Marginal vacuoles in thyroid aspirates

OBJECTIVES

To report on two cases of metastatic follicular carcinoma with marginal vacuoles (MVs) and review smear results in 441 solitary nodular goiters (SNGs) for this cytologic feature.

STUDY DESIGN

The first case was a 55-year-old male who presented with a huge mass in the left hip region; the second case was a 50-year-old male with a thyroid nodule and a large mass on the scalp. The age of the 441 ultrasonographically diagnosed SNG cases ranged from 11 to 75 years. The May-Grünwald-Giemsa-stained fine needle aspiration (FNA) smears of these cases were reviewed by one of the authors (D.K.D.) for various cytomorphologic features, including MVs.

RESULTS

FNA smears from the mass in the hip in the first case showed follicular cells with acinar formation and MVs, indicating metastatic follicular thyroid carcinoma (FTC). These features were of help in detecting the thyroid primary, which had previously gone undetected. Aspiration smears from the thyroid nodule and the mass on the scalp in the second case showed tumor cells of FTC with MVs and microfilariae. Review of 441 SNG cases revealed MVs in 42.6% of hyperplastic nodules; that rate was significantly higher (P < .001) than that of colloid goiter (5.2%) and neoplastic goiter (13.3%) but lower (P < .05) than that of thyrotoxic goiter (100%). MVs were limited to neoplasms with a follicular component; that included 15% of follicular neoplasms and 50% of follicular variant of papillary carcinoma (FVPC). The difference between FVPC and the rest of the neoplastic goiters (6%) was statistically significant (P = .002).

Role of guided fine needle aspiration cytology in diagnosis and classification of liver malignancies

Ultrasound or CT-guided fine needle aspiration was performed on 212 patients with space occupying lesions of the liver during a period of 5 years (1986-1990) to study the utility of fine needle aspiration (FNAC) in the diagnosis of hepatic malignancies. The initial FNAC diagnosis was malignancy in 91 cases. However, following review of the smears by one of the investigators (DKD) 93 (43.9%) cases were found to be malignant. Age of the patients with malignancy ranged from 20 days to 85 years. Male to female ratio was 57:36. The clinical diagnosis was malignancy in 58% which improved to 72% following imaging whereas nonspecific diagnosis was reduced from 34% to 20%. The primary malignancies consisted of 21 cases of hepatocellular carcinoma (HCC) and 7 hepatoblastomas. There were 61 metastatic lesions which included 43 adenocarcinomas, 6 small cell anaplastic carcinomas, 3 leiomyosarcomas, 2 cases each of malignant melanoma, paraganglioma and germ cell tumour, and one case each of squamous cell carcinoma, neuroendocrine tumour and undifferentiated carcinoma/soft tissue sarcoma. In two cases decision between HCC and secondaries was not possible. There were also two cases of non-Hodgkin's lymphoma. Thirty six percent of primary malignancies and 58% of secondaries were correctly diagnosed or suggested as one of the possibilities by combined clinical examination and imaging prior to FNAC. Thus, US/ CT guided FNAC played an important role in diagnosis and classification of malignancies of liver.

Fine-needle aspiration diagnosis of intra-thoracic and intra-abdominal lesions: review of experience in the pediatric age group

Review of fine-needle aspiration (FNA) smears from 121 pediatric patients with intra-thoracic and intra-abdominal lesions revealed 42 (34.7%) cases of neoplasms, 35 (28.9%) cases of tuberculosis, 12 (9.9%) cases of non-tuberculous inflammations, 4 (3.3%) cases of benign cystic lesions, and 28 (23.1%) inadequate/inconclusive cases. The age of the patients ranged from 20 days to 18 yr. Ultrasound and/or CT study done in 105 cases localized the lesions in following common sites: lungs (19 cases), mediastinum (22 cases), liver (14 cases), intestines (11 cases), and lymph nodes (17 cases). The neoplastic lesions consisted of 39 malignant, one suspicious, and two benign neoplasms. Among the neoplasms, the small round cell tumors were the most frequent (27 cases), followed by germ cell tumors (eight cases) and miscellaneous neoplasms (seven cases). The common small round cell tumors were non-Hodgkins lymphoma (eight cases), hepatoblastoma (seven cases), neuroblastoma (five cases), and nephroblastoma (three cases). A combined clinical, imaging, and FNA cytology approach was found to be useful in arriving at a tissue diagnosis.

Inflammatory lesions of the breast: diagnosis by fine needle aspiration

Amongst 1061 breast lesions diagnosed by fine needle aspiration (FNA) over a period of 6 years (1985-1990), 128 were reported to be showing changes consistent with an inflammatory lesion. On review, the cytodiagnosis was found to be inaccurate in 31 cases. The cytological features of the 97 cases that were correctly reported are described in this report. The cytological diagnoses issued in these 97 cases were acute mastitis or breast abscess (57 cases) and tuberculous mastitis (30 cases). Non-specific chronic mastitis and miscellaneous conditions accounted for four and six cases respectively. Acid fast bacilli (AFB) were demonstrated in 28.0% of tuberculous mastitis cases and 10.0% of those diagnosed as acute mastitis or breast abscess. FNA cytology was found to be useful for the diagnosis of inflammatory lesions of breast and their classification, as only five out of 57 cases of acute mastitis/breast abscess and one out of 30 tuberculous mastitis cases were suspected on clinical grounds.

Superficial and deep-seated tuberculous lesions: fine-needle aspiration cytology diagnosis of 574 cases

Over a period of 2 yr (1987-1988), FNA smears in 574 cases were found to have cytologic features suggestive of or consistent with tuberculous lesions. The age of the patients ranged from 6 mo to 75 ye, with a median of 24 yr. The male to female ratio was 273:301. Sites of FNA were superficial lymph nodes (SLN) in 440 (76.7 percent) cases, superficial extranodal sites (SENS) in 50 (8.7 percent), both SLN and SENS in 7 (1.2%), the thoracic cavity in 16 (2.8%), and the abdominal cavity in 61 (10.6%). Cytologic features were described under 3 major cytologic patterns, i.e., type I: epithelioid granuloma without necrosis, type II: epithelioid granuloma with necrosis, type III: necrosis without epithelioid granuloma. Type I, II, and III reactions were observed in 181 (31.5%), 183 (31.9%), and 210 (36.6%) cases, respectively. The overall AFB positivity was 30.8%. The AFB positivities for type I, II, and III cytologic reactions were 5.4%, 32.0%, and 48.5%, respectively. The AFB positivity was low (less than 30.0%) in swellings of the body surface (23.8%) and abdominal organs (18.9%). High positivity (greater than 60.0%) was observed in lesions of the thorax (63.6%) and thyroid (62.5%).

A new technique for chronic venous ulcers of the lower limb: modified Felder-Rob procedure

Subfascial ligation of perforating veins is a commonly performed operative procedure for chronic venous ulcers of the leg. The most widely adopted incision currently used is the posterior midline approach described by Felder. This, however, is associated with significant morbidity due to necrosis of skin overlying the tendo Achillis with consequent exposure-induced necrosis and contracture of the tendon. A new incision based on anatomical studies is described. The procedure was adopted in 45 limbs with chronic venous ulcers. The incision is associated with very minimal morbidity and has given excellent results in the form of a major necrosis rate of only 4.4% (none of which involved the skin over the tendo Achillis or the tendon itself) and an ulcer recurrence rate of 4.4% during the period of follow-up of 2-8 years.

Bilateral turn-table rectus abdominis myocutaneous flaps for an upper abdominal recurrent dermatofibrosarcoma

The use of two "turn-table" rectus abdominis myocutaneous flaps is described using skin extensions from well above the costal margin, to close a large upper abdominal defect. The chest donor site was covered with a deltopectoral flap with primary closure, helped by postoperative arm positioning.

A new incision for subfascial ligation of perforating veins in chronic venous ulcers of the leg

A new incision is described for subfascial ligation of perforating veins in patients with chronic venous ulcers of the leg. It avoids the complications encountered with the conventional midline posterior approach.

Retroperitoneal colopexy for adult rectal procidentia. A new procedure

Nonresective fixation procedures are superior to resections in the management of rectal procidentia. A new operative procedure of retroperitoneal fixation of the redundant rectum and sigmoid after mobilization of the rectum up to the pelvic floor is described. The procedure was performed in 32 patients. In a follow-up ranging up to 11 years, only one recurrence of mucosal prolapse was seen. Rectal, bladder, and sexual functions were normal. There was a low wound infection rate and no mortality. The procedure appears superior to conventional operations for rectal procidentia and, at the same time, avoids usage of prosthetic materials for fixation with their known risk of complications.

Dartos-based scrotal myocutaneous flaps: their place in regional reconstructions

Injection studies were done in cadavers to demonstrate the blood supply of scrotal flaps and lay the foundation of the basis of their use in regional reconstruction. Eighty-seven scrotal flaps, antero-lateral, posterior, extended posterior and bipedicled (including de-epidermized flaps) were used as peninsular or island flaps in 60 patients and 64 situations. The flaps were used for lengthening of phallus stumps, neophalloplasty, providing groin cover, urethral repair, construction of simulated testis, hernioplasty and for providing cover in a precise manner after scrotectomy in filarial scrotum and other conditions.

Genital amebiasis

Five cases of amebiasis of the genital tract involving the cervix, vulva and penis are described. All presented as an ulcerating mass and were clinically suspected to have a tumor. In two cases the amebiasis co-existed with a carcinoma, an association which is extremely rare. The spouse of a patient with penile amebiasis was found to have amebiasis of the cervix suggesting a sexually transmitted mode of infection. The need for histopathological confirmation of all suspected genital malignancies is emphasised due to the striking resemblance of genital amebiasis to a carcinoma. The co-existence of amebiasis with carcinoma is of interest and suggests a possible etiological relationship.

Refashioning of phallus stumps and phalloplasty in the treatment of carcinoma of the penis

The surgical management of 41 patients with carcinoma of the penis is presented. Conservative surgery in the form of a circumcision or a glansplasty was done in eight patients with one recurrence. Circumcision as an adequate procedure is advocated for lesions near the apex of the preputial sac permitting a 2 cm clearance; glansplasty after local excision requires further evaluation. The details of technique of lengthening and refashioning of the residual phallic stump after partial amputation in a further 20 patients is described using a technique which leaves a satisfactory penile stump in patients who would normally be candidates for a total amputation. In a third group of patients requiring a total amputation of penis, reconstruction was done in two stages using scrotal flaps in four with satisfactory results. The reconstructed phallus was adequate as a urinary conduit but was unsuitable for sexual function. A one stage procedure involving covering of the urethra with scrotal flaps appears an attractive alternative to the staged procedure. Conventional multistage reconstructions are not recommended.

Problematic ulcerative lesions in sexually transmitted diseases: surgical management

Chronic intractable ulcerative lesions, with or without lymphedema, are occasional sequelae of various sexually transmitted diseases that lead to gross morbidity. This study of 15 such cases, including seven of granuloma inguinale, four of lymphogranuloma venereum, three of confined lesions (granuloma inguinale and lymphogranuloma venereum), and one of sexually transmitted amebic ulcer of the penis, employed surgical procedures aimed at sound healing after a single-stage procedure. The surgical techniques included full skin cover by direct flaps, myocutaneous flaps, sliding flaps (floating island), and excision of the involved rectum (two cases). Nine lesions healed by primary intention, one by spontaneous contraction of the wound, and two needed limited secondary procedures. In view of the paucity of literature on the subject, an argument is made for identifying such cases and saving them from prolonged morbidity by a suitable single-stage surgical procedure.

Gluteus maximus myocutaneous flap cover for sacral radiation ulcers

Myocutaneous flap cover of postirradiation ulcers has recently been recognized as a useful and effective method of treating these non-healing ulcers. This study presents the results of three cases of postirradiation sacral ulcers treated by gluteus maximus myocutaneous flaps. In one case a conventional island flap was used, whereas in the other two cases a new technique of a total rotation gluteus maximus myocutaneous flap is described.

The total gluteus maximus rotation and other gluteus maximus musculocutaneous flaps in the treatment of pressure ulcers

The use of musculocutaneous flaps in the treatment of pressure ulcers has been widely accepted. This study presents the results of the use of various types of gluteus maximus musculocutaneous flaps such as island flaps, advancement flaps and new total gluteus maximus rotation flaps with or without an inferior gluteal fasciocutaneous extension, in the treatment of pressure ulcers.

Fistula-in-ano: treatment by fistulectomy, primary closure and reconstitution

One hundred and twenty cases of fistula-in-ano were treated in 11 years by fistulectomy and primary closure. Injection of dye into the tract helped in identifying the tract and its ramifications which were excised. A lateral sphincterotomy was added in most cases for relief of postoperative pain and to promote good healing. Of the cases, 83.3% healed well in 2 weeks as compared with 4-5 weeks or more with conventional methods resulting in great economy in hospital stay and morbidity. Follow-up of these cases for a variable period, up to five years, revealed only three recurrences, indicating a comparable long term effectiveness of this procedure as in the conventional method.

Surgical reconstruction of the sequelae of penile and scrotal gangrene: a plea for simplicity

Gangrene of the scrotum with or without involvement of the penile skin and occasionally beyond these limits, is not an uncommon problem in some parts of the world. Various workers have used different techniques to provide skin cover including transplantation of testes, free skin grafts, axial groin flaps and myocutaneous flaps. This study brings out our experience with the treatment of 43 cases in the last 11 years. In three cases the gangrene had spread beyond the scrotum and penis and cover had to be supplemented with split-skin grafts. In all the other cases, cover was provided with scrotal skin remnants at the edge of the lesion and on the penis with the inner layer of the prepuce, which had remained intact.

Meatoplasty for gross urethral stenosis: a technique of repair and a review of 32 cases

This paper is a review of the treatment of 32 cases of meatal stenosis arising as a complication of recurrent balanoposthitis (26 cases) or balanitis xerotica obliterans (six cases). There was gross scarring of the glans and the terminal urethra resulting in a contracted glans and a pinhole meatus. These deformities were treated successfully by segmental excision of all the scar on the glans and resurfacing the raw area with a local preputial or penile skin flap. In two patients a ventral midline flap was introduced as an island flap. In no case was a ventral slit made as the only definitive treatment of the meatal stenosis. Two instruments were made specifically to facilitate this type of operation.

Single layer abdominal wound closure in children

A single layer closure of abdominal incisions was done, including the skin, musculo-aponeurotic layer and peritoneum, with a modified 'figure-of-eight' technique, using thick monofilament nylon interrupted sutures. This technique leaves no suture material in the wound after suture removal on the 14th postoperative day. One hundred and fifty-two transverse incisions of the abdomen in children of all ages were analysed. Easy closure in difficult cases, no wound dehiscence and a greatly reduced infection rate are the advantages. We recommend this technique as a routine, particularly in poor risk patients, contaminated wounds and closure of colostomy wounds.

Gustatory syndrome following radical neck dissection

Gustatory syndrome in the temple region is common. This is a report of an unusual presentation in the submandibular region following a cervical block dissection.

Inguinal hernias: a preliminary study on a technique of repair based on the keel principle

Most adult hernias have a defect in the posterior wall of the inguinal canal even though the initial defect, in an indirect hernia, is the presence of a sac at the internal ring. It is imperative to strengthen the posterior wall without disturbing the normal shutter mechanism of the inguinal canal. A technique is described which achieves this by applying the keel principle to the repair. Data regarding 215 such repairs done during the last five years is presented. The follow-up available however does not satisfy the standard critical criteria and as such this is presented only as a preliminary report and a rational idea.

Rectus abdominis myocutaneous flap--clinical experience with ipsilateral and contralateral flaps

This study summarizes our experience with the use of 15 superior and inferior rectus abdominis myocutaneous flaps for filling defects in the chest wall, pectoral region, abdominal wall and groin. An extension of this flap above the costal margin, recommended in the study, provides valuable additional tissue. The flap is reliable and easily constructed.

Orchiopexy: trans-septal ipsilateral positioning

Orchiopexy based on a method of testicular fixation by ipsilateral placement with a valvular passage through the septum is described. By passing the testis through the soft septum twice, a low scrotal position is assured without tension or risk of compression of the cord.

Rectus abdominis myocutaneous island flap for bridging defect after cystectomy for bladder exstrophy

A case of adult exstrophy of the bladder was managed with urinary diversion, excision of the bladder, and closure of anterior abdominal defect, using a rectus abdominis myocutaneous island flap. This procedure is recommended as sound in cases in which reconstruction of the bladder is not feasible.

Parotid fistulas: a review

A series of 17 cases of parotid fistulas seen at one hospital over a 10-year period is presented with detailed analysis of aetiological factors, clinical presentation and therapy. Distinctions between glandular and ductal fistulas have been enumerated and the poorer prognosis of the ductal fistulas, especially of the proximal part, is emphasized. Two-thirds of the fistulas were iatrogenic. Malignancy and oral leucoplakia were unusual causes. Direct duct suture is rarely successful. Ablative surgery carries a significant risk of facial nerve injury. A wide choice of treatment exists for glandular and distal duct fistulas, while for the proximal duct injuries excision is usually necessary. A new alternative operation of vein grafting for such cases is described. Successful closure is obtained in only 50 per cent of patients with long standing fistulas with any method of treatment.

The use of myocutaneous flaps in block dissections of the groin in cases with gross skin involvement

Various myocutaneous flaps (upper sartorius, upper gracilis and lower rectus abdominis) have been used in a series of 17 block dissections of the groin with gross skin involvement. Only one of these flaps developed appreciable necrosis. The sartorius flap is restricted in its application for anatomical reasons. The rectus abdominis flap can only be used from the opposite side in unilateral cases, though it does appear to be the most dependable flap. The gracilis flap appears to be the most suitable for the majority of the patients who usually present with bilateral involvement of the lymph nodes and skin.

Amoebic ulcer of the penis

This is a report of a rare entity—an amoebic ulcer of the penis. The gross loss of glans and terminal urethra was repaired by a new technique using an island based anterolateral dartos flap.

Postoperative arm positioning after mastectomy and other procedures in the pectoral region

Mastectomy is the commonest operative procedure in the pectoral region. Other procedures include raising of deltopectoral or pectoralis major myocutaneous flaps. Proper postoperative positioning allowing the least tension on the wound and a primary closure without a skin graft is desirable. An attempt was made to mathematically quantify the effect of various arm positions on skin tensions over the axilla, the chest wall and the cervico-thoracic region. It was found that the position of 90 degrees flexion at the shoulder with 90 degrees flexion of the elbow with the hand pointing across or cephalically, on alternate days, was the most suitable. This position does not compromise movements at the shoulder.

The use of preputial skin to replace conjunctiva and to correct ectropion

The prepuce can provide a large amount of soft delicate skin suitable for replacement of lost conjunctiva or in the surgical treatment of ectropion. Three typical examples of its uses are described: two of ectropion following burns and one case with a carcinoma of the conjunctive which was excised and replaced with a free graft from the inner lining layer of the prepuce.

Primary closure of excisional defects of the breast with local flaps: a problem in the treatment of advanced carcinoma of the breast in developing countries

Large, advanced, fungating breast tumours are a special problem in developing countries. The surgical treatment is often confined to rescue and relief and primary closure of the excisional defect is highly desirable. Split-skin grafts are often unsatisfactory for many reasons. Full thickness local flaps, cut as thickly as possible, give the best results and the "sheet anchor" in skin cover is the medially based deltopectoral flap. Myocutaneous flaps can be useful in treating low inner quadrant growths and lesions which leave no room for a deltopectoral flap.

Epidermal cysts - a clinicopathological and biochemical study

The findings of a clinicopathological and biochemical study of epidermal cysts and a review of the relevant literature are presented. A punctum was found in 40% of 34 epidermal cysts that were studied in detail. The findings of the histological study were in favour of the punctum being the orifice of an obstructed hair follicle from which at least a proportion of the epidermal cysts are likely to develop. The biochemical analysis of the contents of the cysts revealed a very low protein and lipid content, thus ruling out any "sebaceous' contribution. Bacteriological study of clinically inflamed cysts showed that inflammation in these lesions was usually aseptic unless there was a communication between the cyst cavity and the exterior.

Non-chromaffin, non-functioning retroperitoneal paragangliomas: a report of three additional cases with a review of the literature

A review of the literature has revealed only 24 cases of retroperitoneal non-functional paraganglioma recorded up to the present date. This report presents three additional cases, in two of which metastasis had occurred at the time of surgery. The clinical presentation and the biological behaviour of these tumours are reviewed in detail, as also are recommendations regarding therapy.