Measurement of malignant spiculated mass lesions on mammogram: Do we include the length of the spicules?

AIM: The aim of this study is to determine if the core size or size with spicules has a better correlation with the final histologic size of spiculated mass lesions. METHODS: A retrospective study of 48-month duration from January 2014 to December 2017 of biopsy-proven invasive ductal carcinoma presenting as spiculated mass lesions on mammogram was conducted. RESULTS: There were 195 patients in the study. The mean of the core size was 16.6 mm; when spicules were included the mean size was 27.4mm and final histologic size 21.1 mm. Using unpaired Student 't' test difference in the means was statistically significant (p<0.0001). Pearson number (R) core size versus final histologic size was 0.535 (P < 0.001) and for size with spicules versus final histologic size was 0.495 (P < 0.001). CONCLUSION: Our study demonstrated that the core size has a stronger positive correlation to final histologic size and should be used preoperatively in decision-making about surgery.

Is it Possible to Predict Non Sentinel Node Positivity on the Basis of mRNA Copy Numbers of CK19 Receptor in Breast Cancer?

AIMS: To determine if there is any correlation between the number of positive non-sentinel lymph nodes (NSLN) and the mRNA copy numbers of cytokeratin 19 receptor on one step nucleic acid amplification (OSNA) in the sentinel lymph node (SLN). METHODS: An 8-year retrospective study of consecutive patients who had primary surgery and sentinel node biopsy for breast cancer from January 2011 to December 2018 was carried out. All these patients had intra-operative analysis of sentinel lymph nodes by OSNA. Patients who had neoadjuvant chemotherapy or neoadjuvant endocrine therapy were excluded. RESULTS: There were 1159 patients with an age range of 24 to 90 years and a mean age of 63 years in this study. A total of 1324 SLNs were analyzed by OSNA. Macrometastasis was found in 120 patients and they underwent axillary lymph node dissection (ALND). A total of 2405 NSLNs were analyzed. Of the patients who had ALND, 51 (43%) patients had negative NSLNs and 69 (57%) had positive NSLNs. The mean mRNA copy numbers respectively for the 2 groups were 853,665 and 609,855. The difference between the means is not statistically significant (P = 0.82). Also the Receiver Operating Characteristic (ROC) Curve of the total CK-19 mRNA copy number for both groups-negative and positive NSLN were almost identical (Figure 3) indicating mRNA copy numbers cannot be used to discriminate between positive and negative non-sentinel lymph nodes. CONCLUSION: It is clear from our study that in patients who have ALND due to macromets on OSNA, there is no correlation between the total tumor load as represented by mRNA copy numbers and the likelihood of positive non-sentinel lymph nodes. We therefore cannot rely solely on the mRNA copy numbers to decide on ALND.

A curious cause of appendicitis.

A previously healthy 10-year-old boy presented to the emergency department with central abdominal pain, loose stool and vomiting. He was diagnosed with gastroenteritis, but was well enough to be discharged. The next day he reattended with ongoing diarrhoea and vomiting, with the pain now localised to the right iliac fossa (RIF). Acute appendicitis was suspected, and he was taken for laparoscopic appendicectomy. At surgery, a gangrenous appendix was found, with pus extending from the pelvis up to the liver. The appendix was excised and thorough peritoneal washout performed. Postoperatively, he received 48 hours of intravenous antibiotics and was discharged home. Unfortunately the boy presented again 11 days later with right lower quadrant pain and fever. Ultrasound revealed a collection in the RIF, and he returned to theatre for washout. His recovery was slow until the peritoneal pus sent for bacterial culture grew Salmonella enteritidis, identification of which facilitated appropriate antibiotic treatment.

Non-healing gastro-duodenal ulcer: A rare presentation of primary abdominal tuberculosis.

INTRODUCTION: We present a case of primary gastrointestinal tuberculosis that has culminated in ulcer formation, in the absence of pulmonary involvement in an immunocompetent patient. PRESENTATION OF CASE: A 28-year-old Asian male presented to casualty with a 1-week history of epigastric cramping abdominal pain and several episodes of non-bilious vomiting. The patient deteriorated clinically, becoming more cachectic and given his unexplained weight loss, an oesophageal-gastro-duodenal endoscopic imaging confirmed a duodenal ulcer. The biopsy of the non-healing ulcer was the hallmark of the disease, revealing evidence of granulomatous inflammation consistent with tuberculosis bacilli. DISCUSSION: Gastrointestinal tuberculosis with ulceration is rare with respect to the oesophagus, stomach and duodenum. This case proves to be unique, as our patient had experienced primary isolated gastric tuberculosis in the absence of pulmonary tuberculosis in a healthy individual. Immunohistochemical staining, histopathology and radiological investigations have demonstrated their importance in confirming abdominal tuberculosis and the extent of bowel involvement. CONCLUSION: This case has illustrated the difficulties associated with a prompt diagnosis of an unusual case of primary duodenal tuberculosis from chronic peptic ulcer disease in an immunocompetent patient.

Acute abdominal pain and radiological pneumoperitoneum - always an indication for laparotomy?

Pneumoperitoneum in the presence of acute abdominal pain is well recognised as an indication for laparotomy. We present a case of acute abdominal pain in the presence of an incidental pneumoperitoneum secondary to the rupture of pneumatosis intestinalis. We will discuss the importance of clinical context in the diagnosis and management of pneumoperitoneum and pneumatosis intestinalis.

A forgotten migrated intrauterine contraceptive device is not always innocent: a case report.

The incidence of transuterine perforation and migration of intrauterine contraceptive devices (IUCDs) into the abdominal cavity has been estimated at less than 0.1%. It has been suggested that intraperitoneal IUCD have low morbidity and may be left in situ. We report the first case of closed loop small bowel obstruction due to migration of a "Saf-T-Coil" IUCD into the abdominal cavity, where it became embedded in the omentum and ultimately, 31 years after deployment, coiled both arms around a loop of ileum. This late complication underlines the dangers of intra-abdominal foreign bodies, even when chemically and biologically inert.

Every wheeze does not merit a puffer! Case of an overnight cure of chronic asthma.

The peril of incorrect diagnostic labelling is highlighted by this case of acute respiratory distress caused by a retrosternal recurrent goitre. An initial clinical diagnosis which cannot be fully validated on investigation with unexpected or poor response to treatment should prompt consideration and investigation for an alternative explanation.

Upper gastrointestinal bleeding due to gastric stromal tumour: a case report.

INTRODUCTION: Gastro-intestinal stromal tumours are the most common mesenchymal tumours of the gastro-intestinal tract. This case report highlights the necessity of early surgical intervention in such cases to avoid mortality due to rebleeding and to raise the awareness of rare causes of upper gastrointestinal bleed and their management. CASE PRESENTATION: A 61-year-old male presented to the accident and emergency department with a one-day history of haemetemesis with coffee ground vomiting. After initial resuscitation, he underwent upper gastrointestinal endoscopy under sedation which demonstrated a large, bleeding, gastric mass with a central crater along the greater curvature of the stomach. A partial gastrectomy was performed taking a wedge of the stomach with clearance from the tumour, with no signs of extraperitoneal disease. CONCLUSION: Early surgical intervention, either open or laparoscopic resection, is the treatment of choice to prevent rebleeds. In general, complete surgical resection is accomplished in 40-60% of all gastro-intestinal stromal tumours patients, and in >70% of those with primary non- metastatic gastro-intestinal stromal tumour. In our case we had completely excised the tumour. Following surgery, all patients must be referred to centres which have more experience in treating gastro-intestinal stromal tumours. Imatinib is proven to be the first effective systemic therapy in cases of unresectable or metastatic disease. All gastro-intestinal stromal tumours have the potential for aggressive behaviour with the risk being estimated from tumour size and mitotic count.

Occult small bowel perforation in a patient with Ehlers Danlos syndrome: a case report and review of the literature.

Patients who present with a co-existing connective tissue disorder add a degree of complexity to operative intervention. We present an unusual case of a 53-year-old Caucasian female patient with Ehlers Danlos syndrome who presented with an occult perforation of the distal ileum. The patient had known small bowel diverticulae yet the perforation occurred within the normal bowel wall. The pre-operative CT only showed malrotation of the large bowel and did not correlate with the intra-operative findings. Our case has highlighted that although small bowel perforation is a rare occurrence, it may be more common in Ehlers Danlos and may present with atypical features. Perforation may also occur alongside normal bowel as well as diverticulae within the bowel. Where diverticulae exists within a patient with Ehlers Danlos syndrome and there is some diagnostic uncertainty, there should be a lower threshold for operative intervention. We present in the discussion a number of salient features and learning points.

Management of an incidentally found large adrenal myelolipoma: a case report.

Adrenal myelolipoma is a rare benign neoplasm composed of mature adipose and hematopoietic tissue. Most lesions are small, unilateral and asymptomatic, discovered incidentally at autopsy or on imaging studies performed for other reasons. We would like to present a case report of this rare tumour. Cross-sectional imaging is helpful in making a pre-operative diagnosis. The size of the lesion should be a criterion for surgical intervention.

Pneumococcal sepsis presenting as acute compartment syndrome of the lower limbs: a case report.

INTRODUCTION: Acute compartment syndrome is a surgical emergency requiring immediate fasciotomy. Spontaneous onset of acute compartment syndrome of the lower limbs is rare. We present a very rare case of pneumococcal sepsis leading to spontaneous acute compartment syndrome. CASE PRESENTATION: A 40-year-old Caucasian man presented as an emergency with spontaneous onset of pain in both legs and signs of compartment syndrome. This was confirmed on fasciotomy. Blood culture grew Streptococcus pneumoniae. CONCLUSION: Sepsis should be strongly suspected in bilateral acute compartment syndrome of spontaneous onset.

Small cell carcinoma of the anus: a case report.

Small cell carcinoma of the anus is a very rare but aggressive tumour. We present a case of a 60-year old lady with small cell carcinoma of the anus. She had no metastatic disease on presentation. She had chemotherapy and radiotherapy but developed distant metastasis after completion of treatment. Immunohistochemistry is required to make a diagnosis. Chemotherapy remains the mainstay of treatment for small cell carcinoma of the anus with or without metastatic disease. Radiotherapy is for local control and relief of symptoms.