Need For Tissue Diagnosis Research Articles

Microsurgical Resection of Trigeminal Schwannoma Through Transorbital Approach: 2-Dimensional Operative Video.

We present the case of an asymptomatic 34-year-old woman who was found to have an incidental left trigeminal schwannoma.1,2 Owing to the rapid increase in size on imaging, an atypical finding for this type of lesion,3 as well as the risk of cranial nerve involvement and need for tissue diagnosis, the patient underwent a microsurgical left transorbital approach with lateral orbitotomy to resect the lesion.4,5 Piecemeal resection was performed, and the internal contents of the cavernous sinus were preserved. Ultimately, gross total resection was achieved with no residual disease identified on postoperative imaging. No new neurologic deficits were noted after surgery. The technical considerations for the transorbital approach and the literature review on the outcomes for middle fossa lesions accessed by a lateral orbitotomy are reviewed.6-10 The patient consented to the procedure and to the publication of her images. Institutional Review Board approval was deemed unnecessary due to the retrospective, case-report nature of this work.

Primary Skeletal Muscle Diffuse Large B Cell Lymphoma in Lumbar Region – A Rare Occurrence

Diffuse large B cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma worldwide. Patients most often present with a rapidly growing tumour mass in single or multiple, nodal, or extranodal sites. Extranodal involvement is seen in up to 40% cases. Initial presentation as soft tissue lesion is rare. We report a case of extranodal DLBCL in an elderly male, presenting as a soft tissue mass in the left lumbar region, clinically suggestive of lipoma. The patient had no palpable lymphadenopathy. Complete blood counts were within normal limits. Initial ultrasonography was suggestive of abscess, possibly of tubercular origin. On fine needle aspiration cytology, features were of a malignant neoplasm; a lymphomatous process. Subsequent histopathological evaluation followed by IHC confirmed the diagnosis of DLBCL. Primary extranodal DLBCL involving the soft tissue is rare. Owing to its non- specific and unusual clinical presentation, accurate diagnosis may be delayed. Besides, imaging modalities are also diagnostically challenging due to a wide range of differentials, thereby emphasising the need for tissue diagnosis. Histopathological examination and immunohistochemistry are paramount in accurate diagnosis and tailoring treatment options.International Journal of Human and Health Sciences Vol. 08 No. 01 Jan’24 Page: 95-98

Acoustic Radiation Force Impulse (ARFI) Elastography of Focal Splenic Lesions: Feasibility and Diagnostic Potential.

Nontraumatic focal splenic lesions (FSL) are rare, and the need for tissue diagnosis must be weighed against the very high risk of bleeding after a splenic biopsy. The aim of this study was to explore the feasibility and diagnostic potential of acoustic radiation force impulse (ARFI) elastography as a noninvasive method for different benign and malignant FSLs. No human studies on the elastographic characteristics of FSL exist. This was a retrospective analysis of 34 patients with FSLs, who underwent abdominal B-mode ultrasound (B-US), contrast-enhanced ultrasound (CEUS), and standardized ARFI examinations between October 2021 and December 2022 at our university hospital. The inclusion criteria were: (i) FSL size ≥ 1 cm; (ii) 10 valid ARFI measurements of the FSL, as well as of the normal splenic parenchyma (NSP) as an in vivo reference; and (iii) diagnostic confirmation of FSL etiology based on histological examination (8/34; 23.5%) or clinical evaluation, which included a clinical and sonographic follow-up (FU), CEUS morphology, and/or morphology on cross-sectional imaging (26/34; 76.5%). CEUS was performed on all patients and the FSLs were classified according to the current guidelines; cross-sectional imaging was available for 29/34 (85.3%). The mean FU duration was 25.8 ± 30.5 months. The mean ARFI velocity (MAV) of the FSL (MAVL), the NSP (MAVP), and the ratio of the MAVL to the MAVP (MAVL/P) were calculated and compared. Of the 34 FSLs, 13 (38.2%) were malignant (mFSL) and 21 (61.8%) were benign (bFSL). The MAVL of all 34 FSLs (2.74 ± 0.71 m/s) was lower than the MAVP (3.20 ± 0.59 m/s), p = 0.009, with a mean MAVL/P ratio of 0.90 ± 0.34. No significant differences in the MAVL were observed between the mFSL (2.66 ± 0.67 m/s) and bFSL (2.79 ± 0.75 m/s). There were also no significant differences between the MAVP in patients with mFSL (3.24 ± 0.68 m/s) as compared to that in the patients with bFSL (3.18 ± 0.55 m/s). Likewise, the MAV L/P ratio did not differ between the mFSL (0.90 ± 0.41 m/s) and bFSL (0.90 ± 0.30 m/s) groups. ARFI elastography is feasible in evaluating the stiffness of FSLs. The lesions' stiffness was lower than that of the NSP, regardless of the FSL etiology. However, differentiation between benign and malignant FSL with the help of this elastographic method does not appear possible. Larger prospective studies are needed to validate these findings.

Ribbing disease- radiograph to the rescue in an overlooked cause of painful shin

Ribbing disease or multiple diaphyseal sclerosis is a rare clinical entity, which is often confused with many other differential diagnoses when it primarily involves the tibia and fibula. An accurate diagnosis alleviates the need for tissue diagnosis and aids in better clinical management and outcome of the patient. The case report highlights the classical imaging findings, appearance on cross-sectional imaging, and the admirable role of radiographs in diagnosing the entity.

Histopathological spectrum of nonneoplastic lesions of large intestine- A three year study

Large intestine is a site for an array of different nonneoplastic and neoplastic lesions. Clinical manifestations may overlap, thus making the diagnosis difficult and creating the need for tissue diagnosis. Our study aims at detail histopathological examination of the different non neoplastic lesions of large intestine. A total of 30 nonneoplastic lesions of large intestine were studied over a period of 3 years. Both resected specimens and endoscopic biopsy specimens were included. Histopathological findings were studied along with analysis of the distribution of lesions and correlation of the histopathological findings with clinical parameters. The lesions were distributed in all age groups, with maximum frequency in 5 to 8 decades. The frequency was significantly higher in males (23 cases- 76.7%) as compared to females (7 cases- 23.3%). The most common lesion was perforation (10 cases), followed by gangrene (4 cases). Two cases had gangrene with perforation. Other lesions included Hirschprung’s disease (5 cases), Crohn’s disease (two cases) and one case each of Enteric duplication cyst, tuberculosis, amoebic colitis with perforation and Peutz-Jeghers polyp. Three cases had nonspecific inflammation. Our study emphasizes the importance of histopathological examination in the management of colonic lesions

Malakoplakia in Thoracic Transplant Recipients

Malakoplakia is a rare granulomatous disease characterized by the presence of Michaelis-Gutmann bodies on histopathologic analysis. Lesions manifest in a wide range of organs with cutaneous, gastrointestinal, and genitourinary systems being most common, and often result in significant comorbidities owing largely to misdiagnoses and the similar appearance to malignancy or granulomatous processes. Most patients are immunocompromised, including the solid-organ transplant population. Among organ recipients, malakoplakia is most commonly seen in renal transplantation, and only rarely reported in thoracic organ recipients. Herein we report 2 cases of malakoplakia in thoracic transplant patients that highlight the critical need for tissue diagnosis to avoid delay in management.

Presentation, Management and Short-Term Outcomes of Extradural Spinal Tumours at The University Teaching Hospital in Lusaka, Zambia

Objectives: To investigate the clinical presentation of patients with extradural spinal tumours and establish the factors that determined the treatment they received and outline the outcomes of that treatment at the University Teaching Hospital between January 2013 and December 2016.
 Material and Methods: This was a retrospective study of the presentation, management and short- term outcome of extradural spinal tumours at the University Teaching Hospital. A questionnaire was used to obtain data from patients' hospital records. Data was analysed using Microsoft Excel and the Statistical Package for Social Sciences version 25 software.
 Results: Of the 62 patients in the study,34 were female and 28 male. The age range was 14 to 87 years, with a mean of 55.03. Backache (93.8%), Limb weakness (91.9%), loss of sensation (50%), urine and stool incontinence (43.5% and 41.9% respectively), back deformity (11.3%), night pain (85.5%), weight loss(67.7%), poor appetite (61.3%), fever (35.5%) and night sweats(29%) were common symptoms. Sixty-eight percent of patients were bedridden. Visual Analogue Scale scores were greater than 5 in 84% of patients. A muscle power grade of 3 or less (n=48), impaired muscle tone (n=38), abnormal reflexes (n=52), presence of a sensory level(n=37) and back deformity (n=17) were common signs. Plain radiography, Computed Tomography Scans, Magnetic Resonance Scans and Tecnetium Bone scans were done in 60, 35, 17 and 2 patients respectively. The commonest surgical host category was A (64%). Secondary Extradural Spinal Tumours comprised 82% while 18% were primary. Surgery was done in 14 patients with 1 failing to afford implants. Forty-eight received nonsurgical treatment. Nineteen percent of patients had improved pain scores but the rest remained the same or worsened after treatment. Complications included decubitus ulcers, Urinary Tract Infection, Deep Veinous Thrombosis, pneumonia, sepsis and joint stiffness. Fourty patients died and eighteen patients were lost to follow-up.
 Conclusions: The ages of patients followed normal distribution with female to male ratio of 1.2 to 1. Most patients presented with symptoms and signs of advanced disease. The type of extradural spinal tumour, stage of disease, completeness of diagnostic workup, availability of implants, need for tissue diagnosis, type of surgical host and availability of nonsurgical treatment modality determined the choice of treatment. Poor outcomes in quantity and quality of life are a reflection of the late presentation, delayed diagnosis, lack of resources and difficulty of treating these tumours. Extradural spinal tumours are not uncommon and cause significant morbidity and mortality in those affected.

Presentation, management and short-term outcomes of extradural spinal tumours at the University Teaching Hospital in Lusaka, Zambia

Objectives: To investigate the clinical presentation of patients with extradural spinal tumours and establish the factors that determined the treatment they received and outline the outcomes of that treatment at the University Teaching Hospital between January 2013 and December 2016.
 Material and Methods: This was a retrospective study of the presentation, management and shortterm outcome of extradural spinal tumours at the University Teaching Hospital. A questionnaire was used to obtain data from patients' hospital records. Data was analysed using Microsoft Excel and the Statistical Package for Social Sciences version 25 software.
 Results: Of the 62 patients in the study, 34 were female and 28 male. The age range was 14 to 87 years, with a mean of 55.03. Backache (93.8%), Limb weakness (91.9%), loss of sensation (50%), urine and stool incontinence (43.5% and 41.9% respectively), back deformity (11.3%), night pain (85.5%), weight loss(67.7%), poor appetite (61.3%), fever (35.5%) and night sweats(29%) were common symptoms. Sixty-eight percent of patients were bedridden. Visual Analogue Scale scores were greater than 5 in 84% of patients. A muscle power grade of 3 or less (n=48), impaired muscle tone (n=38), abnormal reflexes (n=52), presence of a sensory level(n=37) and back deformity (n=17) were common signs. Plain radiography, Computed Tomography Scans, Magnetic Resonance Scans and Tecnetium Bone scans were done in 60, 35, 17 and 2 patients respectively. The commonest surgical host category was A (64%). Secondary Extradural Spinal Tumours comprised 82% while 18% were primary. Surgery was done in 14 patients with 1 failing to afford implants. Forty-eight received nonsurgical treatment. Nineteen percent of patients had improved pain scores but the rest remained the same or worsened after treatment. Complications included decubitus ulcers, Urinary Tract Infection, Deep Veinous Thrombosis, pneumonia, sepsis and joint stiffness. Fourty patients died and eighteen patients were lost to follow-up.
 Conclusions: The ages of patients followed normal distribution with female to male ratio of 1.2 to 1. Most patients presented with symptoms and signs of advanced disease. The type of extradural spinal tumour, stage of disease, completeness of diagnostic workup, availability of implants, need for tissue diagnosis, type of surgical host and availability of nonsurgical treatment modality determined the choice of treatment. Poor outcomes in quantity and quality of life are a reflection of the late presentation, delayed diagnosis, lack of resources and difficulty of treating these tumours. Extradural spinal tumours are not uncommon and cause significant morbidity and mortality in those affected.

Anaesthesia for a biopsy of corpus callosum in patient with a recent intra-operative anaphylaxis to an unknown anaesthetic allergen: a case report

BackgroundAnaphylaxis in general anaesthesia occurs with a frequency of 1:5000-1:20000. This clinical summary reports on the use of an effective risk management strategy employing second line anaesthesia agents and alternative endotracheal intubation tools in a patient with a recent history of an intra-operative anaphylaxis to an unknown anaesthetic agent.Case presentationA 71-year-old male presented for a repeat biopsy of corpus callosum 4 days following the cancellation of the procedure for a presumed anaphylactic reaction to an unknown anaesthetic agent.During the repeat care episode, the decision was made to proceed based on the urgent need for tissue diagnosis to facilitate further treatment and lack of feasibility for more definitive identification of the causative agent(s). A consideration was made of the optimum ways to manage and mitigate risk in this setting.The airway was managed using flexible endoscopic intubation in a spontaneously ventilating awake patient. Continuous remifentanil infusion was maintained throughout the case. Anaesthesia was maintained with sevoflurane at less than one MAC, with an uneventful completion of the biopsy of corpus callosum. All of the anaesthetic agents used during the prior care episode, with the exception of remifentanil, were avoided.ConclusionIn cases of an anaphylaxis to an unknown anaesthetic allergen, anaesthetic strategy consists of careful risk mitigation and deployment of second agent approaches. Awake flexible endoscopic intubation and remifentanil infusion are viable alternatives to standard induction techniques.

Clinicoradiological features of intraneural perineuriomas obviate the need for tissue diagnosis.

This study aimed to define a set of clinicoradiological parameters with a high specificity for the diagnosis of intraneural perineurioma, obviating the need for operative tissue diagnosis. The authors retrospectively reviewed MR images obtained in a large cohort of patients who underwent targeted fascicular biopsy and included only those patients for whom the biopsy yielded a diagnosis. Clinical and radiological findings were then tested for their ability to predict a tissue diagnosis of intraneural perineurioma. The authors propose a new set of diagnostic criteria, referred to as the Perineurioma Diagnostic Criteria. The sensitivity, specificity, positive predictive value, and negative predictive value of several clinicoradiological methods of diagnosis were compared. A total of 195 patients who underwent targeted fascicular biopsy were included in the cohort, of whom 51 had a tissue diagnosis of intraneural perineurioma. When the clinicoradiological methods used in this study were compared, the highest sensitivity (0.86), negative predictive value (0.95), and F1 score (0.88) were observed for the decision trees generated in C5.0 and rPart, whereas the highest specificity (1.0) and positive predictive value (1.0) were observed for the Perineurioma Diagnostic Criteria. This study identified clinical and radiological features that are associated with a diagnosis of perineurioma. The Perineurioma Diagnostic Criteria were determined to be the following: 1) no cancer history, 2) unifocal disease, 3) moderate to severe hyperintensity on T2-weighted MR images, 4) moderate to severe contrast enhancement, 5) homogeneous contrast enhancement, 6) fusiform shape, 7) enlargement of the involved nerves, and 8) age ≤ 40 years. Use of the Perineurioma Diagnostic Criteria obviates the need for tissue diagnosis when all of the criteria are satisfied.

CT-based radiomic analysis of hepatocellular carcinoma patients to predict key genomic information.

e15623 Background: The utilization of computed tomography (CT) has virtually replaced the need for tissue diagnosis in hepatocellular carcinoma (HCC). Imaging features (e.g. size, shape and vascularity) have been associated with patient survival. However, the full potential of CT in HCC diagnosis may not be reached, as high-throughput computing allows for extraction of quantitative features that are not part of radiologists’ lexicon. The purpose of this study was to investigate the ability of radiomic analysis to successfully identify specific doxorubicin chemoresistant genes on CT images of treatment-naïve hepatocellular carcinoma (HCC). Methods: We identified 27 treatment-naïve patients with a single HCC tumor from The Cancer Genome Atlas (TCGA) whom had gene expression profiles. Baseline CT images were obtained from The Cancer Imaging Archive (TCIA). 3D Slicer software was used for manual tumor segmentation and final segmented images were reviewed by a board-certified radiologist. Following tumor segmentation, texture analysis was performed on MATLAB environment. A total of 310 rotation invariant texture features, which measure tumor heterogeneity, were obtained (first-order histogram and grey level co-occurrence matrix). The mRMR method was used to select the most relevant radiomic features. ROC analysis and LOOCV were used to assess the performance of five specific genes known to confer doxorubicin chemoresistance (TP53, TOP2A, CTNNB1, CDKN2A and AKT1). Results: Radiomic analysis identified TP53 (AUC = 86.61%, Specificity = 92.31%, Sensitivity = 92.9%), TOP2A (AUC = 78.0%, Specificity = 69%, Sensitivity = 85.7%), CTNNB1 (AUC = 86.8%, Specificity = 92.3%, Sensitivity = 85.7%), CDKN2A (AUC = 76.9%, Specificity = 76.9%, Sensitivity = 78.6%) and AKT1 (AUC = 72.5%, Specificity = 69.2%, Sensitivity = 85.7%) in treatment-naïve HCC CT studies. Conclusions: The identification of specific genes that confer chemoresistance to doxorubicin can be reliably ascertained via the use of radiomic analysis. This study may help tailor future treatment paradigms via the ability to categorize HCC tumors on genetic level and identify tumors which may not have a favorable response to doxorubicin based therapies.

Re-Examining the Need for Tissue Diagnosis in Pediatric Diffuse Intrinsic Pontine Gliomas: A Review.

Diffuse intrinsic pontine glioma (DIPG) is a malignant brain tumor of childhood that carries an extremely poor prognosis. There are ~200-300 new cases diagnosed each year, [1, 2] and little progress has been made in changing the prognosis and outcome of the tumor since it was first documented in the literature in 1926 [3]. The median overall survival is 8-11 months [4], with an overall survival rate of 30% at 1 year, and less than 10% at 2 years [4]. This review will provide background information on DIPGs, a historical look at the trends in caring for DIPG, and current trends in diagnosis and treatment. By changing the way we care for these terminal tumors, we can work towards having a better understanding of the underlying molecular biology, and attempt to develop better chemotherapeutic tools to combat the disease.

Small Bowel Carcinoma in the Setting of Long Standing Crohn’s Disease

The small bowel comprises the longest portion of the gastrointestinal tract but despite that, it is an uncommon site for malignancies. In patients with Crohn’s Disease there is a 6-320 fold increased relative risk of small bowel adenocarcinoma compared to the general population. This increased risk is due, in part, to the pathology of Crohn’s disease, a chronic inflammatory bowel disease, which leads to an increased risk of dysplasia secondary to mucosal inflammation and healing. The presentation of small bowel carcinoma varies and may be subtle, often leading to delayed diagnosis. In Crohn’s patients, symptoms often present similarly to those of a flare, with abdominal pain, change in bowel habits, anemia, or with symptoms suggesting new fistulae or strictures. Due to the non-specific nature of symptoms, the diagnosis is often delayed as clinicians attempt to treat the flare before undertaking extensive investigation. It is therefore critical that recurrent Crohn’s symptoms, especially those suggesting obstruction or new stricture or fistula in patients with long standing disease quiescence, raise the suspicion for the development of cancer. There are currently no recommendations for cancer surveillance in Crohn’s patients, likely in part due to the difficulty in endoscopic surveillance of the small bowel and the overall low prevalence of Crohn’s disease in all patients with small bowel adenocarcinoma. With newer technology, such as CT or MR enterography, imaging to survey the bowel is more feasible, although this will not obviate the need for tissue diagnosis in Crohn's patients with positive imaging findings.

Surgical Results of Long Posterior Fixation With Short Fusion in the Treatment of Pyogenic Spondylodiscitis of the Thoracic and Lumbar Spine

A single-institution, single-surgeon retrospective review. To evaluate the clinical results of long posterior instrumentation with short posterior or posterolateral fusion for pyogenic spondylodiscitis of the thoracic and lumbar spine retrospectively. There are controversies concerning the optimal treatment for pyogenic spondylodiscitis, in terms of approach, grafting, and instrumentation. Reports of long posterior fixation with short fusion without debridement of infected tissue for pyogenic spondylodiscitis are rare. From June 1997 to June 2007, 48 patients with pyogenic spondylodiscitis were treated. The indications for surgery were neurological compromise, significant vertebral body destruction with kyphosis and segmental instability, failure of medical treatment, and the need for tissue diagnosis. All patients received long posterior instrumentation with or without posterior decompression, depending on whether the patients had neurological deficit. During operation, no debridement of infected tissue was done. Clinical outcomes were assessed using the criteria of Kirkaldy-Willis and the visual analogue scale for pain. The neurological outcome was graded using Frankel grading system. Segmental kyphotic angle and fusion were recorded and analyzed. The average follow-up time was 64 months. The visual analogue scale scores improved from an average of 7.2 before surgery to 2.2 after surgery. Twenty-eight patients with initial neurological impairment had an average improvement of 1.03 grades, using the Frankel grading system, at the final follow-up. The segmental kyphotic deformity improved by an average of 8.5° immediately after operation and lost an average correction of 3.0° at the final follow-up. No relapse of infection was found among these 48 patients. The posterior approach with long segmental fixation and short posterior or posterolateral fusion without debridement of the infected tissue was effective for pyogenic spondylodiscitis of the thoracic and lumbar spine.

Mortality in patients undergoing covered self-expandable metal stent revisions in malignant biliary stricture: Does pathology matter?

Background and Aims Partially covered metal stents have been extensively used for palliation of obstructive jaundice in malignant distal biliary strictures and can be removed in cases of malfunction or need for tissue diagnosis. We investigated independent predictors of mortality in patients undergoing partially covered metal stents revision (i.e., removal and replacement). Methods Patients with a distal malignant biliary obstruction palliated with a partially covered metal stent were followed-up prospectively over 5 years until malfunction or death. All patients who required removal of their partially covered metal stents were captured in a specific database. Multivariate analysis was performed on non-surgical patients to assess for independent predictors of death using known risk factors including type of malignancy (adenocarcinoma versus all others), age greater than 55, gender, and exposure to adjuvant chemotherapy and/or radiotherapy. Results Forty-two patients (28 men, mean age of 62 ± 12 years) underwent partially covered metal stents removal. Of these, biliary drainage was achieved in 38 patients by placement of a new partially covered metal stent ( n = 32) or plastic stent ( n = 6). The remaining 4 patients did not undergo stent replacement because of refusal (2), resolution of obstruction (1) and unrelated death (1). Long-term follow-up post removal in patients who were not surgical candidates ( n = 31) was 35 weeks (95% CI 28–40), with a survival rate of 29% at 10 months. Logistic regression analysis in the 31 patients with unresectable disease showed that a histologic diagnosis of adenocarcinoma was associated with increased mortality post partially covered metal stents revision. Conclusions Partially covered metal stents revision should be undertaken especially when dealing with a non-adenocarcinoma type cancer.

Is there a uniform approach to the management of diffuse parenchymal lung disease (DPLD) in the UK? A national benchmarking exercise

BackgroundBenchmarking is the comparison of a process to the work or results of others. We conducted a national benchmarking exercise to determine how UK pulmonologists manage common clinical scenarios in diffuse parenchymal lung disease (DPLD), and to determine current use and availability of investigative resources. We compared management decisions to existing international guidelines.MethodsConsultant members of the British Thoracic Society were mailed a questionnaire seeking their views on the management of three common scenarios in DPLD. They were asked to choose from various management options for each case. Information was also obtained from the respondents on time served as a consultant, type of institution in which they worked and the availability of a local radiologist and histopathologist with an interest/expertise in thoracic medicine.Results370 out of 689 consultants replied (54% response rate). There were many differences in the approach to the management of all three cases. Given a scenario of relapsing pulmonary sarcoidosis in a lady with multiple co-morbidities, half of respondents would institute treatment with a variety of immunosuppressants while a half would simply observe. 42% would refer a 57-year old lady with new onset DPLD for a surgical lung biopsy, while a similar number would not. 80% would have referred her for transplantation, but a fifth would not. 50% of consultants from district general hospitals would have opted for a surgical biopsy compared to 24% from cardiothoracic centres: this may reflect greater availability of a radiologist with special interest in thoracic imaging in cardiothoracic centres, obviating the need for tissue diagnosis. Faced with an elderly male with high resolution CT thorax (HRCT) evidence of usual interstitial pneumonia (UIP), three quarters would observe, while a quarter would start immunosuppressants. 11% would refer for a surgical biopsy. 14% of UK pulmonologists responding to the survey revealed they had no access to a radiologist with an interest in thoracic radiology.ConclusionFrom our survey, it appears there is a lack of consensus in the management of DPLD. This may reflect lack of evidence, lack of resources or a failure to implement current guidelines.

Pathological fracture of the atlas secondary to plasmacytoma

Plasmacytoma of the atlas with pathological fracture has not been previously reported. A 72-year-old man was admitted to our clinic with a 5-month history of occipital headache. Neurologic examination revealed mild occipital neuralgia, difficulty with movements of the cranium, hyperactive deep tendon reflexes, but no Babinski sign. Magnetic resonance imaging (MRI) of the cervical spine showed a 1 × 2 cm well-circumscribed extradural mass, with lytic destruction and fracture of the lateral mass of C1. Preoperatively dynamic cervical radiographs showed no instability. Using a transcondylar approach, the tumor was removed, and posterolateral fixation and fusion (using iliac autograft) was performed. Biopsy was reported as plasmacytoma. The patient was pain-free with bony fusion 3 years after surgery. This paper presents a pathologic fracture of C1. Although the primary treatment of plasmacytoma is non-surgical, the need for tissue diagnosis in relevant areas may dictate an open biopsy procedure. Such cases may require a decompression and reconstruction procedure.

Different professionals’ knowledge and perceptions of the management of people with pancreatic cancer

AbstractBackground: Pancreatic cancer is generally associated with a very poor prognosis. The knowledge, beliefs and opinions of clinicians caring for people with pancreatic cancer may affect preferences for particular therapies and may impact upon patient outcomes. The aim of this study was to conduct a postal survey of clinicians who consult patients with pancreatic cancer to assess their knowledge regarding the disease itself and the effectiveness of various treatments, and to gauge their opinions regarding aspects of management.Methods: A 20‐item multiple‐choice questionnaire was mailed to medical and radiation oncologists, gastroenterologists, general surgeons and hepatopancreatobiliary (HPB) surgeons in Australia. Questions assessed knowledge of survival following surgery for resectable disease, and survival and response rate following chemoradiation for locally advanced disease and chemotherapy for advanced disease. Beliefs regarding the need for tissue diagnosis and perceptions of benefit of various treatment strategies were also sought.Results: Overall, knowledge was fair (average knowledge score 4.1 out of 8); 56% of HPB surgeons and 55% of medical oncologists had good knowledge, compared with 39% of gastroenterologists and general surgeons. There were marked differences in opinion regarding requirement for tissue diagnosis before further management. There was considerable variation in opinion regarding the benefit of postoperative adjuvant chemotherapy.Conclusion: These findings argue strongly for the development of evidence‐based guidelines. Multidisciplinary management teams may help educate individual clinicians and professional groups and are likely to result in improved outcomes for patients.

Cutaneous Infection With Rapidly-Growing Mycobacterial Infection Following Heart Transplant: A Case Report and Review of the Literature

Nontuberculous mycobacteria are ubiquitous and infrequently cause disease in humans, most commonly in immunocompromised hosts. One type of nontuberculous mycobacteria is Mycobacterium abscessus. This rapidly growing mycobacterium is a soil or water saprophyte. It was previously classified as a subspecies of Mycobacterium chelonae; however, current taxonomy now designates it as a separate species. Rapidly growing mycobacteria are resistant to the usual antituberculous drugs. This emphasizes the need for tissue diagnosis and obtaining specimens for culture and drug susceptibility testing. M abscessus has been reported to cause infection in renal transplant patients, but is less well described in cardiac transplant recipients. We report the case of a 65-year-old man who presented 5 years after transplantation for heart failure, with a 2-day history of progressive right lower extremity swelling and redness. He recalled no antecedent trauma and denied any unusual epidemiologic exposure. Medical history included diabetes with peripheral neuropathy and renal insufficiency, hypertension, and right-sided heart failure felt to be due to obstructive sleep apnea. A punch biopsy of the area grew M abscessus sensitive only to clarithromycin (MIC not reported), amikacin (30 μg/mL), and kanamycin (30 μg/mL). On subsequent clinic visits, the patient had decreased leg swelling and resolution of the papular lesions. Ten weeks into antimycobacterial therapy, the patient had an increase in creatinine to 4.9 mg/dL from a baseline of 2.0 with fluid overload necessitating discontinuation of aminoglycoside therapy. He completed 6 months of treatment with oral clarithromycin. We describe these findings and review the literature in this report.

Towards a minimally invasive staging strategy in NSCLC: analysis of pet positive mediastinal lesions by EUS-FNA

Lung Cancer 2004;44:53–60. Annema JT, Hoekstra OS, Smit EF, Veselic M, Versteegh MIM, Rabe KF. Study Summary: This study addresses the yield of EUS-FNA for confirming mediastinal lymph node metastasis in NSCLC patients with a PET scan positive for mediastinal disease. The authors prospectively enrolled 36 suspected or confirmed NSCLC patients with positive findings on PET scan in the mediastinal area. Twenty-six (72%) patients also had >1-cm mediastinal lymph nodes on chest computed tomography (CT). Regardless of PET findings, EUS-FNA examination was performed for all lymph node stations accessible from the esophagus. The cytology specimen was obtained from lymph nodes >5-mm in diameter and was examined by an on-site cytologist. EUS-FNA confirmed mediastinal lymph node involvement in 25 (69%) patients. Subsequent surgical staging (mediastinoscopy 2 patients, thoracotomy 10 patients) showed malignancy in 3 patients and reactive lymph nodes in 7 patients. Thus, EUS-FNA correctly detected 25 of 28 (89%) of patients with N2/N3 disease. Location of lymph node metastasis was outside the reach of mediastinoscopy in 8 of these patients. Overall, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 93%, 100%, 100%, 80%, and 94%, respectively. There were no procedure-related complications. Comments: Several studies have used PET scan for mediastinal staging of patients with NSCLC and found it to be better than chest CT scan for this purpose. In 1 study, the sensitivity and specificity of PET scan for mediastinal staging were 91% and 86%, respectively (N Engl J Med 2000;343:254–261). An important limitation of PET scan is its high false-positive rate. For instance, in a recent study, more than one third of PET positive lymph node stations were later found to be false-positive (Ann Thorac Surg 2003;75:231–236). False-positive mediastinal lymph nodes on PET scan may lead to inappropriate denial of curative surgery. Therefore, the current recommendation is to confirm PET positive lesions with biopsy (Chest 2004;125:2300–2308). Mediastinoscopy is most commonly used for this purpose. This is the first study to combine PET with EUS-FNA for mediastinal staging. The study establishes EUS-FNA as an effective noninvasive alternative to mediastinoscopy for PET-positive patients. The study does not address the potential role of EUS-FNA in NSCLC patients with negative PET findings. An important observation was a false-positive PET in 7 of 36 (19%) of patients. This reaffirms the need for tissue diagnosis for all patients with a positive PET scan. Furthermore, 8 of 28 (29%) of PET positive lymph nodes were located in regions unsuitable for mediastinoscopy, again suggesting the complimentary value of EUS-FNA and mediastinoscopy in these patients. The safety and noninvasive nature of EUS-FNA makes it an attractive choice before subjecting the patient to a more invasive surgical staging. The future studies should address the cost-effectiveness of PET followed by EUS-FNA approach to mediastinal staging.