Giant orbital leiomyoma in a pediatric patient: diagnostic and therapeutic challenge

This manuscript describes an exceptional case of a long-standing orbital leiomyoma in a 14-year-old male. The tumor was unusually large, causing severe proptosis and significant involvement of the ocular muscles. The patient presented with amaurosis, complete ophthalmoplegia, spontaneous eye pain, and the inability to close the eyelids, leading to psychological distress. Due to the tumor's size and progression, a right orbital exenteration was performed to remove all orbital contents, including the tumor and the eyeball. The surgical procedure aimed to prevent tumor recurrence and improve the patient's quality of life. The histopathological analysis confirmed the diagnosis of orbital leiomyoma. This case presents a particular interest due to the degree of evolution it has reached. Complete tumor excision and long-term follow-up are necessary to prevent recurrence and ensure optimal patient outcomes. This report underscores global healthcare disparities and the complexity of managing rare orbital neoplasms in diverse country settings.

An unusual extranodal natural killer/T-cell lymphoma presenting as chronic laryngitis: A case report

RATIONALE

Nasal-type, extranodal natural killer (NK)/T-cell lymphoma is a rare lymphoma. The tumor usually shows ulcerative and necrotic lesions in the nasal cavities and sinuses. Tissue involvement outside the nasal cavity is uncommon.

PATIENT CONCERN

We describe a 30-year-old man with a 2-month history of hoarseness, weight loss, and dyspnea.

DIAGNOSIS

Magnetic resonance image (MRI) showed edema of the larynx with obliteration of the airway. Laryngoscopic examination described necrotic tissue in the glottis and larynx. The biopsy showed chronic, necrotizing laryngitis, with no granulomas, vasculitis, or atypical cells. The immunologic and microbiologic study was negative. Later, after immunosuppressive therapy, the patient presented erythema and diffuse enlargement of the right arm. MRI showed myositis of the biceps and brachial muscles. Infection was rule out, and direct microscopy showed an extensive muscle infiltration by mononuclear cells and abundant mitosis. Immunohistochemistry was positive for CD3, CD8, Ki 67 (90%), and CD56 compatible with extranodal NK/T cell lymphoma.

INTERVENTIONS

The patient initially received immunosuppression treatments (corticoids, cyclofosfamide, and Rituximab) with relapsing episodes. When lymphoma was diagnosed, chemotherapy was started.

OUTCOMES

The patient died during chemotherapy.

LESSONS

Nasal-type, extranodal NK/T-cell lymphoma should be suspected even when there are no classical findings of neoplasms on histology. Immunohistochemistry is mandatory to rule it out.

Intramuscular hemangioma within the biceps brachii causing the limitations of elbow extension and forearm pronation: A case report

RATIONALE

Intramuscular hemangiomas are rare benign vascular neoplasms, merely accounting for 0.8% of all hemangiomas. Moreover, there are few case reports of intramuscular hemangiomas in the upper extremities.

PATIENT CONCERNS

A 24-year-old male patient presented with a 5-year history of intermittent pain of the right elbow joint. He had observed a swelling of the right cubital fossa over the past 2 years, leading to the limitations of elbow extension and forearm pronation.

DIAGNOSIS

The patient was diagnosed with intramuscular hemangioma of the biceps brachii.

INTERVENTIONS

Surgical excision of the tumor was performed for this patient and postoperative early functional exercises were permitted.

OUTCOMES

The movements of the right elbow and forearm reached the normal range of motion at 5 weeks after surgery. There was no evidence of recurrence during the 5-month follow-up.

LESSONS

Optimal management of intramuscular hemangioma is critical, including precise evaluation, good microsurgical technique and early functional exercises, which may result in a satisfying outcome.

Cavernous hemangiomas of the temporalis muscle with prominent formation of phleboliths: Case report and review of the literature

RATIONALE

Hemangiomas are benign tumors characterized by an abnormal proliferation of blood vessels, most often occur in the skin and subcutaneous tissue, intramuscular hemangioma, a distinctive type of hemangioma within the skeletal muscle, account for <1% of all hemangiomas, temporalis muscle is a very uncommon site, cavernous hemangioma of the temporalis muscle with prominent formation of phleboliths is rare reported.

PATIENT CONCERNS

A 62-year-old man presented with a slowly increased mass in his right temporal fossa.

DIAGNOSES

Computed tomography (CT) scan showed the lesion across the zygomatic arch, with many calcified nodules differ in sizes and no erosion to the bone, magnetic resonance imaging (MRI) showed an oval lesion with hypointense and isointense on T2-weighted imaging within the temporal muscle, and preoperation diagnosis was hemangioma.

INTERVENTIONS

The tumor was resected under general anesthesia.

OUTCOMES

The mass was excised completely, and the histopathology examination confirmed the diagnosis of cavernous hemangioma with prominent formation of phleboliths. The patient recovered very well without dysfunctions.

LESSONS

Cavernous hemangioma should be suspected when mass occurs in this region. CT and MRI are important for the early diagnosis of tumor, and resection the tumor completely is recommended.

Diplopia as Rare Initial Manifestation of Gastric Cancer

N/a.

Painful Intramuscular Lipoma of the Infraspinatus: Unusual Location and Presentation

Intramuscular lipomas are considered a rare type of benign lipomas. They are usually located deeper and are less palpable than subcutaneous lipomas. A painful presentation with no palpable mass will make clinical diagnosis difficult; in these cases, further imaging should be considered. Only a small number of cases of intramuscular lipomas present with pain; these are located in the supraspinatus and deltoid muscles. To the authors' knowledge, there have been no previous reports of painful intramuscular lipomas involving the infraspinatus muscle. This article describes a case of intramuscular lipoma uniquely located in the infraspinatus muscle and presenting with shoulder pain. A 49-year-old woman presented with 2 months of left shoulder pain. There was no history of preceding trauma. Pain was aggravated by lying on the left shoulder and by the hand behind the back similar to Crass position. On the physical examination, her shoulder joint range of motion was slightly decreased. Simple radiography showed no significant abnormality, but ultrasonography revealed a hyperechogenic mass within the infraspinatus muscle. There was focal tenderness over the mass, but definite palpation of the mass was not possible. Magnetic resonance imaging revealed a well-circumscribed, homogeneous lesion measuring 43 × 28 × 16 mm within the infraspinatus muscle, leading to a diagnosis of intramuscular lipoma. Her pain was not improved with medication, suprascapular nerve block, and steroid injections. Finally, surgical intervention was done and intramuscular lipoma was confirmed by specimen. After excision, her shoulder pain was improved and resolved.

Rare Case of Intramasseteric Cavernous Hemangioma in a Three-Year-Old Boy: A Diagnostic Dilemma

Intramuscular hemangiomas are rare, benign tumors of vascular origin. The masseter is the muscle most commonly involved in the head and neck region. Because of their infrequency, deep location, and unfamiliar presentation, these lesions are seldom correctly diagnosed clinically. This case report presents a severe facial asymmetry caused by a left intramasseteric cavernous hemangioma in a 3-year-old boy. We were unaware of the exact nature of the tumor until intraoperative examination. The routine investigations performed before operation failed to establish a diagnosis. Surgical excision was performed, and 1 year after the operation we observed that the patient's facial asymmetry had been corrected. In this article, we review the literature on intramasseteric hemangioma, discuss the clinical and radiologic diagnostic methods, and review the treatment methods.

[MAZABRAUD SYNDROME: A CASE REPORT]

We report a case of Mazabraud syndrome diagnosed in a 53 year old female patient. This disease is characterized by the association of a fibrous dysplasia with one or several intramuscular myxoma(s). The literature related to this pathology is poor and only reports a few cases. The aetiology has not been fully established: a genetic hypothesis seems most likely given the common association with McCune-Albright syndrome. Although rare, the incidence of Mazabraud syndrome seems underestimated, probably out of ignorance. The aim of this article is to describe Mazabraud syndrome and its common features. The management of fibrous dysplasia of bone and benign soft tissue tumors will also be outlined.

Double crush syndrome of the median nerve revealing a primary non-Hodgkin's lymphoma of the flexor digitorum superficialis muscle

Extranodal manifestations of lymphoma are well described in the literature and occur in 20 to 30% of patients. Skeletal muscle involvement is rare. We describe the case of a patient with non-Hodgkin's lymphoma in a forearm muscle. At the age of 86, the featured patient started experiencing continuous, progressive and high intensity pain that was more frequent at night and localized in the right dominant hand. It was associated with paresthesia and hypoesthesia, primarily in the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to the diagnosis of carpal tunnel syndrome. The patient underwent carpal tunnel release at a private hand center. The progression was unfavorable. Additional clinical examination and electrodiagnosis showed compression of the anterior interosseous nerve (double crush syndrome). The patient was referred to our university hand center for further management. Magnetic resonance imaging showed a large mass of about 20cm occupying the entire anterior compartment of the forearm and enclosing the median nerve. Biopsies were performed and revealed a diffuse large B-cell primary non-Hodgkin's lymphoma. The patient underwent chemotherapy and radiotherapy. Six months later, the patient was in complete remission. Muscular involvement during lymphoma is rare. Biopsy is mandatory; needless radical surgery can be avoided because lymphoma is primarily a non-surgical disease. The key points of the treatment process are reviewed.

Mazabraud's syndrome and thyroid cancer, a very rare and confusing association: a case report

BACKGROUND

Mazabraud's syndrome is defined as the association between fibrous dysplasia and intramuscular myxomas. The syndrome was first described in 1967 and, up until now, less than 100 cases have been reported worldwide. Here we report the association between this rare syndrome and thyroid cancer. When a malignant disease occurs in a patient affected by this syndrome, the differential diagnosis between benign and malignant bone lesions should be undertaken carefully.

CASE PRESENTATION

We report the case of a 57-year-old Caucasian male, admitted for diffuse bone pain localized in the left leg and for the presence of an indolent, slow-growing mass in the left shoulder. The patient also presented with a thyroid nodule, highly suggestive of a malignancy. The radiologic examination showed multiple osteolytic lesions. The suspicion of multiple myeloma or bone metastases arising from a thyroid cancer was considered. Electrophoresis of proteins was negative and therefore excluded the diagnosis of multiple myeloma; the thyroid surgery was indicated. Thyroidectomy confirmed the papillary thyroid carcinoma, and the bone lesions were considered to be metastases from the thyroid cancer. After surgery, under thyroid-stimulated hormonal conditions, the patient underwent radioiodine therapy and a post-therapy radioiodine whole body scan. The lack of radioiodine uptake, both in the bone lesions and shoulder mass, suggested the possibility of less differentiated, non-avid radioiodine lesions, or the absence of any relation between pathologies. Considering the low level of the specific tumor marker, thyroglobulin, a bone biopsy and resection of the shoulder mass were indicated. The final diagnosis was intramuscular myxoma with polyostotic fibrous dysplasia in the deltoid muscle (Mazabraud's syndrome). A completely incidental cerebral tumor lesion was also discovered.

CONCLUSION

During the evolution of a malignant disease, Mazabraud's syndrome, known as the association of intramuscular myxoma with fibrous dysplasia, should be considered in the differential diagnosis of bone metastasis. This is the first report in the literature of Mazabraud's syndrome occurring in a patient with thyroid cancer.

Medical and legal considerations in managing patients with musculoskeletal tumors

At some point in their careers, many orthopaedic surgeons will have to navigate the legal system as it pertains to medical malpractice. An orthopaedic surgeon will find it helpful to review information on the basic legal elements of medical malpractice law along with suggestions on how he or she can assist the legal defense team if a lawsuit is filed. Surgeons who face litigation within the context of managing patients with musculoskeletal tumors should be aware of the common pitfalls in managing these patients. Knowledge of complementary strategies can provide good patient care and reduce legal risks when caring for patients with musculoskeletal neoplasms.

Fibrous tumor of the superior oblique tendon in Proteus syndrome

Proteus syndrome is a disorder of patchy, or mosaic, postnatal overgrowth. Mosaic somatic mutation of the AKT1 gene has been identified in over 90% of individuals meeting the diagnostic criteria for Proteus syndrome. Onset occurs in infancy and can involve any tissue of the body. The connective tissue and bone, skin, central nervous system, and the eye are commonly involved. Epibulbar tumors, strabismus, and posterior segment involvement have previously been reported. However, there have not been any reports of lesions affecting the extraocular tendons. We report a case of Proteus syndrome patient presenting with vertical strabismus secondary to a fibrous tumor within the superior oblique tendon. The tumor was successfully excised with complete resolution of the strabismus.

[Shoulder pain as the first sign of disseminated lung cancer]

The diagnosis of non-small cell lung cancer is in 50% of the cases not made until the metastatic stage. Distant metastases commonly involve the adrenal glands, the liver, the bones and the central nervous system. Metastases are very rarely seen in skeletal muscles. We report a case with a 47-year-old man, who suffered from strong pain in his right shoulder. The symptoms turned out to be the initial presentation of a disseminated lung cancer. A magnetic resonance scan showed skeletal muscle metastases to m. subscapularis and m. infraspinatus. Metastases to skeletal muscles are rare but should be kept in mind as part of the differential diagnosis in cases where atypical shoulder pain is the only symptom.

Huge recurrent tumoral calcinosis needing extensive excision and reconstruction: report of a rare case and brief literature review

Tumoral calcinosis, a rare benign clinical condition resembling a neoplasm, is characterized by calcium deposits, usually located in the soft tissues around the large joints. It can be primary or secondary to renal failure and hyperparathyroidism. This report describes an unusual case of recurrent tumoral calcinosis presenting as a huge mass infiltrating the skin and muscles of the lumbosacral area. The patient underwent wide excision and reconstruction with bilateral V-Y advancement gluteal fasciocutaneous flaps and at this writing remains disease free 4 years postoperatively. A concise review of the pertinent literature focusing on the diagnosis, treatment options, and preventive measures also is reported.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article.

Prenatal management of diaphragmatic rhabdomyosarcoma presenting with fetal hydrops

Fetal malignant tumors are rare. We present a case of intrauterine diagnosis of a diaphragmatic tumor presenting with fetal hydrops at 32 weeks' gestation. The sonographic findings were bilateral pleural effusion, ascites and skin edema. A large right-sided diaphragmatic tumor was identified. Owing to the findings on ultrasound and magnetic resonance imaging a solid malignant tumor was suspected. The pleural effusions were drained and malignant cells identified. Because of rapid tumor progression Cesarean section was performed and a hydropic female newborn was delivered at 34 + 0 weeks' gestation. There was no sign of metastatic disease. Postnatally tumor biopsy revealed an alveolar rhabdomyosarcoma. Therapy included chemotherapy and secondary surgical intervention. After a good primary response with complete remission after 6 months, the rhabdomyosarcoma relapsed at 12 months with cerebral metastasis. The prognosis was poor.

[Atypical metastatic site of lung adenocarcinoma]

The case concerns a 40 years old smoker male, treated for an adenocarcinoma of the left upper lobe, metastatic in muscle extended to the right femur cortex. The patient had first a surgical excision of the mass of the thigh, an intramedullary femoral nailing, and six courses of chemotherapy (cisplatin-vinorelbine) with concurrent thoracic radiotherapy. This treatment led to disease stability. One year later, hematuria revealed a bladder tumor. Cystoscopy with biopsy concluded to an adenocarcinoma pulmonary origin. The PET-scanner showed an uptake of the bladder mass, a hypermetabolic right adrenal gland and subcutaneous left shoulder nodule. The patient had a partial cystectomy associated with enterocystoplasty and left ureteral reimplantation, plus excision of the subcutaneous nodule located in the left shoulder and a right adrenalectomy during the same time. All of the sites were metastasis from adenocarcinoma of pulmonary origin. A salvage chemotherapy was initiated. In the vast majority of cases, bladder metastasis as primary bladder tumours is revealed by hematuria, cystitis or sometimes vague pelvic pain. Our case is a very unusual bladder metastatic site from lung cancer. We will discuss the different procedures and the therapeutic strategies on the basis of the published data.

Subacute trismus in a kidney transplant recipient

This case report describes a male patient with trismus and generalized muscle weakness as the presenting symptom of disseminated malignancy. Trismus was caused by the presence of multiple small nests of undifferentiated tumor cells between muscle fibers of the masseter muscles as well as of other skeletal muscles. The diagnosis was suggested by increased uptake of 18-fluoro-deoxyglucose on positron emission tomography and subsequent ultrasound examination. The primary tumor was not found on autopsy. The patient was at increased risk for malignancy due to his renal transplantation 16 years before.

A pleuro-peritoneal communication through the diaphragm affected with lymphangioleiomyomatosis

A 30-year-old Japanese woman with lymphangioleiomyomatosis (LAM) developed a left chylothorax and chylous ascites. A pleuro-peritoneal communication was confirmed by a scintigram with (99)mTc-labeled macroaggregated-albumin injected into the peritoneal cavity. Video-assisted thoracic surgery revealed a protruding papillary lesion on the left diaphragm. Chyle was oozing into the pleural cavity through this lesion. Histopathological analyses demonstrated that the protrusion was a diaphragmatic LAM lesion and that LAM-associated lymphangiogenesis enabled communication between the pleural and peritoneal cavities through lymphatic vessels. This case demonstrated a new mechanism for chylous pleural effusion in LAM and illustrates the significance of LAM-associated lymphangiogenesis.

Intramuscular venous malformation in the upper arm with gross calcifications and compression of the ulnar nerve

We report an unusual case of intramuscular venous malformation with calcifications that presented with features of involvement of the ulnar nerve.

An unusual cause of low back pain: paravertebral muscle metastases of lung cancer

Paravertebral muscle metastasis is an extremely rare cause of low back pain. Lipomas, haemangiomas, hibernomas and liposarcomas should be considered first in the aetiology of paravertebral muscle masses. Schwannoma, neurofibroma, ganglioneuroma and paraganglioneuromas that show contiguous spread should also be included in the differential diagnosis. Haematogenous metastases are most frequently caused by lung cancers. Lung cancers typically metastasize to liver, brain, bone, kidney, and adrenal glands. They rarely metastasize to skeletal muscles due to metabolism, high tissue pressure and blood flow of muscles. Our case was a 48-year-old male who had been smoking 40 cigarettes per day and presented to our clinic with low back pain and a mass in the lower back region. The mass in his lower back region was excised and histopathological examination confirmed metastasis of a neuroendocrine tumour. Further examinations revealed the lung as the primary source of the metastasis.

[Tendon sheath lipoma associated with quadriceps tendon rupture. Case report]

BACKGROUND

Tendon sheath lipoma is an uncommon tumor characterized morphologically by mature fatty tissue lobes adherent to the tendon or intersecting its fibers. The association with quadriceps tendon rupture is unusual. Etiologic factors that may condition those ruptures have not yet been fully described. However, several authors suggest the existence of a subjacent pathology such as metabolic or inflammatory diseases. Minimal trauma may lead to such ruptures as well as associated ligamentous or bony injuries. The prognosis regarding quadriceps tendon rupture mainly depends on the lap between injury and time of repair.

CLINICAL CASE

We present the case of a quadricipital tendinous rupture produced by the presence of a benign neoplasm, which is a very infrequent association. The patient was surgically treated for quadriceps tendon reconstruction via tendinous reinsertion at the patella. Currently, during rehabilitation, the patient is symptom free with an almost-complete flexion/ extension of his left knee.

CONCLUSIONS

We consider that importance must be given to neoplastic disease as a cause of tendinous rupture, regardless of their infrequency and unusual clinical presentation.

Cavernous haemangioma of the temporalis muscle: case report and review of the literature

Haemangiomas are benign vascular neoplasms characterized by an abnormal proliferation of blood vessels. They may occur in any vascularized tissue including skin, subcutaneous tissue muscle and bone. These tumours are common in infancy and childhood and commonly involve subcutaneous or mucosal tissues. Intramuscular haemangiomas, a distinctive type of haemangioma occurring within skeletal muscle, account for less than 1% of all haemangiomas. They occur more often in trunk and extremity muscles, whereas involvement of the temporal muscle is extremely rare. Herein, the case is reported of a 38-year-old male who presented with a round, painless mass in the left temporal fossa, which was interpreted as an intramuscular haemangioma after a magnetic resonance imaging scan. In this report, clinico-pathological findings are described in an additional case of haemangioma involving the temporal muscle, and a review is made of the international literature on this subject.

Problems with diagnostic work-up of musculoskeletal pain due to glomus tumour. Four case reports

INTRODUCTION

Glomus tumours are rare benign neoplasms of myoepithelial origin. Due to characteristic and painful symptoms, glomus tumours are a major clinical problem.

MATERIAL

Four histologically confirmed cases of glomangioma treated at the Orthopaedics & Traumatology Department between 1999 and 2007.

RESULTS

The most significant symptom was extreme pain causing a decrease in the quality of life. Regardless of the location of the tumour, the correct diagnosis was delayed by 1.5 to 3 years.

CONCLUSIONS

Due to its rare occurrence, glomus tumours are often missed out in the differential diagnosis of musculoskeletal pain. The agonising pain makes glomus tumours a significant clinical problem that should be remembered about, especially as surgery brings about spectacular improvement.

Signaling pathways initiated by beta-hydroxy-beta-methylbutyrate to attenuate the depression of protein synthesis in skeletal muscle in response to cachectic stimuli

To investigate the mechanism by which beta-hydroxy-beta-methylbutyrate (HMB) attenuates the depression of protein synthesis in the skeletal muscle of cachectic mice, a study has been carried out in murine myotubes in the presence of proteolysis-inducing factor (PIF). PIF inhibited protein synthesis by 50% within 4 h, and this was effectively attenuated by HMB (25-50 muM). HMB (50 muM) alone stimulated protein synthesis, and this was attenuated by rapamycin (27 nM), an inhibitor of mammalian target of rapamycin (mTOR). Further evidence for an involvement of this pathway was shown by an increased phosphorylation of mTOR, the 70-kDa ribosomal S6 kinase (p70(S6k)), and initiation factor 4E-binding protein (4E-BP1) and an increased association of eukaryotic initiation factor 2 (eIF4E) with eIF4G. PIF alone induced a transient (1-2 h) stimulation of phosphorylation of mTOR and p70(S6k). However, in the presence of HMB, phosphorylation of mTOR, p70(S6k), and 4E-BP1 was increased, and inactive 4E-BP1-eIF4E complex was reduced, whereas the active eIF4G.eIF4E complex was increased, suggesting continual stimulation of protein synthesis. HMB alone reduced phosphorylation of elongation factor 2, but this effect was not seen in the presence of PIF. PIF induced autophosphorylation of the double-strand RNA-dependent protein kinase (PKR), leading to phosphorylation of eIF2 on the alpha-subunit, which would inhibit protein synthesis. However, in the presence of HMB, phosphorylation of PKR and eIF2alpha was attenuated, and this was also observed in skeletal muscle of cachectic mice administered HMB (0.25 g/kg). These results suggest that HMB attenuates the depression of protein synthesis by PIF in myotubes through multiple mechanisms.

Sarcomas in children with neurofibromatosis type 1-poor prognosis despite aggressive combined therapy in four patients treated in a single oncological institution

OBJECTS

Patients with neurofibromatosis type 1 (NF1) are predisposed to developing soft tissue sarcomas (STS).

MATERIALS AND METHODS

We report on four cases of STS diagnosed in locally advanced, unresectable stages in children with NF1 (three girls, one boy; age = 8 months-14 years). All patients received protocols for STS: Cooperative Weichteilsarkomstudie 91, 96 and 2002. One patient with limb rhabdomyosarcoma entered complete remission but developed late metastatic relapse and died of progression despite complete excision and autologous bone marrow transplantation. The other patient with bladder rhabdomyosarcoma died of neutropenia-related sepsis without remission. Patients with malignant peripheral nerve sheet tumour and malignant triton tumour located in the pelvis did not respond to therapy. One of them died of disease progression, while the other is disease-free 6 years post-therapy after mutilating tumour resection.

CONCLUSION

STS in NF1 seem to display poor prognosis in spite of combined therapy; thus, children with NF1 should remain under detailed control of the oncologist.

Successful management of a bilateral diaphragmatic lymphangioma

A 5-year-old boy developed two episodes of massive chylothorax due to a huge bilateral diaphragmatic lymphangioma. Two episodes of chylothorax were well controlled only after parenternal octreotide. The lymphangioma showed more than 90% shrinkage after intralesional sclerotherapy with bleomycin.

Venous reconstructions in lower limbs associated with resection of malignancies

BACKGROUND

Patients with tumors in the limbs who undergo surgical treatment may have involvement of major vessels. Major arteries are always reconstructed for limb salvage. Major veins may be reconstructed to avoid the onset of venous hypertension signs and symptoms. The objective of this study was to analyze the results from surgical treatment of a sample of patients who underwent lower limb venous reconstructions associated with the resection of malignant tumors.

METHODS

Follow-up was performed of 17 patients with malignant tumors involving major vessels in the lower limbs. The median length of follow-up was 22 months. Venous reconstruction concomitant to arterial reconstruction was performed in 15 patients, and an isolated venous reconstruction was performed in 2 patients. The venous substitutes used were the contralateral long saphenous vein (n = 12), expanded polytetrafluoroethylene prosthesis (n = 3), and Dacron prosthesis (n = 2).

RESULTS

Vascular complications occurred in seven patients: three occlusions of the venous graft, edema in seven patients, and one rupture of the arterial graft. The primary 2- and 5-year patency rates of venous reconstructions were 79.3% and 79.3%, respectively. Nonvascular complications occurred in six patients: neurological deficit (n = 3), partial necrosis of the flap (n = 2), wound infection (n = 1), hematoma (n = 1), and enteric fistula (n = 1). Eight patients were still alive and disease free, although one of them underwent above-knee amputation as a result of local disease recurrence. One patient experienced regional disease recurrence and is undergoing chemotherapy. Eight patients died due to pulmonary metastases. The 2- and 5-year overall survival rates were 58.6% and 42.4%, respectively. The 2- and 5-year thrombosis-free survival rates were 51.9% and 35.2%, respectively.

CONCLUSIONS

Lower limb venous reconstructions associated with tumor resection in this study gave good functional results, although the prognosis for these patients had been unfavorable. The saphenous vein is a suitable substitute.

A case of intramuscular hemangioma presenting with large-angle hypertropia

Purpose

To report the case of a patient with large-angle hypertropia of an intramuscular hemangioma of the right superior rectus muscle (SR).

Methods

A 63-year-old man with progressive vertical deviation of the right eye for the past 6 months visited our strabismus department; his condition was not painful. An examination indicated that he had 60PD of right hypertropia at distance and near in primary gaze. Additionally, a significant limitation of his downgaze was noted. The right eye appeared mildly proptotic, and the upper and lower eyelids were slightly edematous. Corrected vision was 20/20 in both eyes.

Results

Orbital magnetic resonance imaging (MRI) studies revealed fusiform enlargement of the right superior rectus muscle, with prominent but irregular enhancement following gadolinium administration. Incisional biopsy revealed an intramuscular hemangioma in the superior rectus muscle with cavernous-type vessels.

Conclusions

This case demonstrates that intramuscular hemangioma should be considered in the differential diagnosis of isolated extraocular muscle enlargement and unusual strabismus.

Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm

BACKGROUND/PURPOSE

Tumors of the diaphragm in the pediatric population are extremely rare. We present 5 cases diagnosed at the Hospital for Sick Children, Toronto, and together with a review of the world literature, provide an approach to the diagnosis and management of these tumors.

METHODS

A clinical retrospective review of patients diagnosed as having primary diaphragmatic tumor (PDT) at the Hospital for Sick Children as well as a review of the world literature.

RESULTS

Forty-one cases of PDT in the pediatric population have been described from 1868 to 2005 inclusive. There is an equal incidence in boys and girls, they are found with the same frequency on the left as on the right, and 78% are malignant. Rhabdomyosarcoma is the most commonly occurring malignant tumor. The mean age at diagnosis is 10 years. "Chest-associated" symptoms are more common than "abdomen-associated" symptoms. Imaging often fails to identify the site of origin as the diaphragm. Surgery is the cornerstone of therapy for PDT.

CONCLUSION

A multidisciplinary team approach is needed for successful treatment and management of PDT.

Not all pain in the left iliac fossa is diverticular disease: A case study of a psoas myxoma and review

Intramuscular myxomas are rare, benign, mesenchymal tumours that may present to a wide variety of specialties. We present a case study of an intramuscular myxoma in the psoas muscle, followed by a review of the literature regarding the diagnosis and treatment of intramuscular myxomas

Acute compartment syndrome complicating an intramuscular haemangiosarcoma in a dog

Acute compartment syndrome in dogs is a rare complication of muscle trauma, but it has not been previously reported as a consequence of neoplasia in dogs. This case report describes the occurrence of a compartment syndrome of the femoral compartment in an 11-year-old, male, mixed-breed dog caused by acute bleeding of an intramuscular haemangiosarcoma. The compartment syndrome was relieved by immediate fasciotomy. The dog was euthanased following acute recurrence of clinical signs seven weeks after surgery.

Femoral compartment syndrome due to haemangiosarcoma in the semimembranosus muscle in a dog

A five-year-old, entire male German shepherd dog was presented to the Veterinary Teaching Hospital-Koret School of Veterinary Medicine because of an acute, painful swelling of the right thigh and severe lameness of two-weeks duration. On physical examination, a firm and painful mass was detected in the hamstring region. Radiography and ultrasonography revealed a soft tissue mass, with a 250 cc fluid accumulation craniomedial to it. Intracompartmental pressure measurement with a Wick catheter demonstrated significantly elevated pressure within the right caudal femoral compartment (25 to 28 mmHg compared with 5 to 7 mmHg in the unaffected leg). Surgical exploration of the area was undertaken, fasciotomy and mass excision were performed, and resolution of the clinical signs was achieved. The mass was identified by histopathology results as haemangiosarcoma. Two and a half months after surgery, which was followed by adjunct chemotherapy (doxorubicin), the dog was readmitted with a subcutaneous mass in the same area, although he was not lame at this time. Radiographs of the thoracic cavity demonstrated widely disseminated metastases in the lungs. At that point, the owner elected to have the dog euthanased.

Metastases to the peripheral nervous system

Cancer metastasis can affect any part of the nervous system. When the peripheral nervous system is involved, the usual targets are cranial nerves, nerve roots and plexi. However, peripheral nerves and muscles can also be affected by compression or infiltration of neoplastic cells. This review focuses in the diagnosis and treatment of metastatic complications of cancer involving plexi, peripheral nerves and muscles.

Extraskeletal Ewing sarcoma of the diaphragm presenting with hemothorax

Ewing sarcoma is a relatively uncommon malignant bone neoplasm that usually occurs in children and young adults and involves the major long bones, pelvis, and ribs. Primary diaphragmatic Ewing sarcoma is extremely rare. To the best of our knowledge, only three cases of primary Ewing sarcoma of the diaphragm have been reported. A 12-year-old girl presented spontaneous occurrences of the right hemothorax. After drainage, a roentgenogram film, computed tomography, ultrasonography, and magnetic resonance image showed a giant mass on the right diaphragm. Primary diaphragmatic tumor was resected totally by right posterolateral thoracotomy, and histologically, an extraskeletal Ewing sarcoma was identified. The patient received adjuvant radio-chemotherapy, and there was no evidence of disease 10 months after the operation. Although extremely rare, extraskeletal Ewing sarcoma should be kept in mind in the differential diagnosis of diaphragmatic soft tissue tumors.

Cystic hygroma in the quadriceps muscle: a sanguine diagnosis for knee pain

Reported here is a 28-year-old female who presented with severe right knee pain and swelling nearby the joint. Ultrasonography, magnetic resonance imaging and eventually surgery were performed. She was diagnosed to have a cystic hygroma in the vastus lateralis muscle. This is the first patient of a cystic hygroma in the quadriceps muscle.

Multiple Bilateral Extraocular Muscle Metastases as the Initial Manifestation of Breast Cancer

A 75-year-old woman had gradually progressive binocular diplopia and 2 months later had breast cancer diagnosed. Examination showed bilateral external ophthalmoplegia with lid retraction and lag and no pupillary abnormalities. Orbital magnetic resonance imaging showed enlargement and enhancement of all extraocular muscles bilaterally. A right orbital biopsy was consistent with metastatic breast carcinoma. Positron emission tomography, bone scan, and computed tomography of the chest, abdomen, and pelvis failed to disclose other evidence of breast cancer metastases. It is unusual to encounter metastatic breast cancer affecting every extraocular muscle before the diagnosis of the primary carcinoma.

The management of malignant psoas syndrome: case reports and literature review

Malignant psoas syndrome (MPS) was first described in 1990, and is characterized by proximal lumbosacral plexopathy, painful fixed flexion of the ipsilateral hip, and radiological or pathological evidence of ipsilateral psoas major muscle malignant involvement. There have been 23 case reports of MPS in medical journals. Despite being associated with a severe and difficult pain, there is no definitive approach to management presented in the palliative care literature. We review the relevant clinical features and the subsequent multidisciplinary pain management in relation to four new cases of malignant involvement of the psoas muscle, and the 23 case reports in the literature. We propose that MPS comprises a continuum of symptoms and signs related to the degree of anatomical destruction with associated inflammatory reaction and muscle spasm, and also the degree of lumbosacral plexopathy causing neuropathic pain. A protocol is presented for the management of the complex pain issues of MPS directed at likely mechanisms. The treatment options include opioids, agents for neuropathic pain, muscle relaxants to manage psoas muscle spasm, and anti-inflammatory agents to reduce peritumoral edema. Direct anti-tumor measures also need to be considered. Further prospective study is needed to validate the proposed methods of assessment and treatment.