Preventative strategies for low anterior resection syndrome

BACKGROUND

A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly understood and challenging to treat. Despite this, prevention strategies are commonly overlooked. Our aim was to review the pathophysiology of LARS and explore current evidence on the efficacy and feasibility of prophylactic techniques.

METHODS

A literature review was performed between [1st January 2000 to 1st October 2023] for studies which investigated preventative interventions for LARS. Mechanisms by which LARS develop are described, followed by a review of prophylactic strategies to prevent LARS. Medline, Cochrane, and PubMed databases were searched, 189 articles screened, 8 duplicates removed and 18 studies reviewed.

RESULTS

Colonic dysmotility, anal sphincter dysfunction and neorectal dysfunction all contribute to the development of LARS, with the complex mechanism of defecation interrupted by surgery. Transanal irrigation (TAI) and pelvic floor rehabilitation (PFR) have shown benefits in preventing LARS, but may be limited by patient compliance. Intraoperative nerve monitoring (IONM) and robotic-assisted surgery have shown some promise in surgically preventing LARS. Nerve stimulation and other novel strategies currently used in treatment of LARS have yet to be investigated in their roles prophylactically.

CONCLUSIONS

To date, there is a limited evidence base for all preventative strategies including IONM, RAS, PFP and TAI. These strategies are limited by either access (IONM, RAS and PFP) or acceptability (PFP and TAI), which are both key to the success of any intervention. The results of ongoing trials will serve to assess acceptability, while technological advancement may improve access to some of the aforementioned strategies.

Variations in the definition and perceived importance of positive resection margins in patients with colorectal cancer - an EYSAC international survey

INTRODUCTION

Microscopically positive resection margins (R1) are associated with poorer outcomes in patients with colorectal cancer. However, different definitions of R1 margins exist. It is unclear to what extent the definitions used in everyday clinical practice differ within and between nations. This study sought to investigate variations in the definition of R1 margins in colorectal cancer and the importance of margin status in clinical decision-making.

MATERIALS AND METHODS

A 14-point survey was developed by members of The European Society of Surgical Oncology (ESSO) Youngs Surgeons and Alumni Club (EYSAC) Research Academy targeting all members of the multidisciplinary team (MDT) treating patients with colorectal cancer. The survey was distributed on social media, in ESSO's monthly newsletter and via national societies.

RESULTS

In total, 137 responses were received. Most respondents were from Europe (89.7%), with the majority from Denmark (56.9%). Less than 2/3 of respondents defined R1 margins as the presence of viable cancer cells ≤1 mm of the margin. Only 60% reported that subdivisions of R1 margins (primary tumour vs tumour deposit vs metastatic lymph node) are routinely available. More than 20% of respondents reported that pathology reports are not routinely reviewed at MDT meetings. Less than half of respondents considered margin status in decision-making for type and duration of adjuvant chemotherapy in Stage III colon cancer.

CONCLUSION

The definitions and perceived clinical importance of microscopically positive margins in patients with colorectal cancer appear to vary. Adoption of an international dataset for pathology reporting may help to standardise current practices.

SP2.1.11Real-world use of workplace-based assessments in surgical training: a UK nationwide exploration of trainee perspectives and consensus recommendations from the Association of Surgeons in Training

Background

The utility of Workplace-Based Assessments (WBAs) in surgical training depends on the way they are completed. This study aims to ascertain the real-world usage of WBAs, as perceived by UK surgical trainees.

Methods

An anonymous national online questionnaire was conducted via the Association of Surgeons in Training (ASiT). The evaluation employed mixed methods to interpret quantitative and qualitative data. Suggestions for improvement were identified from free-text comments and considered through a formal two-round modified Delphi consensus process by ASiT council members.

Results

Analysis included 906 complete responses from all surgical specialities across all training levels. WBA use was perceived to deviate markedly from the Joint Committee on Surgical Training standards with significantly identified misuse across all surgical specialities. Inaccurate completion was acknowledged by 89.6% of respondents, and some trainers appear complicit with 40.9% of respondents aware of 'unobserved sign-off', and 33.6% aware of 'password disclosure' by trainers.

Most trainees felt the Annual Review of Competency Progression (ARCP) respected WBA quantity above quality (55.4%), and a third felt pressure to overstate the number completed (32.0%). Main reasons for misuse were time restraints, lack of engagement and the will to achieve career progression targets.

Conclusions

UK surgical trainees perceive a significant deviation from WBAs standards due to multiple factors. The frequency and nature of misuse are worrying and undermines the existing evidence for the WBAs role in training. We present consensus recommendations from ASiT for the improvement of WBA use in UK surgical training.

935 Identification and Management of Electrolyte Abnormalities in Surgical Patients Requiring Total Parenteral Nutrition: An Audit of Current Practice at A University Hospital

Aim

Electrolyte abnormalities are a common and serious consequence of nutritional deficiencies when patients are nil-by-mouth. Timely intervention with a multidisciplinary approach is known to improve outcome. This audit aimed to assess adequacy of initial electrolyte management and timing of dietetics referral in acute surgical patients requiring total parenteral nutrition in a university hospital.

Method

A retrospective audit of all general surgery patients referred to dietetics for total parenteral nutrition between January-December 2019 was performed. The following audit standards (from the time following admission) were applied: monitoring of electrolytes every 48-hours, treatment of electrolyte abnormalities within 24-hours of discovery; and referral to the dietetics service within 48-hours of nil-by-mouth being commenced.

Results

Data from 52 patients (27 females, median age 66) were analysed. Fifty-one (98%) had electrolytes measured every 48-hours, however magnesium, phosphate and/or calcium were not measured prior to dietetics input in 9 (17%). Forty electrolyte abnormalities requiring treatment were found in 28 patients (54%), though only 18 (64%) commenced treatment within 24-hours. The most common electrolyte abnormalities not corrected within 24-hours were phosphate and calcium (50%). 46% of patients were referred to dietetics after 48-hours of nil-by-mouth status.

Conclusions

In our unit, we found that basic electrolytes were frequently monitored in patients placed nil-by-mouth, however calcium, phosphate and magnesium were often omitted prior to dietetics input, and correction of abnormalities was sometimes delayed. Introduction of a local protocol-based approach for electrolyte monitoring with streamlined dietetics referrals is likely to improve adherence to best practice.

Evaluation of DNA ploidy and S-phase fraction in fine needle aspirates from breast carcinoma

BACKGROUND

The use of fine-needle aspiration (FNA) as a primary tool in the diagnosis of breast carcinoma provides opportunity for early proliferative characterization of the tumor. This study was undertaken to assess DNA ploidy and S-phase (SPF) fraction by flow cytometry in fine needle aspirates of patients with breast cancer.

METHOD

Fifty patients of breast cancer diagnosed on fine needle aspiration cytology (FNAC) and who subsequently underwent either mastectomy or lumpectomy were included. Material obtained by FNAC was subjected to DNA ploidy and SPF analysis. Immunohistochemical estimation of Ki-67 was done on histopathology sections. The proliferation markers (SPF and Ki-67) were compared with each other and with the histopathologic parameters.

RESULTS

On DNA flow cytometry, 27 (54%) cases were aneuploid and 23 (46%) cases were diploid. The median SPF was 12.43% and 4.03% in aneuploid and diploid tumors respectively. Median Ki-67 among aneuploid tumors was 28.6% compared to 8.7% among diploid tumors. Aneuploid tumors were significantly associated with higher values of SPF and Ki-67, with Kappa 0.437 and agreement of 72%. Diploid tumors showed lower values of SPF and Ki-67, with Kappa 0.455 and agreement of 72.7%. Correlation among SPF and Ki-67 was highly significant with Kappa value 0.446, P value of .002 and agreement of 72.3%.

CONCLUSION

DNA ploidy and proliferative activity by flow cytometric SPF estimation on fine needle aspirates from breast cancer can provide valuable prognostic and predictive information at the time of diagnosis in patients with breast cancer. This might help in selection of appropriate treatment modality.

Prostaglandin E2 receptors and their role in gastrointestinal motility - Potential therapeutic targets

Prostaglandin E₂ (PGE₂) is found throughout the gastrointestinal tract in a diverse variety of functions and roles. The recent discovery of four PGE₂ receptor subtypes in intestinal muscle layers as well as in the enteric plexus has led to much interest in the study of their roles in gut motility. Gut dysmotility has been implicated in functional disease processes including irritable bowel syndrome (IBS) and slow transit constipation, and lubiprostone, a PGE₂ derivative, has recently been licensed to treat both conditions. The diversity of actions of PGE₂ in the intestinal tract is attributed to its differing effects on its downstream receptor types, as well as their varied distribution in the gut, in both health and disease. This review aims to identify the role and distribution of PGE₂ receptors in the intestinal tract, and aims to elucidate their distinct role in gut motor function, with a specific focus on functional intestinal pathologies.

Clinico-pathological spectrum of cutaneous sarcoidosis: an experience from a government institute in North India

Background and aims

Sarcoidosis is a multisystem granulomatous disease of unknown etiology and cutaneous involvement is the second most frequent manifestation in systemic sarcoidosis.

The aim of the present study is to evaluate the clinical and pathological spectrum of cutaneous sarcoidosis and compare the same with literature available.

Methods

The present retrospective study was conducted from January 2010–March 2015 and fifteen cases diagnosed as cutaneous sarcoidosis on biopsy were reviewed. The histological spectrum of cutaneous sarcoidosis was evaluated.

Results

The mean age at diagnosis was 46 years. Nine (60%) cases out of 15 were females. Most common cutaneous lesions were nodules (46.6%) followed by papules (40%). Classically, lymphocyte-poor, non-caseating epithelioid cell granulomas, was the most common histologic finding. Inclusion bodies were seen in 20% cases with occasional presence of fibrinoid necrosis (13.3%). Peri-adnexal granuloma, seen in one case, raised the possibility of tuberculoid leprosy. Foreign body was seen in one case supporting the opinion that sarcoidosis and granulomatous foreign body reaction are not mutually exclusive. Epidermal changes including atrophy, loss of rete pegs, acanthosis, papillomatosis, hyperkeratosis, parakeratosis and basal cell vacuolation were seen in 46.6% cases. Reticulin was positive in all the cases while special stains for acid fast bacilli and fungi were negative.

Conclusion

The clinical presentation of cutaneous sarcoidosis may be variable. Presence of naked, reticulin-rich granulomas is the most characteristic histopathological finding. Correlation of clinical history with histologic examination is essential to exclude other granulomatous diseases including leprosy, syphilis, other infectious granulomatous diseases and foreign body reaction.

Use of the eLogbook in surgical training in the United Kingdom: A nationwide survey and consensus recommendations from the Association of Surgeons in Training

INTRODUCTION

Accurate recording of operative cases is essential during training to demonstrate experience. However, indicative numbers delineating minimum desirable experience may incentivise exaggeration or misrepresentation of experience. This study aimed to determine perceptions of real-world eLogbook use among UK surgeons in training.

MATERIAL AND METHODS

An anonymous online questionnaire was disseminated electronically using a pre-planned yield-maximisation strategy, incorporating regional champions, email and social media. Evaluation employed mixed methods in a combined interpretation of quantitative and qualitative data from the questionnaire. Recommendations for development of the eLogbook were itemised from respondents' free text items and a modified Delphi process, conducted within the Council of the UK national trainee representative body, the Association of Surgeons in Training, determined the strength of each recommendation.

RESULTS

Analysis included 906 complete responses from training-grade surgeons (34.8% female) from all UK recognised specialties and all grades of training. More than two-thirds (68.5%) believed that overstatement or misrepresentation of case involvement occurs. A fifth (20.8%) reported witnessing trainees logging cases they had not actually participated in and almost a third (32.7%) had witnessed overstatement, yet few (15.1%) had raised such an issue with a supervisor. Most (85.2%) respondents had few or no eLogbook entries validated. More than a quarter of respondents felt pressure to overstate their involvement in cases (28.6%) and the number recorded (28.1%). Almost a third (31.5%) felt the required case number for completion of training was not achievable. Female trainees were less likely to feel well supervised (p = 0.022) and to perceive targets for completion of training were achievable (p = 0.005). Thematic analysis identified four key themes to explain logbook misuse: Pressure to achieve training milestones; eLogbook functionality issues; training deficiencies and probity.

CONCLUSIONS

Inaccurate operative recording was widely reported, primarily in response to perceived pressure to achieve targets for career progression. Operative logbooks may not be as accurate as intended. Consensus recommendations are made for improvement in the eLogbook and its use.

Attracting medical students and doctors into surgical training in the UK and Ireland

AIMS

Core surgical training (CST) programmes in the UK have seen a significant reduction in competition ratios over the past five years. This study aimed to determine motivating factors and perceived barriers to pursuing a career in surgery amongst junior doctors in training and medical students attending an annual conference.

METHODS

A self-reported, electronic questionnaire was distributed to medical students, foundation year doctors, and doctors in postgraduate surgical training programmes (DIPST) who attended the Association of Surgeons in Training (ASiT) Conference in 2016. Respondents ranked factors attracting them to a career in surgery and factors that could improve perceptions of surgical careers. Chi-square test was used to test for differences between groups (a = 0.05, R Studio, V3.3.1).

RESULTS

Of 394 respondents (response rate = 50.9%), 44.9% were medical students or foundation doctors ('Pre-CST') and 55.1% were DIPST ('Peri/post-CST'). Practical application of skills (97.4%), enjoyment of the theatre environment (95.4%) and positive experiences in surgical firms (84.7%) were primary driving factors towards a surgical career. Availability of private practice (32.2%), and sustainability of consultant jobs (49.0%) had less influence. For 'Pre-CST' respondents, role models (82.8% pre-CST v 74.9% peri-post CST, p < 0.05) and defined career progression (67.2% pre-CST v 47.0% peri-post CST, p < 0.001) were particularly important. 91% of all respondents agreed that a better balance of training and service within worked hours would improve perceptions of surgery.

CONCLUSION

Addressing the motivating factors and perceived barriers to surgical careers will help bolster recruitment of the future surgical workforce.

Diagnostic Utility of Endometrial Aspiration Cytology in Women with Abnormal Uterine Bleeding

Context

Abnormal uterine bleeding (AUB) is a common problem for which women seek gynecological consultation. Endometrial aspiration cytology (EAC) has emerged as a minimally invasive and cost-effective diagnostic procedure for screening the endometrial status of these patients that can aid in diagnosis in high-burden and resource-limited settings.

Aims

The study was conducted to evaluate the utility of EAC in women with AUB, and the cytological diagnosis was compared with the histopathology.

Materials and Methods

A total of 100 patients presenting with AUB were subjected to EAC using a 4-mm Karman's cannula. Later, they also underwent endometrial dilation and curettage. The cytology smears were evaluated for architectural and cytomorphological features. The cytological diagnoses henceforth made were compared with the histopathological diagnosis to calculate sensitivity, specificity, and diagnostic accuracy of EAC.

Results

EAC showed a sample adequacy of 89% viz a viz 90% for histopathology. EAC showed a sensitivity of 87.5% and 100% for diagnosing benign and malignant conditions, respectively. There was a good overall agreement between cytological and histopathological diagnosis (κ = 0.585).

Conclusions

EAC is an effective and minimally invasive procedure for the primary investigation of women with AUB.

Role of fine-needle aspiration cytology and core needle biopsy in diagnosing musculoskeletal neoplasms

Background:

The management of musculoskeletal neoplasms requires an accurate diagnosis, histologic type, and degree of tumor differentiation.

Aim:

The present study was undertaken to compare the accuracy of fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB) in the diagnosis of musculoskeletal tumors and further to compare the results with histopathological examination of surgical specimens. Grading of malignant tumors was also compared on these techniques.

Materials and Methods:

This prospective study was conducted on 50 patients with musculoskeletal neoplasms. Detailed history, clinical examination, and radiological investigations were undertaken. FNAC followed by CNB were performed in each case. The tumors were categorized as benign and malignant with a definitive histotype diagnosis. For malignant neoplasms, cytologic and histologic gradings were done into three grades. The sensitivity and specificity of FNAC and CNB were compared.

Results:

Of the 50 cases with musculoskeletal neoplasms, 32 (64%) were bone tumors and 18 (36%) were soft tissue tumors. The sensitivity of FNAC and CNB for categorizing bone tumors into benign and malignant was 94.7%. For soft tissue tumors, FNAC had a sensitivity of 90.9% and CNB had a sensitivity of 100%. The specificity of both the techniques, FNA and CNB for bone and soft tissue tumors was 100%. For malignant bone tumors, cytologic grade was concordant with CNB grade in 72.2% of the cases. Cytologic grade was concordant with the grade on CNB in 81.8% cases for malignant soft tissue neoplasms.

Conclusion:

FNAC and CNB alleviate the need for an open biopsy in diagnosing and grading musculoskeletal neoplasms, thus facilitating appropriate therapeutic intervention.

Fine-needle aspiration cytology of cutaneous granular cell tumor: Report of two cases with special emphasis on cytological differential diagnosis

Granular cell tumors (GCTs) are uncommon neoplasms with recently postulated origin from Schwann cell or neural crest. It can appear in different parts of the body and is most commonly found in the tongue. The cutaneous presentation is not that uncommon. Fine needle aspiration cytology (FNAC) has been suggested to be the diagnostic modality of choice. It will help to differentiate benign tumors from malignant ones and to differentiate GCT from frequent misdiagnoses such as granular histiocytic reaction, xanthogranuloma, rhabdomyoma, oncocyte rich lesions, alveolar soft part sarcoma (ASPS), epithelioid sarcoma, and carcinoma. We report two cases of GCT who presented with subcutaneous swellings in the right thigh and the left lumbar region for 24 months and 18 months, respectively. In the first case, a cytodiagnosis of chronic inflammation showing histiocytes was suggested while GCT was found in the second case. Subsequent histologic examination of the first case and immunocytochemistry in the second case gave the confirmatory diagnosis of GCT.

Langerhans cell histiocytosis in children diagnosed by fine-needle aspiration

BACKGROUND

Langerhans cell histiocytosis (LCH) is a rare intricate pediatric neoplasm with varied clinical manifestations and multiple treatment modalities.

AIM

To study the cytological features of LCH and the differential diagnoses on fine-needle aspiration (FNA).

MATERIALS AND METHODS

FNA was performed using a 23-gauge needle fitted to a 10 mL syringe mounted on syringe holder. LCH was diagnosed on FNA smears in seven cases confined to the head and neck region, which included three cases of lymphadenopathy, three cases of scalp swelling, and one case of orbital swelling.

RESULTS

The age of the patients ranged from 25 days to 11 years and male-to-female ratio was 1:1.3. Clinically, the diagnoses suggested were tuberculosis, inflammatory lesion, abscess, and malignancy. The cytologic findings included high cellularity, isolated Langerhans cells (LCs) with prominent nuclear indentation, grooves and abundant vacuolated cytoplasm, multinucleated giant cells, eosinophils, and lymphocytes. Areas of necrosis were noted in one case. Histopathology, along with positive S-100 immunohistochemistry, confirmed the diagnosis of LCH.

CONCLUSIONS

LCH is a rare disease occurring predominantly in children and can be diagnosed with ease on FNA cytology by the presence of characteristic Langerhans cells. The S-100 positivity aids in suggesting a diagnosis of LCH.

Evaluation of brush cytology and DNA image cytometry for the detection of cancer of the oral cavity

BACKGROUND

Cancer of the oral cavity is the sixth most common malignancy reported worldwide. This study was undertaken to evaluate the efficacy of brush cytology and the adjunctive role of DNA image cytometry (ICM) in the diagnosis of oral cancer.

METHOD

Oral brush smears and biopsy were obtained from 100 consecutive patients presenting with suspicious oral lesions. DNA-ICM was performed on 96 cytology smears which had adequate cellularity.

RESULTS

On cytology, 54 cases were benign, 36 were malignant, 6 were suspicious for malignancy, and 4 were inadequate due to scanty cellularity. On histopathologic examination, 49 cases were diagnosed as squamous cell carcinoma and 51 cases as benign. The sensitivity of brush cytology for the detection of cancer was 83.3% and the specificity was 95.8%. The positive and negative predictive values were 95.2% and 85.2%, respectively, with a diagnostic accuracy of 86%. Out of 96 cases analyzed by image analysis to assess DNA ploidy, 33 cases were aneuploid and 63 were diploid. The sensitivity, specificity, positive predictive value, and negative predictive value of DNA-ICM were 68.7%, 100%, 100%, and 76.1%, respectively, giving a diagnostic accuracy of 81%. The combination of cytology and DNA cytometry increased the sensitivity to 92% and specificity to 100%.

CONCLUSION

The study demonstrates the usefulness of DNA-ICM as an adjunct to brush cytology to diagnose oral cancer. It reduces the false negative cases on cytology and also adds to objectivity in cytologically doubtful cases.

Renal cell carcinoma arising in ipsilateral duplex system

Congenital anomalies of the kidney and urinary tract are common and include a wide anatomic spectrum. Duplex systems are one of the more common renal anomalies, with the majority being asymptomatic. Little is known about the molecular pathogenesis of these anomalies; however, certain causative genes have been implicated. The finding of renal cell carcinoma arising in a kidney with the duplication of pelvicalyceal system and ureters, as in the present case, is uncommon. The association between a duplex system and renal cell carcinoma may be more than a coincidence, requiring a deeper insight and further elucidation.

Cytological diagnosis of small cell osteosarcoma of the bone

Small cell osteosarcoma (OS) is a rare histological variant of OS that poses unique diagnostic difficulties. We present a case of a 10-year-old child who underwent fine needle aspiration cytology (FNAC) from a mass in the right thigh. The cytological findings were those of a malignant small round cell tumor, closest to small cell OS. The FNAC findings were confirmed on histopathology.

Intraoral and Oropharyngeal Lesions: Role of Fine Needle Aspiration Cytology in the Diagnosis

The oral cavity is affected by a wide range of pathologic lesions, for which a morphologic diagnosis is required for proper management. Fine needle aspiration (FNA) is being increasingly used for preliminary diagnoses of such lesions. This is retrospective analysis of intraoral and oropharyngeal lesions diagnosed with FNAC over a period of 7 years. Out of total 55 cases, a definite diagnosis could be made on cytology in 50 cases (90.9 %). These 50 cases were further included in the study. Thirty cases were reported as non-neoplastic and 20 as neoplastic (11 benign and nine malignant). The diagnoses were made taking into account the background material (blood, mucin) and the predominant cells present (neutrophils, lymphoid cells, macrophages, hemosiderin laden macrophages, squamous cells, basaloid cells, spindle cells, giant cells). Histopathological diagnosis was available in 17 cases and corresponded with FNA diagnosis in 16 cases (94.12 %). No significant complications were seen in patients undergoing these FNAs. It can be concluded that FNA is a simple and rapid diagnostic test that can be useful for preliminary assessment of oral and oropharyngeal lesions.

Pulmonary hydatidosis in a tertiary care hospital

Background:

Hydatid disease is caused by the larval stage of Echinococcus. Liver is the most commonly involved organ followed by the lungs. Pulmonary hydatidosis can be primary or secondary. The disease may be asymptomatic for several years. Cause of concern is the fatal anaphylaxis, which may be life threatening.

Materials and Methods:

The present retrospective study is over a period of ten years (2003-2012). The demographic data including the clinical features, radiological findings, other organ involvement, surgical and medical management done and histopathological findings were compiled from the records.

Results:

During the study period a total of eight cases, five male and three female, with age ranging from eight to 43 years were diagnosed as pulmonary hydatid disease. Five patients had presented with complicated cysts. Six patients had solitary cysts involving the lung while bilateral lung involvement was seen in two cases. One patient had multiple pulmonary cysts. Three patients had associated cysts in liver and two in spleen. Surgical lobectomy was done in four cases. Histopathology showed acellular laminated ectocysts in all the cases, whereas endocyst with brood capsules was seen in five cases.

Conclusions:

Pulmonary hydatidosis is not uncommon. Anaphylaxis, although rarely seen, may be a disastrous event. High index of clinical suspicion and mass awareness for interruption of transmission of parasite can lead to proper treatment and possible eradication.

Evaluation of grading and hormone receptor immunostaining on fine needle aspirates in carcinoma breast

Background:

Grading and hormone receptor determination in breast carcinoma are predictive factors for response to hormonal therapy.

Aim:

This study was undertaken to grade breast carcinoma and to determine estrogen receptor (ER) and progesterone receptor (PR) expression on fine-needle aspiration cytology (FNAC). Furthermore, the objective was to compare the results with histological grading and immunohistochemistry on surgical material.

Materials and Methods:

Fifty cases of breast carcinoma diagnosed on FNAC were included. The cytological grading was done according to the Robinson's grading system. The corresponding histology sections were graded using the modified Bloom-Richardson system. Immunostaining for ER and PR was done on smears and tissue sections.

Results:

On both cytological and histological evaluation, 49 cases were infiltrating ductal carcinoma and one case was colloid carcinoma. On comparing cytological and histological grading, 78% were correctly graded on cytology. The sensitivity, specificity, positive predictive value and negative predictive value for ER detection on immunocytochemistry (ICC) were 55.6%, 95%, 93.8% and 61.3%, respectively. The sensitivity, specificity, positive and negative predictive value for PR detection on ICC were 57.7%, 95.2%, 93.8% and 64.5%, respectively. The correlation for ER and PR between cytology and histology was 72.3% and 74.5%.

Conclusion:

The grading along with ER and PR immunostaining of breast carcinoma on smears is advocated because of high concordance between cytology and histology. This allows the patient to be treated with hormonal therapy on the basis of FNAC alone.

Biomechanical abdominal wall model applied to hernia repair

BACKGROUND

Most surgical innovations require extensive preclinical testing before employment in the operative environment. There is currently no way to develop and test innovations for abdominal wall surgery that is cheap, repeatable and easy to use. In hernia repair, the required mesh overlap relative to defect size is not established. The aims of this study were to develop a biomechanical model of the abdominal wall based on in vivo pressure measurements, and to apply this to study mesh overlap in hernia repair.

METHODS

An observational study of intra-abdominal pressure (IAP) levels throughout abdominal surgery was conducted to identify the peak perioperative IAP in vivo. This was then applied in the development of a surrogate abdominal wall model. An in vitro study of mesh overlap for various defect sizes was then conducted using this clinically relevant surrogate abdomen model.

RESULTS

The mean peak perioperative IAP recorded in the clinical study was 1740 Pa, and occurred during awakening from anaesthesia. This was reproduced in the surrogate abdomen model, which was also able to replicate incisional hernia formation. Using this model, the mesh overlap necessary to prevent hernia formation up to 20 kPa was found, independent of anatomical variations, to be 2 × (defect diameter) + 25 mm.

CONCLUSION

This study demonstrated that a surgically relevant surrogate abdominal wall model is a useful translational tool in the study of hernia repair. Surgical relevance This study examined the mesh overlap requirements for hernia repair, evaluated in a biomechanical model of the abdomen. Currently, mesh size is selected based on empirical evidence and may underpredict the requirement for large meshes. The study proposes a relationship between the defect size and mesh size to select the appropriate mesh size. Following further trials and investigations, this could be used in clinical practice to reduce the incidence of hernia recurrence.

Multilocular peritoneal inclusion cyst mimicking an ovarian tumor: A case report

Peritoneal inclusion cysts are uncommon abdominopelvic cysts seen in perimenopausal women. It is often misdiagnosed clinically as an ovarian tumor due to similar presentation and mimicking findings on radiology. We describe a perimenopausal woman presenting with pelvic mass. Her clinical finding on radiology suggested an ovarian tumor; however, biopsy revealed it as peritoneal inclusion cysts. We discuss the possible ways to avoid such mistakes.

Abdominal aortitis on PET CT: A case report and review of the literature

INTRODUCTION

Aortitis often occurs in patients with systemic vasculitis.

PRESENTATION OF CASE

We reported a 73 year old man with giant cell arteritis who was presented with abdominal pain and weight loss.

DISCUSSION

Aortitis was diagnosed on PET-CT scan performed because initial investigations raised the possibility of pancreatic pathology.

CONCLUSION

This case highlights the utility of PET-CT in the diagnosis of abdominal aortitis and the need to consider aortitis as a differential in patients with abdominal pain with a history of vasculitis.

Fine-needle aspiration cytology of metastatic squamous cell carcinoma thyroid: A rare entity

Metastasis to the thyroid gland is rare with majority of cases discovered during an autopsy. Clinical presentation with a palpable thyroid or functional disturbances in thyroid is uncommon. We report isolated metastasis of laryngeal squamous cell carcinoma (SCC) to the thyroid gland diagnosed on fine-needle aspiration cytology which is minimally invasive and a preferred preliminary diagnostic modality in palpable thyroid swellings. A diagnosis of extra thyroidal SCC is a diagnosis of exclusion when there is no evidence of a coexistent recognizable primary thyroid cancer and/or molecular signatures suggestive of thyroidal origin.

Direct immunofluorescence pattern and histopathological staging in alopecia areata

Aim:

The present study was designed to categorize alopecia areata (AA) into various stages based on histopathology and further study the direct immunofluorescence (DIF) pattern.

Materials and Methods:

The current study is noninterventional, prospective study on 25 consecutive patients suspected of AA based on clinical assessment. Histomorphologic features and immunoreactivity for IgG, IgM, IgA, and C3, was studied on biopsy material.

Results:

Age of the patients ranged from 6 years to 48 years with a mean age of 28.56 ± 21.8 years. Majority of patients, 9 (36%) were in the age group of 21-30 years. Of 25 patients, 13 (52%) were males and 12 (48%) were females. Male: female ratio was 1.1:1. On histopathology majority of cases were in subacute stage 9 (36%), followed by chronic 7 (28%), acute 5 (20%) and recovery stages 4 (16%). Three (12%) of 4 cases showed characteristic swarm of bees appearance. Two (8%) of the cases showed presence of giant cells. Increased numbers of catagen hair were seen in 12 (48%) cases. Of 25 cases, 9 (36%) cases showed positive DIF with granular deposits. The most common immunoreactant was IgG in 7 (28%) cases, followed by IgA in 4 (16%), C3 in 6 (24%) and IgM in 3 (12%) cases. Of 9 cases showing positive staining, 3 (12%) were in acute stage and 2 (8%) each in subacute, chronic and recovery stages.

Conclusion:

The observations further reiterate that immune mechanisms play a role in the pathogenesis of AA.

Sporotrichoid pattern of nerve abscesses in borderline tuberculoid leprosy: A Case Report (sporotrichoid like abscesses in leprosy)

Linear distribution of multiple subcutaneous nodules or ulcers along the course of lymphatics, classically seen in lymphocutaneous sporotrichosis, has been observed in a number of other infections like localized cutaneous leishmaniasis, cutaneous tuberculous and non tuberculous mycobacterial infections, Pasteurella tularensis, Scopulariopsis blochi, Nocardia brasiliensis, yaws and syphilis. A case of borderline tuberculoid leprosy with multiple cutaneous nodules corresponding to resolving nerve abscesses in a sporotrichoid pattern is being reported.

Dental anxiety screening practices and self-reported training needs among Australian dentists

BACKGROUND

It is recommended that dentists screen for dental anxiety (DA) so that fearful patients may be better managed. The main aim of this study was to determine what dentists are being taught in relation to DA as well as whether and how anxious patients are identified in the clinic.

METHODS

Two hundred and forty-six practising dentists (adjusted response rate = 40.1%), from a random sample of registered Australian dentists, completed a mailed questionnaire.

RESULTS

Dentists estimated that high DA affected 23.3% of children and 19.4% of adults seen. Only 3.7% of dentists reported using a published scale for screening DA, with the most common reason being lack of awareness (56.5%). Approximately one-half of responding dentists directly asked their patients about DA and this was more common among younger dentists (χ(2) = 7.75, p = 0.021). There were few differences in DA screening by other practitioner or practice characteristics (p > 0.05). Only one-third of dentists had received undergraduate training related to DA and only 41.7% considered this to be 'good' or better. Almost 37% of respondents expressed an interest in future training opportunities.

CONCLUSIONS

The use of formal, validated scales for screening DA is minimal. Training in anxiety management appears to be low and is an area that could be expanded upon.

Cytomorphologic spectrum in aspirates of extra-adrenal paraganglioma

Background:

Paraganglioma is a rare tumor arising from clusters of neuroendocrine cells in association with sympathetic and parasympathetic nervous system. It poses a diagnostic challenge because of its widespread anatomic distribution, subtle clinical manifestations, and a variety of morphologic patterns.

Aim:

The aim of this study is to have an insight into the diverse morphologic spectrum of extra-adrenal paraganglioma (EAP).

Materials and Methods:

A retrospective analysis of seven cytologically diagnosed cases of EAP over a period of 10 years was performed. There were five superficial swellings and two deep seated retroperitoneal masses. The superficial swellings were aspirated directly, and the retroperitoneal masses were aspirated under ultrasound guidance using 22-gauge lumbar puncture needle fitted to a 10 mL syringe. Smears were reviewed for cellularity, pattern, cell shape, cytoplasm, nuclear features, and background.

Results:

The age of patients ranged from 25 to 75 years; four patients were males and three were females. Sites involved were carotid body region (four cases), para-pharyngeal space (one case) and para-aortic region (two cases). All the cases yielded hemorrhagic material on fine-needle aspiration. Smears showed scattered and clusters of cells and loosely cohesive acini of tumor cells. Cells were round to polygonal with pleomorphic nuclei, granular chromatin, inconspicuous nucleoli, and moderate to abundant cytoplasm containing fine pink granules and vacuolations. The cases were confirmed on radiology and histopathology.

Conclusion:

The cytologic features in EAP along with pertinent clinicoradiologic findings help in making an accurate preoperative diagnosis of an otherwise rare tumor.

Spectrum of nonhematological pediatric tumors: A clinicopathologic study of 385 cases

Background:

The aim of this study is to understand the epidemiology of tumors in children in our region due to a paucity of studies on the histologic review of the childhood tumors in general and benign tumors in particular.

Materials and Methods:

The records of all the tumors diagnosed histopathologically in children <14 years of age during a period of 8-year (2005-2012) were reviewed.

Results:

A total of 385 tumors were seen in the age range of 1 month-14 years with 231 (60%) in boys and 154 (40%) in girls. Highest number of cases, 224 (58.18%) were in the age group of 10-14 years. Benign tumors comprised 275 (71.43%) cases while the malignant tumors accounted for 110 (28.57%) cases. In benign tumors, vascular tumors were in majority with 68 cases, while in malignant category bone tumors were most common with 36 cases.

Conclusions:

Although the exact incidence rate cannot be provided by this hospital-based study, the information is useful in showing patterns of childhood tumors. We included both benign and malignant tumors, while most of the studies in the past have focused mainly on malignant tumors in children.

Complementary value of DNA flow cytometry and image morphometry in detection of malignant cells in effusion fluids

BACKGROUND

In cytologic evaluation of body cavity effusions, the morphologic changes exhibited by reactive mesothelial cells often confound the diagnosis. This study investigates the role of DNA flow cytometry (DNA FCM) and image morphometry (IM) in improving diagnostic accuracy.

METHODS

53 pleural and 47 ascitic fluid samples were evaluated cytologically. All were also subjected to flow cytometry to assess DNA ploidy. Image morphometry was used to measure nuclear diameter, nuclear perimeter and nuclear area.

RESULTS

On cytomorphology 79% cases were diagnosed as benign, 19% as malignant and 2% as suggestive of malignancy. DNA FCM showed aneuploidy in 13 of 19 malignant cases and diploidy in 6 cases. The mean nuclear area of the benign group was 60.14 ± 39.91 µm² and that of malignant cases was 190.54 ± 56.06 µm². Using DNA FCM and IM, one of the two cases "suggestive of malignancy" was placed in the benign group and the other in the malignant group. Also, these modalities were able to pick up one case of malignancy that was diagnosed as benign on cytology.

CONCLUSIONS

Cytomorphology remains the foremost diagnostic modality in detecting malignant cells in effusions. DNA flow cytometry and image morphometry hold a valuable complementary value.

Spectrum of fungal keratitis: clinicopathologic study of 44 cases

AIM

To determine the causative agents of fungal keratitis and study the predisposing factors over a period of ten years in a single tertiary care hospital.

METHODS

A retrospective analysis of fungal corneal ulcers was done from 2003-2012. Patients' clinical data were noted from the file records. Correlation of histopathological diagnosis was done with the report on fungal culture.

RESULTS

Mycotic keratitis was established in 44 cases by a positive fungal culture. Direct microscopic examination of potassium hydroxide (KOH) mounts revealed fungal elements in 39 cases while 40 cases showed fungus on Gram stained smears. Males (54.55%) were more commonly affected than the females (45.45%). The age ranged from 18 to 82 years. Most common age group to be involved was 41-60 years. Predisposing risk factors were seen in 34 (77.27%) cases. Most common findings on clinical examination were anterior chamber reaction and conjunctival injection seen in all the cases. Other common findings were stromal infiltration and hypopyon seen in 20 (45.45%) and 18 (40.91%) cases respectively. On histopathological examination the fungus was typed, as aspergillus in 34 cases while no definite typing was possible in 10 cases. The predominant isolate was aspergillus flavus (59.09%) followed by fusarium (15.91%). Mixed fungal and bacterial infection was seen in 3 (6.82%) cases.

CONCLUSION

Although culture is the gold standard for definitive diagnosis of fungal keratitis, direct microscopic examination of corneal scrapings or histomorphological evaluation of biopsies allow a rapid preliminary diagnosis. Early administration of antifungal treatment helps in preventing dreadful complications.

Diagnosis of filariasis on cytology: a series of 24 cases

Filariasis has a worldwide distribution, with a special predilection for tropical and subtropical areas. The microfilaria wanders in lymphatics and can be accidentally trapped in the needle during fine-needle aspiration cytology, thus leading to its incidental detection. This is a retrospective study of 24 cases of microfilarial infestation diagnosed on cytology. Accurate recognition and detection of the parasite leads to the institution of specific treatment and prevents chronic manifestations of the disease.