Current status of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms.

The new Kyoto guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) provide evidence-based recommendations for the diagnosis and treatment of IPMN. Endoscopic ultrasonography (EUS) is a diagnostic modality with a high spatial resolution that allows detailed observation and obtaining cyst fluid or tissue samples via EUS-guided fine needle aspiration (EUS-FNA). Currently, EUS is an indispensable examination method for the diagnosis of pancreatic diseases. On the other hand, there have been concerns that EUS imaging tends to be highly operator-dependent, and may lack objectivity. Previous guidelines have assigned EUS as an option for patients with worrisome features. However, recent reports indicate that the sensitivity of EUS for the diagnosis of mural nodules (MNs) is more than 90%, comparable or superior to that of contrast-enhanced computed tomography or magnetic resonance cholangiopancreatography. The specific advantages of EUS in the diagnosis of IPMN are: (1) high spatial resolution imaging for the diagnosis of MNs, (2) contrast-enhanced EUS for differentiation of intra-cystic MNs from mucous clots, and (3) pathological diagnosis using EUS-FNA and differential diagnosis of a pancreatic cystic tumor by cystic fluid analysis. In order to utilize EUS in the diagnosis of IPMN, endoscopists are required to have the skills to provide sufficiently objective imaging findings.

Updated techniques and evidence for endoscopic ultrasound-guided tissue acquisition from solid pancreatic lesions.

Endoscopic ultrasound-guided tissue acquisition (EUS-TA), including fine-needle aspiration (EUS-FNA) and fine-needle biopsy (EUS-FNB), has revolutionized specimen collection from intra-abdominal organs, especially the pancreas. Advances in personalized medicine and more precise treatment have increased demands to collect specimens with higher cell counts, while preserving tissue structure, leading to the development of EUS-FNB needles. EUS-FNB has generally replaced EUS-FNA as the procedure of choice for EUS-TA of pancreatic cancer. Various techniques have been tested for their ability to enhance the diagnostic performance of EUS-TA, including multiple methods of sampling at the time of puncture, on-site specimen evaluation, and specimen processing. In addition, advances in next-generation sequencing have made comprehensive genomic profiling of EUS-TA samples feasible in routine clinical practice. The present review describes updates in EUS-TA sampling techniques of pancreatic lesions, as well as methods for their evaluation.

Effectiveness of direct needle puncture for complete hepaticojejunostomy anastomotic stricture after pancreaticoduodenectomy (with video).

A 79-year-old Japanese woman, who had undergone pancreaticoduodenectomy 6 months prior to presentation owing to pancreatic cancer, complained of jaundice with high fever. Computed tomography revealed proximal bile duct dilatation with complete hepaticojejunostomy anastomotic stricture (HJAS). We performed a single-balloon endoscopy for biliary drainage. The presence of a scar-like feature surrounding the anastomosis was identified as the HJAS. White-light imaging during single-balloon endoscopy revealed that the HJAS contained a milky whitish area (MWA), suggesting that a membranous and fibrosis layer affected continuous inflammation around the center of the anastomosis (within a scar-like feature). Endoscopic dilatation was performed using an endoscopic injection needle, with the MWA used as an indicator. A 23-gauge endoscopic injection needle was used to penetrate the center of the blind lumen within the MWA, and a pinhole was created in the stricture. After confirming the position of the proximal bile duct using a contrast medium with the needle, an endoscopic guidewire with a cannula was inserted into the pinhole. A through-the-scope sequential balloon dilator was used to dilate the stricture, and a plastic stent was inserted into the proximal bile duct. This endoscopic intervention led to positive outcomes. In cases of complete HJAS occlusion, an endoscopic approach to the bile duct is difficult because the anastomotic opening of the HJAS is not visible. Thus, puncturing within the MWA, which can be used as a scar-like landmark within a complete membranous HJAS, is considered a useful endoscopic strategy.

A case of intra-abdominal gossypiboma diagnosed preoperatively by endoscopic ultrasound fine-needle-aspiration.

Gossypiboma is an extremely rare adverse event occurring post-surgery, where surgical gauze is left within the body. If aseptically retained, it can lead to the formation of granulation tissue through chronic inflammation and adhesion with surrounding tissues, potentially persisting asymptomatically for many years. While diagnosis of this condition has been reported through various imaging modalities such as abdominal ultrasound and computed tomography, cases not presenting with typical findings are difficult for preoperative diagnosis, and instances where it is discovered postoperatively exist. Particularly when in contact with the gastrointestinal tract within the abdominal cavity, differentiation from submucosal tumors of the digestive tract becomes problematic. This report describes the imaging characteristics of endoscopic ultrasound and the usefulness of endoscopic ultrasound-fine-needle-aspiration for tissue diagnosis in the preoperative diagnosis of intra-abdominal gossypiboma.

The value of histopathologic examination and Xpert (MTB/RIF) assay in diagnosis of cervical lymph node tuberculosis after coarse needle biopsy guided by CEUS: a retrospective analysis of 612 cases.

OBJECTIVE: To investigate the value of histopathological examination (HPE) and Xpert Mycobacterium tuberculosis bacilli/rifampicin (MTB/RIF) assay in diagnosis of cervical lymph node tuberculosis (LN TB) after coarse needle biopsy (CNB). METHODS: We retrospectively analyzed 612 samples obtained from October 2017 to August 2023 from patients suspected cervical LN TB with surgically pathological, microbial culture confirmed, and clinically confirmed cervical lymph node enlargement who received ultrasound-guided CNB assisted by contrast-enhanced ultrasound (CEUS) at our hospital. All specimens were assessed by HPE and the Xpert (MTB/RIF) assay. We analyzed the results to determine the diagnostic value of HPE and Xpert (MTB/RIF) assay in samples taken after CEUS-assisted CNB of LN TB, and to evaluate the safety of CNB. RESULTS: Based on the comprehensive reference standard established in this study, 532 of 612 patients were diagnosed with cervical LN TB, of which 476 were CNB positive cases, the positive rate of diagnosis was 89.5%。The sensitivity, specificity, positive predictive value, negative and predictive value of HPE were 80.4%, 91.2%, 98.4%, 41.2% respectively, while those of the Xpert MTB/RIF assay were 75.7%, 98.7%, 99.7%, 38.0% respectively. No postoperative complications were noted, and the Clavien-Dindo grade was 2. CONCLUSION: CEUS-assisted CNB has high diagnostic value and is safe for cervical LN TB. The sensitivity of HPE is slightly higher than that of Xpert (MTB/RIF) assay, and the specificity of Xpert (MTB/RIF) assay is higher than that of HPE, so Xpert (MTB/RIF) assay can correct the cervical lymph node tuberculosis with negative HPE.

Comparison of clinical/histological outcomes according to puncture sites in endoscopic ultrasound-guided fine needle biopsy for large pancreatic masses: Multicenter randomized prospective pilot study.

OBJECTIVES: There are no recommendations regarding the optimal puncture site in endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). This multicenter randomized prospective study compared the diagnostic accuracy and histological findings according to the sampling site for pancreatic masses larger than 3 cm. METHODS: Consecutive patients with pancreatic masses larger than 3 cm indicated for EUS-FNB were included in the study. Patients were randomly assigned to two groups for the initial puncture site (central vs. peripheral sampling of the masses). A minimum of four passes were performed, alternating between the center and the periphery. The primary outcome was diagnostic accuracy. RESULTS: A total of 100 patients were equally divided into the central group and the peripheral group. The final diagnosis revealed malignancy in 95 patients (pancreatic cancer [n = 89], neuroendocrine tumor [n = 4], lymphoma [n = 1], metastatic carcinoma [n = 1]), and benign conditions in five patients (chronic pancreatitis [n = 4], autoimmune pancreatitis [n = 1]). There was no significant difference in diagnostic accuracy between the puncture sites. However, combining samples from both areas resulted in higher diagnostic accuracy (97.0%) compared to either area alone, with corresponding values of 88.0% for the center (P = 0.02) and 85.0% for the periphery (P = 0.006). CONCLUSIONS: Both central sampling and peripheral sampling showed equivalent diagnostic accuracy in detecting malignancy. However, combining samples from both areas generated superior diagnostic yield compared to using either sampling site alone. For pancreatic masses larger than 3 cm, it is advisable to consider sampling from various areas of the masses to maximize the diagnostic yield.

Frequency of occupational health hazards and factors responsible among the waste handlers at the tertiary care hospitals of Karachi.

Background & Objectives: Hospital waste handlers (HWHs) are in contact with contaminated waste that put them at risk for occupational health hazards. The objective of the study was to determine the frequency of occupational health hazards and identify factors contributing to them among the HWHs at tertiary care hospitals of Karachi. Methods: A cross sectional survey was conducted from January 2021 till June 2022 on 417 conveniently selected HWHs of the public and private tertiary care hospitals of the Karachi including three Public sector hospitals (Civil Hospital Karachi, National Institute of Child Health, Jinnah Post Graduate Medical Center) and five private sector hospitals (Sohail University Hospital, Darulsehat Hospital, Kharadar General Hospital, Patel Hospital and Hamdard University Hospital) using a structured questionnaire. Chi Square test was applied to determine the differences in occurrence of different hazardous outcomes (Needle stick injury, Sharp Injury, Eye Symptoms, Skin symptoms, Cough) between different groups of age, gender, type of hospitals and status of being trained in Hospital Waste Management (HWM). Results: Around half of the HWHs (52.6%) labeled the bins of the waste according to their level of hazard. Only 17.9% disinfected the infected waste. The proportion of participants who experienced needle stick and sharp injury in the last six months was 16.3% and 15.8% respectively. Majority of them used disposable gloves (95.7%) and face masks (94.3%). One thirds had access to aprons while only 10.5% had access to protective shoes at their work place. HWHs of private sector were significantly less likely to experience Needle stick injuries, skin symptoms, cough, breathing difficulty and throat burning. Conclusion: The HWM practices in tertiary care hospitals of Karachi is far from being satisfactory. HWHs must be trained and monitored for safe disposal of waste.

The Sydney system for lymph node FNA biopsy cytopathology: A detailed analysis of recent publications and meta-analysis and a proposal for the components of an ideal prospective study of a cytopathology reporting system.

BACKGROUND: The Sydney system for fine-needle aspiration biopsy of lymph nodes has five categories, stressing the role of correlation of cytopathology with clinical, ultrasound, and ancillary findings to achieve diagnosis. The five categories constitute a hierarchical system with increasing risk of malignancy from benign to atypical, suspicious, and malignant categories, which informs recommendations for further workup to achieve a final diagnosis as possible. This article analyzes 10 publications using the Sydney system and a meta-analysis of nine of these studies. The primary goal of the analysis is to ascertain the causes of the large ranges in risk of malignancy for the "atypical" and "inadequate" compared to "benign," "suspicious," and "malignant" categories, which were comparable to well-established reporting systems. Research protocols are proposed to improve future studies. METHODS: PubMed literature search from January 2021 to December 2023 identified studies evaluating performance of the Sydney system. RESULTS: Ten studies showed heterogeneity with clinical setting, study design, ultrasound use and rapid on-site evaluation, operator, cutoff points for "positive" cases, with inherent partial verification biases, resulting in a wide range of risk of malignancy, specificity, and sensitivity values. CONCLUSION: Analysis shows the large range is due to heterogeneity of the studies, which suffer from biases and variable statistical analysis that are ultimately included in any meta-analysis, detracting from the usefulness of the risk of malignancy derived by the meta-analysis. Components for ideal analyses of reporting systems are presented.

The utility of next-generation sequencing in challenging liver FNA biopsies.

BACKGROUND: Fine-needle aspiration (FNA) biopsy is increasingly used for the diagnosis of hepatocellular masses. Because distinguishing well differentiated hepatocellular carcinoma (HCC) from other well differentiated hepatocellular lesions (e.g., large regenerative nodules or focal nodular hyperplasia) requires an assessment of architectural features, this may be challenging on FNA when intact tissue fragments are not sampled. Poorly differentiated HCC and intrahepatic cholangiocarcinoma (ICC) may exhibit overlapping pathologic features. Molecular testing can be helpful, because mutations in TERT promoter and CTNNB1 (ß-catenin) are characteristic of HCC, whereas mutations in BAP1, IDH1/IDH2, and PBRM1 may favor ICC. The goal of this study was to assess the role of next-generation sequencing (NGS) in further subclassifying indeterminate liver lesions sampled by FNA. METHODS: A retrospective review of liver cytology cases with NGS on cell block material was performed. Age, radiologic features, background hepatic disease and treatment, outcome, and NGS data were obtained from the electronic medical record. RESULTS: Twelve FNA biopsies that had cell blocks from clinically suspected primary hepatic masses were identified. The presence of a TERT promoter mutation supported a diagnosis of HCC for one well differentiated neoplasm. For three patients, the presence of mutations, such as IDH1, CDKN2A/CDKN2B, and BRAF, supported a diagnosis of ICC. Of the eight poorly differentiated carcinomas, NGS helped refine the diagnosis in six of eight cases, with one HCC, three ICCs, and two that had combined HCC-ICC, with two cases remaining unclassified. CONCLUSIONS: Molecular diagnostics can be helpful to distinguish HCC and ICC on FNA specimens, although a subset of primary hepatic tumors may remain unclassifiable.

A method for predicting needle insertion deflection in soft tissue based on cutting force identification.

The deflection modeling during the insertion of bevel-tipped flexible needles into soft tissues is crucial for robot-assisted flexible needle insertion into specific target locations within the human body during percutaneous biopsy surgery. This paper proposes a mechanical model based on cutting force identification to predict the deflection of flexible needles in soft tissues. Unlike other models, this method does not require measuring Young's modulus (E) and Poisson's ratio (ν) of tissues, which require complex hardware to obtain. In the model, the needle puncture process is discretized into a series of uniform-depth puncture steps. The needle is simplified as a cantilever beam supported by a series of virtual springs, and the influence of tissue stiffness on needle deformation is represented by the spring stiffness coefficient of the virtual spring. By theoretical modeling and experimental parameter identification of cutting force, the spring stiffness coefficients are obtained, thereby modeling the deflection of the needle. To verify the accuracy of the proposed model, the predicted model results were compared with the deflection of the puncture experiment in polyvinyl alcohol (PVA) gel samples, and the average maximum error range predicted by the model was between 0.606 ± 0.167 mm and 1.005 ± 0.174 mm, which showed that the model can successfully predict the deflection of the needle. This work will contribute to the design of automatic control strategies for needles.

Individual Ultrasonographic Characteristics of Thyroid Nodules and Their Cytopathological Correlation to Determine Malignancy Risk.

Background Ultrasonographic evaluation of thyroid nodules is challenging due to their high frequency and low malignancy rate. The risk stratification system developed by the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) focuses on addressing the primary contemporary objectives for these lesions, aiming to decrease unnecessary biopsies while maintaining a similar specificity compared with other risk stratification systems. Generally, when indicative of malignancy by ultrasound findings, the next best step in management is an evaluation by fine needle aspiration biopsy (FNAB) and cytological analysis with The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) results that determine further evaluation requirements, actions that are based on the risk of malignancy (ROM) of the assigned category, which could include surgical intervention. Objectives To validate and analyze the individual impact of each ultrasonographic finding indicative of malignancy in the ACR TI-RADS guidelines based on their respective correlation with results obtained by TBSRTC. Materials and method Reports for 212 thyroid ultrasound-guided FNABs from 2018 to 2020 were assessed. Only 117 had both ACR TI-RADS and TBSRTC reports available and were analyzed. Nodules were divided into two groups: ROM < 5% (Bethesda 1, 2; n = 58), and ROM > 5% (Bethesda 3, 4, 5, 6; n = 59). Statistical analysis was performed using the x2 test and bivariate logistic regression model for each characteristic included in ACR TI-RADS. Results Individual ultrasound characteristics with a more pronounced distribution towards the Bethesda > 5% malignancy group were: solid or almost completely solid composition (n=53, 62.3%), very hypoechoic echogenicity (n=3, 75%), wider-than-tall shape (n=50, 50.5%), lobulated or irregular margin (n=23, 65.7%), punctate echogenic foci (n=18, 72%), and thyroid isthmus location (n=6, 75%). Statistically significant individual ultrasonographic characteristics indicative of malignancy included solid or almost completely solid (p = 0.005), very hypoechoic echogenicity (p = 0.046), margin lobulated or irregular (p = 0.031), and punctate echogenic foci (p = 0.015). No significant association was found in the taller-than-wide shape for differentiating malignant from benign lesions (p = 0.969). Conclusions Specific ultrasound characteristics identified in the ACR TI-RADS system demonstrate a stronger correlation with an increased risk of malignancy when compared with cytologic evaluation results. These characteristics include a solid composition, lobulated or irregular margins, punctate echogenic foci, and very hypoechoic echogenicity. Our findings revealed that the scale points for the taller-than-wide characteristic do not adequately represent its true influence on the risk of malignancy.

Comparison of state-of-the-art biopsy systems for ultrasound-guided breast biopsy using a chicken breast phantom.

PURPOSE: To compare different biopsy systems with different-sized needles by determining the weight of the tissue cores, which is one of the important factors for precise pathological diagnoses, and to provide a rationale for choosing the appropriate breast biopsy system with the appropriate needle for breast cancer biopsy. METHODS: Six different vacuum-assisted biopsy (VAB) systems and one core needle biopsy (CNB) system with different-sized needles in different modes were compared, representing 15 total combinations. Tissue cores were obtained from a chicken breast phantom, which is a common substitute for human breast tissue. Five cores were taken for each combination and weighed. RESULTS: The CNB combination provided significantly lighter tissue cores compared with the VAB combinations with the same-size (14-G) needle (P < 0.01). The combinations using the thickest needle obtained the heaviest among all systems (P < 0.02). The untethered battery-free VAB system yielded the lightest specimen among the VAB systems with the same-sized (12-G) needle (P < 0.04). The percent coefficient of variation (%CV) of the core weights obtained using VAB without a basket was significantly smaller compared with the core weights obtained using VAB with a basket (P < 0.01). CONCLUSION: VAB systems can yield larger tissue cores compared with CNB systems. The size of the tissue cores varies even with the same-sized needle among different VAB systems. When performing a breast tissue biopsy, it is important to consider not only CNB versus VAB but also what specific device to use with which needle size.

The Great Impostor: A challenging case of small-cell melanoma with isolated adrenal metastasis.

Small-cell melanoma masquerading as an adrenal non-Hodgkin lymphoma. The index report illustrates the deceptive cytomorphologic features of a small cell type malignant melanoma metastatic to the adrenal gland. The diagnosis was confirmed by performing immunocytochemistry on the cell block sections. The key cytomorphologic mimics and their distinctive features have also been highlighted.

Diagnostic accuracy of imaging-guided biopsy of peripheral pulmonary lesions: a systematic review.

The histologic definition of peripheral pulmonary lesion (PPL) is critical for a correct diagnosis and appropriate therapy. Non-invasive techniques for PPL biopsy are imaging-guided, using endobronchial ultrasound (EBUS), computed tomography (CT), and electromagnetic navigation bronchoscopy (ENB). To assess the diagnostic accuracy of PPL biopsy and provide a framework for reporting data for accuracy studies of PPL biopsy. A systematic review was conducted on PubMed, Scopus, and Web of Science to identify all the articles assessing the accuracy of EBUS, CT, and ENB between January 2000 and June 2023 basing search queries on keywords emerging from PICO question. Only studies investigating biopsy of PPL and reporting accuracy or necessary data to calculate it independently were included. Risk of bias was based on QUADAS-2 tool. In total, 81 studies were included. Median accuracy was 0.78 (range=0.51-0.94) in the EBUS group, 0.91 (range=0.73-0.97) in the CT group, 0.72 (range=0.59-0.97) in the ENB group, and 0.77 (range=0.61-0.92) in the combined group. Sensitivity and NPV ranges were 0.35-0.94 and 0.26-0.88 in the EBUS group, 0.71-0.97 and 0.46-1.00 in the CT group, 0.55-0.96 and 0.32-0.90 in the ENB group, and 0.70-0.90 and 0.28-0.79 in the combined group. Specificity and PPV were 1.00 in almost all studies. Overall complication rate was 3%, 30%, 8%, and 5% in the EBUS, CT, ENB, and combined groups. CT-guided biopsy was the most accurate technique, although with the highest complication rate. When calculating accuracy, indeterminate results must be considered false negatives according to the "intention-to-diagnose" principle.

Rapid on-site evaluation of fine-needle aspiration specimens using cytotechnologist-performed telecytology: Insights and advantages.

With multiple health care centres expanding and implementing remotely controlled technologies, the role of cytopathology laboratories will become crucial in optimizing collection and assessment of small biopsy specimens for diagnosis and personalized treatment. Cytopathology services provide rapid assessments of samples obtained from fine-needle aspirations and occasionally core needle biopsies (analysed by touch imprints). Over the past few decades, the cost barrier for hospitals, especially small ones, to support a cytopathologist or cytotechnologist for rapid on-site evaluation (ROSE) has been reduced by the introduction of computerized microscopes that allow cytopathologists to perform ROSE without being present at the satellite laboratory (i.e. remotely). Utilization of the cytotechnologist's experience in ROSE alongside these technologies made it possible to perform ROSE with telecytology (ROSE-TC), which positively impacts diagnosis and treatment and also lowers the cost of care. The satellite laboratories that successfully implemented ROSE-TC operate with experienced cytotechnologists who, working independently between the cytopathology laboratory and the biopsy suite, prepare the smears and stain the slides on site for the distant cytopathologists, who can evaluate the slides remotely (usually from their office) simply using the facility intranet. This article aims to encourage big and small centres to use senior-level cytotechnologists for both ROSE and ROSE-TC. This article also defines different types of ROSE, explains our institution's approach to ROSE procedures, and outlines some experience-driven considerations for successful ROSE-TC and its future evolution.

Effect of orientation angle for needle-free jet injection.

In this paper, we report on the delivery efficiency of needle-free jet injections using injectors with typical jet speed vj≈140m/s, orifice diameter do=157µm, and volume V=0.1 mL. The target substrates were either hydrogel tissue phantoms or porcine tissues combined with excised human skin. The novelty of this study is two-fold: First, we investigate the influence of injection angle relative to the skin surface, and second, we also study the influence of the jet path relative to the orientation of muscle fibers. While most commercial jet injectors employ a fitting that would render the device normal to the skin surface, recent studies have proposed oblique injections, which may be beneficial for intradermal or subcutaneous tissue injection. Furthermore, for deeper intramuscular injections, we propose that an angled jet path taking the muscle fiber orientation into account may result in a bolus or dispersion zone that is conducive to increased cellular uptake of the drug.

Degree of fear of needles and preferred allergy immunotherapy treatment among children with allergic rhinitis: caregiver survey results.

Introduction: A child's fear of needles may impact the preferred route of allergy immunotherapy (AIT) when choosing between subcutaneous immunotherapy (allergy shots) or sublingual immunotherapy (SLIT). A survey was conducted to understand caregiver health-seeking behavior for children with allergic rhinitis with or without conjunctivitis (AR/C) and explore if fear of needles impacted AIT decisions. Methods: Caregivers of children ages 5-17 years with AR/C were recruited from the Dynata US research panel to participate in an online survey from May-June 2023. The survey received institutional review board exemption status. SLIT-tablets were described as "under-the-tongue tablets". Results: About a third (34%) of surveyed caregivers (n = 437) reported their child had a severe fear of needles and 47% reported moderate fear. Of surveyed caregivers, 53% and 43% reported they had discussed allergy shots and SLIT-tablets, respectively, with their child's physician. SLIT-tablets were preferred by 84% of caregivers; 6% preferred injections and 10% had no preference. Caregivers of children with a severe fear of needles had the highest preference for SLIT-tablets (95%) vs. injections (2%); 85% and 60% of caregivers of children with moderate and low fear, respectively, preferred SLIT-tablets. Among caregivers of children with a severe fear of needles, a higher percentage agreed that their child would welcome taking SLIT-tablets than that their child would accept taking an ongoing series of allergy shots (93% vs. 43%, respectively). Conclusions: Most caregivers preferred SLIT-tablets over allergy shots for their child with AR/C. Preference for SLIT-tablets corresponded with the child's degree of fear of needles. Fear of needles should be included in AIT shared decision-making conversations.

Avascular Necrosis of Proximal Tibia Associated with Pathological Fracture - A Rare Entity - A Case Report.

Introduction: Epiphyseal infarcts are likely to be treated early because most are symptomatic. However, metaphyseal and diaphyseal infarcts are silent and are diagnosed incidentally. Sarcomas developing in the necrotic bone are extremely rare, but they have been reported in literature. Proximal third tibial shaft pathological fracture due to avascular necrosis (AVN) is an extremely rare occurrence. Case Report: A 56-year-old lady presented with complaints of pain and inability to weight bear over the right leg following an alleged history of trivial trauma while doing household activities. The radiograph showed a transverse fracture at the junction of the proximal third and middle third of the shaft of the tibia. In view of the suspicion of pathological fracture, magnetic resonance imaging of the right leg was done which showed features of AVN. A core biopsy of the lesion was done to rule out tumors considering the risk of malignant transformation. Fixation of fracture was done with intramedullary interlocking nailing of the tibia. The 6-month post-operative follow-up clinical, pathological, and radiological outcome showed complete healing of the fracture. The stabilization of fracture alone without augmentation led to fracture healing. Conclusion: AVN need not always occur in precarious areas such as the head of the femur, proximal radius, and distal fibula. Rarely, AVN of diaphyseal bone can lead to pathological fracture as illustrated in this case report. Fractures can heal following fixation, but the patient has to be followed up for the rare possibility of malignant transformation.

Preoperative cytopathological investigatory aids in the diagnosis of salivary gland lesions.

Salivary gland lesions are a group of heterogeneous lesions inclusive of non-neoplastic and neoplastic lesions. History, clinical examination and preoperative investigations attempt to minimise the challenges faced in diagnosing these diverse lesions. Preoperative investigations include imaging and cytopathology. The advent of onsite evaluation methods to ensure sample adequacy and newer reporting systems that assign risk of malignancy has improved the sensitivity and specificity of cytopathology. The scope of this review is limited to the preoperative cytopathological investigations and the diagnostic challenges met in reporting salivary gland tumours.

In Situ Needle Fenestration during Thoracic Endovascular Aneurysm Repair: Successful Fenestration of Two Overlapping Thoracic Stent Grafts.

Endovascular stent grafting is becoming more common in treating complex thoracic aortic aneurysms and dissections. When it becomes necessary to cover the supra-aortic vessels, maintaining blood supply through the supra-aortic branches can be achieved by performing in situ needle fenestration. We present a case of a 65-year-old man with a type B aortic dissection that extended from the origin of the left subclavian artery. A stent graft was inserted into the thoracic aorta distally of the origin of the left common carotid artery. Due to the stent graft moving distally and not adequately sealing the subclavian artery, a second stent graft was placed more proximally. Both stent grafts were successfully in situ fenestrated using a needle, and a stent graft was inserted into the subclavian artery. In conclusion, during thoracic endovascular aortic repair, in situ needle fenestration can be successfully carried out on two overlapping thoracic stent grafts.