Role of Magnetic Resonance Mammography in the Evaluation of Indeterminate Breast Lesions.

Background: Malignancy of the breast is one of the most common cancers among females worldwide. Magnetic resonance mammography (MRM) is a valuable complement to conventional methods for the early diagnosis of disease, thereby providing patients with a better prognosis. The number of unnecessary biopsies and repeated excisions in cases of indeterminate breast lesions detected on conventional imaging is high. Aims: The purpose of this study was to evaluate the role of MRM in the evaluation of indeterminate breast lesions [Breast Imaging Reporting and Data System (BIRADS) 3/4] found in conventional mammography and ultrasonography (USG), taking the histopathological examination (HPE) as the gold standard. Materials and methods: A total of 38 patients with conventional radiological imaging diagnosis of indeterminate breast lesions (BIRADS 3/4) were included in this study and evaluated using contrast-enhanced MRM according to the MR-BIRADS lexicon (5th edition). Morphological characteristics of lesions were evaluated to determine the probability of malignancy. Histopathology was kept as the gold standard for comparing all the statistical parameters. Results: There were a total of 40 lesions, 35 masses, and five nonmass enhancement (NME) available for evaluation out of the 38 patients. The sensitivity of margins to detect malignancy approached 100%; however, it had a slightly lower specificity of 66.67%. Magnetic resonance imaging (MRI) showed good diagnostic performance with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 85, 90, 89.47, 85.71, and 87.50%, respectively. Conclusion: The MRI has been shown to be useful as a problem-solving tool in breast cancer screening, clarifying indeterminate findings and avoiding unnecessary short follow-ups and percutaneous biopsies. How to cite this article: Mishra E, Kaur N, Kaur R, et al. Role of Magnetic Resonance Mammography in the Evaluation of Indeterminate Breast Lesions. J Assoc Physicians India 2023;71(11):76-84.

Sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial.

BACKGROUND AND AIMS: Sevoflurane is an excellent but expensive anesthetic agent for laparoscopic cholecystectomy. To decrease sevoflurane consumption during surgery adjuvants like dexmedetomidine may be used. Dexmedetomidine is a recently introduced drug which alleviates the stress response of surgery, produces sedation and analgesia. We aimed to evaluate sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy under entropy-guided general anesthesia (GA). MATERIAL AND METHODS: In this prospective randomized control study, 100 American Society of Anesthesiologists physical status I-II adult surgical patients scheduled to undergo laparoscopic cholecystectomy were enrolled. Patients were randomly divided into two groups (n = 50). In dexmedetomidine group, patients received intravenous (IV) dexmedetomidine 0.5 µg/kg over 10 min before induction followed by 0.5 µg/kg/h infusion while in control group, patients received the same volume of normal saline. RESULTS: Sevoflurane consumption was 41% lower in dexmedetomidine group as compared to control group (7.1 [1.6] vs. 12.1 [1.9] ml, P <0.001). A 40% reduction was observed in induction dose of propofol (83.0 [19.1] vs. 127.6 [24.8] mg, P <0.001). Mean Riker sedation-agitation score, visual analog score for pain and Aldrete's score were significantly lower in dexmedetomidine group as compared to control group. None of the patients experienced any significant side effects. CONCLUSION: A 41% reduction in sevoflurane consumption was observed in patients receiving IV dexmedetomidine as an adjuvant in patients undergoing laparoscopic cholecystectomy under GA.

Abdominal cocoon with small bowel obstruction: two case reports.

Abdominal cocoon is a rare condition that results in an intestinal obstruction due to total or partial encapsulation of the small bowel by a fibrocollagenous membrane. Treatment is surgical resection of the membrane and free the bowel. Preoperative diagnosis is possible with combination of sonography and CT scan. We report two cases where the diagnosis of abdominal cocoon was suggested preoperatively based on the sonography and CT scan of abdomen.

Correlation of Morphological Features of Chromosomal Instability and Flow Cytometric DNA Ploidy Analysis in Aspirates of Breast Carcinoma.

OBJECTIVE: Morphological indicators of chromosomal instability (CI), including multipolar mitoses, chromatin bridges (CB), strings, nuclear buds (NB), micronuclei (MN), and deoxyribonucleic acid (DNA) ploidy analysis help in prognostication of breast carcinoma. The present study was done to evaluate CI in breast carcinoma and correlate with DNA ploidy and tumor grade. STUDY DESIGN: Fifty cases of carcinoma breast diagnosed by fine-needle aspiration cytology were included. Robinson's grading method was used on smears to grade breast carcinoma. To assess the morphological features of CI, the best May-Grünwald Giemsa stained smear was chosen. At least 1,000 epithelial cells on oil immersion magnification (×100 objective) were counted. DNA ploidy on the aspirates was done by flow cytometry. RESULTS: All the patients were female, diagnosed as infiltrating ductal carcinoma on cytology. Eight tumors were grade I, 32 were grade II, and 10 were grade III. MN was seen in 48 cases, NB in 45, and CB in 12 cases. Mean MN, NB, and CB scores in aneuploid (24) cases were 9.96 ± 8.42, 5.29 ± 4.71, and 1.08 ± 1.84 while 6.19 ± 6.67, 1.92 ± 1.79, and 0.11 ± 0.33 were seen in diploid (26) cases. Statistically significant positive correlation was observed between CI and DNA ploidy. CONCLUSIONS: Morphological evaluation of CI by light microscopy on routinely stained breast aspirates is feasible, although a meticulous search is required. Cytomorphological features of CI and ploidy have a positive correlation with increasing tumor grade.

Traumatic abdominal wall hernia.

BACKGROUND: Traumatic abdominal wall hernia (TAWH) is uncommonly encountered despite the high prevalence of blunt abdominal trauma. The diagnosis is often difficult because of its varied presentation along with lack of awareness of this entity. METHODS: The case files of all patients with TAWH who were operated at our hospital were retrospectively reviewed and analyzed. RESULTS: A total of 11 patients with TAWH were analyzed (8 males, 3 females). The clinical presentation was varied, with a palpable defect and a reducible swelling (6 patients), localized area of irreducible swelling (3 patients), surgical emphysema (2 patients), and cellulitis/abscess formation (2 patients). All of these patients were operated within 24 hours of hospital admission. Except for the 3 patients who presented late, there was a favorable outcome in all the others. The cause of mortality was septicemia, possibly due to incarceration of bowel in the defect leading to strangulation and perforation. CONCLUSION: TAWH, although uncommon, is associated with significant morbidity and mortality when there is a delay in diagnosis and intervention. Early intervention leads to a significantly better outcome.

Clinico-pathological spectrum of gallbladder disease in children.

AIM: Because of wide variation in clinico-pathological spectrum of gallbladder disease in children the world over, the data of gallbladder disease from this stone belt of India were analysed. METHODS: Children who underwent cholecystectomy over a period of 8 years January 2002-December 2009 were reviewed. RESULTS: Out of 7076 cholecystectomies, 56 (0.79%) were in children. Thirty-nine (69.6%) children were 11-16 years of age. Thirty-seven (66.07%) children were girls and nineteen (33.9%) were boys. In 12 (21.4%) children, cholecystitis was acalculus. Five (8.9%) children had associated haemolytic disease and 4 (7.1%) children had congenital anomaly in the form of choledochal cyst. Ultrasound findings were available in 44 cases and showed cholelithiasis in 36 cases. Twenty-two (39.3%) children had mixed cholelithiasis, 8 (14.2%) pigment cholelithiasis, 10 (17.8%) combined cholelithiasis and 4 (7.1%) patients had small concretions. Microscopically, changes of chronic cholecystitis were seen in 98.2% while 1.7% showed acute on chronic cholecystitis. There was single unusual case of cysticercus in the wall of the gallbladder. CONCLUSIONS: The frequency of gallstone disease is 0.79%. Nonhaemolytic type of cholelithiasis is more common than haemolytic type in this region. Presence of cysticercus in the gallbladder wall in one case was an unexpected finding.

Aspergilloma in a pulmonary hydatid cyst: a case report.

The most common predisposing factor for aspergillomas is the presence of a pre-existing lung cavity secondary to tuberculosis, bronchial cysts and bullae, neoplasms, and pulmonary infarction. However, Aspergilloma within a hydatid cyst is a rare occurrence. A 52-year-old female was presented with chest pain and shortness of breath. Computerized tomography-guided fine needle aspiration (FNA) showed fragment of lamellated membrane of hydatid cyst in a background of amorphous debris. Surgical enucleation of the cyst revealed lamellated hyaline acellular ectocyst of hydatid cyst and collections of acute angle branching septate hyphae conforming to morphology of Aspergillus. Here we describe this rare entity of aspergilloma in a pulmonary hydatid cyst and discuss its management.

Cytomegalovirus-associated pseudotumor simulating gastric malignancy in acquired immunodeficiency syndrome: a case report with review of literature.

We present a case of cytomegalovirus (CMV)-induced pseudotumor of the gastric antrum. Although affliction of the entire gastrointestinal tract with CMV has been described, localization to the stomach and especially the gastric antrum is rare. Kaposi's sarcoma and non-Hodgkin's lymphoma are recognized causes of bowel thickening and obstruction in patients with AIDS, but CMV is an extremely rare cause, with only four cases of CMV-induced pseudotumor reported in the English literature. As the duration of opportunistic infections and length of survival of patients with AIDS increase, CMV pseudotumors are not likely to remain unique. This mass lesion should be included in the differential diagnosis of AIDS patients, along with Kaposi's sarcoma and non-Hodgkin's lymphoma.

Concomitant Lung and Liver Hydatid Cyst Managed as One-Stage Surgery.

OBJECTIVE: Over the world, hydatidosis is endemic in many countries. It is more prevalent in Turkey. We came across with concomitant hydatidosis of the lung and liver and reviewed the management. MATERIAL AND METHODS: This is a prospective study that was carried out in the Government Medical College and Hospital, sector-32, Chandigarh, India, between 2004 and 2010, in the Department of Surgery. A total of five patients diagnosed with concomitant liver and pulmonary hydatid disease underwent surgery. They were operated by thoracotomy and laparotomy in the same sitting. RESULTS: Hydatid cysts located in the lungs were managed by means of cystotomy and capitonnage. For liver cysts, cystotomy and inversion of the cavity with sutures was the surgical method of choice, and a drain was left in place. Excessive biliary drainage occurred in one patient who was managed successfully. CONCLUSIONS: We believe that simultaneous management of pulmonary and hepatic cysts through the thoracic route and by laparotomy is convenient and should be encouraged in patients because this approach decreased morbidity and mortality by deferring second operation. Needle aspiration can be applied only for liver cysts but it is absolutely contraindicated in lung hydatid cysts.

Screening methods (clinical breast examination and mammography) to detect breast cancer in women aged 40-49 years.

OBJECTIVE: The aim of this study is to detect breast cancer rate, nodal status, tumor size, and associated risk factors using clinical breast examination (CBE) and mammography as screening tools in women aged 40-49 years. MATERIALS AND METHODS: A total of 500 women were screened in a time period of 2 years, between the ages of 40-49 years for breast cancer. Screening tools used were CBE and mammography. Clinical history and risk factors related to breast cancer were recorded. CBE was performed to detect any breast pathology followed by mammographic screening. Breast Imaging Reporting and Data System (BI-RADS) mammographic density categories were used for reporting breast imaging on mammography. For women with dense breasts or an inconclusive mammography report, ultrasonography was performed to assess the lesion/s. Suspicious lesion was subjected to fine-needle aspiration cytology or an open surgical biopsy for a confirmatory diagnosis. Women with history of breast cancer were excluded from the study. RESULTS: CBE was normal in almost 90% of the women. Screening mammography revealed Breast Imaging Reporting and Data System (BI-RADS) I and BI-RADS II in 58.4% and 34.6% of women, respectively. Only 7% of women belonged to BI-RADS III and none in BI-RADS IV category. CONCLUSION: The study findings are in agreement with the recommendations of the World Health Organization, US preventive task force and UK guidelines that recommend screening mammography in women starting at 50 years.

Blunt traumatic diaphragmatic hernia: Pictorial review of CT signs.

Blunt diaphragmatic rupture rarely accounts for immediate mortality and may go clinically silent until complications occur which can be life threatening. Although many imaging techniques have proven useful for the diagnosis of blunt diaphragmatic rupture, multidetector CT (MDCT) is considered to be the reference standard for the diagnosis of diaphragmatic injury. Numerous CT signs indicating blunt diaphragmatic rupture have been described in literature with variable significance. Accurate diagnosis depends upon the analysis of all the signs rather than a single sign; however, the presence of blunt diaphragmatic rupture should be considered in the presence of any of the described signs. We present a pictorial review of various CT signs used to diagnose blunt diaphragmatic injury. Multiplanar reconstruction is very useful; however, predominantly axial sections have been described in this pictorial review as the images shown are from dual-slice CT.

Evaluation of grading and hormone receptor immunostaining on fine needle aspirates in carcinoma breast.

BACKGROUND: Grading and hormone receptor determination in breast carcinoma are predictive factors for response to hormonal therapy. AIM: This study was undertaken to grade breast carcinoma and to determine estrogen receptor (ER) and progesterone receptor (PR) expression on fine-needle aspiration cytology (FNAC). Furthermore, the objective was to compare the results with histological grading and immunohistochemistry on surgical material. MATERIALS AND METHODS: Fifty cases of breast carcinoma diagnosed on FNAC were included. The cytological grading was done according to the Robinson's grading system. The corresponding histology sections were graded using the modified Bloom-Richardson system. Immunostaining for ER and PR was done on smears and tissue sections. RESULTS: On both cytological and histological evaluation, 49 cases were infiltrating ductal carcinoma and one case was colloid carcinoma. On comparing cytological and histological grading, 78% were correctly graded on cytology. The sensitivity, specificity, positive predictive value and negative predictive value for ER detection on immunocytochemistry (ICC) were 55.6%, 95%, 93.8% and 61.3%, respectively. The sensitivity, specificity, positive and negative predictive value for PR detection on ICC were 57.7%, 95.2%, 93.8% and 64.5%, respectively. The correlation for ER and PR between cytology and histology was 72.3% and 74.5%. CONCLUSION: The grading along with ER and PR immunostaining of breast carcinoma on smears is advocated because of high concordance between cytology and histology. This allows the patient to be treated with hormonal therapy on the basis of FNAC alone.

Pulmonary hydatidosis in a tertiary care hospital.

BACKGROUND: Hydatid disease is caused by the larval stage of Echinococcus. Liver is the most commonly involved organ followed by the lungs. Pulmonary hydatidosis can be primary or secondary. The disease may be asymptomatic for several years. Cause of concern is the fatal anaphylaxis, which may be life threatening. MATERIALS AND METHODS: The present retrospective study is over a period of ten years (2003-2012). The demographic data including the clinical features, radiological findings, other organ involvement, surgical and medical management done and histopathological findings were compiled from the records. RESULTS: During the study period a total of eight cases, five male and three female, with age ranging from eight to 43 years were diagnosed as pulmonary hydatid disease. Five patients had presented with complicated cysts. Six patients had solitary cysts involving the lung while bilateral lung involvement was seen in two cases. One patient had multiple pulmonary cysts. Three patients had associated cysts in liver and two in spleen. Surgical lobectomy was done in four cases. Histopathology showed acellular laminated ectocysts in all the cases, whereas endocyst with brood capsules was seen in five cases. CONCLUSIONS: Pulmonary hydatidosis is not uncommon. Anaphylaxis, although rarely seen, may be a disastrous event. High index of clinical suspicion and mass awareness for interruption of transmission of parasite can lead to proper treatment and possible eradication.

Low tracheal tumor and airway management: An anesthetic challenge.

We describe a case presenting with tracheal tumor wherein a Microlaryngeal tube was advanced into the trachea distal to the tumor for primary airway control followed by cannulation of both endobronchial lumen with 5.5 mm endotracheal tubes to provide independent lung ventilation post tracheal transection using Y- connector attached to anesthesia machine. The plan was formulated to provide maximal surgical access to the trachea while providing adequate ventilation at the same time. A 32 yrs non smoker male, complaining of cough, progressive dyspnea and hemoptysis was diagnosed to have a broad based mass in the trachea on computed tomography of chest. Bronchoscopy of the upper airway confirmed presence of the mass at a distance of 9 cms from the vocal cords, obstructing the tracheal lumen by three fourth of the diameter. The patient was scheduled to undergo the resection of the mass through anterolateral thoracotomy. We recommend the use of extralong, soft, small sized microlaryngeal surgery tube in tumors proximal to carina, for securing the airway before the transection of trachea and bilateral endobronchial intubation with small sized cuffed endotracheal tubes for maintenance of ventilation after the transection of trachea in patients with mass in the lower trachea.

Fungal necrotizing fasciitis, an emerging infectious disease caused by Apophysomyces (Mucorales).

BACKGROUND: The mucoralean fungi are emerging causative agents of primary cutaneous infections presenting in the form of necrotizing fasciitis. AIMS: The aim of this study was to investigate a series of suspected necrotizing fasciitis cases by Apophysomyces species over one-year period in a northern Indian hospital. METHODS: The clinical details of those patients suspected to suffer from fungal necrotizing fasciitis were recorded. Skin biopsies from local wounds were microscopically examined and fungal culturing was carried out on standard media. The histopathology was evaluated using conventional methods and special stains. Apophysomyces isolates were identified by their morphology and by molecular sequencing of the internal transcribed spacer (ITS) region of the ribosomal genes. Antifungal susceptibility testing was carried out following EUCAST guidelines and treatment progress was monitored. RESULTS: Seven patients were found to be suffering from necrotizing fasciitis caused by Apophysomyces spp. Six isolates were identified as Apophysomyces variabilis and one as Apophysomyces elegans. Five patients had previously received intramuscular injections in the affected area. Three patients recovered, two died and the other two left treatment against medical advice and are presumed to have died due to their terminal illnesses. Posaconazole and terbinafine were found to be the most active compounds against A. variabilis, while the isolate of A. elegans was resistant to all antifungals tested. CONCLUSIONS: Apophysomyces is confirmed as an aggressive fungus able to cause fatal infections. All clinicians, microbiologists and pathologists need to be aware of these emerging mycoses as well as of the risks involved in medical practices, which may provoke serious fungal infections such as those produced by Apophysomyces.

Purse-string closure of a mucous fistula in loop colostomy.

The technique of purse-string closure of a mucous fistula to prevent faecal contamination during loop colostomy is described in six patients who underwent the procedure. Complete faecal diversion was achieved in all six patients without complications.

Renal cell carcinoma arising in ipsilateral duplex system.

Congenital anomalies of the kidney and urinary tract are common and include a wide anatomic spectrum. Duplex systems are one of the more common renal anomalies, with the majority being asymptomatic. Little is known about the molecular pathogenesis of these anomalies; however, certain causative genes have been implicated. The finding of renal cell carcinoma arising in a kidney with the duplication of pelvicalyceal system and ureters, as in the present case, is uncommon. The association between a duplex system and renal cell carcinoma may be more than a coincidence, requiring a deeper insight and further elucidation.