Role of ultrasonography (USG) and color Doppler in the evaluation of thyroid nodules and its association with USG-guided FNAC - A cross-sectional study

Introduction

Thyroid diseases affect approximately 42 million people in India. The majority (15%-40%) of these cases remain asymptomatic and benign and warrant special investigations such as ultrasonography (USG) and fine-needle aspiration cytology (FNAC) for diagnosis. Early diagnosis and management of thyroid disorders determine the disease course in many patients.

Objective

To determine the role of USG and color Doppler in the evaluation of thyroid nodules and its association with USG-guided FNAC.

Methods

We did a cross-sectional analytical study over 2 years, where we recruited 108 patients with thyroid swelling attending the OPD. We used a semi-structured data collection proforma that captured information on sociodemographic details, clinical symptoms, physical examination, and all ne cessary laboratory investigations. All patients underwent USG, color Doppler, and FNAC as a part of the investigation of thyroid nodules. The diagnostic value of ultrasound and Doppler parameters was assessed in terms of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for detection of malignancy in comparison to FNAC.

Results

Approximately 155 nodules were identified from the selected 108 cases, and the prevalence of malignancy among the selected thyroid nodule patients was found to be 9.1%. We observed that malignant tumors were likely to be solitary with lobulated margins, >2 cm in size with <50% peripheral halo, with markedly hypoechoic, predominantly solid, with nodal involvement and extrathyroidal extension, microcalcifications, and central vascularity. We also observed that tumors that had USG characteristics of being taller than wide (91%), poorly defined margins (92%), marked hypoechoic (95%), and microcalcifications (96%) had the highest diagnostic accuracy in detecting malignancy when compared to FNAC.

Conclusion

Thus, through our study findings, we conclude that USG and color Doppler can serve as vital tools for the evaluation of thyroid nodules with high sensitivity and specificity.

Randomised controlled study to compare radiofrequency ablation with minimally invasive ultrasound-guided non-flush ligation and stripping of great saphenous vein in the treatment of varicose veins

INTRODUCTION

Flush ligation at the saphenofemoral junction and stripping of the great saphenous vein is being increasingly replaced by endovenous methods such as radiofrequency or endovenous laser ablation for the treatment of varicose veins. These modalities are expensive and not widely available. A minimally invasive ultrasound-guided surgery with non-flush ligation and stripping under local anaesthesia is a cost-effective alternative with similar postoperative outcomes.

MATERIALS AND METHODS

A total of 62 limbs (58 patients) with saphenofemoral junction incompetence underwent clinical evaluation including the CEAP clinical score, the venous clinical severity score, the venous disability score and venous doppler. Patients were randomly assigned to either group A (radiofrequency ablation) or group B (ultrasound-guided non-flush ligation and stripping of the great saphenous vein) for procedures under tumescent anaesthesia and ultrasound guidance. Patients were followed-up on days 7, 30 and 90 to assess primary (obliteration rates) and secondary (venous clinical severity score and venous disability score) outcomes.

RESULTS

Both the groups showed 100% obliteration of the great saphenous vein at day 90. The venous clinical severity and venous disability scores significantly improved from day 0 to day 90 in both groups (p = 0.0001). There were no major complications. Group A showed significantly lower minor complications (p = 0.001). None required conversation to general anaesthesia.

CONCLUSIONS

The ultrasound-guided non-flush ligation and stripping of the great saphenous vein are as efficacious as radio frequency ablation, with similar obliteration rates, improvement in disability scores and complication profile at a lower cost. It has the potential for wider availability in the community as most surgeons are conversant with the surgical procedure.

Breast Cancer in Indian Women: Genetic Risk Factors and Predictive Biomarkers

Breast cancer is the most common cancer among Indian women with a significant increase in incidence in young women. To identify risk factors for breast cancer in young women, study of BRCA1 and BRCA2 germ line mutations was done in a cohort of 204 Indian breast cancer patients. The study showed a total of 18 mutations in 2.94% of the tested patients, 44% BRCA1 and 78% BRCA2 mutations were found unique to the Indian population. Association of low penetrance genes mainly CYP17, VDR gene and AR-CAG repeat polymorphisms with breast cancer risk showed CYP17 A2 and VDR Poly-A L as high risk alleles, the risk of developing breast cancer among women carrying three high-risk alleles is 4.68 (95% confidence interval [CI]: 0.77–28.0; p for trend = 0.10) compared with women carrying none. CYP17 A2 allele was also found associated with development of breast cancer at young age and can also serve as a target for therapy. Betel quid chewing has been found as a significant and independent risk factor for developing breast cancer in North East Indian women which induces genetic alterations leading to breast carcinogenesis. Studies to assess the predictive role of various tumor markers showed that expression of p-glycoprotein in pretreatment biopsy predicts a poor clinical response to neoadjuvant chemotherapy (NACT) in patients having locally advanced breast cancer. The chemotherapy-induced toxicity (vomiting and alopecia) correlated significantly with clinical and immunohistochemical response (reduction in bcl2/bax ratio) and were found to be a cost-effective and reliable predictor of response to NACT. Androgen receptor (AR) has been identified as independent predictive marker for response to NACT in locally advanced breast cancer cases and can serve as novel therapeutic target for triple negative breast cancers.

CYP17 gene polymorphism and its association with high-risk north Indian breast cancer patients

A single T > C change at the 5' promoter region of the CYP17 gene is reported to be associated with increased risk of breast cancer. This study evaluates the influence of genetic polymorphism of CYP17 on breast cancer susceptibility. Two hundred and forty-two patients with histopathologically confirmed breast cancer and 212 age-matched controls were included in the present study. Information relating to age at onset of the disease, family history and estrogen receptor status was elicited. Investigation for CYP17 polymorphism was carried out in 106 early onset, 80 late onset and 56 familial cases. The frequencies of two CYP17 alleles were also analyzed in 116 (47.9%) cases with known estrogen receptor (ER) status confirmed immunohistochemically. A polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was used to detect the polymorphism, and the genotypes identified were assigned as homozygous wild type (A1A1), heterozygous variant (A1A2), and homozygous variant (A2A2). Associations between the various genotypes in patients and controls were investigated with Fisher's exact test. All the tests were two tailed. The results showed that the frequency of heterozygous and homozygous CYP17 genotype was higher in early onset breast cancer patients (94.3%) than in controls (80.3%), and the difference was significant (P = 0.001). A highly statistically significant increased risk in carriers of homozygous A2 allele was found in young patients (P < or = 0.001) in comparison with patients having late onset condition (P = 0.260). However, no significant association between the genotype and breast cancer risk was observed among women with strong family history. Further, data had showed that patients (80.6%) with at least one A2 allele tended to exhibit ER-independent cell proliferation, although statistical significance could not be established (P = 0.160). The present findings suggest that CYP17 A2 allele gene polymorphism might play a significant role in breast cancer development in young Indian women.

Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country--a prospective study

BACKGROUND

An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving. Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury.

METHODS

The series consisted of a cohort of 50 patients admitted to the surgical emergency with isolated closed head injury, that were not considered for surgery by the neuro-surgeon or shifted to ICU, but had GCS score of less than 8 and SAPS II score of more than 50. First 50 case records from January 2001 that fulfilled the criteria constituted the control group. The patients were managed as per ATLS protocol and intubated if required at any time before decision to perform tracheostomy was taken. These patients were serially assessed for GCS (worst score of the day as calculated by senior surgical resident) and SAPS scores till day 15 to chart any changes in their status of head injuries and predictive mortality. Those patients who continued to have a GCS score of <8 and SAPS score of >50 for more than 24 hours (to rule out concussion or recovery) underwent tracheostomy. All these patients were finally assessed for mortality rate and hospital stay, the statistical analysis was carried out using SPSS10 version. The final outcome (in terms of mortality) was analyzed utilizing chi-square test and p value <0.05 was considered significant.

RESULTS

At admission both tracheostomy and non-tracheostomy groups were matched with respect to GCS score and SAPS score. The average day of tracheostomy was 2.18 +/- 1.0038 days. The GCS scores on days 1, 2, 3, 4, 5, 10 between tracheostomy and non-tracheostomized group were comparable. However the difference in the GCS scores was statistically significant on day 15 being higher in the tracheostomy group. Thus early tracheostomy was observed to improve the mortality rate significantly in patients with isolated closed head injury.

CONCLUSION

It may be concluded that early tracheostomy is beneficial in patients with isolated closed head injury which is severe enough to affect systemic physiological parameters, in terms of decreased mortality and intubation associated complications in centers where ICU care is not readily available. Also, in a selected group of patients, early tracheostomy may do away with the need for prolonged mechanical ventilation.

Is the routine drainage after surgery for thyroid necessary? A prospective randomized clinical study [ISRCTN63623153]

Background

Drains are usually left after thyroid surgery to prevent formation of hematoma and seroma in the thyroid bed. This is done to reduce complications and hospital stay. Objective evaluation of the amount collected in the thyroid bed by ultrasonography (USG) can help in assessing the role of drains.

Methods

A randomized prospective control study was conducted on 94 patients undergoing 102 thyroid surgeries, over a period of fifteen months. Patients included in the study were randomly allocated to drain and non-drain group on the basis of computer generated random number table. The surgeon was informed of the group just before the closure of the wound Postoperatively USG neck was done on first and seventh postoperative day by the same ultrasonologist each time. Any swelling, change in voice, tetany and tingling sensation were also recorded. The data was analyzed using two-sample t-test for calculating unequal variance.

Results

Both groups were evenly balanced according to age, sex, and size of tumor, type of procedure performed and histopathological diagnosis. There was no significant difference in collection of thyroid bed assessed by USG on D1 & D7 in the two groups (p = 0.313) but the hospital stay was significantly reduced in the non-drain group (p = 0.007). One patient in the drain group required needle aspiration for collection in thyroid bed. No patient in either group required re-operation for bleeding or haematoma.

Conclusion

Routine drainage of thyroid bed following thyroid surgery may not be necessary. Not draining the wound results in lesser morbidity and decreased hospital stay.

POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy

BACKGROUND

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is a scoring system that is used widely to predict 30-day mortality and morbidity rates. The Portsmouth predictor modification (P-POSSUM) was developed to overcome the overprediction of mortality by POSSUM, especially in low-risk patients. In this prospective study, the validity of POSSUM and P-POSSUM was tested in patients undergoing emergency laparotomy in a referral hospital of a developing country.

METHODS

Some 120 patients who underwent emergency laparotomy in a single unit were studied. Predicted morbidity and mortality rates were calculated by POSSUM and P-POSSUM equations using both linear regression and the exponential methods of analysis. These were compared with actual outcomes.

RESULTS

When the linear method of analysis was used POSSUM overpredicted morbidity, and there was a significant difference between the observed and predicted values (observed to expected (O : E) ratio 0.68). The prediction was more accurate when the exponential method was used (O : E ratio 0.91). POSSUM also significantly overpredicted mortality when analysed by the linear method (O : E ratio 0.39), but the prediction improved when exponential analysis was used (O : E ratio 0.62). Applying linear and exponential analyses for P-POSSUM, the O : E ratios for mortality were 0.66 and 0.88 respectively.

CONCLUSION

If analysed correctly POSSUM is a good predictor of morbidity and mortality in patients undergoing emergency laparotomy. P-POSSUM predicts mortality equally well. Both equations may be used for risk-adjusted surgical audit of patients undergoing emergency laparotomy.

Metaplastic carcinoma of the breast--a rare breast tumour

Malignant breast neoplasms consisting of mixtures of epithelial and mesenchymal elements, are a rarity. Pathogenesis of such diverse elements within obviously infiltrating carcinomas has been the subject of much controversy. After the advent of immunohistochemistry, it is now generally accepted that metaplasia of the epithelial elements of a carcinoma gives these lesions their pseudosarcomatous appearance. Hence the name metaplastic carcinoma is given to malignant breast neoplasms which show Cytokeratin positivity in both epithelial and mesenchymal elements. We recently encountered such a case, which is being presented here along with relevant review of literature.

Colloid carcinoma of the breast with concomitant metastasis and a tuberculous lesion in the axillary lymph nodes. A case report

A 30-year-old woman presented with a lump in the left breast and left axillary lymphadenopathy that, on fine needle aspiration cytology (FNAC), proved to be duct cell carcinoma with metastasis. Histology of the radical mastectomy specimen showed a mixed colloid carcinoma. Axillary lymph nodes revealed a variety of pathologic changes consisting of reactive hyperplasia, tuberculosis and metastasis. A combination of a tuberculous lesion and metastasis in the same lymph nodes was also found. During follow-up, after radiotherapy, the patient developed left supraclavicular and right cervical lymphadenopathy that, on FNAC, revealed a tuberculous lesion and metastasis, respectively. The rarity of this condition with double pathology is highlighted, and the reason behind the limitations of FNA in subtyping the primary malignancy and its failure to detect the tuberculous lesion in the axillary lymph node are discussed.