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    • Complete surgical excision is sufficient for mature and

    2018-10-22

    Complete surgical excision is sufficient for mature and Grade 1 immature teratomas. Optimal treatment by complete resection followed by close observation and follow-up, withholding chemotherapy until there is an evidence of disease recurrence, is recommended for Grade 2 and 3 immature teratomas. This principle is generally followed for all extragonadal immature teratomas. In a case where the alpha-fetoprotein level starts rising after a few months of complete excision of the teratoma, chemotherapy is administered. The prognosis following complete surgical excision of a gastric teratoma, both mature and immature types, has been shown to be excellent. It holds good, even if there is extension to adjacent organs. kras-pdeδ pathway of tumor offers recurrence-free survival without requiring chemotherapy or radiotherapy. One case of recurrence has been reported in the literature.
    Conclusion
    Acknowledgments
    Introduction Tuberculosis (TB), a re-emerging disease, is a cause of growing worldwide concern because of its increased unusual presentations. Primary hepatic tuberculoma is rare in healthy immunocompetent patients. Most hepatic involvement in TB is considered secondary because of its association with miliary TB. The macronodular form of hepatic TB was first reported in 1858 by Bristowe. Primary hepatic TB results from tubercular bacilli gaining access to the portal vein from a microscopic tubercular focus in the bowel with subsequent healing occurring at the site of entry and leaving no trace.
    Case Report A 56-year-old woman presented with epigastric pain and loss of weight and appetite for the preceding 3 weeks. Clinically, she was jaundiced with right upper quadrant tenderness. Initial blood investigations revealed anemia, a deranged liver profile consistent with obstructive jaundice, and elevated CA 19-9 level (562 U/mL). Carcinoembryonic antigen (CEA) level was 2.7 ng/mL. Abdominal computed tomography (CT) demonstrated an ill-defined heterogeneously enhancing mass of 3.5 cm × 4.0 cm with periportal lymphadenopathy at the hepatic hilum. Cholangiocarcinoma was diagnosed on the basis of the aforementioned history and clinical findings. Endoscopic retrograde cholangiopancreatography showed a hilar stricture (Fig. 1). Following this, the patient underwent a biliary decompression procedure. Later, she underwent a central hepatectomy. Intraoperatively, yellowish nodules on both liver lobes were observed with mesenteric and omental lymphadenopathies, which were not visualized on CT (Fig. 2). A frozen section biopsy showed predominantly lymphoplasmacytic inflammatory infiltrates, multiple granuloma with central necrosis, and multinucleated Langhans-type giant cells suggestive of TB. In addition, a complete histopathological examination confirmed the aforementioned findings (Fig. 3). In subsequent testing, the patient was nonreactive for human immunodeficiency virus, hepatitis B, hepatitis C, and acid-fast bacilli. In addition, thoracic CT scan showed no evidence of pulmonary TB. The patient was placed on antitubercular therapy, and her condition improved. A CT scan 6 months later demonstrated that the size of the lesions was reduced when compared with the size of lesions observed at presentation (Figs. 4 and 5).
    Discussion Approximately one-third of the world\'s population is latently infected with Mycobacterium TB, with 2 million deaths reported annually, predominantly in developing countries. In addition, TB remains the leading cause of death among AIDS patients. Levin classified hepatic TB as miliary TB, pulmonary TB with hepatic involvement, primary hepatic TB, focal tuberculoma or abscess or tuberculous cholangitis. Approximately 80% of hepatic TB are of the miliary form. Isolated primary hepatic TB is rare because of the low oxygen tension within the liver, making it unfavorable for mycobacterial growth. The presence of a deranged hepatic function, hypoalbuminemia, anemia, and hyponatremia are not specific to TB. The sensitivity of serology for acid-fast staining bacilli and blood cultures is as low as 0–45% and 10–60%, respectively. Tuberculin skin test is typically positive and when used in combination with polymerase chain reaction, which has a sensitivity and specificity of 58% and 96%, respectively, improves detection rates. However, these specific tests can be requested only if there is clinical suspicion.