The incidence and outcome of incidental breast lesions detected by computed tomography

INTRODUCTION

In the UK, the majority of breast cancers are diagnosed through symptomatic breast clinics and the breast screening programmes. With increased use of computed tomography (CT) to assess various pathologies, breast lesions are picked up incidentally. The aim of this study was to investigate the incidence and outcomes of breast lesions detected incidentally on CT scans.

PATIENTS AND METHODS

A retrospective study was conducted to assess the incidence and outcome of incidentally found breast lesions, which were detected on chest CT scans that were conducted for other pathologies during the period from February 2007 to October 2008.

RESULTS

A total of 432 chest CT scans were performed over 18 months. Thirty-three (7.63%) patients were found to have an incidental breast lesion. The mean age was 73 years (range, 50-86 years). Of these, 17 (52%) were benign, eight (24%) were primary breast cancer and the remaining eight (24%) had no definite pathology. The detection rate of breast cancer was 1.85%.

CONCLUSIONS

CT is emerging as an important contributor to the detection of occult breast lesions. Radiological awareness of incidental breast lesions is important so that appropriate referral to a specialised breast unit is made.

Non-diabetic macrosomia: an obstetric dilemma

Fetal macrosomia represents a continuing challenge in obstetrics, as it has risk of shoulder dystocia leading to transient or permanent fetal, maternal injury and medicolegal liability. The overall incidence of macrosomia has been rising. Non-diabetic macrosomia is still an obstetric dilemma, as there is no clear consensus regarding its ante-partum prediction and management, as accurate diagnosis is only made retrospectively. The risk of shoulder dystocia rises from 1.4% for all vaginal deliveries to 9.2-24% for birth weights more than 4,500 g. Unfortunately, 50% of all cases of shoulder dystocia occur at birth weights of less than 4,000 g. Brachial plexus injury occurs in 1:1,000 births and permanent damage in 1:10,000 deliveries (12% of all) leading to litigation 1:45,000 deliveries. The prenatal diagnosis of macrosomia remains imprecise. Pre-pregnancy and ante-partum risk factors and ultrasound have poor predictive value. Induction of labour and prophylactic caesarean delivery has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. Caesarean section and induction of labour are associated with increased risk of operative morbidity and mortality with added cost implications.

Coping with placenta praevia and accreta in a DGH setting and words of caution

The incidence of placenta praevia and accreta has been increasing with rising caesarean section rates. We highlight the increasing incidence of severe post-partum haemorrhage due to placenta accreta. Four cases occurred within 3 years (2002--2004) in a small District General Hospital (DGH) with a delivery rate of 1,800 per year. All of the cases had previous caesarean sections and three had an associated anterior low-lying placenta. These patients were diagnosed to have placenta accreta in the third stage of labour, as the placenta was completely adherent and was difficult to remove. However, two of them had a provisional diagnosis made of placenta accreta and prophylactic measures had been taken in the form of counselling and consent for possible hysterectomy. Patients were counselled regarding this condition, and the possible need for hysterectomy was discussed. Two of them had to be managed by post-partum hysterectomy and the other two were treated conservatively. The purpose of writing these case reports is to warn others of the need for vigilance, particularly in keeping their primary caesarean section rates down and being prepared for long-term complications.

A comparative study for the detection of Mycobacteria by BACTEC MGIT 960, Lowenstein Jensen media and direct AFB smear examination

PURPOSE

To compare BACTEC MGIT 960 (M960) with conventional culture on Lowenstein Jensen (LJ) media and direct acid fast bacilli (AFB) smear examination for the detection of Mycobacteria in clinical samples obtained from suspected cases of pulmonary and extra pulmonary tuberculosis (TB).

METHODS

A total of 500 samples were processed for direct AFB smear examination, and culture on M960 and LJ media.

RESULTS

Two hundred fifty-eight out of 500 (51.6%) isolates of Mycobacteria were obtained by combined use of the two culture methods. Two hundred and fifty-three (50.6%) were positive in culture by M960 and LJ media and 28% (140/500) by direct AFB smear examination. The positivity rate of M960 system alone was 34.10% (88/258) and of LJ alone was 1.93% (5/258). Average time to detect growth (TTD) was 9.66 days by M960 and 28.81 days by LJ.

CONCLUSIONS

M960 system is a rapid and sensitive method for early diagnosis of pulmonary and extrapulmonary TB. But for maximum recovery of Mycobacteria , a combination of both M960 and LJ media should be used.

Premature ovarian failure

Premature ovarian failure (POF) is gonadal failure before the age of 40 years. Several rare causes have been discovered yet we still fail to identify the cause in many cases. Although it was once thought to be a permanent condition, a substantial number of patients experience spontaneous remissions and even pregnancy. HRT remains the cornerstone of treatment and the only proven method of achieving pregnancy in these patients is by ovum donation. New alternatives to HRT and fertility preservation are under development. Basic understanding of ovarian physiology and pathogenesis of POF is necessary for the development of newer therapies.

The major histocompatibility complex haplotypes dictate and the background genes fine-tune the dominant versus the cryptic response profile of a T-cell determinant within a native antigen: relevance to disease susceptibility and vaccination

The immune system of a healthy individual responds vigorously to foreign microbial antigens. However, all potentially immunogenic regions (determinants) within an antigen are not functionally of equal relevance in mediating host immunity against the pathogen. Moreover, some of these antigenic determinants are well processed and presented (immunodominant), while others are not revealed (cryptic) from the native antigen. Nevertheless, cryptic determinants are good immunogens in the pre-processed peptide form. Defining the factors influencing the dominance versus the crypticity of antigenic determinants is critical to advancing our understanding of the individual variations in host immunity to infection, autoantigens and vaccination. In this study based on a model antigen, hen eggwhite lysozyme (HEL), we describe that the major histocompatibility complex (MHC) haplotypes imprint and the non-MHC genes modify the dominance versus the crypticity of a specific antigenic determinant. Both the H-2(q)- and the H-2(d)-bearing mice raised potent response to native HEL, but responded differently to its determinant region 57-78, which was dominant in the H-2(q) but cryptic in the H-2(d) mice. The H-2(q)- but not the H-2(d)-bearing mice of three different genetic backgrounds yielded patterns of graded reactivity to epitope 57-78 showing the fine-tuning effect of the non-MHC genes. Interestingly, the F1 (H-2(q) x H-2(d)) mice retained the dominant response profile of the H-2(q) parent regardless of the contributing gender, and also responded to a new sub-determinant 61-75. These results highlight the genetic factors influencing the dominance/crypticity of a specific antigenic determinant.

Inadvertent parathyroid excision during thyroid surgery

BACKGROUND

Thyroidectomy is a commonly performed operation for the treatment of thyroid disease. Inadvertent removal of parathyroid glands is a recognised complication of this operation and may have consequences on the longterm regulation of calcium homeostasis post-operatively. We aimed to establish the incidence of parathyroid gland excision during surgery for thyroid disease and whether there was an effect on calcium control in patients in whom inadvertent parathyroidectomy had occurred.

METHODS

A retrospective review of thyroid operations at our hospital from 2001 to 2004 was carried out, reviewing pathology reports to identify specimens which included parathyroid tissue. Post-operative calcium levels were reviewed in these patients.

RESULTS

Over three years, 126 thyroid operations were performed; 96 total thyroid lobectomies and 30 total thyroidectomies. Of these, 12 (10%) were performed for malignant disease. Parathyroid tissue was removed inadvertently in 5 of 30 thyroidectomies (16.7%) and 17 of 96 total thyroid lobectomies (17.7%) or 17.4% of all thyroid operations during this time. None of the patients in whom a parathyroid gland was removed inadvertently became hypocalcaemic post-operatively and all of these patients were normocalcaemic when followed-up at six weeks.

CONCLUSIONS

In specialist hands there is a risk of removing a single parathyroid gland of approximately 17% during thyroid surgery. However, this does not appear to carry a risk of causing hypocalcaemia post-operatively. Careful capsular dissection will reduce the incidence of removing more than one gland

Day-case breast cancer axillary surgery

INTRODUCTION

The standard locoregional management of breast cancer is excision of the primary tumour and axillary staging with suction drainage of the axilla. The objective of this study was to determine the safety, tolerability and efficacy of day-case surgery without suction drainage.

PATIENTS AND METHODS

A review of complete, prospectively collected data was performed on all breast cancer patients (screening and symptomatic) planned to undergo day-case axillary surgery at a University Teaching Hospital between 2000 and 2002. Postoperative complications were recorded and the notes of patients not discharged on the day of their surgery were also examined to establish the reason for overnight stay.

RESULTS

165 patients underwent intended day-case axillary surgery (axillary dissection level 1/2; median age, 55 years; range, 39-76 years). Of these, 16 (9.7%) were admitted overnight usually due to over-running of theatre lists (n = 13; 81%). 29 patients (17.6%) underwent axillary dissection alone, the remainder had axillary surgery combined with wide local excision (median number of lymph nodes excised 11; range, 2-18). Complications included symptomatic seroma formation in 37 patients (22%) and wound infection in 16 patients (10%).

CONCLUSIONS

Day-case axillary surgery can be performed safely with surgical morbidity comparing favourably to published work of 'traditional' axillary drainage following lymphadenectomy.