Palpable Cervical Nodes Research Articles

Infectious Alopecia in a Dog Breeder After Renal Transplantation

Tinea capitis rarely occurs in renal transplant recipients. We report this living-related renal transplant patient receiving cyclosporine-based therapy who initially presented with severe exfoliation of the scalp with yellowish-white scales and marked hair loss. The lesions extended to the frontal area and both cheeks, resulting in several skin ulcers with perifocal erythematous inflammatory changes, and palpable cervical lymph nodes. A biopsy of a skin lesion revealed fungal infection and culture yielded Microsporum canis. The patient mentioned an outbreak of ringworm in her breeding dogs during this period. After adequate treatment of the patient and her infected animals with griseofulvin and disinfection of the environment, her skin lesions resolved dramatically, with regrowth of hair.

Oral ulcers in an immunosuppressed 5-year-old boy

A 5-year-old white boy presented with a 15-day historyof oral ulcers associated with pain and difficulty ineating. His medical history was significant for hearttransplant 2 years previously, to treat idiopathic myo-cardiopathy. He had been on prednisone, tacrolimusand mycophenolate mofetil for the past 16 months toprevent transplant rejection.Physical examination revealed multiple shallow anddeep ulcerations on the buccal mucosa and dorsum ofthe tongue (Fig. 1a,b), the largest 30 mm in diameter,covered with grey pseudomembranes and surroundedby an erythematous halo. There were no palpablecervical nodes and the rest of the physical examinationwas unremarkable.

B-cell lymphoma mimicking rhinophyma

Conflict of interest: none declared. A 78‐year‐old woman was referred with a history of a persistent rash in the groins that had failed to improve with mid‐potency topical steroid. Examination revealed a poikilodermatous eruption that was suspicious for cutaneous T‐cell lymphoma. Incisional biopsy on two occasions showed a mixed infiltrate in the upper dermis that was found, using immunohistochemistry, to consist mainly of T‐helper cells (CD2+, CD3+, CD4+, CD5+, CD7+) with very few CD8+ cells. There was no epidermotropism or any Pautrier microabcesses. The lymphocytes displayed a mild degree of cytological atypia, but no convincing evidence of lymphoma was seen. T‐cell receptor gene‐rearrangement studies were negative. There were no palpable lymph nodes. A trial of narrowband ultraviolet B was unsuccessful because the patient felt claustrophobic in the cabin, and she was managed symptomatically with 1% menthol in aqueous cream and hydroxyzine 10 mg at night. The patient was kept under regular review and represented in 2005 with a 4‐month history of a bulbous swelling at the tip of her nose, clinically resembling rhinophyma (Fig. 1). Although she had a history of easy flushing, she had not noted any pustules. Short courses of oral erythromycin and aciclovir had afforded no improvement. On examination, she had nontender erythematous nodules and plaques at the tip of her nose, which had a tense and shiny appearance. She also had bilateral palpable cervical lymph nodes. The rash in the groins was unchanged.

Surgical management of carcinoma of the cervical esophagus

The aim of the present study was to clarify the clinicopathological characteristics, reconstruction methods after resection, and prognosis of cervical esophageal squamous cell carcinoma. Seventy-four with squamous cell carcinomas of the cervical esophagus not previously treated who underwent cervical esophagectomy or total esophagectomy with or without laryngectomy were retrospectively analyzed. The operative morbidity and in-hospital mortality rates were 34% (25 patients) and 4% (3 patients), respectively. Alimentary continuity was achieved with free jejunal transfer (50 patients), gastric pull-up (19 patients), and other procedures (5 patients). The frequencies of postoperative complications and death did not differ between free jejunal transfer and gastric pull-up. The overall 3- and 5-year survival rates were 42% and 33%, respectively. The significant clinicopathological factors affecting survival were patient gender, high T factor, lymph node involvement, palpable cervical lymph nodes, vocal cord paralysis, lymphatic invasion, and extracapsular invasion. The pattern of first failure was most often locoregional (82%, 36 patients). The choice of free jejunal transfer or gastric pull-up for reconstruction after surgical resection of cervical esophageal carcinoma depends on the degree of tumor extension. Adverse factors affecting survival should be considered when candidates for the surgery are selected.

Human Bocavirus in Febrile Children, the Netherlands

Human Bocavirus in Febrile Children, the Netherlands

Malignant melanoma and deep penetrating naevus – difficulties in diagnosis in children

A 4-year-old boy presented to our department with a darkly pigmented lesion on the right side of his neck. It was excised and a diagnosis of deep penetrating naevus with atypical features was made. At 4-month follow-up our patient had developed a palpable cervical lymph node. Excision revealed malignant melanoma. We discuss our management and review the literature regarding DPN and melanoma of childhood.

Dapsone as a Potential Treatment for Cutaneous Rosai-Dorfman Disease With Neutrophilic Predominance

A 31-year-old Taiwanese woman, who from her medical history was generally well, presented with 1 slowly enlarging elevated plaque on the posterior aspect of her right shoulder. This had first been detected 3 months before the visit to our clinic. The lesion had originated as a small, tender, erythematous papule and had since grown into a large confluent plaque with satellite papules. She claimed that the lesion was increasing in size, and this was accompanied by intense itching and fever. On physical examination, there was 1 palm-sized, dusky red, elastic firm plaque on the right shoulder. The main lesion was surrounded by multiple 2to 8-mm erythematous satellite papules (Figure 1). There were no palpable cervical, supraclavicular, axillary, or inguinal lymph nodes. A systemic workup that included head, neck, and chest computed tomographic scans showed no involvement of other organs. Workups done to determine the source of her febrile episodes yielded no evidence of active infection. The only abnormal laboratory finding was polyclonal hypergammaglobulinemia found on serum protein electrophoresis. An incisional biopsy was performed. Microscopically, a dense dermal infiltrate extended from the upper dermis deep to the subcutis (Figure 2). The infiltrating cells were mainly composed of histiocytes with large vesicular nuclei. They also had abundant cytoplasm with spidery borders. Neutrophils, lymphocytes, and plasma cells were scattered between the histiocytes, and the presence of lymphocytes engulfed within the histiocytic cytoplasm, a feature called emperipolesis, was also noted. The mixed infiltration was neutrophil predominant. Immunohistochemical studies revealed histiocytes that stained positively for S100 protein and CD-68. Notably, the dermis surrounding the histiocytes was infiltrated by numerous neutrophils. Clinically and histologically, she was diagnosed as having cutaneous Rosai-Dorfman disease (CRD). Before visiting our hospital, she had been treated at a dermatologic clinic for 2 months, first with topical triamcinolone, oral prednisolone (30 mg/d), and then with oral isotretinoin (100 mg/d). However, the lesion had continued to worsen and the symptoms of pruritus and intermittent episodes of fever had progressed during the treatments. Superficial irradiation was suggested, but the patient refused owing to its potential hazards.

Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma: A Case Report

We present a rare case of a 26-year old woman with diffuse sclerosing variant of papillary thyroid carcinoma. The patient was referred to our hospital with diffuse enlargement of the thyroid accompanied with palpable bilateral cervical lymph nodes. Ultrasonography showed a heterogeneous pattern with ill-defined hypoechoic areas in both thyroid lobes. There were multiple small punctate echogenic foci. Fine-needle aspiration cytology revealed typical signs of papillary carcinoma. The patient underwent a total thyroidectomy using a bilateral modified neck dissection. Pathological findings demonstrated diffuse involvement and continuous infiltration of the tumors to both thyroid lobes, lymph nodes and cervical soft tissue. Postoperatively, 100 mCi of 131I was administrated to the small amount of residual thyroid tissue. The patient is free from recurrence one year after the operation.

Radiofrequency Cauterization: An Alternative to Reduce Post-biopsy Hemorrhage

As recently described in animals [1], we applied radiofrequency ablation (RFA) to clinical practice as a technique to reduce the risk of bleeding after biopsy of a highly vascular tumor. A 26-year-old man was admitted for renal core biopsy. Prior fine-needle biopsy of a left kidney mass and a supraclavicular lymph node showed renal cell carcinoma of unknown subtype. Repeat biopsy was performed to diagnose histologic subtype, which can affect experimental treatment options. The patient had first presented 6 months previously with a 6 cm palpable cervical lymph node, weight loss of 9 kg, and fatigue with no hematuria. The CT scan revealed extensive lymphadenopathy throughout his mediastinum and left periaortic region, and a 6 cm left kidney mass with three liver metastases. Laboratory values were normal. A bone scan did not show evidence of metastatic disease. Prior to biopsy, color Doppler ultrasound revealed a very vascular tumor with many large and small vessels throughout the tumor, suggesting increased risk of biopsy-related bleeding [3]. The patient underwent an ultrasound-guided coaxial core biopsy with a 17 gauge 10 cm outer needle and an 18 gauge 15 cm inner needle. Brisk bright red pulsatile blood was seen in the outer needle following removal of the inner core biopsy gun. The stylet was replaced as soon as the pulsatile bleeding was seen. Two grounding pads were rapidly applied to the patient’s thighs and the tissue ablation system was set up. Just prior to removal of the outer biopsy needle, a Radionics (Valleylab, Boulder, CO) RFA probe (20 cm with a 3 cm uninsulated tip) was placed, using tandem technique, immediately adjacent to the biopsy needle and to the same insertion depth, under direct ultrasound guidance. The outer needle was then removed from the patient and the RFA Cool Tip generator (Valleylab, Boulder, CO) was turned on. Tissue was heated to 95°C for about 90 sec during slow withdrawal of the RFA probe, without chilled saline perfusion. The generator was stopped as the uninsulated portion of the needle was withdrawn from the tumor capsule, but prior to crossing dermis. No sign of bleeding was evident by ultrasound 15 min following the procedure or by clinical criteria the day following the procedure. The patient remained clinically stable during and after the application of this technique. The patient did not complain of pain after the procedure. The pathology results showed clear cell carcinoma with papillary features. Five days later an excisional biopsy of a right arm tumor was performed. Results showed leiomyoma. Given the patient’s extensive family history of malignancy (the father had a rare eye adenocarcinoma; 5 of 9 of the father’s siblings had cancer, 2 of them renal cell carcinoma; and the mother’s siblings had renal cell carcinoma, uterine, and esophageal cancers) the diagnosis of hereditary leiomyomatosis renal cell carcinoma syndrome (HLRCC) was made. RFA may be a helpful therapeutic option to avoid the bleeding that may be seen in up to 90% of patients by CT [5] after a percutaneous renal biopsy, depending upon how one defines bleeding. Less than 3% of renal biopsies require transfusion or an intervention to stop the bleeding [6]. Other therapeutic options available are transarterial embolization with polyvinyl alcohol or acrylic particles, collagen pledgets, autologous blood, or metal coils [3]. These techniques, however, do not address the possibility of needle tract seeding with tumor cells, in contrast to RFA in which the tract is treated [4]. Also, treatment with embolization may result in an undesirable infarct in a patient with already compromised renal function. While RFA has been emerging as a viable therapeutic option for certain renal cell carcinomas and has a definitive success rate over 90% with few complications in selected patients [2, 4], it may be a low-risk, nephron-sparing method to facilitate hemostasis in the post-biopsy setting, especially when there is brisk pulsatile flow. A modified biopsy device could easily be manufactured to facilitate use of post-biopsy cauterization to minimize risk of bleeding and needle-tract seeding for high-risk patients. Such a simple maneuver could be performed following any biopsy where needle tract seeding or bleeding were thought to be a higher risk, as might occur when brisk backbleeding is seen from the outer needle, or with uncorrectable coagulopathies, anticoagulation, hypervascular tumors, vascular organ biopsies (i.e., spleen), or with the larger core samples often required for genomic or proteomic analysis. Such a biopsy might be a safer alternative to transjugular liver biopsy as well, although this remains speculative.

Malignant tumours of nasal cavity and paranasal sinuses in north of lraq a fifteen years retrospective study

Objectives: To identify the different pathological types of malignant tumors of nasal cavity' and paranasal sinuses, their different clinical aspects, treatment received and prognosis in north of Iraq. Design : Retrospective study. Settings: Files of patients treated in the hospital of oncology and nuclear medicine in Mosul over 15 years period (1980-1994). Main outcome measures: Types, incidence, age and sex distribution, anatomical sites, clinical presentation, staging, method of treatment and prognosis. Results: They constituted 0.51% of all malignancies and 2.13 % of head and neck cancers. Sinus tumours affected both sexes equally as well as both sides. Nasal cavity tumours were more common in male (male/female=1.4/1) and in the right side (right/left=1.33/1).The commonest age at presentation was the fifth decade. The most common presenting symptom was facial and nasal pain with average delay in diagnosis of about 8.5 months. Tumours of epithelial origin formed the majority of cases (85.68%). All maxillary and ethmoidal cases were advanced at time of diagnosis (T3 or T4), while 60% of nasal cavity tumours were T1 and T2. 21.87% of patients had palpable cervical lymph nodes at presentation. The majority of patients received radiotherapy alone, few cases had surgery alone or both, but prognosis was generally unsatisfactory conclusion: Malignant tumours of nose and sinuses are rare in north of lraq, are usually advanced at presention , and carry poor prognosis. keywords: Malignant Tumours , Nasal Cavity , Paranasal Sinuses

Radiology Quiz Case 3

A 31-YEAR-OLD NORTH AFRICAN MAN PREsented with a 4-month history of headache. He reported several attacks of massive epistaxis, which had stopped spontaneously. His medical history was unremarkable, and he had no history of trauma. Fiberoptic examination showed an asymmetry of the roof of the rhinopharynx. The overlying mucosa was normal. No arterial beating was visualized on fiberoptic examination. There was no palpable cervical node. The findings of the rest of the head and neck examination were normal. The patient underwent standard computed tomography (Figure 1) and magnetic resonance imaging (Figure 2). What is your diagnosis?

Predictive Factors for Recurrence from a Series of 74 Children and Adolescents with Differentiated Thyroid Cancer

The influence of clinical and treatment factors on the risk of recurrence was analyzed from a retrospective series of 74 children and adolescents with thyroid cancer (55 girls, 19 boys; age 2-20 years). Two groups, comparable in terms of age, sex, and previous radiotherapy, were compared according to the presence (group 1) or absence (group 2) of cervical lymph nodes identified by palpation or ultrasonography. Total thyroidectomy (TT) with lymph node dissection (LND) was performed in the 19 group 1 patients, whereas in group 2 patients (n = 55) lobectomy was performed in 29, TT in 26, and LND in 7. Pathology studies showed papillary thyroid carcinoma in 95% of cases. In group 1, tumors were more frequently multifocal (89% vs. 16% in group 2), invasive with extension beyond the thyroid capsule (68% vs. 5% in group 2), and of the diffuse sclerosing variety (63% vs. 4% in group 2) (p < 0.001). With a median follow-up of 61 months, lymph node recurrence was seen in 53% of group 1 patients and in no patients in group 2. Three group 2 patients (10%) were reoperated for a local recurrence after lobectomy. Risk factors for reintervention were young age (< 15 years) (p < 0.01) and cervical lymph nodes (p < 0.001). Survivals without reintervention at 5 and 10 years were, respectively, 58% and 38% for group 1 and 94% and 90% for group 2 (p < 0.001). At the time of analysis, 68% of group 1 patients and 98% of group 2 patients were in remission. In conclusion, the presence of palpable cervical lymph nodes at diagnosis is associated with more invasive forms of malignancy and is a predictive factor of recurrence regardless of the extent of the initial surgery.

Solitary extramedullary plasmacytoma arising in the pterygoid fossa

A case of solitary extramedullary plasmacytoma of the left pterygoid fossa is presented, which is an unusual location for such tumors. A 54-year-old male patient was admitted for retro-orbital and left-sided facial pain which had persisted for several months. Physical, nasal endoscopic and optic examinations showed no abnormalities. No palpable cervical lymph nodes were found. MRI revealed a 2-cm mass in the left pterygoid fossa. A biopsy was carried out and the resulting histological evaluation of the mass confirmed a plasmacytoma. A comprehensive work-up, including bone marrow biopsy, total-body skeletal survey, technetium scintigrams, determination of urine Bence-Jones protein and serum myeloma protein, chest radiograph, total blood count and urinalysis, was carried out in order to rule out multiple myeloma. All of these studies were unremarkable in terms of a systemic disease and therefore the patient was diagnosed as having a solitary extramedullary plasmacytoma of the pterygoid fossa. He was referred for radiation therapy, receiving irradiation of 50 Gy for 6 weeks. The clinical manifestations, imaging findings, pathology and treatment procedures of extramedullary plasmacytoma are described, together with a review of the literature.

Primary sinonasal tuberculosis in north-west Pakistan.

To record the frequency of primary involvement of nose and paranasal sinuses with tuberculosis in today's situation in the north-west region of Pakistan. An observational study. The Department of ENT and Head and Neck Surgery, Khyber Teaching Hospital, Peshawar from 1986 to 1996. A total of ten cases of primary sinonasal tuberculosis were included. The inclusion criteria were biopsy and acid-fast bacilli (AFB) examination after Ziel Neelsen (ZN) staining. Patients were put on anti-tuberculous chemotherapy. Response to the therapy and compliance of the patients were studied through follow up. Patients were admitted and offered surgical treatment wherever needed. The primary sinonasal tuberculosis affected mainly young adults (18-60 years), both genders almost equally. Majority (80%) of the patients belonged to far-flung rural areas and all (100%) were poor. More frequent presenting features were granular lesion and mass in the nose (40%), epistaxis (30%), septal perforation (30%), external deformity (30%), palpable cervical lymph nodes (30%) and others. All the cases were diagnosed microscopically. Compliance to treatment was not good. The incidence of primary tuberculosis of nose and paranasal sinuses has risen in the recent past. The patients manifested no evidence of pulmonary tuberculosis.

Sentinel lymph node dissection in papillary thyroid carcinoma.

Occult lymph node (LN) metastasis is common in papillary thyroid carcinoma. Sentinel lymph node (SLN) biopsy has been proven to be successful and accurate to predict the nodal status in melanoma and breast cancer. We investigate the use of SLN in papillary thyroid carcinoma. Patients of previously untreated papillary thyroid carcinoma, diagnosed preoperatively by fine-needle cytology without any palpable cervical LN are prospectively studied. Blue dye injection was utilized for the SLN biopsy followed by central compartment lymphadenectomy. The histopathological results of the SLN and lymphadenectomy specimens were compared. Fifteen consecutive patients underwent surgery including SLN biopsy for papillary thyroid carcinoma. Occult nodal metastases were identified in 10 patients (67%). The other five cases had no nodal metastasis. SLN were found in 10 cases. One, two and three SLN were present in three, three and four patients, respectively. SLN were located in the central compartment in eight cases. The SLN were found in the lateral compartment in one case. In the remaining one case, the SLN were found in both the central and lateral compartments. Of the group with found SLN, false negative occurred in one case. The overall accuracy of the SLN in predicting the nodal status was 90%. The sensitivity, specificity, positive predictive value and negative predictive value were 88%, 100%, 100% and 67%, respectively. No complications were directly related to SLN biopsy. Occult nodal spread is frequently encountered in papillary thyroid carcinoma. SLN biopsy is safe and feasible in papillary thyroid cancer, however further studies are necessary to improve the diagnostic accuracy prior to routine clinical use.

Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes.

To determine the incidence of clinically positive lateral cervical nodes at presentation and after initial treatment in patients with well-differentiated thyroid cancer. Retrospective chart review. University-affiliated teaching hospitals. A total of 508 patients who underwent a thyroidectomy as part of their initial treatment for well-differentiated thyroid carcinoma between January 1978 and December 1999. Neck dissections were performed only for clinically palpable cervical nodes. Recurrence in the neck and survival. Forty-four patients (9%) had palpable lateral cervical lymph nodes at the time of surgery. All 31 patients younger than 45 years presenting with palpable positive nodes are alive and free of disease; 4 of 13 patients 45 years or older have died of thyroid cancer. Only 16 (3%) of 464 patients who did not undergo initial neck dissection had recurrence in lateral cervical nodes. Recurrence is more likely when the initial tumor is larger than 4 cm. In 216 patients younger than 45 years, there were 5 (2%) recurrences in lateral cervical nodes; these patients remain alive and free of disease. In 248 patients 45 years or older, there were 11 (4%) with recurrent disease in the lateral neck; 4 of these patients have died of thyroid cancer. An aggressive approach to detecting and treating occult lateral cervical nodes by techniques such as jugular node sampling, sentinel node biopsy, or image-guided needle biopsy is not necessary in most patients. Attempts to detect and remove occult lateral cervical lymph node metastases might be considered in older patients with large primary tumors.

Fever, abdominal pain, and interstitial pneumonia in a 13-year-old female

CASE PRESENTATION The patient is a 13-year-old female who presented with a 4-week history of fever, 3 days of abdominal pain, and 1 day of vomiting. Fever was intermittent, low grade, lasting for a few hours daily, and associated with generalized myalgia. One week before evaluation, fever was persistent and up to 40° C. She had daily abdominal pain, lasting for hours, located in the right upper quadrant and epigastrium, dull and mild in intensity with no aggravating or relieving factor identified. She was admitted to All Children’s Hospital, St. Petersburg, FL for further evaluation and care. Past medical history was significant for congenital hydrocephalus of unidentified etiology. Several ventriculo-peritoneal shunt revisions had been performed in the past, with the last revision 6 months before her visit. She had a history of asthma, currently in remission, with no bronchodilator use in the past 2 years. Review of systems revealed an eight-pound weight loss over a 6-month period with increasing tiredness. There were no night sweats, nasal symptoms, cough, dyspnea, chest pain, diarrhea, or urinary tract symptoms. She was not on any medication. There was no history of environmental, insect, or medication allergies. The travel history included visits to Washington DC and Maryland 4 months before admission, and Tennessee 2 months before admission. There was exposure to goats and deer but no history of tick bite during these visits. There was no history of tuberculosis exposure, nor family history of allergic or autoimmune disease. Social history was non-contributory. Physical examination revealed a thin girl in no apparent distress. Temperature was 38.8° C, pulse 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 90/60 mm Hg. Pertinent findings included palpable bilateral non-tender cervical lymph nodes, 1.5 1.5 cm in diameter. Chest was clear to auscultation, without any wheezing or crepitation. Abdomen was soft, non-tender nor distended, liver was palpable 3 cm below right costal margin with mild tenderness.

Squamous Cell Carcinoma of the Lower Lip and Supra-Omohyoid Neck Dissection

Purpose: The aim of this study is to evaluate our approach to patients with squamous cell carcinoma of lower lip.Patients and methods: This study includes 31 lower lip squamous cell carcinomas followed up between 1994 and 2000. Primary treatment was applied to 28 patients of whom 23 were in stages I-II and five in stages III-IV. Three patients presented locoregional recurrence. Neck dissection was performed during primary lip resection in patients with palpable cervical lymph node involvement. Patients with unpalpable cervical lymph nodes were divided into two subgroups: one was submitted to elective neck dissection (n = 11) and the other had isolated lip resection (n = 8). Unilateral or bilateral selective supra-omohyoid neck dissection (SOHND) was performed according to the localisation of the disease. Radical dissection was performed in a secondary intervention, when SOHND revealed lymph node metastases. Radiotherapy and chemotherapy were applied for curative and/or adjuvant treatment in addition to surgery in patients with locoregional recurrence and metastatic lymph nodes or with perineural involvement.Results: Occult cervical metastasis within a single lymph node was found in one of the 11 No patients who underwent elective neck dissection. Delayed neck metastasis developed in one of the eight patients in whom isolated lip resection (without neck exploration) was performed. Chemoradiotherapy was administered to this patient, but he died. Neck metastasis was established histologically in four of five patients in stages III-IV. Postoperative radiotherapy was used on these patients. One of the patients in this group died due to inoperable local recurrence in the neck, another died because of distant metastasis. Local mandibular recurrence was seen in one of these patients after three years. Comment: Six patients (19%) died due to lower lip carcinoma in this series. Our findings show the importance of elective neck dissection and intact surgical resection margins.

Diagnosis and management of patients with thyroid nodules.

Fewer than 5% of all adults will have a palpable thyroid nodule, but this is still a large number of individuals who require evaluation. Although most thyroid nodules are a result of a benign disease process (more than 95%), the possibility of thyroid cancer is always a consideration. Important aspects of history taking with a patient in whom a thyroid nodule has been noted include age, gender, family history of thyroid or endocrine disease, prior low dosage head and neck radiation, recent hoarseness, dysphagia, and symptoms of hypermetabolism. Key features of evaluation by physical examination are the size and location of the thyroid abnormality, the degree of firmness of the nodule, the presence of other nodules in the thyroid, palpable cervical lymph nodes, vocal cord paresis or paralysis, and tachycardia and/or tremor. The major categories of thyroid abnormality in such patients include cysts, adenomas, thyroiditis, and cancer. Although radionuclide scans, ultrasound examination and computer tomography have all been employed in the assessment of thyroid nodules, and thyroid stimulating hormone assay is useful for confirming a euthyroid state, fine needle aspiration biopsy (FNAB) has proved to be the most efficient diagnostic tool. The findings from FNAB allow avoidance of operative treatment for a large portion of these patients with palpable thyroid nodules, but a diagnosis of "follicular neoplasm" on FNAB usually requires operation, despite the fact that many such patients do ultimately prove to have a benign lesion. The extent of operation in patients undergoing surgery will depend on the diagnostic findings before operation, but unilateral thyroid lobectomy is the minimum procedure when surgery is required.

Differential diagnosis of lymph node lesions. A semiquantitative approach with power Doppler sonography.

To assess the value of power Doppler for distinguishing reactive from malignant lymph node disease. In a prospective study, 48 untreated patients with palpable cervical lymph node enlargement (n = 211) underwent examination with power Doppler sonography. The perfusion sites were subdivided into three groups: central, peripheral, and hilar perfusion. In addition, the authors qualified the intensity of perfusion using a semiquantitative scale from 0 (no perfusion) to III (high perfusion). Finally, the overall perfused lymph node area was measured and the percentage of perfused nodal area was calculated. Power Doppler sonography showed perfusion in 183 of 211 lymph nodes. Histologic examination revealed 67 reactively enlarged lymph nodes, 72 metastases, and 44 lymphomas. Reactively enlarged lymph nodes showed characteristically intense hilar perfusion (82.1%), whereas nodal metastases exhibited mainly peripherally located flow (84.7%) of grade intensity I to III. Lymph nodes invaded by malignant lymphoma were highly perfused, displaying color signals in the center as well as in the nodal periphery (90.9%). The perfusion patterns of lymph nodes provide useful additional information in the differential diagnosis of cervical lymphadenopathy.