Low Malignancy Rate Research Articles

Mixed Echoic Thyroid Nodules on Ultrasound: Approach to Management

PurposeTo evaluate malignancy risk according to ultrasound (US) features and size change on follow-up US in mixed echoic thyroid nodules and to suggest management guidelines thereof.Materials and MethodsAmong patients who underwent US-guided fine needle aspiration biopsy, 316 mixed echoic nodules in 303 patients were included after excluding the patients with pure solid or cystic nodules or without further cytopathologic evaluation. We evaluated malignancy risk according to US features and changes in size and shape on follow-up US.ResultsThe malignancy rate was 31.6% (6 of 19) for nodules with suspicious US features and 2.7% (8 of 297) for nodules without suspicious US features (p<0.001). Among 265 nodules with no suspicious US features and initial benign cytology, 15 nodules with suspicious US change and decreased size, 25 nodules with no suspicious US change and increased size, and 225 nodules with no suspicious US change and no change in size were observed on follow-up USs. The malignancy risk thereof was 0%, 0% and 0.4%, respectively (p=1.000).ConclusionMixed echoic nodules with no suspicious US features and benign cytology can be followed up using US, as they revealed very low malignancy rates, even if they showed growth on follow-up US.

Lower Malignancy Rates in Renal Allograft Recipients Converted to Sirolimus-Based, Calcineurin Inhibitor-Free Immunotherapy: 24-Month Results From the CONVERT Trial

Long-term immunosuppression imposes increased malignancy risk in renal allograft recipients, significantly contributing to overall morbidity and mortality. This study examined malignancy rates in renal allograft recipients at 2 years after conversion to a sirolimus (SRL)-based, calcineurin inhibitor (CNI)-free regimen. This open-label, randomized, multicenter study (the CONVERT Trial) randomly assigned 830 patients to SRL conversion (n=555) or CNI continuation (n=275). Patients with history of posttransplant lymphoproliferative disease or known/suspected malignancy within 5 years before screening were excluded. As part of standard safety measurements, subjects were monitored for any malignancy occurrence; both skin and nonskin malignancies were reported, even if the patient discontinued from the therapy. Malignancy rates were analyzed based on exposure time to study drugs (i.e., number of events per 100 person-years of follow-up). At 2 years postconversion, the total number of malignancies per 100 person-years of exposure was significantly lower among SRL conversion patients compared with CNI continuation (2.1 vs. 6.0, P<0.001). Patients undergoing SRL-based, CNI-free therapy had significantly lower rates of the subset of nonmelanoma skin carcinomas through 2 years postconversion (1.2 vs. 4.3, P<0.001). This difference persisted after excluding patients with a history of malignancy before randomization. The rate of all other malignancies was not significantly different between treatment groups (P=0.058). In renal allograft recipients, SRL-based immunosuppression was associated with a lower rate of malignancy at 2 years postconversion compared with continuation of CNI-based immunosuppression. This reduction was driven by a significant reduction in nonmelanoma skin carcinoma rates; the rate of all other malignancies was numerically lower but did not achieve statistical significance.

Use of BI-RADS 3–Probably Benign Category in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial

To determine (a) how often the Breast Imaging Reporting and Data System (BI-RADS) category 3 was used in the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST), either at the time of screening mammography or after work-up, (b) how often subjects actually returned for the recommended follow-up examination, and (c) the rate and stages of any malignancies subsequently found in subjects for whom short-term interval follow-up was recommended. This study was approved by the Institutional Review Board at all institutions where subjects were enrolled. All subjects participating in DMIST gave informed consent and the study was HIPAA-compliant. A total of 47,599 DMIST-eligible and evaluable subjects, all of whom consented to undergo both digital and screen-film mammography, were included in this analysis. Cases referred for short-term interval follow-up based on digital, screen-film, or both imaging examinations were determined. Compliance with the recommendations and the final outcome (malignancy diagnosis at biopsy or no malignancy confirmed through follow-up) of each evaluable case were determined. A total of 1114 of the 47,599 (2.34%) subjects had tumors assigned a BI-RADS 3 category and were recommended to undergo short-interval follow-up. In this study, 791 of 1114 (71%) of the subjects were compliant with the recommendation and returned for short-interval follow-up. Of the women who did not return for short-interval follow-up, 70% (226 of 323) did return for their next annual mammography. Among all subjects whose tumors were assigned a BI-RADS 3 category either at screening mammography or after additional work-up, nine of 1114 (0.81%) were found to have cancer. Of the nine biopsy-proved cancers, six were invasive cancers and three were ductal carcinoma in situ stage Tis-T1c. The invasive cancers were all less than 2 cm in size. In DMIST, radiologists used the BI-RADS 3 classification infrequently (2.3% of patients). Tumors assigned a BI-RADS 3 category had a low rate of malignancy. The relatively high rate of noncompliance with short-interval follow-up recommendations (323 of 1114, or 29%) supports prior recommendations that radiologists thoroughly evaluate lesions before placing them in this category.

Routine Evaluation of Adult Tonsillectomy Specimens

Tonsil excision is a common surgery for both children and adults. Prior studies have consistently shown that the rate of malignancy in tonsil specimens is low and that the possibility of true, occult malignancy is remote. Practice trends accept triage of pediatric tonsillectomies for exemption or gross exam only. However, for adults, despite a low malignancy rate, routine histological evaluation of tonsillectomy specimens is standard of care at most health care facilities. The authors performed a retrospective review of all tonsil specimens received in their department over 45 months with categorization of pathological diagnosis and surgical indication. Of 1746 adult tonsillectomy specimens removed during this time, there were no incidental/occult malignancies. These data indicate that gross examination of adult tonsillectomy specimens excised for chronic tonsillitis or sleep apnea is sound practice, and this, taken together with other published data, provides a basis for consensus-derived practice guidelines.

Systematic comparison of sporadic and syndromic pancreatic islet cell tumors

Pancreatic islet cell tumors (ICTs) occur as sporadic neoplasias or as a manifestation of multiple endocrine neoplasia type 1 (MEN1) and von Hippel-Lindau disease (VHL). Molecular classification of ICTs is mandatory for timely diagnosis and surveillance. Systematic comparison of VHL-ICTs and sporadic ICTs has been lacking. Our registry-based approaches used the German NET-Registry with 259 patients with neuroendocrine tumors (NETs), who were primarily diagnosed with NETs, and the German VHL-Registry with 485 molecular genetically confirmed patients who had undergone magnetic resonance imaging or computed tomography of the abdomen. All patients provided blood DNA for testing of the MEN1 and VHL genes for intragenic mutations and large deletions. In the NET-Registry, 9/101 patients (8.9%) with ICTs had germline mutations, 8 in MEN1 and 1 in VHL. In the VHL-Registry, prevalence of NETs was 52/487 (10.6%), and all were ICTs. Interestingly, of those with VHL p.R167W, 47% developed ICTs, compared to 2% of those with p.Y98H. In total, there were 92 truly sporadic, i.e. mutation-negative ICT patients. Comparing these with the 53 VHL-ICT patients, the statistically significant differences were predominance of female gender (P=0.01), multifocal ICTs (P=0.0029), and lower malignancy rate (P<0.001) in VHL-ICTs compared to sporadic cases. VHL was prevalent in <0.5% of NETs, while NETs occur in ∼10% of VHL, virtually exclusively as ICTs, which are rarely the first presentation. Patients with NETs should not be subjected to genetic testing of the VHL gene, unless they have multifocal ICTs, other VHL-associated tumors, and/or a family history for VHL.

Nephrectomy for multicystic dysplastic kidney and renal hypodysplasia in children: where do we stand?

Little is reported in literature regarding correct management of benign lesions of the kidney. The aim of our study is to present a series of total and partial nephrectomies performed in the last 5 years and to discuss indications. Patients with benign lesions who underwent nephrectomy and partial nephrectomy at our institution in the period 2003-2008 were retrospectively included in the study. Notes were carefully reviewed and demographic data, symptoms onset, preoperative diagnosis, investigations, medical and/or surgical treatment, postoperative complications and definitive histological reports were collected. Forty procedures were performed. Twelve patients were preoperatively diagnosed of having multicystic dysplastic kidney (MCDK), which was confirmed in 10, whereas the remaining 28 patients of having severe dysplasia or hypodysplasia. Thirty-four patients underwent total nephrectomy, six underwent partial nephrectomy. Histopathological analysis confirmed segmental or complete abnormalities of the involved kidney in all cases. No malignancies were detected. Our study confirmed the extremely low malignancy rate of MCDK and hypodysplastic kidneys. The 20% mismatch of pre- and post-operative diagnosis suggests a common aetiology and shared therapeutic strategies for MCDK and hypodysplasia. At present, there is no consensus regarding correct indications for nephrectomy in paediatric age. As nephrectomy seems not to provide any advantage over preservation, but surgical and anesthesiological risks, we should be prudent in preserving every asymptomatic poorly or non-functioning kidneys maintaining a strict follow-up. Randomised controlled studies on larger multicentric series are strongly warranted to define this topic.

The Incidence of Cancer Diagnosis Following Microdochectomy

The Incidence of Cancer Diagnosis Following Microdochectomy

Prevalence of malnutrition on admission to hospital – Acute and elective general surgical patients

Malnutrition is a common finding in elective general surgical patients on admission to hospital and is associated with greater postoperative morbidity, prolonged length of stay and higher cost of treatment. The situation in acute general surgical patients has not been clarified. The aim of the study was to investigate the prevalence of malnutrition in both acute and elective (scheduled admission) general surgical patients in a prospective cross-sectional study. Over an eight-week period 460 (310 acute, 150 elective) consecutive patients were recruited. The primary end point was nutritional status within 48 h of admission determined using the patient-generated subjective global assessment (PG-SGA) tool. Body mass index, upper arm circumference and triceps skin fold were measured and upper arm muscle circumference derived. Admission plasma albumin and total cholesterol, total lymphocyte count and grip strength were measured. Length of total hospital stay was recorded. In the acute setting 52% of patients were malnourished or at risk (including nearly half of those with a BMI greater than 25 kg/m2) compared to 38% of those who presented electively (P = 0.004). In the elective group, 66 (44%) patients presented with malignancy compared to 15 (5%) in the acute group (P < 0.001). Length of hospital stay increased significantly with worsening PG-SGA scores (P < 0.001 for both groups). Malnutrition risk was found to be highly prevalent in acute surgical patients despite having a much lower malignancy rate than elective surgical patients. Admission screening should be strongly advocated for both acute and elective patients.

Pathology of B3 lesions of the breast

Breast needle core biopsy is a widely used technique for evaluation of mammographic and clinical breast abnormalities, screen detected and symptomatic. The majority of biopsies can be coded as B2 (benign) or B5 (malignant). However, certain lesions merit a B3 designation, signifying ‘uncertain malignant potential’. This is a heterogenous group including atypical intraduct epithelial proliferation, lobular neoplasia, radial scar, papillary lesions and columnar cell change. Their common denominator is the low but significant rate of malignancy within the lesion or adjacent tissue, necessitating excision biopsy for full histological examination. In this article we review the morphology and biological significance of B3 entities.

Diagnostische Wertigkeit des Göttinger Scores zur Malignitätsvorhersage von ausschließlich in der MRT darstellbaren Mammaläsionen

To determine whether lesion scoring allows valid BI-RADS ((R)) classification and prediction of malignancy of breast lesions detectable solely with MRI. Retrospective analysis of 86 patients who underwent MRI-guided localization and excisional biopsy of 100 breast lesions detectable only with MRI. Breast MRI was performed at 1.5 Tesla by means of a T 1w dynamic GE sequence. The positive predictive value (PPV) for malignancy was calculated for each score criterion separately, for the total score, and for corresponding BI-RADS classes. The PPV was correlated with histology. 31% (31/100) of breast lesions detectable only with MRI were malignant. Of the single score criteria only the lesion morphology criterion was significantly correlated with malignancy. The malignancy rate according to the breast MRI score was 0% for score 3, 18.2% for score 4, 32.1% for score 5 and each 50% for lesions of score 6 and 7. After translation into BI-RADS the malignancy rates were 0% for BI-RADS 3, 24.6% for BI-RADS 4 and 48.5% for BI-RADS 5 lesions. The thus defined BI-RADS classes were significantly correlated with malignancy. The combination of different lesion criteria to form a total breast MRI score and its translation into BI-RADS is useful in case of lesions detectable only with MRI. It enables standardized BI-RADS classification with satisfying PPV of malignancy for each BI-RADS class. Because of their low malignancy rate (18.2%), we suggest classifying lesions with a breast MRI score of 4 points as BI-RADS 4a.

Pheochromocytoma and Extra-adrenal Paraganglioma: Updates

Advances in genetics and gene expression profiling have led to new ways of thinking about the pathobiology of pheochromocytoma and extra-adrenal paraganglioma. These developments are concurrent with the publication and dissemination of the 2004 World Health Organization bluebook on pathology and genetics of endocrine tumors. To summarize new information required by pathologists for effective participation in patient management and research. Literature review and primary material from Tufts Medical Center. The World Health Organization reserves the term pheochromocytoma for tumors arising from chromaffin cells in the adrenal medulla. Closely related tumors in extra-adrenal sympathetic and parasympathetic paraganglia are classified as extra-adrenal paragangliomas. A pheochromocytoma is an intra-adrenal sympathetic paraganglioma. Although arbitrary, this nomenclature emphasizes important distinctive properties of intra-adrenal tumors, including an often adrenergic phenotype, relatively low rate of malignancy, and predilection to occur in particular hereditary syndromes. Malignancy is defined by presence of metastases not local invasion. Occult germline mutations characteristic of familial syndromes are now found in more than 20% of patients with apparently sporadic tumors, bringing the percentage of tumors with a known genetic basis close to 30%. In addition, tumor location and risk of malignancy vary with the underlying genetic defect. The "10 percent rule" for pheochromocytoma/paraganglioma--10% familial, 10% malignant, 10% extra-adrenal--is therefore no longer tenable. Current roles of pathology are limited to diagnosing primary or metastatic tumors and identifying features suggestive of malignant potential or hereditary disease. Future roles may involve more definitive assessment of malignancy, genotype-phenotype correlation, and identification of targets for therapy.

Indeterminate or Suspicious Breast Lesions Detected Initially with MR Imaging: Value of MRI-directed Breast Ultrasound

To retrospectively determine the value of magnetic resonance imaging (MRI)-directed breast ultrasonography (US) in the evaluation of indeterminate or suspicious lesions identified on contrast-enhanced, breast MRI. A total of 395 patients presenting for breast MRI during a 4-year period was retrospectively reviewed. Seventy-one patients were recommended for MRI-directed US for further characterization of indeterminate or suspicious breast lesions detected on MRI. Fifty-five patients (all female; age 31-80 years) had US. Their MRI and US were reviewed and tested for correlations with histologic results or long term follow-up. Logistic regression analyses were used to test for associations between MRI lesion characteristics and US detection rate. US identified 46 of 97 (47%) lesions depicted at MRI from 55 patients (47 [85%] of these patients had histories of breast malignancies). Twelve cancers were found from the 97 lesions (12%). Biopsy was avoidable in 10 lesions (10%). The detection rate with US was slightly higher with "mass" (55% [23/42]) lesions described in MRI than "non-mass" lesions or lymph nodes (42% [23/55]). There was a significant positive association (odd ratio = 1.23: 95% CI = 1.05-1.43, P = .01) between US detection rate and MRI mass lesion size. There was no statistical significance between US detection rate and the presence of malignancies; 42% (5/12) of MRI malignant lesions were not visualized with US. MRI-directed US reduced the number of biopsies required for indeterminate or suspicious MRI lesions. Nevertheless, the lesions which were biopsied had a low rate of malignancy.

Pathology of Pheochromocytoma and Extra‐adrenal Paraganglioma

The 2004 WHO classification of endocrine tumors defines pheochromocytoma as a tumor arising from chromaffin cells in the adrenal medulla. Closely related tumors in extra-adrenal sympathetic and parasympathetic paraganglia are classified as extra-adrenal paragangliomas. A pheochromocytoma is an intra-adrenal sympathetic paraganglioma. While arbitrary, this nomenclature serves to emphasize important distinctive properties of intra-adrenal tumors that must be taken into account in clinical practice and research. Those include an often adrenergic phenotype, a relatively low rate of malignancy, and a predilection to occur in particular hereditary syndromes. Current roles of pathology are limited to distinguishing primary or metastatic pheochromocytomas/paragangliomas from other endocrine or nonendocrine tumors, and flagging tumors that show features suggestive of malignant potential or syndromic disease. Future roles may involve more definitive assessment of malignancy, genotype-phenotype correlation, and identification of targets for therapy. Pathology practice currently rests mostly on interpretation of conventional histological sections stained with hematoxylin and eosin, with variable ancillary application of immunohistochemical staining. Malignancy is currently defined by the presence of metastases, not local invasion. Local invasion alone is a poor predictor of metastases, and the absence of apparent invasion does not preclude development of metastases. The two types of aggressive behavior might therefore have different biological underpinnings, and those will be resolved most effectively if consistent terminology is employed. In order to be optimally informative, pathology reports must employ consistent nomenclature and incorporate standard elements. Templates or checklists for minimal standard reporting are recommended by several pathology associations, but identification of some recommended and optional elements is currently subjective or inconsistent.

The role of major duct excision and microdochectomy in the detection of breast carcinoma

BackgroundThe association of nipple discharge with breast carcinoma has resulted in numerous women undergoing exploratory surgery to exclude malignancy. The aim of this study was to determine whether pre-operative factors can identify those patients that are most at risk of carcinoma.MethodsAll patients over a 14-year period (1991–2005) who had a microdochectomy or subareolar exploration for the evaluation of nipple discharge were assessed. Patient characteristics, pre-operative imaging and pathological findings were analysed.ResultsOf the 211 patients included in this study, 116 patients had pathological (unilateral, uniductal serous or bloody) discharge. On excision, 6% (n = 7) of patients with pathological discharge and 2.4% (n = 2) of patients with non-pathological discharge were diagnosed with carcinoma. Overall, major duct excision resulted in the diagnosis of carcinoma in 4.3% (n = 9), ADH/LCIS in 4% (n = 8), papilloma in 39% (n = 83), and duct ectasia or non-specific benign disease in 53% (n = 111) of patients. In the patients determined to have malignancy, 44% (n = 4) were premenopausal. No patient with a non-bloody discharge in the total population analysed (28%; n = 59/211), or in the population with a pathological discharge (21%; n = 24/116) was found to have carcinoma upon excision.ConclusionMicrodochectomy or major duct excision performed for nipple discharge resulted in a low rate of malignancy on excision. Conservative management of non-bloody nipple discharge can be considered in patients with no other clinical or radiological signs of malignancy.

THYROIDECTOMY IS SAFE AND EFFECTIVE FOR RETROSTERNAL GOITRE

Retrosternal goitre was defined as any thyroid enlargement identified below the thoracic inlet at operation, with the patient's neck held in extension. The aim of this study was to determine the characteristics of the patients, the goitres, the surgery and its morbidity (including tracheomalacia, recurrent laryngeal nerve palsy and hypocalcaemia) and the incidence of malignancy in order to establish guidelines for managing patients with a retrosternal goitre. Data were collected prospectively on all thyroidectomies carried out by a single surgeon over 14 years. Patients underwent appropriate preoperative assessment and thyroidectomy was carried out using a standardized capsular dissection technique. There were 199 cases of retrosternal extension. Retrosternal extension was significantly more common on the left side than on the right side (ratio 3:2, P < 0.05). Most patients (83.4%) had significant symptoms that were relieved by surgery. Of the 199 thyroidectomies, none required a sternal split. The rate of malignancy was low (2.5%). Postoperative morbidity was 30%, the majority being asymptomatic temporary hypocalcaemia. There were no patients with permanent recurrent laryngeal nerve palsies or permanent hypoparathyroidism. There was one case of tracheomalacia. There was no death. Retrosternal goitre is a frequently symptomatic condition, with a low but definite rate of malignancy. Surgery is usually possible through a cervical incision and with an acceptable risk of significant morbidity. Thyroidectomy should be recommended as the treatment of choice.

Upper gastrointestinal endoscopy in patients aged 85 years or more. Results of a feasibility study in a district general hospital

We performed a cross sectional analysis of the feasibility and yield of upper gastrointestinal endoscopy (UGE) in a cohort of patients aged 85 years or more. The study involved 218 patients who underwent diagnostic upper gastrointestinal endoscopy in a district general hospital between 1994 and 1998. Indication, use of sedation, endoscopic findings and treatment after endoscopy were evaluated. Indications for gastroscopy were suspicious of upper gastrointestinal bleeding (UGI) bleeding (41%), anemia (15%), and presence of dyspeptic- (31%), alarm- (9%) and/or reflux symptoms (3%). Serious UGI disease (cancer, peptic ulcer, reflux oesofagitis and/or erosive gastritis/duodenitis) was detected in 97 patients (44%). With respect to clinical presentation, serious UGI disease was present in 61% with bleeding, in 57% with reflux symptoms, in 42% with alarm symptoms, in 33% with anemia and in 28% with dyspepsia. Carcinoma was detected in eight patients (3.8%), all of them were treated with supportive care. In very old people gastroscopy is generally performed on sound indications reveals serious UGI disease in almost one out of two patients, markedly influences medical treatment, and reveals low malignancy rates (3.8%). In these patients, UGE is worthwhile and should not be omitted because of age considerations.

Excision biopsy findings of patients with breast needle core biopsies reported as suspicious of malignancy (B4) or lesion of uncertain malignant potential (B3).

The UK National Health Service Breast Screening Programme has proposed five categories for reporting breast needle core biopsies. The majority of cores are reported as benign (B1), normal (B2) or malignant (B5). The predictive value of the two borderline categories suspicious of malignancy (B4) and lesion of uncertain malignant potential (B3) was studied. Over a 2-year period a total of 3822 breast needle core biopsies were performed, with 2997 from symptomatic patients and 825 from women undergoing mammographic screening, including 43 B4 reports (40 patients) and 120 B3 reports (116 lesions in 115 patients). The frequencies of B4 (2.5% versus 0.7%) and B3 cores (7.3% versus 2.0%) were both higher in screening than in symptomatic patients. B4 was most commonly used for small fragments of atypical cells separate from the main core or focal atypical intraductal proliferations. The criteria for calling a core B3 were: atypical intraductal epithelial proliferations (including foci that in excision specimens would be classified as atypical ductal hyperplasia), lobular neoplasia, radial scar, papillary lesion, fibroepithelial lesion with cellular stroma and spindle cell proliferations. Excision biopsies were performed in 39 patients with B4 core and 96 with B3 core. Invasive carcinoma or ductal carcinoma in situ was seen in 33 of the patients with B4 (85%) and in 29 of those with B3 cores (25%). Some categories of B3 core were associated with a higher rate of malignancy (40% for atypical intraductal epithelial proliferations and 46% for lobular neoplasia). The positive predictive value for carcinoma is high following a B4 core (86%). The lesion should be excised, but definitive cancer treatment is not appropriate. In some cases a definite diagnosis of malignancy can be made on repeat core. The B3 group is more heterogeneous and has a lower rate of malignancy on further biopsy (25%). The majority of B3 lesions require excision. All these patients should be discussed at multidisciplinary meetings.

Management of 100 consecutive cases of pancreatic serous cystadenoma: wait for symptoms and see at imaging or vice versa?

Pancreatic serous cystadenomas have a low malignancy rate. When nonsymptomatic, in selected patients, they can be managed without surgery; however, a high degree of diagnostic reliability is crucial. We admitted 100 consecutive cases (87 women with a median age of 51.86 years). Of these, 44 were symptomatic and 56 were diagnosed incidentally. Ultrasound correctly diagnosed 53% of the cases, incorrectly 31%, and was nondiagnostic in 16%. Computed tomography scan had similar rates (54%, 34% and 12%, respectively), while magnetic resonance imaging improved diagnostic accuracy to 74% and reduced incorrect diagnoses to 26%. In 21 cases, exploratory needle aspiration of the cyst was carried out; only 8 samples (38%) resulted in a diagnosis; in 12 patients (57%) insufficient material was acquired to allow for diagnosis, one case demonstrated epithelial dysplasia. In 1 patient an exploratory puncture resulted in a very serious bleeding. Sixty-eight patients were treated surgically, the 44 symptomatic cases and another 24 patients with ill-defined oligocystic lesions that could not be differentiated as serous or mucinous in the preoperative period. Two patients underwent resection because of frank tumor growth. In the two time periods analyzed (the first 7 years and the subsequent 6.5 years) the relationship between cases observed/operated on did not significantly change. Twenty-one (30.8%) distal pancreatectomies, 14 (20.5%) intermediate resections, 10 (14.7%) pancreaticoduodenectomies 4 (5.8%) enucleations, and 1 (1.4%) duodenum-preserving pancreatic head resection were carried out. Nine patients (13.2%), underwent exploratory laparotomy with a diagnostic biopsy. Another 9 underwent decompressive interventions with cystojejunostomies. The morbidity was 27.9%, with a reoperation rate of 7.3% and zero mortality. In general the patient's pain resolved in the postoperative period. Median follow-up was 43 months (range, 4-191 months). One patient died from other causes, and all others are currently alive. In the group of 32 patients who did not undergo operation, the median follow-up is 69 months (range, 8-164 months). Until more sophisticated technologies can be developed, the current diagnostic work-up will not result in increased preoperative diagnosis of serous-cystic tumors of the pancreas. This is mainly relevant to the oligocystic forms, which account for about one fourth of all serous tumors observed.

A Case of Malignant Transformation of Sertoli-Leydig Cell Tumor of Both Ovary

The Sertoli-Leydig cell tumor is a rare sex cord stromal tumor that has low grade malignancy and low bilateral occurrence rate. About two third of recurrence appears within 1 year after the initial treatment and most common recurrence sites are intraperitoneal cavity and retroperitoneal lymph nodes. The frequency of malignant transformation is high in the poor differentiated cell type, retiform pattern, and tumor rupture. In young women with stage I, unilateral salpingo-oophorectomy is performed to preserve uterus and reproductive function. In more advanced stages, hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection are performed and occasionally chemotherapy can be combined. We experienced a rare case of malignant metastasis in Sertoli-Leydig cell tumor, and presented with a brief review of literature.

Influence of iodine intake on the diagnostic power of fine-needle aspiration cytology of the thyroid gland.

In order to determine whether the iodine intake influences the diagnostic power of ultrasound-guided fine-needle aspiration cytology (US-FNAC), patients with nontoxic nodular goiter from an area with sufficient iodine intake (IS) (n = 938, median iodine excretion [MIE] = 103 microg/L) and from an iodine-deficient (ID) area (n = 3,601, MIE = 75 microg/L) were investigated. Elevated rates of multinodularity (59.6% vs. 49.6%, p < 0.001), nonpalpable nodules (47.6% vs. 37.3%, p < 0.001) and nondiagnostic US-FNACs (8.8% vs. 5.1%, p = 0.008), and a lower malignancy rate (1.2% vs. 2.3%, p = 0.006) were found in the ID area. Follicular tumors were encountered among positive findings. Cytohistologic comparison (ID, n = 416; IS, n = 97) revealed that the sensitivity, specificity, and diagnostic accuracy of US-FNAC were similar in the two areas (95.5% vs. 92.3%, 78.3% vs. 71.1%, 82.4% vs. 80.6%, IS vs. ID area, respectively), while a lower malignancy rate and a higher ratio of benign to malignant tumors were observed in the ID than in the IS area (10.1% vs. 22.6%, p < 0.001, and 4.38 vs. 1.50, p < 0.001, respectively). This resulted in a lower positive predictive value of US-FNAC in the ID (36/106) than in the IS area (21/36, p = 0.001), because the rate of false US-FNAC was higher in benign (67/184) than in malignant tumors (4/61, p < 0.001).