Performance of thyroid fine needle aspiration biopsy in a low- and middle-income country.

Introduction The 6 categories of the Bethesda System for Reporting Thyroid Cytology (TBSRTC) with associated risk of malignancy (ROM) provide evidence-based clinical management guidelines. This study aimed to determine the ROM and accuracy of FNAB in South Africa (SA). Methods Thyroid specimens from 3 pathology laboratories registered between January 2015 and December 2019 were considered for inclusion. ROM was obtained per TBSRTC category by cytohistological correlation and dividing the total number of specimens with malignant histology by the total number of cases operated. Accuracy was calculated based on the Bethesda category and eventual malignant histology. Results Seventeen thousand seven hundred and seventy-three histology and 4 791 cytology cases were identified. Of the 4 791 cytology cases, 931 (19%) underwent surgery. More than a third (333, 35.8%) of cases were confirmed as malignant following histological assessment, with the majority being benign (584, 62.7%). The ROM for the non-diagnostic and benign categories was 24.3% and 20.5%. The highest ROM was for category VI (91.5%), followed by categories V (69.5%), IV (51.9%) and III (38.8%). Thyroid FNAB had a sensitivity of 73%, specificity of 74%, and overall accuracy of 74%. Conclusion Bethesda categories II and IV have a relatively higher ROM in SA compared to findings from other developed countries. The diagnostic accuracy of thyroid FNAB in SA and the high rate of non-diagnostic diagnoses (38%) require further investigation. A national thyroid registry could provide location-specific data to aid the implementation of appropriate local policies and national guidelines for practicing thyroid surgeons.

From Incidence to Intervention: A Comprehensive Look at Breast Cancer in South Africa.

The formidable impact of breast cancer extends globally, with South Africa facing pronounced challenges, including significant disparities in breast cancer screening, treatment and survival along ethnic and socioeconomic lines. Over the last two decades, breast cancer incidence has increased and now accounts for a substantial portion of cancers in women. Ethnic disparities in terms of screening, incidence and survival exacerbate the issue, leading to delayed diagnosis among Black patients and highlighting healthcare inequities. These concerning trends underscore the urgency of enhancing breast cancer screening while mitigating treatment delays, although obstacles within the healthcare system impede progress. The intersection of breast cancer and human immunodeficiency virus (HIV) further complicates matters and particularly affects the Black population. Tackling the aforementioned disparities in breast cancer in South Africa mandates a multifaceted strategy. Robust screening efforts, particularly those targeting marginalised communities, are crucial for early detection. Concurrently, expedited treatment initiation is imperative. Addressing HIV-related complexities requires tailored interventions to ensure effective care. These multifaceted disparities require pan African research and cooperation as well as tailored interventions to enhance breast cancer care within the African region.

Life expectancy of patients with diabetic foot sepsis post-lower extremity amputation at a regional hospital in a South African setting. A retrospective cohort study.

BACKGROUND: Diabetes foot sepsis (DFS) is the leading cause of amputation of lower extremities. Over 50 % of patients who have had major lower extremity amputation due to DFS are dead within 4 years following the procedure. AIM: To determine the life expectancy of patients following amputation for DFS at a regional hospital in South Africa. METHODS: We conducted an audit of patients who had DFS and were admitted over a 5-year period. The duration from admission to time of death was recorded in days. Occurrence of death was confirmed from family members of the deceased using structured telephonic interview questionnaires. Categorical findings were summarized using actual counts and percentages and compared using either the Chi-square or Fisher's exact test. We used the mean with standard deviation or median and range to compare parametric and non-parametric continuous data, respectively. The Shapiro-Wilk test was used to test normality of data. Multivariate logistic regression was done to establish factors that were strongly associated with the mortalities. Adjusted survival curves were added to compare the rate of occurrence of mortality between males and females with age as a confounder. Statistical significance was set at a p-value below 0.05. RESULTS: 197 were found of which 100 % of participants had Type 2 diabetes mellitus and 63.5 % were males. Associated comorbidities included hypertension in 73.6 %, obesity in 66 %, alcohol use in 64.5 % and smoking in 58.4 %. 190 participants had an amputation and 19.3 % died. CONCLUSION: DFS was more common in males and 96 % of the patients had an amputation. Mortality rate within 4 years following amputation was 19.3 % and was higher in females and individuals with multiple comorbidities.

The Usefulness of Fine Needle Aspiration Cytology in the Management of Parotid Gland Masses at a Tertiary Academic Hospital.

Background: Fine needle aspiration cytology (FNAC) is an integral part of the preoperative work-up of parotid tumours. Aim: To determine the rate of concordance between FNAC and histology following parotidectomy. Methods: A review of records of patients who had parotidectomy which was preceded FNAC was done. Data collected included patients' demography, presenting symptoms and clinical signs; cytology and post-operative histology results. Results: Seventy-seven records were found and 14 were excluded. Forty-five (71%: 45/63) of the tumours were benign, 21% (13/63) malignant and 8% (5/63) inflammatory lesions. Forty-one (91.1%: 41/45) of the benign tumours had concordance between FNAC and final histology. Seven (63.6%: 7/11) of FNAC diagnosed malignancies were confirmed on histology. Conclusion: Around 71% of parotid masses were benign. Painful masses are more likely to be malignant and FNAC is more reliable for the diagnosis of pleomorphic adenoma than rare benign and malignant tumours of the parotid gland.

An obscure cause of bowel obstruction: Jejunal herniation into uterine cavity.

INTRODUCTION AND IMPORTANCE: Adhesions and external hernias are the two most common causes of small bowel obstruction. Perforation of organs within the abdomen or pelvis following manual vacuum aspiration is known to lead to an acute presentation. CASE PRESENTATION: We report a case of a 33-year-old female with small bowel obstruction due to herniation of a loop of intestine through a uterine defect with symptoms starting 63 days following manual vacuum aspiration. CLINICAL DISCUSSION: Intra-abdominal or pelvic perforations usually present immediately which makes our case unique as the patient started having symptoms 63 days post manual vacuum aspiration. The most feared complication of prolonged small bowel obstruction is ischaemia which may lead to perforation. In our case, it is plausible that jejunum partially herniated into the uterine cavity shortly after manual vacuum aspiration, forming a jejunal plug, leading to the delayed onset of symptoms. This delay in onset of symptoms might have led to progressive massive dilatation of the small bowel and subsequent ischaemic necrosis. CONCLUSION: Detailed history taking is pertinent as bowel obstruction could still occur a prolonged period after manual vacuum aspiration. A double-contrast enhanced CT scan of the abdomen proves invaluable in the context of surgical planning and facilitating the collaboration of a multidisciplinary team, particularly when the underlying causes of bowel obstruction remain elusive upon initial presentation.

Diagnosis and management of a pelvic solitary fibrous tumor in a postmenopausal woman - a case report.

Background: Solitary fibrous tumors, previously known as hemangiopericytomas, originate from mesenchymal tissue and can occur at many body sites, such as the thorax, head and neck, retroperitoneal space and abdomen. These tumors are generally rare and pelvic location is extremely uncommon. Consequently, pelvic solitary tumors could be mistaken for ovarian cancer in menopausal women. This report presents a case of pelvic solitary tumor to highlight the importance of considering this diagnosis in a postmenopausal woman presenting with a solid pelvic mass, normal tumor markers and no ascites. Case: A 54-year-old woman presented with amenorrhea, abdominal pain, constipation, nausea, vomiting, and frequency of urination. On examination she had a pelvic mass of approximately 20-24 weeks in size. Ultrasound and computed tomography imaging showed a well-defined, round, centrally hypodense, irregular thick and peripheral, enhancing solid mass originating from the left ovary. Carcinoembryonic antigen, carbohydrate antigen-125, and carcinoembryonic antigen 19-9 were all normal. Intraoperatively the tumor was attached to the peritoneum and mesentery. Part of the large bowel, including the sigmoid colon, were attached to it. The exact origin of the tumor could not be ascertained during surgery. The tumor was successfully excised, and specimen sent for histology and immunochemistry analysis. The definitive diagnosis was confirmed with immunochemistry. The patient had an uneventful postsurgical course and was discharged on day 4 after surgery for routine gynecological follow-up. Conclusion: Solitary fibrous tumor is very rare; however, the diagnosis should be considered in a postmenopausal woman with solid pelvic mass, normal tumor markers and no ascites.

Multi-Omics and Management of Follicular Carcinoma of the Thyroid.

Follicular thyroid carcinoma (FTC) is the second most common cancer of the thyroid gland, accounting for up to 20% of all primary malignant tumors in iodine-replete areas. The diagnostic work-up, staging, risk stratification, management, and follow-up strategies in patients who have FTC are modeled after those of papillary thyroid carcinoma (PTC), even though FTC is more aggressive. FTC has a greater propensity for haematogenous metastasis than PTC. Furthermore, FTC is a phenotypically and genotypically heterogeneous disease. The diagnosis and identification of markers of an aggressive FTC depend on the expertise and thoroughness of pathologists during histopathological analysis. An untreated or metastatic FTC is likely to de-differentiate and become poorly differentiated or undifferentiated and resistant to standard treatment. While thyroid lobectomy is adequate for the treatment of selected patients who have low-risk FTC, it is not advisable for patients whose tumor is larger than 4 cm in diameter or has extensive extra-thyroidal extension. Lobectomy is also not adequate for tumors that have aggressive mutations. Although the prognosis for over 80% of PTC and FTC is good, nearly 20% of the tumors behave aggressively. The introduction of radiomics, pathomics, genomics, transcriptomics, metabolomics, and liquid biopsy have led to improvements in the understanding of tumorigenesis, progression, treatment response, and prognostication of thyroid cancer. The article reviews the challenges that are encountered during the diagnostic work-up, staging, risk stratification, management, and follow-up of patients who have FTC. How the application of multi-omics can strengthen decision-making during the management of follicular carcinoma is also discussed.

Comparison between preoperative biopsy and post-excision histology results in sarcoma: experience at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.

BACKGROUND: Tumour size, grade and subtype are the main prognostic factors in adult patients presenting with soft-tissue sarcoma. Planning for appropriate management, including the need for additional staging investigations and neoadjuvant therapy, is dependent on reliable preoperative histopathological results. OBJECTIVES: To determine whether there is agreement between preoperative and post-excision histological findings in patients presenting with soft-tissue sarcoma, and whether the agreement is influenced by the subtypes of sarcomas. PATIENTS AND METHODS: Records of adult patients who had soft-tissue sarcomas excised were reviewed. Kaposi's sarcoma and gastrointestinal stromal tumours were excluded. Data were retrieved from the Department of Anatomical Pathology of the National Health Laboratory Service and theatre records at Chris Hani Baragwanath Academic Hospital, and included patient demography, tumour sites and size, HIV status, biopsy types and post-excision histological findings. RESULTS: Records of 153 patients were found (median age 44 years). The majority of the sarcomas were >5 cm in diameter, deep seated and localised in extremities. The commonest subtype, irrespective of HIV status, was dermatofibrosarcoma protuberans. Fine-needle aspiration biopsy (FNAB) results were inaccurate in determining the malignant nature, grade and subtype of sarcoma. Rates of accurate tumour subtype classification following core needle and incision biopsies when compared with post-excision histological findings were 73.1% and 78.3%, respectively. CONCLUSION: FNAB should not be used in the primary evaluation of soft-tissue tumours. A report of spindle cells on the FNAB smear should be followed by core needle or incision biopsy. Incision biopsy is superior to core needle biopsy in the classification of sarcomas by subtype.

Salmonella thyroiditis: a case report and review of the literature.

Thyroid abscesses are rare, and Staphylococcus aureus is the main causative organism. Abscesses caused by other organisms are even rarer. This report describes a case of salmonella thyroiditis in an HIV-positive patient. Fine-needle aspiration cytology was performed and Salmonella sp. were cultured. The patient was successfully treated with antibiotics and incision and drainage.