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Introduction: Schwannomas (Schs) are benign tumor masses that rarely occur intra-abdominally and rarely reach larger diameters. When present, they occur as rare solitary nerve sheath tumors of peri-neural Schwann cells. Schwannoma mostly affects the nerves of the extremities, trunk, or the head and neck region. They are more common in female patients, mostly among patients between the third and fifth decade. They occur spontaneously but could also be found in association with a group of genetic autosomal dominant disorders called type 2. When present intra-abdominally, schwannomas grow slowly without significant clinical signs and symptoms. Clinical importance is presented in cases of occupying intra-abdominal space and impingement of surrounding structures, which causes intermittent pain. Only 0.5–5% of all retroperitoneal tumors are schwannomas and their malignant transformation is very rare. Case report: The authors present a case of a large intra-abdominal schwannoma in a 70-year-old female patient. She underwent CT scanning due to refractory left-sided subcostal pain, which revealed a large tumor mass in the left-sided hemiabdomen. Preoperative cytologic biopsy confirmed Sch. The patient underwent an MRI scan upon admission to our department, which revealed the origin of the tumor at the left-sided L3 level and intra-abdominal tumor spreading with the largest diameter of 25 cm. The patient underwent multidisciplinary surgical excision, confirmed by MRI scan in a period of five months postoperatively. Conclusions: Its rare presentation leads to the necessity to adequately evaluate such patients, especially to avoid any hidden diagnosis which might lead to further complications. The goal of a multidisciplinary approach should be emphasized as maintaining a good postsurgical condition without neurological deficits. [ABSTRACT FROM AUTHOR]

One-third of cancer pain patients do not experience adequate pain relief using analgesic ladder by the World Health Organization. Interventional procedures, such as epidural morphine, have been considered. This study aimed to review the literature comparing the effects of epidural administration of morphine with the oral route. This systematic review included randomized controlled trials (RCTs) conducted with patients with gastrointestinal neoplasm. A search was conducted on PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and CINAHL databases to identify studies published up to May 2023. The retrieved study was evaluated using the Risk of Bias 2 (RoB 2) tool and qualitatively synthesized. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Prospero: CRD42021264728). Only one RCT, a crossover trial, was included in this systematic review. The study was conducted with ten participants (one withdrawal) and reported a statistically significant difference between both subcutaneous and epidural morphine solutions and oral morphine. The adverse events were not described. The included study presents some concerns of bias and low certainty of evidence on the effectiveness and security of epidural morphine administration. The available literature does not suffice to elucidate whether morphine administration via the epidural route is more effective than other routes. Further RCTs are necessary to improve the level of evidence on the effectiveness and risk-benefit of epidural morphine in the management of cancer pain in gastrointestinal neoplasm patients. [ABSTRACT FROM AUTHOR]

Background. Teratomas are neoplasms that arise from pluripotent germ cells, derived from two or more layers of germ cells. They are classified as mature tumors (cystic or solid), which contain well-differentiated tissues, or as immature tumors, which contain immature and embryonic structures. Its most frequent location is the female and male gonads; the mesenteric location is rare and approximately 40 cases have been described in the world literature. Within the diagnostic and therapeutic approach, computed tomography and magnetic resonance imaging are used to characterize the lesion, assess intra-abdominal extension and the relationship with other structures. The diagnosis must be confirmed by histopathological examination. Clinical case. A 56-year-old female patient with a history of infiltrating ductal carcinoma of the left breast in remission. In follow-up studies, incidental abdominal tomography finding of an abdominopelvic lesion dependent on the mesentery at the level of the mesogastrium, smooth contours with fat-liquid level. Extension studies with negative tumor markers. Results: Due to high clinical and imaging suspicion of teratoma, the patient was taken to resection of the lesion. Histopathological examination confirmed the diagnosis of mature cystic teratoma of the mesentery. Conclusion: Mesenteric teratoma is a rare clinical entity and is considered one of the differential diagnoses of an abdominal mass with a compressive effect. Diagnosis is mainly based on clinical examination and imaging findings. Early surgical excision is the mainstay of treatment; laparoscopic or open approach depends on the clinical characteristics and the experience of the surgeon. [ABSTRACT FROM AUTHOR]

Introduction: Schwannomas (Schs) are benign tumor masses that rarely occur intra-abdominally and rarely reach larger diameters. When present, they occur as rare solitary nerve sheath tumors of peri-neural Schwann cells. Schwannoma mostly affects the nerves of the extremities, trunk, or the head and neck region. They are more common in female patients, mostly among patients between the third and fifth decade. They occur spontaneously but could also be found in association with a group of genetic autosomal dominant disorders called type 2. When present intra-abdominally, schwannomas grow slowly without significant clinical signs and symptoms. Clinical importance is presented in cases of occupying intra-abdominal space and impingement of surrounding structures, which causes intermittent pain. Only 0.5–5% of all retroperitoneal tumors are schwannomas and their malignant transformation is very rare. Case report: The authors present a case of a large intra-abdominal schwannoma in a 70-year-old female patient. She underwent CT scanning due to refractory left-sided subcostal pain, which revealed a large tumor mass in the left-sided hemiabdomen. Preoperative cytologic biopsy confirmed Sch. The patient underwent an MRI scan upon admission to our department, which revealed the origin of the tumor at the left-sided L3 level and intra-abdominal tumor spreading with the largest diameter of 25 cm. The patient underwent multidisciplinary surgical excision, confirmed by MRI scan in a period of five months postoperatively. Conclusions: Its rare presentation leads to the necessity to adequately evaluate such patients, especially to avoid any hidden diagnosis which might lead to further complications. The goal of a multidisciplinary approach should be emphasized as maintaining a good postsurgical condition without neurological deficits.

Desmoid-type fibromatosis (DF) is a locally aggressive myofibroblastic tumor accounting for approximately 0.03% of all neoplasms and less than 3% of all soft tissue tumors.1 The estimated incidence in the general population is 2 to 4 cases per million per year. In the past, this lesion was considered as an aberrant healing response against local trauma, irritation, or inflammation; however, later a clonal proliferation of the spindle cell was confirmed, and local recurrence as well as distant metastasis was identified.2 DF affects 10%-20% of patients with familial adenomatous polyposis. Sporadic DF predominantly affects young adults, especially women, and it is often related to pregnancy.3 Although it may occur in nearly every body part, it usually involves the extremities and trunk, including the abdominal wall and intra-abdomen. Intra-abdominal desmoid tumors are mainly located within the mesentery or pelvis.4 A bulky desmoid tumor located in the pelvis or lower abdominal wall near the uterus may be preoperatively suspected as a large subserosal uterine leiomyoma. Genetic alterations in theAPCandCTNNB1genes are thought to be vital events resulting in hereditary and sporadic DF. Sporadic DF is associated with a high incidence (85%) of mutations in theCTNNB1gene, which may lead to uninhibited activation of the Wnt pathway and the accumulation of excessive cytoplasmic β-catenin, ultimately resulting in tumor development.5 The early diagnosis of DF is challenging. The findings of computed tomography (CT) and magnetic resonance imaging (MRI) can guide the decisions regarding patient management, but the ultrasound features of DF are non-specific. The relationship between the tumor and the adjacent structures should be carefully evaluated to decide the feasibility of surgery.6 Complete surgical resection is usually the standard treatment in patients with resectable desmoid tumors. However, the local recurrence rate is still high after resection alone due to its infiltrative pattern and positive margins after surgical resection.7 Radiotherapy is another treatment modality for desmoid tumors, but its efficiency is controversial. Recently published meta-analysis and the review suggested the benefit of postoperative radiotherapy over surgery alone in long-term cure and prevention of recurrence.8 Low-dose chemotherapy or systemic therapy (such as hormonal therapy, non-steroidal anti-inflammatory therapy, or targeted therapy) in patients with advanced unresectable tumors or recurrent disease after surgery and/ or radiotherapy is also used.9 A 24-year-old lady presented with gradually progressive pain in the whole abdomen for six months. She had a prior history of lower uterine cesarean section done 3 years back and a history of missed abortion 4 years back. On per-abdominal examination, a 10x8 cm large mass was palpated mainly in the right lower abdomen, with side-to-side mobility. The speculum examination showed a smooth cervix. Per-vaginal examination revealed a large mass felt through the right fornix. Abdominal computed tomography showed bilateral normal ovaries and a large heterogeneous mass measuring 11x9 cm close to the uterus. A possibility of pedunculated subserosal leiomyoma was considered. Given progressive clinical symptoms, laparotomy was performed. On per-operative examination, a large mass was identified as closely adhered to the mesentery of the right colon. The uterus and bilateral adnexa were free of tumor. The tumor was excised in toto with the right colon. Gross examination revealed a rounded mass of size 11x9 cm with a smooth outer surface. The tumor was densely adhered to the cecum and appendix and had engulfed the appendix (Figure 1A). The cut surface shows a solid, whitish, firm lesion with prominent trabeculations (Figure 1B). Figure 1 A - Gross view of the giant globular tumor with a smooth surface and closely adhered to the right colon and appendix;the white arrowhead points towards the tip of the adhered appendix (scale bar= 5 cm); B - Cut surface of the tumor shows a solid, well-circumscribed whitish tumor with areas of trabeculations (scale bar= 5 cm); C - Photomicrograph shows a low-grade spindle cell mesenchymal tumor of low cellularity densely adhered to the serosal surface of the appendix with infiltration of muscularis of the appendix (H&E,40x); D - Photomicrograph shows spindle cell tumor with bland elongated nuclei and moderate cytoplasm disposed over a hyalinized and myxoid stroma interspersed with thin-walled vessels. (H&E, 100x); E - Photomicrograph shows tumor cells positive for smooth muscle actin (SMA) immunohistochemistry (100x); F - Photomicrograph shows tumor cells with nuclear localization of beta-catenin (100x).: Microscopic examination revealed a mesenchymal tumor with low cellularity, composed of bland spindled cells over a densely collagenized matrix interspersed with thin vascular channels (Figure 1D). Mitosis, necrosis, and significant atypia were absent. The tumor was adhered within the serosal surface of the appendix and colon and also showed infiltration of the retroperitoneal skeletal muscle fibers (Figure 1C). On IHC, the tumor cells were positive for Vimentin, Smooth muscle actin (SMA) and showed nuclear localization of beta-catenin with cyclinD1 (Figures 1E and 1F). IHC for h-caldesmon, S-100, CD117, DOG-1, myogenin, ALK, and STAT-6 were negative, ruling out other differential diagnoses, including leiomyoma, nerve sheath tumor, gastrointestinal stromal tumor, spindle cell rhabdomyosarcoma, inflammatory myofibroblastic tumor, and solitary fibrous tumor. Ki-67 labeling was ~2-3%. The DF diagnosis was rendered based on the histology and IHC features. Our patient was advised postoperative close follow-up with clinical and imaging modalities at regular intervals. In summary, awareness about this rare tumor in intra-abdominal locations in young female patients with a prior history of childbirth and surgery and its possible clinical and imaging overlap with leiomyoma prevents aggressive treatment in DF patients. A pre-operative biopsy can confirm the diagnosis. However, in symptomatic patients, surgery is the mainstay of therapy. A search for possible CTNNB1 and APC gene mutation is vital.

Purpose: Robotic assistance is rapidly evolving and may help physicians optimize needle guidance during percutaneous interventions. The purpose of the study was to report feasibility, safety, accuracy, immediate clinical success and short-term local tumor control after robotic-assisted computed tomography (CT)-guided thermal ablation of abdominal tumors., Materials and Methods: Forty-one patients who underwent percutaneous thermal ablation of abdominal tumors using robotic-assisted CT-guided were included. All ablations were performed with robotic assistance, using an optically-monitored robotic system with a needle guide sent to preplanned trajectories defined on three-dimensional-volumetric CT acquisitions with respiration monitoring. Endpoints were technical success, safety, distance from needle tip to planned trajectory and number of needle adjustments, and complete ablation rate., Results: Forty-one patients (31 men; mean age, 66.7 ± 9.9 [standard deviation (SD)] years [age range: 41-84 years]) were treated for 48 abdominal tumors, with 79 planned needles. Lesions treated were located in the liver (23/41; 56%), kidney (14/41;34%), adrenal gland (3/41; 7%) or retroperitoneum (1/41; 2%). Technical success was achieved in 39/41 (95%) patients, and 76/79 (96%) needle insertions. The mean lateral distance between the needle tip and planned trajectory was 3.2 ± 4.5 (SD) mm (range: 0-20 mm) before adjustments, and the mean three-dimensional distance was 1.6 ± 2.6 (SD) mm (range: 0-13 mm) after 29 manual depth adjustments (29/78; 37%) and 33 lateral adjustments (33/78; 42%). Two (2/79; 3%) needles required complete manual reinsertion. One grade 3 complication was reported in one patient (1/41; 2%). The overall clinical success rate was 100%. The 3-month local tumor control rate (progression free survival) was 95% (38/41)., Conclusion: These results provide further evidence on the use of robotic-assisted needle insertion regarding feasibility, safety, and accuracy, resulting in effective percutaneous thermal ablation of abdominal tumors., Competing Interests: Declaration of competing interest The authors declare there is no conflict of interests., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Competing Interests: Competing interests: None declared.

Competing Interests: Conflict of interest: None

We present a case of an extremely rare type of soft-tissue sarcoma with an atypical clinical presentation. The patient, a female in her 20s with Li Fraumeni syndrome, had prior surgery for a large intra-abdominal tumour that was given the diagnosis of malignant myxoid spindle cell neoplasm. Her recurrence manifested as diffuse intra-abdominal sarcomatosis for which she ultimately underwent subtotal debulking with palliative intent. Final pathology rendered the diagnosis of myxoid pleomorphic liposarcoma, a newly described entity, distinct from the more common liposarcoma subtypes. The optimal treatment for this typically aggressive disease is currently unknown; until that is better defined, management should be carried out by sarcoma specialists., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Splanchnic nerve neurolysis (SNN) shows beneficial effects in reducing malignancy-associated refractory abdominal pain. Using adjuvants, such as dexmedetomidine to improve the pain was studied., Objective: To detect any role of dexmedetomidine as an additive to local anesthetics with an alcohol injection in the chemical SNN process to improve pain in patients having upper-abdominal cancer., Study Design: Double-blinded, prospective randomized study., Setting: Department of Anesthesia and Intensive Care, faculty of medicine, Minia University,Egypt., Methods: Forty patients with upper-abdominal malignancy-associated refractory abdominal pain underwent fluoroscopic guided SNN were divided into 2 groups. The SNN was performed by using 1.5 mL lidocaine 1%, dexmedetomidine 2 μg/kg, and then an injection of 4.5 mL of ethanol 96% on each side in group D and without dexmedetomidine in group C is done. Patients gave the score of abdominal pain expressed by the Visual Analog Scale (VAS), which measures the pain intensity. Scors were recorded prior to injection, during injection, after injection by 5 min, and after 2, 6, 12, 24, 72 hours, one week (W), 2 W, one month (M), and 2 M. Also, we recorded the amount of morphine required to relieve the residual pain after injection, the effect of procedure on quality of life (QOL), and any complication after injection., Results: VAS scores showed a significant increase in group C in comparison to group D during injection, after injection by 5 min, 2, 6, 12, 24 hours, one and 2 months (P < 0.0001, 0.0001, 0.029, 0.031, 0.025, 0.040, 0.020, 0.015), respectively. The morphine requirement was significantly increased at one W, one M, and 2 M in group C in comparison to Group D (P < 0.044, 0.017, 0.033) with no significant change in the QOL observed between groups., Limitations: The limitations of this study were a relatively small sample size and short period of follow-up., Conclusions: This study revealed that using dexmedetomidine in the chemical SNN process improves the pain results from injection of alcohol and refractory cancer related pain with reduction in the consumption of morphine in patients with upper-abdominal malignancy.