Efficacy of perioperative systemic tranexamic acid along with topical hemocoagulase in decreasing axillary drain output in breast cancer patients undergoing axillary lymph node dissection: A randomized, double-blind, placebo-controlled, superiority trial.

BACKGROUND: Excess and prolonged axillary drainage is a frequent nuisance following axillary lymph node dissection (ALND) in breast cancer patients. No consensus exists about the best method to prevent this consistently and reliably. Tranexamic acid (TA) has been found to reduce the amount and duration of drainage, but the reduction is not optimal. We hypothesized that systemic administration of TA along with the topical application of hemocoagulase (H) to the axillary dissection bed may decrease the cumulative axillary drain output and shorten the requirement of drainage after ALND as compared to placebo. PATIENT AND METHODS: Seventy women undergoing ALND for breast carcinoma were randomized into two groups, the intervention (TA + H) group and the control (C) group. The cumulative drain output (primary objective), duration of drainage, incidence of seroma formation after drain removal, number of seroma aspirations required, volume of seroma aspirated, and incidence of surgical site infection (SSI) were compared. RESULTS: The mean cumulative output in the TA + H group was significantly lower than the C group (290 ± 200 mL vs. 552 ± 369 mL, p < 0.001). Axillary drains were removed significantly earlier in the TA + H group (6.6 ± 2.2 vs. 11.7 ± 6.0 days, p < 0.001), but the incidence of seroma formation (p = 0.34), number of aspirations required (p = 0.33), volume of seroma aspirated (p = 0.47), and the incidence of SSI (p = 0.07) were similar. CONCLUSIONS: Perioperative systemic administration of tranexamic acid along with topical application of H to the axillary dissection bed is effective in reducing cumulative axillary drain output after ALND. This strategy may also facilitate earlier removal of suction drains.

From Causatum to Erratum, all in a name.

BACKGROUND: This study highlights how a trivial mistake in collecting timed blood samples of parathyroid hormone (PTH) during parathyroidectomy (PTX) can potentially become a serious error affecting surgical closure. METHODS: For the measurement of serum PTH, the intact PTH (iPTH) test was used to obtain baseline, preoperative, intraoperative, and postoperative samples of PTH, to guide the surgical team regarding adequacy of PTX. RESULTS: Due to the lack of proper guidelines, all types of samples for PTH are labeled as iPTH by the Laboratory Information Services (LIS) software. Due to a human error in marking the PTH vacutainers generated for different time point samples by LIS, samples were swapped. The values in the lab revealed a spurious rise in PTH post-PTX. The laboratory physician carefully observed the tubes and identified the reason for this mistake. The timely action therefore led to surgical closure, otherwise it could have led to unwarranted extended PTX. CONCLUSIONS: In cases where timed samples are mandatory, having a common code for all requisitions can invariably lead to pre-analytical error, therefore proper discriminative measures need to be introduced to avoid these mistakes.

A Search for Uniformity in Human Chorionic Gonadotropin (hCG) Reporting.

Varying reports across different laboratories or across different analysers in the same lab for the same sample is not an uncommon phenomena. Experts call this a lack of harmonization. A test that is harmonized provides the same results regardless of the manufacturer of reagents used or the laboratory where the test is performed. When laboratory tests are not harmonized, the entire continuum of patient care can be affected in a number of ways. Here, we present a case of varying reports for a single serum human chorionic gonadotropin (hCG) sample on two different immunoassay platforms for a young female presenting with an abdominopelvic mass. The lab reports for serum hCG for this particular patient showed inconsistent results with the same sample within the same lab. The phenomena behind this was lack of harmonization of test results. We introspect many of the factors responsible for lack of uniformity in hCG results amongst the major ones being with use of antibodies directed against different epitopes of hCG (analyte) and the heterogeneity of the hCG molecule itself. Harmonization is a process to ensure that different clinical testing procedures used by different laboratories give equivalent results. Harmonizing test results will enable healthcare providers to use clinical guidelines with greater confidence for diagnosing disease and managing patients.

Anorectal Melanoma-Brownish Black Mass Not Always a Hemorrhoid.

The non-specific clinical symptoms of anorectal brownish-black mass do not help to differentiate colorectal cancer, hemorrhoids, rectal ulcers which result in a delayed diagnosis or lead to inadequate management of lethal anorectal melanoma. Primary malignant melanoma of the anorectal region is an uncommon tumor, constituting approximately 1% of anal canal tumors which may be misdiagnosed clinically as hemorrhoids. Because of aggressive behavior and poor prognosis, efficient and prompt diagnosis is required in these cases. We report 2 cases of this rare tumor.

Cervical Neuroendocrine Carcinoma: A Rare Case Report.

Neuroendocrine carcinoma is a rare tumor in the uterine cervix with a dismal prognosis. Clinically, it is difficult to differentiate from other cervical malignancies. Clinical presentation varies from vaginal bleeding, discharge per vaginum and cervical mass. For better clinical outcomes, it is vital to diagnose promptly and accurately. We report a 35-year-old female presented with whitish discharge per vaginum and lower abdominal pain for six months. Per speculum reveals an irregular, firm mass measuring 4x3 cm involving both the cervical lips, which turned out to a small cell neuroendocrine carcinoma.

Uncommon Metastasizing Site of Adrenocortical Carcinoma.

Adrenocortical carcinoma (ACC) is a very rare tumor having a poor prognosis. Approximately 25% of these cases may present with metastases at the time of diagnosis. Common sites of metastasis are lung, liver, and lymph nodes. The bone metastases in ACC are less frequent. We report a case of a 35-year-old male presented with right parotid region swelling, rendered with a diagnosis of ACC metastasizing to the mandible ramus, which is an uncommon site.

Malignant glomus tumor of the index finger.

Glomus tumor (GT) is a benign mesenchymal tumor with an estimated incidence of 1.5 to 2% of soft tissue tumors. The majority of glomus tumors are benign and are mostly seen in the superficial skin & soft tissue of upper and lower distal extremity. The malignant variant of the glomus tumor is scarce. We report a case of a recurrent glomus tumor diagnosed in a 28-year-old male patient, who complained of painful swelling in the proximal phalanx of the right index finger. The magnetic resonance imaging of the hand revealed a well-defined multilobulated soft tissue mass at the palmar aspect of the 2nd digit along the shaft of the proximal phalanx. Histopathology revealed a well-circumscribed tumor arranged in solid sheets, nests and cords interconnect by vessels of varying size. The tumor cells were round to oval, showed moderate nuclear pleomorphism, eosinophilic cytoplasm, atypical mitoses (>5/10HPF), and necrosis. Immunohistochemically tumor cells reveal diffuse and strong cytoplasmic positivity with smooth muscle actin (SMA). Based on histomorphology and immunohistochemistry, a final diagnosis of malignant glomus tumor was made. We report this case due to its rarity, and it to be included among the differential if the lesion is painful and recurrent.

Primary Malignant Melanoma of Anorectum CT Findings: a Single Tertiary Center's Experience.

Anorectal melanoma is a rare malignancy with very aggressive course. This case series emphasize the role of imaging, contrast-enhanced computed tomography in evaluating such cases before surgery. CT scan of four patients with pathologically proven primary anorectal malignant melanoma was included. CT findings were analyzed from the picture archiving and communication system for the site of involvement, morphological shape, presence of perirectal and anal infiltration, lymphadenopathy, liver metastasis, and occurrence of bowel obstruction for all the four patients. All the four patients presented as polypoidal mass that caused focal expansion and obscuration of rectal lumen without causing colonic obstruction. Perirectal infiltration was seen in 2/4 patients and involvement of anal canal was seen in 3 patients. Distant metastasis was seen in the liver in three out of four patients. In conclusion, primary anorectal malignant melanoma is a rare, highly aggressive tumor and should be considered in patients with a bulky intraluminal polypoid mass that does not cause colonic obstruction in the anorectal region with large-sized lymphadenopathy.

Pigmented Malignant Lesion of Central Arch Gingiva of Mandible.

Primary oral malignant melanoma (OMM) is a rare malignant lesion with a relatively poor prognosis. The clinical presentation may be nodular, macular, or mixed type, with or without pigmentation. The pigmented lesions in the oral cavity may be either melanocytic or non-melanocytic and neoplastic or non-neoplastic lesions. For all the pigmented lesions of the oral cavity, clinicians must consider OMM as a differential diagnosis. Hence, a histopathological examination is required. Herein, we report a case of pigmented growth over the central arch and gingival mucosa, which turned out to be an OMM.

Ovarian Carcinoid Misinterpreted as Endometrioid Adenocarcinoma in Mature Cystic Teratoma.

Mature cystic teratoma (MCT) is the most common benign germ cell tumor of the ovary and contains the different tissues that originate from the endoderm, mesoderm, and ectoderm. The monodermal teratoma has a component of only the germ layer. Ovarian carcinoid is rare and considered as a monodermal teratoma. We report a case of carcinoid tumor arising in MCT in a 60-year-old postmenopausal woman.

Malignant glomus tumor of the index finger

Glomus tumor (GT) is a benign mesenchymal tumor with an estimated incidence of 1.5 to 2% of soft tissue tumors. The majority of glomus tumors are benign and are mostly seen in the superficial skin & soft tissue of upper and lower distal extremity. The malignant variant of the glomus tumor is scarce. We report a case of a recurrent glomus tumor diagnosed in a 28-year-old male patient, who complained of painful swelling in the proximal phalanx of the right index finger. The magnetic resonance imaging of the hand revealed a well-defined multilobulated soft tissue mass at the palmar aspect of the 2nd digit along the shaft of the proximal phalanx. Histopathology revealed a well-circumscribed tumor arranged in solid sheets, nests and cords interconnect by vessels of varying size. The tumor cells were round to oval, showed moderate nuclear pleomorphism, eosinophilic cytoplasm, atypical mitoses (>5/10HPF), and necrosis. Immunohistochemically tumor cells reveal diffuse and strong cytoplasmic positivity with smooth muscle actin (SMA). Based on histomorphology and immunohistochemistry, a final diagnosis of malignant glomus tumor was made. We report this case due to its rarity, and it to be included among the differential if the lesion is painful and recurrent.