Final Histopathology Report Research Articles

Should we prioritise proper surgical staging for patients with Atypical endometrial hyperplasia (AEH)? Experience from a single-institution tertiary care oncology centre

ObjectiveThe study aimed to evaluate the incidence of concurrent endometrial cancer (EC) and lymph node positivity in patients with Atypical Endometrial Hyperplasia (AEH) who underwent surgical staging with sentinel lymph node evaluation. It also sought to identify the risk factors associated with detecting concurrent endometrial cancer in patients with a preoperative diagnosis of AEH. Study designA retrospective study was conducted at Amrita Institute of Medical Sciences, involving 54 cases of AEH diagnosed on pre-operative biopsy specimens and undergoing staging surgery between January 1, 2015, and December 31, 2020. The study analysed demographic parameters, clinical presentations, pathological features, and clinical outcomes. Categorical variables were expressed in numbers and percentages, normal distribution data were presented as mean, and non-normal distribution data were presented as median and range. ResultsFifty-four patients diagnosed with AEH underwent surgical staging. The median age was 54 years. Final HistoPathology Report (HPR) showed 48.14 % with AEH and 51.85 % with concurrent EC. Among those with concurrent EC, 96.4 % had type I EC, and one patient was upgraded to type 2 EC. Among them, 17.8 % patients belonged to high-intermediate and high-risk categories. Patients with AEH and concurrent EC were more likely to be diabetic (OR: 3.56, p = 0.04), have a BMI ≥25 kg/m2 (OR: 1.47, p = 0.04), exhibit a thickened endometrial lining of ≥9 mm (OR: 3.13, p = 0.05) on ultrasound, and undergo preoperative biopsy at a non-oncology centre (OR: 8.33, p = 0.001) whereas experiencing heavy menstrual bleeding had a substantially lower likelihood (OR: 0.29, p = 0.01) of developing concurrent EC. ConclusionThe study revealed that more than half of patients undergoing staging surgery for AEH were found to be at risk of having concurrent EC in their final HPR. The research also pointed out that surgical staging can help identify both low-risk and high-risk ECs, which may require additional treatment. Higher BMI, diabetes mellitus, and an endometrial thickness of ≥9 mm were identified as significant risk factors for concurrent EC. Additionally, heavy menstrual bleeding was associated with a decreased risk of concurrent EC.

MiNEN of base of tongue - first case report in literature.

Mixed neuroendocrine and non-neuroendocrine neoplasms (MiNENs) refer to a heterogenous group of rare neoplasms which is usually composed of a neuroendocrine population which is either well differentiated and more frequently poorly differentiated along with a non-neuroendocrine component, each of the above accounting for at least 30% of the tumour population. It is most commonly seen in the gastro-entero-pancreatic tract. MiNENs have an aggressive behaviour due to its high grade neuroendocrine component and have poor prognosis. This is the first case reported in literature of a MiNEN in the oropharynx. 69 year old male patient with no co morbidities presented to the outpatient department with complains of odynophagia for 1 month. He had history of neoadjuvant chemotherapy followed by transoral robotic surgery (TORS) with right selective neck dissection (SND) done in 2019 for carcinoma base of tongue. On flexible laryngoscopy, an ulcerative lesion was noted over the left base of tongue. Although PET scan done showed no significant abnormalities. Biopsy from the lesion showed features of poorly differentiated carcinoma along with morphological features of poorly differentiated neuroendocrine carcinoma (small cell carcinoma). He was planned for upfront surgery (TORS with left SND). Post operatively recovery was uneventful and patient was on ryles tube feed for 12 days. Final histopathology report showed features of mixed neuroendocrine non neuroendocrine neoplasm. He has been on follow up for 1 year with no features of recurrence. MiNEN is an aggressive tumour which has poor prognosis and is most commonly located in the gastrointestinal tract. This is the first case reported in oropharynx who has been successfully treated and has been on follow up.

Assessment of the diagnostic efficacy of radiological and functional evaluation of primary adrenal mass and its' surgical outcomes.

Objective of this study was to assess the diagnostic efficacy of the most commonly used radiological evaluation in form of contrast enhanced computed tomography of abdomen with adrenal protocol, basic functional evaluation and surgical outcomes of primary adrenal masses. We have retrospectively analysed the institutional records of 108, patients admitted from August 2017 to September 2023, who had underwent surgical intervention for their adrenal mass after thorough evaluation and stabilization. Flank pain was the most common symptoms in 44 (40.74%) patients. Non-functional adrenal adenoma was found in 36 (33.33%) patients. Pheochromocytoma was the most the common functional adrenal mass found in 24 (22.22%) patients. CECT abdomen had suggested features of malignancy in 16(14.81%) patients. In final histopathological report 26(24.07%) patients had pheochromocytoma and 12 (11.11%) patients had adrenocortical carcinoma. CECT abdomen had sensitivity of 75%, specificity of 95.6%. Plasma free metanephrines and normetanephrine analysis had shown sensitivity of 90%, specificity of 92.86%, aldosterone to renin ratio had sensitivity of 92%, specificity of 100%. Sensitivity and specificity of the low-dose dexamethasone suppression test and plasma dehydroepiandrosterone was 100% in our study. Eighty patients (74.07%) were operated with laparoscopic adrenalectomy, 20 (18.52%) patients with open adrenalectomy. Eight patients (7.41%) were converted from laparoscopic to open. Laparoscopic approach had significantly lesser mean operating time, lesser blood loss, lesser hospitalization and lesser post-operative complications. Radiological analysis and functional analysis has shown good sensitivity and high specificity. Laparoscopic approach has advantage of lesser operative time, lesser hospitalization and lesser post-operative complications.

Giant Bowen’s disease of anterior abdominal wall with invasive squamous cell carcinoma-A rare case report

A 65 years old male presented to the out-patient department of Dermatology with complaints of a large verruco-erosive lesion on left anterior abdominal wall for 15 years. A wedge incision biopsy was done which showed features of Bowen’s disease. The patient was referred to department of General Surgery where a complete excision was done. The final histopathology report confirmed the diagnosis of Bowen disease with a focus of invasive carcinoma component. This case report is unusual for its clinical presentation, duration and location of the lesion.

An Audit of Intraoperative Frozen Section at a Tertiary Care Center

ABSTRACT Background: Frozen section (FS) is an important diagnostic tool for intraoperative decision-making. Audit of FS is an integral aspect of qualitative measure of pathology services. The aim of the study was to correlate FS diagnosis with final diagnosis and study diagnostic accuracy. Materials and Methods: The study was conducted for a period of 12 months from July 1, 2021, to June 31, 2022, at a tertiary care center. A total of 122 consecutive frozen cases were studied retrospectively. The FS and corresponding formalin-fixed paraffin-embedded tissue section with their final histopathological examination reports were studied and analyzed. The results were analyzed as concordant and discordant rates, which were compared with other similar studies. Reasons for discordance were discussed. Results: The patients were in the age range of 3 months to 87 years with a male:female ratio of 1.1:1. The turnaround time from receipt of sample to release of frozen report ranged from 10 to 40 min (average = 20 min). Indications of FS were for primary diagnosis of lesion (n = 66), resection margin assessment (n = 41), lymph node assessment (n = 12), and assessment of donor liver tissue (n = 3). Maximum number of specimens were from the surgery department, and the most commonly sampled site was oral cavity. The concordance and discordance rates were 95.90% and 4.10%, respectively. Conclusion: Intraoperative FS diagnosis aids in proper surgical decision-making and management. Periodic audit of FS and analysis of discrepancies is important to avoid mistakes in FS diagnosis.

A rare case of an aggressive polymorphous adenocarcinoma of minor salivary gland in the retro-maxilla

Abstract Polymorphous adenocarcinoma (PAC) is a low-grade malignant tumour of minor salivary glands of the oral cavity, which rarely presents with invasive features. Low metastatic and excellent survival rates are some of its favorable features. A 36-year-old woman reported with swelling, pain, and mobility of teeth in the left upper inner cheek region. Contrast enhanced computed tomography (CECT) revealed a large, lobulated, heterogenous mass in the left retro-maxillary region with a few enlarged left cervical lymph nodes (levels IB and II). After surgery, the final histopathology report gave a definitive diagnosis of PAC with certain invasive characteristics – perineural invasion, infiltration into skeletal muscle, and depth of invasion of 10 mm, which recurred in a different location 1.5 years later. A few predictable features of PAC include incidence in elderly women, asymptomatic presentation, occurrence in the posterior hard of soft palate, very low incidence of nodal or distant metastases, perineural spread, skeletal muscle infiltration, and low rates of recurrence with good survival outcomes. However, in our case, the patient appeared to present with a relatively aggressive form of PAC, considering her young age, symptomatic presentation, uncommon anatomic location in the retro-maxilla, cervical nodal metastasis, perineural and skeletal muscle infiltration, and local recurrence within a short period. Although PAC is a low-grade tumour with excellent prognosis, it may occasionally present with invasive characteristics, and early diagnosis and prompt management with strict adherence to post-operative regimens and follow-up is of prime importance to prevent any untoward outcomes.

BRAF Detection in FNAC Combined with Semi-Quantitative 99mTc-MIBI Technique and AI Model, an Economic and Efficient Predicting Tool for Malignancy in Thyroid Nodules.

Technology allows us to predict a histopathological diagnosis, but the high costs prevent the large-scale use of these possibilities. The current liberal indication for surgery in benign thyroid conditions led to a rising frequency of incidental thyroid carcinoma, especially low-risk papillary micro-carcinomas. We selected a cohort of 148 patients with thyroid nodules by ultrasound characteristics and investigated them by fine needle aspiration cytology (FNAC)and prospective BRAF collection for 70 patients. Also, we selected 44 patients with thyroid nodules using semi-quantitative functional imaging with an oncological, 99mTc-methoxy-isobutyl-isonitrile (99mTc-MIBI) radiotracer. Following a correlation with final histopathological reports in patients who underwent thyroidectomy, we introduced the results in a machine learning program (AI) in order to obtain a pattern. For semi-quantitative functional visual pattern imaging, we found a sensitivity of 33%, a specificity of 66.67%, an accuracy of 60% and a negative predicting value (NPV) of 88.6%. For the wash-out index (WOind), we found a sensitivity of 57.14%, a specificity of 50%, an accuracy of 70% and an NPV of 90.06%.The results of BRAF in FNAC included 87.50% sensitivity, 75.00% specificity, 83.33% accuracy, 75.00% NPV and 87.50% PPV. The prevalence of malignancy in our small cohort was 11.4%. We intend to continue combining preoperative investigations such as molecular detection in FNAC, 99mTc-MIBI scanning and AI training with the obtained results on a larger cohort. The combination of these investigations may generate an efficient and cost-effective diagnostic tool, but confirmation of the results on a larger scale is necessary.

Clinical and Pathological Predictors of Recurrent Breast Cancer

Objectives: Recurrence of breast cancer is common. There are reported risk factors for recurrence which are patient age, tumor size, tumor grade, (lymph vascular invasion (LVI), extensive intraductal component (EIC), and margin status. Nodal involvement also contributes to the recurrence rate as well as hormonal status, and if the patient receives neoadjuvant/adjuvant therapy or not. The aim of this study is to look for the clinical and pathological predictors of patients who have recurrent breast cancer after surgical treatment. Methods: We conducted a retrospective cohort study at one center (Royal hospital) between 2010 to 2020 for patients who were treated surgically for nonmetastatic breast cancer. We collected the clinical which was mainly the age at the diagnosis and pathological predictors (final histopathology report of the surgical specimen) from the medical records system of the hospital after obtaining the ethical approval. Total sample size was 270 Omani patients. The primary endpoint was the time to locoregional recurrence or systemic recurrence as the first event. A multivariate analysis of the predictors was carried and a P-value of < 0.05 was considered statistically significant with 95% CI. Results: Out of 270 patients with breast cancer who were surgically treated, 113 had recurrence and 157 had no recurrence. There were 104 patients with recurrence have invasive ductal carcinoma (IDC) and 9 patients with high-grade ductal carcinoma in situ (DCIS). The Mean age of patients with recurrence was 44.0 while in patients without recurrence was 48.3. The difference in age between the two groups is not statistically significant in predicting the recurrence (p = 0.816). ER, LVI, EIC, nodal involvement, grade, margin, and type of tumor were the significant predictors of recurrence by bivariate analysis. However, High grade (Hazard ratio (HR) = 3.823, 95% CI: 1.104-13.240; p = 0.034), EIC (HR = 17.407, 95% CI: 1.538-196.999; p = 0.021), and nodal involvement (HR = 2.314, 95% CI: 1.123-4.767; p = 0.023) remain the significant predictors for recurrent breast cancer in the multivariate Cox regression analysis. By using Kaplan-Meier, the median survival time was 132 months and the recurrence-free survival at two years was 88.0% (The recurrence rate = 12.0%). Conclusions: High grade, extensive intraductal component, and nodal involvement are significant predictors for breast cancer recurrence. The recurrencefree survival at 2 years is 88.0%. Our recommendation is a close follow-up for patients with these predictors.

ROLE OF ULTRASONOGRAPHY IN RESPONSE ASSESSMENT FOLLOWING NEOADJUVANT CHEMOTHERAPY IN LOCALLY ADVANCED BREAST CARCINOMA: EXPERIENCE FROM A TERTIARY CARE CENTER

Objective: Neo-adjuvant chemotherapy (NACT) has a pivotal role in the treatment of locally advanced breast carcinoma (LABC). In this study, we assess the efficiency of ultrasound in the response assessment of NACT in patients with LABC using RECIST criteria and its correlation to the final histopathological report. Methods: 40 patients with LABC underwent clinical examination and ultrasonography (USG) of the bilateral breast and axilla before starting NACT. After receiving three cycles of NACT, a repeat USG and clinical examination were done to assess the response to chemotherapy. Patients with responsive disease underwent radical surgery, and we correlate the findings of histopathological examination (HPE) with those of post-NACT USG findings. Results: After three cycles of NACT, clinical examination showed a complete response in 15 (37.5%) patients and a partial response in 21 (52.5%) patients. While USG detected a complete response in 8 (20%) patients and a partial response in 28 (70%) patients, seven patients, in whom clinical examination did not find any disease, were detected by USG. HPE showed a complete pathological response in 5 specimens, and in the rest of 31 cases, HPE revealed a residual tumor. USG did not miss any of the pCR cases but overestimated CR cases by 9% (3 patients). On the other hand, all partial response diagnoses by USG were acknowledged by HPE. Conclusion: To conclude, it can be said that USG can be used as an effective radiological tool for response assessment and subsequent treatment decisions, especially in places where there is a lack of infrastructure and affordability.

The Incidence of Thyroid Cancer in Bethesda III Thyroid Nodules: A Retrospective Analysis at a Single Endocrine Surgery Center.

Fine-needle aspiration cytology (FNAC) is widely used to diagnose and monitor thyroid nodules. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is the standard for interpreting FNAC specimens. The risk of malignancy in Bethesda III nodules, also known as Atypia of Undetermined Significance (AUS), varies significantly throughout several studies published worldwide. This retrospective study examines the risk of cancer in thyroid FNAC categorized as Bethesda III as identified in the final histopathology of thyroidectomy specimens at a single endocrine surgery center. This retrospective cohort analysis included 1038 consecutive patients who underwent elective thyroid surgery with complete follow-up data between January 2020 and March 2024. Preoperative data on clinical and pathological characteristics have been collected. The final histopathology report from the thyroidectomy specimen was compared to the results of the preoperative FNAC on nodules that were judged to be Bethesda category III. Statistical methods were performed using SPSS version 29. A total of 670 ultrasound-guided FNACs (64.5%) performed during the study period were included in the final analysis. The study population was predominantly female, represented by 79.6% of patients with a mean age of 42.5 (SD 12.1), while 20.4% were male and significantly older with mean age of 45.13 years (p = 0.02). The FNAC inadequacy rate was 5.1%, which was associated with a high risk of malignancy (6 out of 34; 17.6%). Out of the total sample size of 170 patients classified as group III, 57 were found to have malignancies in final surgical histopathology, representing 33.5% of the cases within this category. The secondary gender-related outcome analysis showed that female patients classified under the Bethesda II category had a significantly higher risk of malignancy, with a rate of 21.2%, compared to males who had a malignancy rate of 3.4% in the same Bethesda category (p = 0.001, chi-square test). However, the female patients exhibited prognostically superior non-invasive tumors compared to male individuals (p = 0.02, chi-square test). This study's results indicate that Bethesda categories II and III are associated with a higher risk of malignancy in comparison to the reports of the first and third editions of the TBSRTC, particularly for female patients classified under category II.

Abstract PO2-28-11: How to improve margins in breast cancer surgery: a

Abstract Objective: Intraoperative specimen mammography (ISM) is a diffuse technique that allows surgeons to check specimens immediately after lumpectomy, instead of intraoperative frozen sections, definitely abandoned. in Italy and Europe, because it is regarded as too expensive and time-consuming examination. Although the specimen is slightly compressed, the radiological image can be distorted by tissue overlap, and this may affect the evaluation of tumor borders, resulting in extension of the lumpectomy. As ISM may be less precise due to inadequate compression, a vacuum effect was applied to the specimen to increase the precision of margin detection. Study design: This study was conducted at St. Anna Hospital Breast Unit, Turin, Italy. Women who underwent lumpectomy for cancer were eligible for inclusion. BCS resection was performed with a free margin, and the surgical specimen was imaged immediately by SSM and evaluated by an expert radiologist and surgeon.Inclusion criteria were: breast cancer detected by a screening test, and treatment with surgical lumpectomy. Both standard ISM (sISM) and vacuum ISM (vISM) were performed. A dedicated breast surgeon at the study institution performed both surgery and radiological scans, and their interpretation. A dedicated radiologist reviewed all of the images. ISM was performed by a digital specimen mammography system (Faxitron, Bioptics Inc., Tucson, AZ, USA) in the operating room. Specimen registration and ISM analysis took 3 min. sISM (two orthogonal projections) was performed. Specimens were sealed in plastic bags in the vacuum apparatus (TissueSAFE Milestone Medical, Sorisole, Italy); this process took a few seconds. 152 specimens obtained after lumpectomy from 1 April 2021 to 31 April 2022 were scanned. sISM (two orthogonal projections) was performed. Next, the specimen was placed in a vacuum bag, and vISM was performed. Additional tissue was removed if the surgeon considered that excision was inadequate. Finally, the specimen was sent for definitive histopathological analysis, which is the gold standard for the assessment of surgical margins. Intraoperative histological margin assessment was not performed. The sISM and vISM images and final histopathology reports were compared. A first experience on a limited number of patients to demonstrate feasibility of the technique, is reported in table 1 and 2. Results: For sISM, specificity was 43,85% [95 % confidence interval (CI) 35.96-51.73], sensitivity was 40.91% (95 % CI 33.09-48.73), positive predictive value (PPV) 10.98% (95 % CI 6.01-15.95) and negative predictive value (NPV) 81.43% (95 % CI 75.25-87.61). For vISM, specificity 92,31% (95 % CI 88,07-96.54), sensitivity 72.73% (95 % CI 65.65-79.81), PPV 61.54% (95 % CI 53.80-69.27) and NPV 95.24% (95 % CI 91.85-98.62). Conclusion: ISM is a valid, safe and quicker alternative to intraoperative histopathological study, but has been reported to be limited due to less compression than standard SSM. Consequently, ISM may result in a high percentage of false-positive results, meaning unnecessary wider resections that lead to increased operative times and worse aesthetic results. A vacuum effect was performed on the specimen to increase the precision of margin detection. vISM images seem to be easier to interpret than sISM images (Figs. 1–3) as they are characterized by a vacuum-created radiolucent rim that better defines the tumor margins. These data suggest that the vacuum technique is feasible, cost-saving and yields results that are similar to those from frozen sections but without the limitations, such as prolonged operating time, high variability in sensitivity due to pathologists abilities, risk of compromising the histology, and unreliability for small lumps and ductal carcinoma in situ. Keywords: Breast cancer; Intraoperative mammography; Lumpectomy; Specimen mammography; Vacuum intraoperative mammography. Table 1. Clinical Data IC, invasive cancer; DCIS ductal carcinoma in situ; ADH, atypical ductal hyperplasia; ILC, invasive lobular cancer; B3, lesions of uncertain malignant potential; IMPC, invasive micropapillary carcinoma; NST, no special type; sISM, standard intraoperative specimen mammography; vISM, vacuum intraoperative specimen mammography. ª Margin: 0, involved; 1, free Table 2. Figure 1 - 2 - 3 Standard intraoperative specimen mammography (left) and vacuum intraoperative specimen mammography (right). Citation Format: Maria Grazia Baù, Vincenzo Marra, Alessandra Surace, Donatella Tota, Maria Piera Mano, Aurelia Mondino, Alessandro Bottero, Elisabetta Robba. How to improve margins in breast cancer surgery: a [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-28-11.

Clinicopathological Outcome of Early and Late Onset Renal Cell Carcinoma: An Observational Study

ABSTRACTIntroduction Renal Cell Carcinoma (RCC) is considered a disease of old age and is typically found in the 6th-8th decade of life. The diagnosis of RCC is increasing more rapidly in younger age patients. This study was conducted to evaluate the clinicopathological pattern and outcome of early onset RCC and compare them with the older age group patients.MethodsThis was a single center retrospective observational study. All the patients undergoing radical or partial nephrectomy during the period of November 2019 to October 2022 for renal masses and whose final histopathology report showed RCC were included in the study. Clinicopathological patterns and outcome were compared between the two age groups.ResultsAmong 47 patients, 17 (36.2%) patients were at or below the age of ≤46 years and 30 (63.8%) patients in older age group. There was significant difference in male (29): female (18) ratio between the two age groups (p < 0.005). Younger age patients (≤46 yrs) had higher stage of disease at presentation compared with the older age (>46 yrs) patients [tumor extension into major veins and perinephric tissue (T3) and above 26 vs 21] and they had significantly higher mortality rate (29.4% vs 3.33%, p =0.010).ConclusionPatients aged ≤46 years of age were more frequently affected by RCC with female predominance. Younger age group had higher stage of disease at presentation with higher mortality in comparison to older age group.KeywordsClinicopathological; early onset; late onset; renal cell carcinoma

Accuracy of ultrasound in predicting thyroid malignancy: a comparative analysis of the ACR TI-RADS and ATA risk stratification systems.

Thyroid nodules are very common in clinical practice, and ultrasound has long been used as a screening tool for their evaluation. Several risk assessment systems based on ultrasonography have been developed to stratify the risk of malignancy and determine the need for fine-needle aspiration in thyroid nodules, including the American Thyroid Association (ATA) system and the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS). The aim of this study was to compare the performance of the ATA and ACR TI-RADS systems in predicting malignancy in thyroid nodules based on the nodules' final histopathology reports. We performed a retrospective review of medical records to identify patients who underwent thyroid surgery at King Abdulaziz University from 2017 to 2022. The ultrasound features of the nodules with confirmed histopathology (benign versus malignant) were evaluated. Both ATA and ACR TI-RADS scores were documented. The analysis included 191 patients who underwent thyroid surgery and fulfilled the inclusion criteria. Hemithyroidectomy was performed in 22.5% of the patients, and total thyroidectomy was performed in 77.0% of them. In all, 91 patients (47.6%) were found to have malignant nodules on histopathology. We then compared the histopathology reports with the preoperative ultrasonographic risk scores. The estimated sensitivity and specificity in identifying malignant nodules were, respectively, 52% and 80% with the ATA system and 51.6% and 90% with the ACR TI-RADS system. Both ATA and ACR TI-RADS risk stratification systems are valuable tools for assessing the malignancy risk in thyroid nodules. In our study, the ACR TI-RADS system had superior specificity compared with the ATA system in predicting malignancy among high-risk lesions.

Synchronous early rectal adenocarcinoma and neuroendocrine tumour: A treatment strategy

IntroductionSynchronous colorectal adenocarcinoma with neuroendocrine tumour (NET) are a unique combination of tumours. These may be incidental lesions, usually a histopathological diagnosis rather than a clinical diagnosis from symptoms, examination or even gross appearances.AimThis paper aims to highlight our management strategy on manging a middle-aged woman with synchronous rectal adenocarcinoma and NET.Case studyA 53-year-old woman presented with lower gastrointestinal bleeding with constitutional symptoms. Clinical examination and colonoscopy revealed a classical rectal adenocarcinoma, confirmed via biopsy. However, the final histopathology reports of the resected tumour revealed an early rectal adenocarcinoma with synchronous NET.Results and discussionWe review the relevant literature and a discussion regarding guidelines available for diagnosis, follow-up and surveillance of this rare case.ConclusionsThere are no current guidelines for surveillance colonoscopy after detecting gastrointestinal NET, particularly synchronous tumours. NET may be another colorectal cancer risk factor with similar mutations and common genetic markers. Clinicians should consider doing a colonoscopy when or if their patients are diagnosed with any gastrointestinal NET. Detection of any NET warrants a thorough evaluation of the whole colon for colorectal cancer and close surveillance so that timely management can be achieved.

Primary Malignant Melanoma of Tongue: Rare and Aggressive Malignant Tumor.

Primary melanoma of the oral cavity is extremely rare, accounting for 0.2-8% of all melanomas. Lesions arising from mucosal melanocytes occur most frequently on the gingiva or palate. Mucosal melanomas carry a worse prognosis than cutaneous melanomas. Very few studies have been published due to rarity of disease. 46 year old lady presented with black colored lesion over left side of her tongue for 6 weeks. On examination there was 3 × 2.5cm black colored patch over left lateral part of tongue in middle 1/3rd, not crossing midline. Tip and base of tongue were free. Biopsy was suggestive of malignant melanoma of tongue. Patient underwent surgery (wide local excision of left lateral border of tongue lesion + left selective neck dissection). Final Histopathological report revealed malignant melanoma of tongue with all margins free, Depth of invasion 3mm, Lympho-vascular invasion present, and no perineural invasion, left level III cervical lymph node metastases. Patient thus received adjuvant RT. Immunotherapy was also advised in multidisciplinary clinic, but patient was non-compliant. Early diagnosis will be promoted by careful oral examination and early biopsy of pigmented and non-pigmented masses. Early diagnosis and treatment will improve the prognosis of patients with oral malignant melanoma.

Robotic Pancreaticoduodenectomy with 'SMA-First Approach (Posterior and Right Medial)' and 'Triangle Operation'.

Notable improvements in pancreatic cancer surgery have been due to utilization of the superior mesenteric artery (SMA)-first approach1 and triangle operation (clearance of triangle tissue between origin of SMA and celiac artery).2 The SMA-first approach was originally defined to assess resectability before taking the irreversible surgical steps. However, in the present era, resectability is judged by the preoperative radiology, and the benefit of the SMA-first approach is by improving the R0 resection rate and reducing blood loss. The basic principle is to identify the SMA at its origin and in the distal part, to guide the plane of uncinate dissection. This video demonstrates the combination of the posterior and right medial SMA-first approach along with triangle clearance during robotic pancreaticoduodenectomy (RPD). The technique consisted of early dissection of SMA from the posterior aspect, by performing a Kocher maneuver using the 'posterior SMA-first approach'. The origin of the celiac artery, along with the SMA, was defined early in the surgery. During uncinate process dissection, the 'right/medial uncinate approach' was used to approach the SMA. 'Level 3 systematic mesopancreatic dissection' was performed along the SMA,3 culminating in the 'triangle operation'.2 RESULTS: The procedure was performed within 600min, with a blood loss of 150mL and no intraoperative or postoperative complications. The final histopathology report showed a moderately differentiated adenocarcinoma (pT2, pN2), with all resection margins free. The standardized technique of the SMA-first approach and triangle clearance during RPD is demonstrated in the video. Prospective studies should further evaluate the benefits of this procedure.

Neuroendocrine tumor of the appendix masquerading as acute appendicitis with a mucocele on CT scan: a rare finding

IntroductionNeuroendocrine tumors (NETs) of the appendix are rare and are often discovered incidentally during surgery for acute appendicitis or other unrelated conditions (Modlin et al. in Gastroenterology 128:1717–1751, 2005, Alsaad et al. in Oncol Rep 16:1105–1109, 2006, Frilling et al. in Lancet Oncol 15:e8–e21, 2014). These tumors can range from asymptomatic incidental findings to clinically significant tumors with metastases (Alsaad et al. in Oncol Rep 16:1105–1109, 2006, Gomes et al. in World J Emerg Surg 10:60, 2015, Paiva et al. in Eur J Cancer 38:702–705, 2002, Burke et al. in Am J Surg Pathol. 9:661–674, 1985). This case report presents a rare case of a NET of the appendix presenting as acute appendicitis.Case descriptionA 23-year-old male presented with right lower quadrant abdominal pain, nausea, and vomiting for 2 days. A CT scan revealed a mucocoele of the appendix. The patient underwent laparoscopic appendectomy, and the appendix was sent for histopathological examination. The final pathological report confirmed a NET of the appendix with a Ki-67 index of 1% and no lymphovascular invasion. Due to tumor invasion to the cecum and its large size (3–4 cm), the patient underwent right hemicolectomy. The final histopathology report of the resected specimen confirmed the diagnosis of NET of the appendix.DiscussionThe clinical diagnosis of NETs of the appendix can be challenging due to their rarity and non-specific presentation. Symptoms of NETs of the appendix can mimic those of acute appendicitis, making it difficult to differentiate between the two conditions. Imaging studies, such as CT scans, can provide valuable information about the size and location of the tumor (Gomes et al. in World J Emerg Surg 10:60, 2015, Maggard et al. in Ann Surg 240:117–122, 2004, Burke et al. in Am J Surg Pathol. 9:661–674, 1985, Frilling et al. in Lancet Oncol 15:e8–e21, 2014). However, the definitive diagnosis is made through histopathological examination of the resected specimen. The treatment of NETs of the appendix depends on factors such as the size, location, and grade of the tumor. Small tumors confined to the appendix with no lymph-vascular invasion can be treated with appendectomy alone, while larger tumors or those that have spread beyond the appendix may require more extensive surgery, such as right hemicolectomy (Gomes et al. in World J Emerg Surg 10:60, 2015, Mestier et al. in Dig Liver Dis 52:899–911, 2020, Maggard et al. in Ann Surg 240:117–122, 2004, Burke et al. in Am J Surg Pathol. 9:661–674, 1985, Frilling et al. in Lancet Oncol 15:e8–e21, 2014, Pavel et al. in Neuroendocrinology 103:172–185, 2016). In some cases, additional treatments such as chemotherapy or radiation therapy may be recommended.ConclusionThis case report emphasizes the importance of considering NETs of the appendix in the differential diagnosis of acute appendicitis. Imaging studies can provide valuable information, but the definitive diagnosis is made through histopathological examination. The treatment approach for NETs of the appendix depends on various factors and requires a multidisciplinary approach for optimal management.

Clinico Pathological Study of Solitary Thyroid Nodule - A Prospective Study of 50 Cases.

Background: A common Presentation of thyroid disorder is solitary nodule. A discrete swelling in an impalpable gland is termed as solitary nodule of thyroid. The majority of solitary thyroid nodule are benign. The incidence of malignancy is more common in female with mean age 35 years. Timely intervention in nodular lesion of thyroid can significantly reduce morbidity and mortality.Objectives: The objective of this study was to evaluate the clinicopathological aspects of solitary thyroid nodule.Materials and Methods: This study was conducted in the department of otolaryngology and general surgery of Shaheed Monsur Ali Medical College and Hospital in 50 patients with Solitary Thyroid Nodule from July 2016 to July 2019. All the patients those who were diagnosed solitary thyroid nodule underwent thyroid surgery after through clinical evaluation, USG and FNAC. The histopathological reports were evaluated and correlated with clinical diagnosis and discussed.Results: Out of 50 patients’ majority were female only 8 were male patients. Peak incidence observed in the age group 30 to 40 years. Most of the patients presented with a swelling in front of neck 100% followed by pain 8%, dysphagia 4% and change of voice 4%. Swelling is located in the right lobe 70% followed by left lobe 26%. On FNAC examination they were presented with colloid nodular goitre 66%, follicular neoplasm 14%, thyroiditis 8%, papillary carcinoma 4% & cystic lesions 8%. But final histopathological report showed highest 30 (60%) cases was nodular goiter then follicular adenoma 10 (20%) and 6 (12%) were malignant.Conclusion: From this study we considered that STN is present most commonly in female. Most of them are benign, but remarkable proportion 12% of solitary thyroid nodule were malignant, so careful assessment of thyroid nodule is important for early diagnosis and treatment. KYAMC Journal Volume: 14, No: 03, October 2023: 161-164.

Role of Intraoperative Frozen Section Assessment of Proximal Bile Duct Margins and the Impact of Additional Re-Resection in Perihilar Cholangiocarcinomas.

Intraoperative frozen section (FS) analysis to assess the bile duct margin status is commonly used to assess the completeness of resection during surgery for perihilar cholangiocarcinoma (pCCA) resection. However, the impact of additional re-section on the long-term outcome after obtaining an initial positive margin remains unclear. Patients diagnosed as pCCA on preoperative imaging and subjected to curative intent surgery from May 2013 to June 2021 with a minimum follow-up of 2years were included. Intraoperative FS analysis of the proximal bile duct margin was performed in all patients. A positive margin was defined by the presence of invasive cancer. Out of the 62 patients with a preoperative diagnosis of pCCA on imaging, 35 patients were included for final analyses after excluding patients with inoperable disease (on staging laparoscopy or local exploration) and other/benign pathology on the final histopathology report. Out of the 35 patients, patients with postoperative 90-day mortality were excluded from the final survival analysis. FS analysis revealed an initial positive margin in 10 (28.5%) patients. Among 10 patients who underwent re-resection to achieve negative proximal margins, only 5 patients achieved a negative margin (secondary R0). An initial positive margin was associated with poor long-term outcomes. Median disease-free survival (DFS) and overall survival (OS) were 16 and 19.6months for patients with an initial positive margin, but 36 and 58.2months for patients with an initial negative margin, respectively (p = 0.012). The median DFS and OS were significantly lower for those with secondary R0 as compared to primary R0 (16 vs. 36months for DFS, p = 0.117 and 19.6 vs. 58.2months for OS, p = 0.027, respectively). An intraoperative FS positive proximal hepatic duct margin dictates poor long-term outcomes for patients with resectable pCCA. Additional resection has a questionable benefit on survival, when a secondary negative margin is achieved.

The Oncological Safety of Submental Flap Reconstruction in Head-and-Neck Cancers: An Extended Follow-up Study.

The oncological safety of a submental (SM) flap is thought to be controversial. The objective of our study was to validate our previous study regarding the oncological safety of SM flaps in oral cavity reconstruction. An electronic database was searched from 2015 to 2021 for all head-and-neck tumor patients, where reconstruction was performed using a SM flap. Eighty-eight oral cavity squamous cell carcinoma patients, among whom 71 were males (81.8%), with a mean age of 55.3 years (range: 25-79 years), were retrieved from the database. The sites of involvement were 37 buccal mucosa, 27 lower alveolus, and 24 tongues. The mean follow-up was 33.5 months. The SM flap reconstruction was done for 88 patients; 3 had complete loss of flap, 17 had incomplete loss/partial necrosis, and 68 patients had uneventful recovery of the flap. We had 16 patients with local recurrence. Of these, 4 (4.5%) patients had clear margins and no lymphadenopathy at the level I at the final histopathology report. This study provides validation of the oncological safety of the SM flap and establishes that nodal positivity at level I alone does not contribute to recurrence at the primary site.