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 28636733
DOI: 10.1177/014556131709600622 -
The Journal of Laryngology and Otology Sep 2017To identify deep neck infection factors related to life-threatening complications.
Univariate and multivariate models for the prediction of life-threatening complications in 586 cases of deep neck space infections: retrospective multi-institutional study.
OBJECTIVE
To identify deep neck infection factors related to life-threatening complications.
METHODS
This retrospective multi-institutional study comprised 586 patients treated for deep neck infections between 2002 and 2012. The statistical significance of variables associated with life-threatening complications of deep neck infections was assessed.
RESULTS
During treatment, life-threatening complications occurred in 60 out of 586 cases. On univariate analysis, life-threatening complications were linked to: dyspnoea, neck movement disturbance and dysphonia (all p < 0.001); and parapharyngeal, anterior visceral or pretracheal deep neck involvement (all p < 0.002). Aetiology was significantly linked to tonsils (p < 0.001). Regarding infection type, fasciitis was a significant factor (p < 0.001). Candida albicans was a significant bacterial culture (p < 0.001). A multivariate step-wise model disclosed fewer significant variables: retropharyngeal space (p = 0.005) and major blood vessels area (p = 0.006) involvement, and bacterial culture C albicans (p < 0.001).
CONCLUSION
It can be predicted that patients with deep neck infections, with neck movement disturbances, dysphonia, dyspnoea and swelling of the external neck, accompanied by severe pain, and inflammatory changes in the retropharyngeal space and large vessel areas, with culture-confirmed infection of C albicans, are likely to develop life-threatening complications.
Topics: Adult; Aged; Aged, 80 and over; Bacterial Infections; Female; Humans; Male; Middle Aged; Models, Theoretical; Neck; Retrospective Studies; Severity of Illness Index; Survival Analysis; Young Adult
PubMed: 28578716
DOI: 10.1017/S0022215117001153 -
Zhonghua Er Bi Yan Hou Tou Jing Wai Ke... Jun 2016To study the pathological and clinical features and the surgical results of the mass in the pretracheal space.
OBJECTIVE
To study the pathological and clinical features and the surgical results of the mass in the pretracheal space.
METHODS
From 1999 to 2004, 8 females and 3 males with an average of 43 years (from 32 to 61 years) were included CT scan, nuclear imaging, ultrasound and ultrasound-guided aspiration, endoscopic and laboratory measure were used in the evaluation for the masses before operation. Complete removal of mass was carried out in all patients under general anesthesia, and continuous negative pressure draining was routinely used.
RESULTS
Six masses with firm consistency could be moved easily transversely, but slightly moveable with swallowing. On contrast CT or ultrasound, all the masses had clear circumscription and showed rounded or lobular shape. No hemorrhage, chylous or lymph leakage, or recurrent laryngeal injury was encountered. Goiter was found in 6 cases, parathyroid adenoma in 2 cases, and thymoma, parathyroid cyst or lymphatic cyst was diagnosed in the rest three patients respectively. No recurrence was found with the following-up of 7 - 42 months.
CONCLUSIONS
Goiter, parathyroid adenoma and thymoma were common lesions presenting as mass in the pretracheal space and surgically curable without complications.
Topics: Adult; Cysts; Endoscopy; Female; Goiter; Humans; Male; Middle Aged; Parathyroid Diseases; Parathyroid Neoplasms; Thymoma; Tomography, X-Ray Computed; Ultrasonography
PubMed: 27345882
DOI: 10.3760/cma.j.issn.1673-0860.2016.06.010 -
Zhonghua Er Bi Yan Hou Tou Jing Wai Ke... Sep 2015To review the recent diagnosis and treatment experience with deep neck infection and emphasize the importance of radiologic evaluation, microbiology and appropriate...
OBJECTIVE
To review the recent diagnosis and treatment experience with deep neck infection and emphasize the importance of radiologic evaluation, microbiology and appropriate treatment selection in these patients.
METHODS
A respective review was conducted in 95 cases who were diagnosed as having deep neck from Jan. 2006 to March 2015.
RESULTS
The primary diseases in 95 patients with deep neck infection were acute tonsillitis or acute laryngitis (27 cases), infection of upper respiratory tract (23 cases), odontogenic infection or oral inflammation (16 cases), foreign bodies in esophagus (9 cases), acute cervical lymphadenitis (5 cases) and cause uncertain (15 cases). Computed tomography was performed in all of patients to identify the location, extent, and character (cellulitis in 47 cases or abscesses in 48 cases) of the infections. The locations of abscess were parapharyngeal abscess (25 cases), retropharyngeal abscess (9 cases), submaxillary space abscess (6 cases), pretracheal space abscess (5 cases) and esophageal abscess (3 cases).
COMPLICATIONS
mediastinitis (2 cases), pericarditis (1 case), bilateral pneumothorax (2 cases), and upper digestive tract (1 case). Bacterial cultivation performed in 35 patients and positive results were detected in 21. All patients were given intravenous antibiotic therapy. Tracheotomy was performed in 4 cases. Preoperative contrast enhanced CT was performed in 42 patients and indicated the formation of abscess. Three cases with the symptoms of septic shock were transferred to ICU and one was cured. All the patients were cured except two who died of massive hemorrhage of upper digestive tract and septic shock.
CONCLUSIONS
The airway patency in patients with deep neck infections must be ensured. Drainage may be mandatory in selected cases at presentation or in cases who fail to respond to parenteral antibiotics within the first 24-48 hours. Imaging evaluation plays a significant role in the diagnosis and rational therapeutic management in deep neck infection. Bacterial cultivation can help to make the effective treatment and provide reliable evidence for the etiopathogenisis.
Topics: Anti-Bacterial Agents; Bacterial Infections; Cellulitis; Drainage; Esophagus; Foreign Bodies; Humans; Laryngitis; Neck; Retropharyngeal Abscess; Retrospective Studies; Tomography, X-Ray Computed; Tonsillitis; Treatment Outcome
PubMed: 26696352
DOI: No ID Found -
Journal of Laparoendoscopic & Advanced... Jul 2015Natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and...
BACKGROUND
Natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) is an improvement in surgical interventions. In this study we developed an innovative transtracheal endoscopic thyroidectomy technique and explored its feasibility in animal models.
MATERIALS AND METHODS
Transtracheal endoscopic thyroidectomy was performed in anesthetized dogs and pigs. The endoscope was advanced into the pretracheal space via a longitudinal incision on the anterior tracheal wall. Hemithyroidectomies and partial lobectomy were performed using special double-lumen endotracheal tubes and conventional endoscopic instruments. The tracheal wall incision was closed using absorbable sutures, and the animals were sacrificed at Day 5 postsurgery.
RESULTS
Hemithyroidectomy and partial thyroidectomy were successfully performed on pigs and dogs. The average operative time for each model was 69.4 minutes. No significant complications were encountered during surgery.
CONCLUSIONS
The transtracheal endoscopic thyroidectomy technique is feasible and has the potential to be an alternative method for other types of thyroid surgeries.
Topics: Animals; Dogs; Feasibility Studies; Female; Male; Natural Orifice Endoscopic Surgery; Operative Time; Sutures; Swine; Thyroidectomy; Tracheotomy
PubMed: 26075801
DOI: 10.1089/lap.2014.0452