Entrapment of the Subscapular Artery between the Radial Nerve and the Posterior Wall of the Axilla: An Anatomical Variation with Clinical Significance.

OBJECTIVE: The subscapular artery vascularizes a substantial region of the thoracic wall, and the significance of its distribution is well depicted in the diversity of reconstructive procedures that rely on its blood supply. The aim of this study is to present an uncommon anatomical variation of the artery and discuss the clinical implications of its presence. CASE REPORT: This case report depicts a rare variant of compression and the kinking of the subscapular artery by the radial nerve on the posterior wall of the axilla that was encountered during dissection of a male cadaver of Greek origin. CONCLUSION: The use of autologous tissues in the reconstruction of defects and treatment of lymphedema is expanding, so the need to establish safer surgical dissections is also becoming more apparent. The case of entrapment of the subscapular artery by the radial nerve is extremely rare, however, utilizing tissues perfused by this artery for reconstructive purposes could potentially be futile and unsuccessful due to the inadequate blood supply or vessel thrombosis. Hence, the surgeon should adapt the treatment plan according to preoperative findings, as the presence of anatomical variants should always be suspected.

Keystone Flap Type IV in Breast Reconstruction: A Case Report.

OBJECTIVE: The objective of this paper is to present and document a specific case of breast reconstruction using an adapted Type IV Keystone Flap technique, with a droplet-shaped design with a reduced flap ratio, and to identify the qualities of this method. CASE REPORT: A 41-year-old woman, with a history of myocardial infarction and low ejection fraction, underwent a lumpectomy, resulting in a lower medial quadrant deficit in her left breast. After she developed skin and tissue necrosis and infection, implementing the Type IV Keystone Flap effectively addressed the deficit, ensuring sufficient coverage. The flap extended dropwise beneath the deficit, progressing anteriorly towards the upper rectus abdominis, with a ratio of 2.5:1. The flap's novel droplet shape allowed for the utilization of fewer perforators, while ensuring adequate blood supply and tissue coverage, leading to improved perfusion and aesthetic outcome. CONCLUSION: The application of the adapted Type IV Keystone Flap highlights its capacity as a versatile and effective method for breast reconstruction post-lumpectomy. With the advantages of a short learning curve, easy execution, and acceptable risk profile, it offers a valuable alternative for patients who may not be suitable for more complex surgeries. Further research is recommended to confirm its broader applicability and to conduct a comparative analysis with other techniques.

An Ectopic External Jugular Vein Draining into the Axillary Vein: a Rare Anatomical Variation with Clinical Implications.

OBJECTIVE: The external jugular vein drains a considerable part of the head and neck and constitutes a vessel implicated in various procedures in the cervical region. The aim of this study is to present an uncommon anatomical variation of the external jugular vein, and discuss the clinical implications of its presence. CASE REPORT: We present a rare case of an ectopic external jugular vein terminating into the axillary vein, that we came across during routine dissection of a male cadaver of Greek origin. CONCLUSION: The venous system of the external jugular vein is used during procedures for the treatment of various conditions such as cardiac arrhythmias, hydrocephalus and defects of the head and neck. Hence, encountering the unpredictable course of a variant draining into the axillary vein may complicate these interventions, leading to multiple manipulations and undesirable results. Surgeons should be aware of the alternate anatomy of the venous system of the cervical region, and mindful of the possibility of encountering them.

A cross sectional study of HPV type prevalence according to age and cytology.

BACKGROUND: A cross sectional study to investigate HPV prevalence according to age and cytology. METHODS: Women presenting to a gynaecological outpatient clinic for a Pap smear test were included in the study (n=3177). All women had cervical cytology and HPV testing. RESULTS: Overall prevalence of any 24 HPV type analysed was 33.1% (95% CI 31.5% to 34.7%) and HPV 16 and HPV 42 were the most frequent (6.7% (95% CI 5.8% to 7.6%), 6.8% (95% CI 5.9% to 7.6%)), in total samples. Multiple HPV infection rate was 12.9% (95% CI 11.8% to 14.1%). High risk HPV (hrHPV) types were present in 27.4% (95% CI 25.8% to 28.9%) of the samples.HPV prevalence was highest among 14 to 19 y.o (46.6% (95% CI 40.7%-52.4%)) and second highest among 30-34 y.o. (39.7%, 95% CI 35.4%-44%). HPV 16 was highest among 20-24 (9.0% (95% CI 6.4%-11.6%)) and second highest among 50 to 54 y.o. (6.3% (95% CI 2.9% to 9.8%).In Low-grade Squamous Intraepithelial Lesions (LgSIL) cytology samples, the most frequently detected hrHPV types were: 16 (14.5% (95% CI 12.1% to 16.9%)), 51 (13.0% (95% CI 10.7% to 15.3%)) and 53 (9.1% (95% CI 7.2% to 11.1%)) and in High-grade Squamous Intraepithelial Lesions (HgSIL) were: HPV 16 (37.2% (95% CI 26.5% to 47.9%)), HPV 51 (17.9% (95% CI 9.4% to 26.5%)) and HPV 18 (12.8% (95% CI 5.4% to 20.2%)). CONCLUSIONS: In the population studied, HPV 16 and 51 were the most frequent detected hrHPV types. HPV positivity, hrHPV and multiple HPV types infections were higher in young women, while HPV prevalence declined with increasing age and presented two peaks a higher (14-19 y.o.) and a lower one (30-34 y.o.) These results may contribute to the creation of a national screening programme.

The Superficial Temporal Artery: Anatomy and Clinical Significance in the Era of Facial Surgery and Aesthetic Medicine.

OBJECTIVE: The aim of this review was to present the vascular pattern of the STA, as well as anatomical variations, and to accentuate the areas which should be taken into consideration during manipulations along the course of the artery. BACKGROUND: The STA may be encountered during several aesthetic procedures on the face, and iatrogenic trauma could be an incriminating factor of diverse sequelae. The constant increase in demand for facial aesthetic procedures has rendered it imperative to maximize safety and patient satisfaction. METHODS: We conducted a narrative literature review using the electronic databases of PubMed and Google Scholar, retrieving studies concerning the anatomy and variations of the STA. Moreover, we identified registered clinical cases presenting complications which involved the artery. DISCUSSION: The anatomic morphology of the STA is described and classification systems summarized, on the basis of the studies retrieved. In addition, the STA is related to defined landmarks, and specific danger zones are emphasized. Finally, the clinical significance of the artery is reflected in registered cases of adverse events following specific aesthetic surgeries. CONCLUSION: Thorough knowledge of the anatomical variability of the STA, and awareness of the danger zones involved in aesthetic procedures, combined with intraoperative vigilance could increase safety and minimize the advent of relevant sequelae.

Paget's disease of the vulva detected in vulvar and vaginal brushing smears: a case report.

UNLABELLED: BACKGROUND; Vulvar Paget's disease comprises only 1-8% of malignant vulvar tumors. It is associated with an underlying carcinoma in 20-30% of cases. Clinically, it manifests as erythematous areas with hyperkeratotic plaques, accompanied by pruritus. Histologically, it is characterized by large, pale cells with mucicarmine-positive cytoplasm, isolated or in aggregates, in the epidermis. CASE: A 75-year-old woman presented with erythematous plaques covering the entire vulvar, vaginal and perianal area and pruritus. Smears were taken from all 3 sites and stained with Papanicolaou stain. Additionally, biopsies were taken from the vulva, vagina and outer borders of the lesion and were stained with hematoxylin-eosin and also for periodic acid-Schiff stain, CK7, CEA, S-100 and CK20. The cytologic examination revealed numerous round to columnar, moderately enlarged atypical cells, dispersed or in loose groups, with abundant clear cytoplasm, vesicular nuclei and prominent nucleoli. The histologic findings confirmed the cytologic diagnosis. No indication of an underlying adenocarcinoma was found. CONCLUSION: Although the histologic examination of a vulvar lesion is necessary in order to confirm the diagnosis of vulvar Paget's disease and rule out the possibility of an underlying invasive adenocarcinoma, the cytologic examination of vulvar smears is useful for alerting the clinician to the possibility of vulvar Paget's disease.

Intraoperative real-time fluorescence angiography with indocyanine green for evaluation of intestinal viability during surgery for an incarcerated obturator hernia: a case report.

BACKGROUND: Bowel incarceration represents a dreaded complication amongst patients with hernias. The intraoperative evaluation of the bowel perfusion following hernia reduction with regard to the need for resection of ischaemic bowel can be challenging. In this case report we discuss intraoperative fluorescence angiography with indocyanine green (ICG) as an objective means of accessing bowel perfusion following hernia reduction. CASE PRESENTATION: The case of a 92-year-old, caucasian, female patient presenting with symptoms of small bowel obstruction secondary to an incarcerated left sided obturator hernia is presented. An incarcerated segment of the small bowel was reduced during emergency laparoscopy. Intraoperative ICG fluorescence angiography revealed ischaemic changes in the normal appearing bowel, so that the involved segment was resected. The postoperative course was uneventful and the patient was discharged home safely on postoperative day seven. CONCLUSION: Intraoperative ICG fluorescence angiography provides an objective method of judging bowel perfusion and therefore represents a useful tool for assessing intestinal perfusion in patients with incarcerated hernia.

Recent Trends in HPV Infection and Type Distribution in Greece.

BACKGROUND/AIM: This study gives an insight into recent trends for Human papillomavirus (HPV)-specific infection and its fluctuation over the years 2011-2016. MATERIALS AND METHODS: A total of 2,417 Caucasian women between the age of 18 and 71 years underwent their annual gynaecologic examination at the Outpatient Gynaecological Clinic in the study period. RESULTS: Overall HPV prevalence was 43.9%, and high-risk HPV accounted for 31.3%. HPV16 was the most common high-risk type followed by HPV51 and HPV31. HPV positivity was higher in those with low- and high-grade squamous intraepithelial lesions (HSILs) than in women with a normal cytological test. HPV infection was highest in 2011.The prevalence of single infections remained higher than multiple infections over the entire study period. HPV16 prevalence was very high in the first years of the study and HPV18 exhibited highest prevalence in 2011. Younger women exhibited a significant increase in HPV infection from 2014. Overall HPV infection decreased over the study period. CONCLUSION: These data suggest that HPV vaccination might reduce the frequency of HSILs and cervical cancer and are useful for the development of a national screening programme.

Giant colonic diverticulum-a rare cause of acute abdomen.

Giant colonic diverticulum (GCD), defined as diverticulum larger than 4 cm, is a rare entity. It is generally a manifestation of colonic diverticular disease and can have dramatic complications such as perforation, abscess, volvulus, infarction and adenocarcinoma. This report documents the case of a 63-year-old man coming to the Emergency Department with acute abdomen due to a perforation of a GCD. In the plain abdominal X-ray the 'Balloon-sign' was revealed, computed tomography scan and Hartmann's procedure were performed. Acute abdomen can occur as a manifestation of a complication of a GCD, and this report highlights the fact that GCD should be considered for patients with a high risk of diverticular disease and abdominal pain.

Challenging differential diagnosis of an extra-adrenal paraganglioma; the role of fine needle aspiration cytology.

Paragangliomas are rare neoplasms that arise from neural crest cells of the autonomous system. Herein, we present a case of a 37-year-old patient with a history of retroperitoneal paraganglioma and tuberculous infection presenting with a paraganglioma of the neck that was initially misdiagnosed as metastatic tumor originating from the lungs. Cytological features from fine needle aspiration and immunocytochemistry pointed to the right diagnosis. However, distinguishing between primary and metastatic site of a paraganglioma can be very challenging due to the overlapping features of these entities. Furthermore, this case underlines the value of a detailed medical history in the era of modern diagnostic modalities. Diagn. Cytopathol. 2017;45:565-568. © 2017 Wiley Periodicals, Inc.

Bax and Bak expression in cervical smears of women with low-and high-risk HPV types: A study of 120 cases.

BACKGROUND: Human papillomavirus (HPV) is known to be involved in the carcinogenesis of squamous cells in uterine cervix cancer, mostly by binding and inactivating the p53 and pRb tumor suppressor genes. Lately, evidence has emerged suggesting that HPV oncoproteins may interact with proteins involved in cellular apoptosis as well. AIM: This study aimed to investigate the expression of proapoptotic proteins Bax and Bak in women with low-risk and high-risk HPV types as opposed to HPV-negative women, and in women with normal pap smear compared to women with abnormal Papanicolau test (Pap) smear. MATERIALS AND METHODS: A total of 120 liquid-based cervical samples were subtyped for HPV types with microarray hybridization and then stained and evaluated immunocytochemically for Bax and Bak expression. Statistical analysis was performed on the Bax and Bak scores (percentage of positive cells × staining intensity), the overall percentage of positive cells, and the most prevalent staining intensity group found in each sample. RESULTS: A weak association between negative Bax staining and cytologically normal Pap smears was discovered, whereas cytologically abnormal samples tended to stain weakly or moderately positive. No other statistically significant difference was found in the other analyzed parameters. CONCLUSION: Cytologically normal pap smears seem to have a slight tendency to stain negative for Bax as opposed to cytologically abnormal pap smears. Although the association is weak, it is an indication that there might be a connection between the expression of Bax and the development of cervical intraepithelial dysplasia, which warrants further investigation in larger-scale studies.

Liquid-based cytology in breast fine needle aspiration. Comparison with the conventional smear.

OBJECTIVE: To compare the various cytologic features on AutoCyte Prep (ACP) (AutoCyte, Inc., Burlington, North Carolina, U.S.A.) and conventional preparation (CP) specimens from breast fine needle aspiration cytology material with a semi-quantitative scoring system. STUDY DESIGN: A total of 100 randomized cases were studied. In each case, 2 passes were performed. One pass was used for CPs (Giemsa and Papanicolaou stain). The other pass produced material for the ACP technique and Papanicolaou stain. Both the conventional and liquid-based preparations were studied independently by two observers and compared for cellularity, obscuring and/or informing background, representative diagnostic material, preservation of cytomorphologic features, presence of monolayer cells and architectural arrangement. RESULTS: Comparing the two preparations, the results were as follows: (1) ACP was superior to CP in 2 features, lack of obscuring background and presence of monolayer arrangement with preservation of cell architecture; (2) ACP was inferior to CP in 1 feature, lack of informing background; and (3) ACP was equal, with small deviations, to CP in the rest of the features evaluated: cellularity, representative diagnostic material, preservation of cell morphology and architectural arrangement. CONCLUSION: The new technology of liquid-based cytology in breast FNA showed a good correlation with CP plus the advantages of: (1) easier and less time consuming evaluation of cell morphology (clear background, no overlapping, smaller area to screen); (2) reproducibility, a factor of great importance to quality control; and (3) possibility of adjunctive investigations (immunocytology, flow cytometry) on the same material.

Prevalence and expression of human papillomavirus in 53 patients with oral tongue squamous cell carcinoma.

BACKGROUND/AIM: Human papillomavirus (HPV) infection has been considered a potential risk factor for the development of oral tongue squamous cell carcinoma (SCC). The purpose of the present study was to investigate HPV infection and high-risk HPV E6/E7 mRNA expression in SCC of the oral tongue in 53 Greek patients. MATERIALS AND METHODS: Fifty-three biopsies were collected from patients with SCC of the oral tongue and tested for HPV DNA and E6/E7 mRNA expression. RESULTS: The overall prevalence of HPV DNA was 11.3% (6/53), while high-risk HPV DNA was found in 7.5% (4/53) of SCC of the oral tongue. E6/E7 mRNA expression was observed in 9.4% (5/53) samples examined. HPV 16 was the commonest genotype identified by both DNA and RNA assays. A total of 28.3% (15/53) of the patients were non-smokers and non-drinkers. HPV infection was strongly associated with abstinence from tobacco and alcohol (p=0.013). CONCLUSION: The presence of high-risk HPV E6/E7 mRNA expression suggests that HPV may be implicated in the pathogenesis of SCC of the oral tongue.

E6/E7 mRNA expression of high-risk HPV types in 849 Greek women.

AIM: The goal of this study was to investigate human papillomavirus (HPV) geno typing and high-risk HPV E6/E7 mRNA expression in 849 women. PATIENTS AND METHODS: 849 Cervical samples were obtained from patients attending an outpatient clinic to have their annual gynaecological check-up. All patients underwent a conventional Pap test. The patients were also offered HPV test with the knowledge that it is not part of the screening. RESULTS: Overall prevalence of HPV DNA was 41.3%, while E6/E7 mRNA expression was found in 20.7% of the patients. HPV DNA and E6/E7 mRNA expression were detected in 21.1% and 9.1% of normal cytological samples, respectively, 38.1% and 23.8% of atypical squamous cells of unknown significance, 84.8% and 40.7% of low-grade squamous intraepithelial lesions, and 96.4% and 89.3% of high-grade squamous intraepithelial lesions, respectively. HPV 16 was the most frequent genotype identified. CONCLUSION: E6/E7mRNA detection might be useful as a screening marker for the early prediction of active infections and subsequent progression to severe dysplasia.

Submandibular ectopic thyroid tissue diagnosed by ultrasound-guided fine needle biopsy.

Ectopic thyroid gland is rarely seen in the submandibular region, thereby posing difficult diagnostic and management problems. Two Caucasian women presented with painful swelling in the submandibular region, which increased in size considerably during the preceding months. Ultrasound-guided fine needle biopsy (Ug-FNB) revealed ectopic thyroid tissue. In conclusion, ectopic thyroid gland with or without pathology should be included in the differential diagnosis of submandibular swelling and Ug-FNB should be one of the first diagnostic tools utilized for this rare clinical entity.

Oncocytoma of the lacrimal gland diagnosed initially by fine-needle aspiration cytology.

Oncocytomas are benign tumors that infrequently involve ocular adnexa. We describe a case of oncocytoma of the lacrimal gland which was initially diagnosed by fine-needle aspiration cytology. An 83-year-old patient presented to the cytology laboratory with a peripunctal mass in the right eye. The tumor was aspirated. The cytoplasm of the tumor cells was rich in eosinophilic granules. The initial cytological diagnosis was oncocytoma. The tumor was then completely excised and the histological diagnosis confirmed the initial cytological one. Oncocytoma is a rare entity which must be considered in differential diagnosis of a peripunctal mass in elderly patients. The literature was reviewed confirming the rarity of such a presentation and the novelty of this case. Cytological criteria of malignancy are not yet established.

Ancient schwannoma of lumbar spine and review of the literature on paraspinal tumors, the role of preoperative biopsy: a case report.

INTRODUCTION: Schwannomas are rare encapsulated tumors that derive from the nerve sheath and should be removed due to their infrequent, but existent possibility of malignancy. CASE PRESENTATION: We report a case of a mass located in the L5 lumbar spine in a 42 year old man, presented with intermittent lumbar pain. Ultrasound, CT and MRI were used to examine the characteristics of the lesion. Fine needle aspiration showed cytologic characteristics of benign schwannoma and final histological diagnosis was ancient schwannoma. An extraperitoneal approach, through a left paramedian incision was used to approach the site of the mass. The lesion originated from the nerve root of the L4-L5 lumbar spinal space and a complete excision was achieved. CONCLUSION: A great variety of tumors should be differentiated when a paraspinal mass is discovered, including neurogenic, neuroendocrine and vascular tumors, as well as malignancies, cystic and inflammatory masses. Fine needle aspiration is a useful and reliable tool in the preoperative evaluation of paraspinal masses. A review of the literature is also presented.