Journal of Clinical Case Reports

Circulating tumor cells (CTCs) are closely related to the prognosis of patients with malignant tumors, meaning they have important value in the evaluation of treatment efficacy and prognosis of cancer patients. During a nonoperative treatment for a patient with advanced esophageal cancer, we performed dynamic monitoring of circulating tumor cell counts to evaluate the efficacy. Compared with the clinical stage (cTNM) prognostic evaluation system, dynamic monitoring of CTCs showed great value in therapeutic effect evaluation and prognostic evaluation in nonoperative treatment of patients with advanced esophageal cancer.

Objective: To find factors possibly related to the persistence of a midluteal central endometrial echo usually associated with lower pregnancy rates.
Methodology: 2 groups of women with regular menstrual cycles were followed by transvaginal ultrasound scan examinations during the follicular and luteal phases of the cycle. One group consisted of 31 parous women who requested assisted reproduction treatment and gender selection for family completion. The other group consisted of 79 nulliparous women monitored during infertility investigations. There was no history of prior uterine surgery or recent hormonal medication. The age and body mass index of all women were recorded beforehand. Presence of polycystic ovaries, midcycle endometrial thickness, uterine arteries pulsatility index and ovulation time were recorded. Endometrial texture and serum progesterone level were examined 7-9 days after ovulation. All monitored indices were assessed in relation to the two studied groups and to the presence or absence of a central endometrial echo.
Results: No differences were detected between the two groups regarding age, body mass index, polycystic ovaries prevalence, midcycle endometrial thickness, midcycle uterine arteries pulsatility index or midluteal serum progesterone. A central midluteal endometrial echo was evident in 6 of 31 women in the parous group (19.4%) and 26 of 79 (32.9%) in the nulliparous group (p=0.119). It was significantly more common in women with polycystic ovaries (19 of 34, 55.9%) than the non-polycystic ovaries group (13 of 76, 17.1%); p<0.001. All other parameters examined had no significant correlation with the luteal phase persistent central endometrial echo.
Conclusion: Local uterine factors might be responsible for the persistent midluteal central endometrial echo as it had no significant correlation to the uterine arteries blood perfusion or midluteal serum progesterone. It might be corelated to endometrial hyperandrogenisation because of its significant correlation to polycystic ovaries. Other local possibilities need to be explored.

Objective: Spontaneous pneumoperitoneum is a rare condition. It presents a challenge to the surgeon as the clinical presentation and radiological findings mimic perforated viscus resulting in unnecessary surgical intervention. The aim of this article is to describe a case of a spontaneous pneumoperitoneum in an elderly patient who underwent diagnostic laparoscopy and review of literature.
Case presentation: A 77-year-old female with multiple comorbidities presented to the emergency department with productive cough, shortness of breath, vomiting and abdominal pain. On examination she had tenderness in epigastric region. Chest X-ray and CT showed free air and fluid in peritoneal cavity.
Results: The patient underwent diagnostic laparoscopy that did not reveal any gastrointestinal perforation.
Conclusion: Spontaneous pneumoperitoneum is frequently mistaken for perforated viscus. If the patient presents with features of peritonitis, diagnostic laparoscopy has a vital role as it prevents unnecessary midline laparotomy.

Background: Giant Congenital Melanocytic Naevus (GCMN) is a morphological skin alteration present from birth, involving up to 80% of the body surface. GCMN could have a detrimental effect on body perception due to several factors including its aspect, extension and the potential exposure to significant number of surgical interventions.
Objective: This pilot study assessed quality of Body Image (BI) and psychological adjustment in subjects with GCMN and their parents.
Methods: Subjects and parents underwent a multi-method assessment including a semi-structured interview, a self-administered rating scale to assess BI (Body Uneasiness Test, BUT) and two personality tests: A self-report (MMPI-2RF/A) and a performance test (Rorschach, R-PAS method).
Results: Ten families were enrolled in the study. GCMN subjects were all females with high average surgical interventions (median=13). In GCMNs a substantial impairment of BI was detected by the BUT (global severity index=2.34 ± 0.81; Body Image Concern=3.25 ± 0.95), MMPI-2RF/A presented normal ranges and R-PAS showed elevations for the quality of human representations (PHR/GPHR: 119.1 ± 8.1). Mothers showed a trend for health concerns at MMPI-2RF (Malaise: 64.2 ± 9.5), fathers showed under-reporting in almost all tests.
Conclusion: This set of GCMN females with relevant surgical history shows significant BI impairment with several aspects of non-integrated body identity at unconscious level, that may result in inability to envision the self and relations with others in adaptive way. Parents show different profiles, including conscious health concerns in mothers and denial in fathers. Families with a GCMN subject could benefit from integrated approaches including medical advice, psychological support and social integration projects.

The 2016 World Health Organization Classification of Tumors recognized mucinous tubular and spindle cell carcinoma (MTSCC) as a rare histological variant of renal cell carcinoma (RCC). To date, a limited number of studies have reported this tumor concerning histology, and only a handful of those have reported cytological and ultrastructural features. This study aims to report a case of MTSCC in a female patient in her early 50s who presented with a chief complaint of gross hematuria, and to discuss relevant cytological and ultrastructural findings. Imaging revealed a 30 mm tumor in the left kidney, suggesting the presence of RCC, and left nephrectomy was performed. In addition, scratched cytology of tumor surface revealed clusters of tumor cells with clear cell boundaries extending two-dimensionally in papillary or dendritic arrangements with interspersed blood vessels and stromal components that were stained light green. Histologically, the tumor was composed of small and uniform cells arranged in elongated tubular architectures and spindle fascicles with occasional papillary structures; the stroma was acidophilic and contained colloidal substances that tested positive for Alcian blue and periodic acid-Schiff stain. Concordant with immunohistochemical results, the tumor was diagnosed with MTSCC. Furthermore, transmission electron microscopy revealed tubular structures with microvilli, abundance of mitochondria in the cytoplasm, cellular interdigitations and widened interstitium.

Splenic infarction is a rare cause of acute abdomen whose aetiology is stratified according to age group. In patients under the age of 40 most causes are attributable to hematological or genetic pathologies, while in patients over 40 years old, the thromboembolic manifestations play a major role. The diagnosis of splenic infarction can be almost an enigma for the doctor who is evaluating a patient with non-specific abdominal pain, possible hyperpyrexia or rise in phlogosis and LDH indexes. The scientific literature on splenic infarction is rather scarce and consists mostly of articles with few cases. In this article, with the help of a rather emblematic clinical case that has come to the attention of the Emergency Department of the S. Anna Hospital in Ferrara, and subsequently to the Surgery Unit, we want to reflect not so much on the diagnosis of this pathology but rather on the therapeutic strategies following the diagnosis. Is splenic infarction a pathology of surgical interest? On what terms and times should surgical treatment be proposed to the patient? Is there an alternative to surgery? How should follow-up be conducted in these patients? These are questions to which the literature currently available has not yet been able to answer and, in the future, we hope we will start researches on the treatment of a condition which does not seem to be so rare.

Although Bipartite Patella is usually asymptomatic, it may become symptomatic after repeated traumas. The treatment of avulsed and painful bipartite patella consists conservative treatments including, rest and physiotherapy but surgical treatment can be required in inconclusive cases. Surgical treatment consists, open or arthroscopic excision of the painful fragment and release of the lateral retinaculum. In this case report, we present 19-yearold male patient who underwent arthroscopic resection of his type III avulsioned bipartite patella. While we were performing the arthroscopic surgery for the treatment, we minimized the problems related to open surgery.

Nivolumab is an immune checkpoint inhibitor used to treat various advanced malignancies including metastatic non-small cell lung cancer. The side effects of immunotest inhibitors are different from traditional cytotoxic chemotherapy and pericardial effusion is one of the adverse effects of immunotherapy. However, here we present a 59-year-old male with advanced non-small cell lung cancer (NSCLC) treated with nivolumab who successfully managed reduction of pericardial effusion in patients treated by Nivolumab after 11 cycles. During the treatment, he underwent only one pericardial puncture and drainage of pericardial effusion.

Nicolau syndrome (NS) is a rare but well-known complication of intramuscular Benzathine Penicillin (BP) injection, manifesting by symptoms of livedoid discoloration of the skin, edema, as well as classical clinical features of myalgia, muscle weakness and pigmenturia immediately after intramuscular. NS or embolia cutis medicamentosa was first described in 1925 by Nicolau and Freudenthal following intramuscular injection of bismuth salt for the treatment of syphilis. Since then, a few cases have been reported both in adult and children.

Three patients attended our gynaecology clinic with left iliac fossa pain for second opinion. One patient had sharp pain which started two weeks previously. It improved slightly over one week before getting worse and unbearable. Clinical examination and routine investigations including ultrasound and CT scanning were normal. Laparoscopic examination showed two abnormal looking appendices epiploicae which were excised. One was darker and firm and the other was large with few hyperaemic areas and bruised pedicle indicating recent torsion. Appearance and consistency of the two appendages most likely reflected the cause of the two pain episodes respectively. Histological assessment showed necrotic fat tissue with no evidence of inflammatory cells. The patient felt well thereafter and was discharged from the clinic. The other two patients presented with intermittent left iliac fossa pain for 3 and 6 years respectively. Both patients noticed increased pain frequency and intensity with progressive weight gain. Diagnostic laparoscopy showed a large irregular gap in the left broad ligament in one patient and a small fenestration in the same ligament in the other one. Left salpingectomy to disrupt the medial margin of the large gap and laparoscopic suturing of the small fenestration were done in the two patients respectively. The surgical objective was to prevent bowel herniation through these gaps which was the most likely cause of pain. Both patients recovered well and had no further symptoms. Accordingly, patients with acute or chronic pelvic or lower abdominal pain of unidentifiable aetiology should be subjected to diagnostic laparoscopy and further surgical intervention as necessary.