Haycocknema perplexum myositis: the first description of subclinical disease and a proposed distinctive triad to evoke clinical suspicion.

Introduction: Haycocknema perplexum is an exceedingly rare cause of parasitic myositis endemic to Australia, more specifically, Tasmania and North Queensland. There is a paucity of literature regarding this diagnosis, with only nine previously described cases. Diagnosis: This report details two cases of biopsy-confirmed H. perplexum myositis from Townsville University Hospital and describes the first-ever case of subclinical infection. There is limited known information regarding the H. perplexum life cycle and a definitive host which has hindered the development of a non-invasive diagnostic test. A review of the previously described cases has identified the hallmark features of this enigmatic condition: a triad of serological markers including deranged hepatic function, persistent eosinophilia and an elevated creatine kinase. Conclusions: This report aimed to raise awareness of H. perplexum myositis and the possibility of subclinical infection, which suggests a protracted disease course. Further research is required to identify a non-invasive diagnostic test, given that early diagnosis and timely initiation of albendazole treatment may drastically limit patient disability.

Home physiotherapy with vs. without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty.

The aim of this retrospective cohort study was to compare home physiotherapy with or without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty. METHODS: A total of 900 patients (including 810 females and 90 males) who had undergone total knee arthroplasty were divided into group A (n = 300) and group B (n = 600). Patients in group A had home physiotherapy on their own after discharge from hospital. The physiotherapist did not visit them at home. Patients in group B received home physiotherapy under supervision of physiotherapist for 6 weeks after discharge from hospital. Patients' age, range of motion of the knee, and forgotten joint score-12 were assessed. A p < 0.05 was considered statistically significant. RESULTS: In group A, the mean age was 69.1 ± 14.3 years (range: 58 to 82 years); in group B, the mean age was 66.5 ± 15.7 years (range: 56 to 83 years) (p > 0.05). Preoperatively, the mean range of motion of the knee in group A and B was 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p > 0.05). The mean forgotten joint score-12 of group A and B were 11.90 ± 11.3 and 11.72 ± 12.1 (p > 0.05), respectively. Six weeks after total knee arthroplasty, the mean ROM of the knee in group A and B was 109.7° ± 22.3° and 121° ± 21.5°, respectively (p < 0.05). The mean postoperative forgotten joint score-12 of the group A and B was 24.5 ± 16.4 and 25.6 ± 17.4, respectively (p > 0.05). The rate of manipulation under anaesthesia was 3% in group A and 0.2% in group B (p < 0.05). CONCLUSION: After total knee arthroplasty, frequent physiotherapist's instruction helps the patients improve knee exercises and therefore decrease the risk of revision surgery. The home physiotherapy under supervision of physiotherapist lowers the rate of manipulation under anaesthesia. LEVEL OF EVIDENCE: Therapeutic study, Level IIa.

Classic type intradural extramedullary ependymoma of the lumbar spine: A new case report of a usual tumour in an unusual location.

Classic type intradural extramedullary (IDEM) ependymomas of the lumbar spine are rare entities. Only two such cases have previously been reported in the literature. Here the authors report a new case and describe radiological, surgical and histological findings as well as review the literature. Unlike previously encountered lumbar IDEM ependymomas, this case was an incidental finding and surgically managed on the grounds of radiological progression over 8 years.

Chromosome 7 aneuploidy in clear cell and papillary renal cell carcinoma: detection using silver in situ hybridization technique.

BACKGROUND: Chromosome 7 aberrations in renal cell carcinoma (RCC) have been reported in papillary renal cell carcinoma (pRCC) and clear cell renal cell carcinoma (ccRCC). However, the implication of these anomalies on prognosis and survival is still unclear. RCC Chromosome 7 aberrations have commonly been detected by fluorescent in situ hybridization and chromogenic in situ hybridization but not silver in situ hybridization (SISH). AIM: The purpose was to report chromosome 7 aberrations in ccRCC and pRCC using SISH in paraffin-embedded tissues and determine the association between the anomalies with clinical and pathological features. MATERIALS AND METHODS: Cases of ccRCC and pRCC from University Malaya Medical Centre (2001-2009) were analyzed. Chromosome 7 staining was performed using an automated SISH method and association tests between chromosomal anomalies, clinical features and survival were performed. RESULTS: SISH is a feasible technique to detect chromosome 7 aberration in RCC. Chromosome 7 aberrations with nuclear grading, staging and survival yielded no significant correlation. Surprisingly, there was a significant association between gender and chromosome 7 expressions. Though grade did not reach statistical significance for survival in our RCC cases, there was a significant correlation between overall survival with race and stage. CONCLUSION: Chromosome 7 aberrations in ccRCC showed no prognostic significance. Nevertheless, staging and grading systems that include prognostic variables could hold better promise.

Fine needle aspiration biopsy, core needle biopsy or excision biopsy to diagnose breast cancer - which is the ideal method?

BACKGROUND: The ideal method for diagnosis of breast cancer is debatable. METHODS: The methods of diagnosis of 436 new cases of breast adenocarcinoma presenting from Jan 2005 till Dec 2006 at the University Malaya Medical Centre (UMMC) were examined in this study. RESULTS: A total of 388 cases presented to the breast unit in UMMC primarily and 48 cases were diagnosed in non-breast units in other hospitals and referred for management. Fine needle aspiration cytology (FNAC) was the commonest mode of initial diagnosis in 278 cases followed by core needle biopsy and surgical excision. In UMMC, FNAC was the commonest initial method (68.3%) compared to cases diagnosed outside UMMC, where 37.5% of cases were diagnosed by excision. Tumours less than 2cm were more likely to be diagnosed by excision biopsy. CONCLUSION: The biopsy method used to confirm the diagnosis is influenced by where the patient first presents, and by the size of the tumour.

Fine needle aspiration cytology of neuroendocrine carcinoma of the breast--a case report and review of literature.

Neuroendocrine carcinomas of the breast are uncommon tumors known to occur in the elderly. While focal neuroendocrine differentiation may be noted in many ductal and lobular carcinomas, the term neuroendocrine carcinoma is to be applied when more than 50% of the tumor shows such differentiation. This case report details the cytological features of a neuroendocrine carcinoma that was encountered in our hospital. The fine needle aspiration (FNA) smears showed discohesive polygonal cells with abundant cytoplasm, many of which contained eosinophilic granules located at one pole. Histology of the mastectomy and axillary lymph nodes specimen from this patient showed features of neuroendocrine carcinoma--solid type, with metastasis, confirmed with immunohistochemistry. The patient is disease free seven months after surgery. This case highlights the need to closely observe cytological details to identify this rare tumor that may otherwise appear to be invasive duct carcinoma--not otherwise specified on FNA. The implications of diagnosing neuroendocrine differentiation for prognosis and management are also discussed.

Needle tract sinus following aspiration biopsy of papillary thyroid carcinoma: a case report.

BACKGROUND: Fine needle aspiration biopsy (FNAB) of the thyroid is a simple and safe investigation. Dissemination of malignant cells during FNA for papillary thyroid carcinoma is extremely uncommon. CASE: We report a 49-year-old woman who presented with a multicystic goiter and palpable cervical lymph nodes. Three sessions of FNAB (a total of 12 needle passes) from a complex cyst overlying the thyroid isthmus using a 22-gauge needle failed to reveal malignant cells. Following the FNAs she developed a persistent discharging sinus at the needle insertion site. Exploration of the neck and histopathologic examination confirmed a well-differentiated papillary thyroid carcinoma infiltrating the skin and strap muscles at a single focus. Debulking surgery with adjuvant radiotherapy had a satisfactory outcome in our patient. CONCLUSION: Skin sinus formation might have been prevented in our case by using a needle with a caliber < 22 gauge and avoiding multiple sessions of aspiration of the same thyroid nodule.

Follicular dendritic cell sarcoma of inguinal lymph node--a case report.

Follicular dendritic cell sarcomas (FDCS) are rare neoplasms that involve lymph nodes or extranodal sites. They show varied histological features and thus can be mistaken for carcinoma or sarcoma. Correct identification is important for further management. A 43-year-old Indian female presented with a three-month history of progressive swelling at the right inguinal region. It was excised completely and was reported as lymph node with metastatic poorly differentiated carcinoma based on Haematoxylin and eosin (H&E) stain findings. Computerized tomography (CT) scans of thorax, abdomen and pelvis were normal and did not reveal a primary site. Following this, the case was referred to one of the authors. The slides were reviewed and a variety of immunocytochemical markers were done. The tumour cells were negative for epithelial, melanocytic, neural, leucocyte and soft tissue tumour markers. They were immunopositive for CD21, CD35 and negative for CD68. Based on the immunocytochemical findings, a final diagnosis of FDCS was made. This case highlights the histological and immunophenotypical profile of a rare tumour which requires a high index of suspicion for diagnosis.

Fetus in fetu or differentiated teratomas?

Two cases of congenital teratoma were operated upon. In view of the high degree of organoid differentiation of the teratomas with rudimentary limbs, intestine, brain-like and pulmonary tissues, it was difficult to distinguish it from fetus-in-fetu. In the light of the data obtained and extensive review of related literature, we consider that fetus-in-fetu and teratoma may not be unrelated entities. Our cases support the view held that fetuses in fetu are highly differentiated teratomas.

Feasibility of breast conservation surgery in locally advanced breast cancer downstaged by neoadjuvant chemotherapy: a study in mastectomy specimens using simulation lumpectomy.

BACKGROUND: The response of locally advanced breast cancer (LABC) to neoadjuvant chemotherapy (NACT) offers these patients previously treated by mastectomy, the chance for breast conservation. AIM: This study aims to assess the feasibility of lumpectomy in patients with LABC treated by NACT, with residual tumor < or =5 cm. SETTINGS, DESIGN: Single group prospective study from August 2001 to June 2003 in a teaching hospital. MATERIALS AND METHODS: Thirty patients with LABC whose tumors reduced with NACT to 5 cm were included. Simulation lumpectomy was performed on the mastectomy specimens to achieve 1 to 2 cm clearance from tumor and hence margin negativity. Multiple sections of the inked margin were studied. STATISTICAL ANALYSIS: Margin positivity was correlated with patient factors. Chi square test and Fisher's exact test used as appropriate. P value 0.05 was considered significant. RESULTS AND CONCLUSIONS: After three cycles of NACT, 4 patients (13%) had complete clinical response including 2 with complete pathological response. Twenty-two (73%) showed partial response and 4, no response. Fourteen out of thirty (47%) had tumor involvement of margins. Tumors with post-chemotherapy size> 4 cm were margin positive in 10/13 (77%). Tumors with post-chemotherapy size>3 cm were margin positive in 13/24 (54%). Tumors with post-chemotherapy size 3 cm were margin negative in 5/6 (83%). Pre-chemotherapy tumor size and post-chemotherapy tumor size were significantly associated with margin positivity (P=0.003). Tumors in the subareolar location had significantly higher incidence of residual tumor in the nipple areola complex. (P=0.04). Margin positivity of lumpectomy on downstaged tumors can be reduced by removing the nipple areola complex in subareolar tumors and by limiting breast conservation to tumors with post-chemotherapy size < or =3 cm.

Leiomyoma of the vagina: an unusual presentation.

Vaginal leiomyomas are rare. They usually arise from the anterior vaginal wall. We report a case of a vaginal leiomyoma arising from the right lateral wall that presented as a gluteal swelling with pus discharging per vagina, creating a clinical dilemma in diagnosis. Preoperative imaging and biopsy may help to rule out malignancy. The size of the tumor necessitated abdominoperineal approach and hysterectomy for better surgical access. To the best of our knowledge such a clinical presentation of a vaginal leiomyoma has not been reported in the literature.

Rehydrated air-dried Pap smears as an alternative to wet-fixed smears.

OBJECTIVE: To assess the effect of rehydration on air-dried Pap smears and to compare them with conventional, wet-fixed smears. STUDY DESIGN: Paired cervical smears were obtained from 419 women. One set was labelled "Routine" (fixed immediately in 95% ethanol) and the other, "Rehydrated" (air-dried, rehydrated and then fixed). The latter were further subdivided into groups A-F depending on the duration of air drying. The staining quality of the smears was assessed, after adequate blinding to remove bias, and graded. The chi 2 test was performed to compare parameters in the two sets of smears. RESULTS: Of the 397 pairs found to have adequate cellularity, 6% of the Routine group and 4% of the Rehydrated were "unsatisfactory due to poor fixation." Smears rehydrated within two hours of air drying as well as those refrigerated within two hours and rehydrated after 48 hours produced a staining quality as good as that of the conventional, wet-fixed smears. Rehydration caused lysis of red blood cells in the background. CONCLUSION: Rehydration of air-dried Pap smears within two hours of preparation produces staining quality equal or superior to that of conventional, wet fixed ones. It has the added advantage of being less cumbersome for the clinical personnel involved in smear making.

Discrete epithelioid cells: useful clue to Hodgkin's disease cytodiagnosis.

Diagnosis of Hodgkin's disease is made with more confidence than diagnosis of non-Hodgkin's lymphoma on cytology. This study was undertaken to describe the presence of granulomas and a new cytologic feature, discrete epithelioid cells (DECs), in smears from Hodgkin's disease. Fine-needle aspiration smears from 39 cases of biopsy-proven Hodgkin's disease, collected over a period of 43 months, were reviewed. Epithelioid granulomas were seen in 38.5% of the smears. DECs, which were noted in 70% of the cases, may be useful in raising the suspicion of Hodgkin's disease when other features are not evident; their presence should encourage the cytopathologist to obtain aspirations from other lymph nodes.

A study of fibroepithelial tumours of the breast.

Cytological parameters were studied in 18 fibroepithelial tumours of the breast including 8 benign phyllodes, 1 malignant phyllodes, and 9 fibroadenomas between 1999 to 2001. Cytology smears were studied without knowledge of previous cytodiagnosis by 3 different observers. Histopathologic parameters were studied in 18 fibroepithelial tumours by 3 observers. Cyto-histological correlation was carried out. Cytological criteria by Chinoy et al (1999) were utilized to give revised cytodiagnosis. Initial cytodiagnosis and revised cytodiagnosis were correlated with histopathological diagnosis. 8/9 cases of fibroadenoma (88%) studied were correctly diagnosed on FNAC after semiquantitative team approach as opposite to 44% initial cytodiagnosis. Cytological distinction between benign phyllodes and fibroadenoma was improved after semiquantitative approach to various parameters. Diagnosis of malignant phyllodes posed no problems in cytodiagnosis. Present study supports the role of FNAC in distinguishing benign from malignant phyllodes and distinguishing fibroadenoma from phyllodes tumour. The latter being a rare fibroepithelial tumour, its study is interesting.