Thymic cyst: is a correct preoperative diagnosis possible? Report of a case and review of the literature.

UNLABELLED: A case of a giant cervico-mediastinal cyst of thymic origin in an 8-year-old child is presented. The cyst was asymptomatic except for deformity due to its size. In spite of several diagnostic approaches like ultrasonography, computed tomography, cyst puncture with biochemical analysis of cyst content and direct contrast injection and radiography after emptying of the cyst, the ultimate diagnosis as to the origin of the cyst was not disclosed until after operation and histopathological examination of the operative specimen. On a more general basis the diagnostic possibilities and pitfalls are discussed. CONCLUSION: a correct preoperative diagnosis of a thymus cyst is difficult and in many instances impossible even when all diagnostic measures at hand are utilized, including radiographic methods, computed tomography, magnetic resonance imaging, ultrasonography and biochemical examination of cyst aspirate and estimation of tumour markers in cyst fluid and serum.

Serial quantitative PCR analysis of bone marrow samples from breast cancer patients to monitor systemic micrometastases.

BACKGROUND: We have previously developed a quantitative calibrated PCR assay to measure cytokeratin 19 (CK19) expression in haematopoietic tissue in order to detect systemic micrometastases. PATIENTS AND METHODS: Serial measurements of CK19 expression in bone marrow of patients with primary breast cancer were performed at operation, at 3 weeks and 6 months postoperatively. RESULTS: Reference values for CK19 expression were established by analysing bone marrow samples from 48 healthy female volunteers or patients without epithelial cancer. Samples from breast cancer patients with CK19 values above the upper reference limit were considered positive. Bone marrow samples taken at operation were positive in 29 out of 141 patients (20.6%) and remained positive in 12, turned negative in 4 and were unavailable in 13 at 6 months postoperatively. CONCLUSION: Serial measurements increase the reliability of detecting micrometastases perioperatively. Further studies are in progress to evaluate the relationship between elevated CK19 values and clinical outcome.

The history is important in patients with suspected acute appendicitis.

BACKGROUND/AIMS: The clinical diagnosis of acute appendicitis is incorrect in 20-30% of patients undergoing surgery. We analysed the clinical importance of nine commonly used symptoms and signs in 544 consecutive patients with regard to the correct diagnosis of acute appendicitis. METHODS: Open population-based prospective study. The degree of the surgeon's certainty of the preoperative diagnosis was assessed. The final diagnosis was based on histology. Logistic regression was used to analyze the independent value of nine symptoms and signs to predict acute appendicitis by calculating odds ratio (OR) with 95% confidence intervals (CI). RESULTS: In 434 of 544 patients (80%) acute appendicitis was confirmed. A history of nausea or vomiting (OR = 2.3; CI = 1.11 to 4.76) and pain migration to right iliac fossa (OR = 1.9; CI = 1.12 to 3.22) were significant predictors of acute appendicitis. Pain migration was found to be an independent predictor in females and nausea or vomiting in males. In the group of patients (29%) with an uncertain preoperative diagnosis, pain migration predicted a correct diagnosis in females (OR = 4.7; CI = 1.2 to 18), while tenderness over McBurney's point was a significant predictor in males (OR = 8.3; CI = 1.1 to 63). CONCLUSIONS: A history of pain migration and nausea or vomiting were independent predictors for the correct diagnosis of acute appendicitis in patients undergoing surgery. Thus, patient history is important in this patient group.

Structured data collection improves the diagnosis of acute appendicitis.

BACKGROUND: Structured preoperative data collection and computer-assisted methods are claimed to improve diagnostic accuracy in patients with acute abdominal pain. The aim of this study was to evaluate a possible age- and sex-related effect of using structured data collection in the preoperative diagnosis of patients with suspected acute appendicitis. METHODS: Between 1989 and 1994, clinical and demographic data from 1764 consecutive patients were recorded. In 1990 and 1992, various detailed symptom, clinical and laboratory data were collected prospectively on a structured registration form. Age- and sex-specific diagnostic accuracy as well as perforation rate were calculated for each year. RESULTS: Diagnostic accuracy increased significantly by 5 (95 per cent confidence interval (c.i.) 1-9) per cent when structured data registration was applied. In female patients aged between 13 and 40 years, diagnostic accuracy increased by 16 (95 per cent c.i. 8-24) per cent. Significant changes in diagnostic accuracy were not seen in other subgroups. Perforation rates remained unchanged during the entire study period. CONCLUSION: In this population-based study, diagnostic accuracy in patients operated on for suspected acute appendicitis increased for all patients when structured preoperative data collection was used. However, the only subgroup with a significant increase in diagnostic accuracy was female patients aged between 13 and 40 years. Perforation rate was unaffected by structured data collection.

Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis.

This prospective study was performed to investigate epidemiological characteristics in terms of the age- and sex-specific incidence in patients with perforated and nonperforated appendicitis. The study population comprised 1486 consecutive patients who underwent appendectomy for suspected acute appendicitis between 1989 and 1993. Two patient cohorts [n = 544 (37%)] were analyzed with regard to prehospitalization duration of symptoms and in-hospital observation time. The crude incidence of acute appendicitis was 86 per 100,000 per year. Although the incidence of nonperforated appendicitis was highest among adolescents and young adults (13-40 years of age), perforated appendicitis occurred at almost the same incidence in all sex and age groups. The diagnostic accuracy was 76%. Perforated appendicitis occurred in 19%, with higher rates in small children and the elderly, irrespective of gender. A high diagnostic accuracy was not associated with an increased rate of perforation. In small children and the elderly, the diagnostic accuracy was low and the perforation rate high. Patients with perforation had a significantly longer duration of symptoms as well as in-hospital observation time than did patients with nonperforated appendicitis. Perforated appendicitis showed a different incidence pattern than nonperforated appendicitis and was associated with a significantly longer duration of symptoms and in-hospital observation time, probably due to patient-related factors. We suggest this observation deserves attention regarding clinical diagnosis and treatment decision-making for patients with suspected acute appendicitis.

Inherited breast carcinoma--prospective findings in 1,194 women at risk.

According to preset criteria, 1,194 women at risk for inherited breast carcinoma were selected and subjected to examination. Six hundred and three women were examined once, 591 were followed for a mean of 1.8 years. Twenty infiltrating cancers (median age 49 years) and 16 precancers (median age 44 years) were found, demonstrating that breast carcinoma continued to occur in the selected families as expected under the hypothesis of dominant inheritance. At first round, 14 (1.2%) infiltrating carcinomas and a total of 22 (1.8%) cancers or precancers were found. Incidence rates of 0.58% pr. year for infiltrating cancers, and 1.04% pr. year for cancer or precancer were calculated. This confirms the tentative conclusions that were drawn in our previous report. These are the first prospective reports documenting how to delineate a high risk group for premenopausal breast cancer, and how to diagnose cancer at an early stage. All but two affected women had cancer without lymph node metastasis. Although a longer observation time is needed, we cautiously conclude that the results are in keeping with our aim of providing safety for those at risk. Clinical use of predictive genetic testing may be implemented within these families.

[Depression fractures of the skull in newborn infants. Treatment with vacuum extractor]. / Impresjonsfraktur av kraniet hos nyfødte. Vakuumekstraktorbehandling.

Depressed skull fracture in newborns, usually called "ping-pong" lesion, is rare. The fractures may interfere with the function and growth of the brain and may establish an epileptogenic focus. Therefore early elevation is usually necessary. Traditionally, these lesions have been considered to be indication for neurosurgical elevation. During recent years, non-surgical elevation by means of breast pump or vacuum extractor have been reported. This procedure is technically feasible and less traumatic to the infant, and should be attempted before considering operative intervention. If the fractures are combined with bone fragments in the cerebral tissue or if epidural or subdural hematomas exist, surgical treatment is indicated. A case is described in which a depression fracture of the skull was successfully reduced by vacuum extractor.

Diagnosis of brain metastases from a primary hemangiosarcoma of the spleen with magnetic resonance imaging.

BACKGROUND: Primary malignant splenic neoplasms are rare tumors. Apart from involvement of the spleen by malignant lymphoma, hemangiosarcoma is the most common form of primary malignant neoplasm in the spleen. The diagnosis often is made at autopsy or after spontaneous splenic rupture. The prognosis is usually poor, and widespread metastases soon occur. METHOD: Currently, no case of metastasis to the brain has been reported to the authors' knowledge. RESULTS: This case report describes a patient who, as the first sign of metastatic disease, had symptoms from brain metastases 3 months after splenectomy. CONCLUSION: Magnetic resonance imaging was diagnostic.

Rapid C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis.

C-reactive protein (CRP) has been measured in plasma of patients with acute appendicitis and in controls without appendicitis to test the accuracy and diagnostic performance of a new rapid test kit for CRP (NycoCard CRP). The values obtained for CRP by the rapid test correlated well (Rs = 0.92) with the reference method for measuring CRP. The sensitivity, specificity and predictive values were calculated at different cut-off values. At values > 10 mg l-1 a sensitivity of 58% and a negative predictive value of 72% were found. Higher values of sensitivity were observed for men than for women, 69% and 44% respectively. Patients with acute appendicitis who had had symptoms for more than 24 h, had elevated CRP values (cut-off > 10 mg l-1) in more than 80% of cases. Our study shows that the rapid CRP test and the reference CRP test gave an almost identical result.

[Acute appendicitis. Preoperative observation time and diagnostic accuracy]. / Akutt appendisitt. Preoperativ observasjonstid og diagnostisk treffsikkerhet.

The indication for operative treatment of suspected acute appendicitis is based mainly on clinical examination. In this retrospective study of 327 emergency laparotomies the accuracy of the surgeons diagnosis was 69.4%. The overall rate of unnecessary laparotomy was 28.4%, and 45.6% of the operated females, aged 12 to 40 years, did not actually require surgery. The median postadmission delay before operation was three hours 28 minutes. With increasing observation time, the diagnostic accuracy was significantly decreased from 77.7 to 52.2%, and the incidence of perforation rose from 18.6 to 33.3%. 8.7% of the patients with a surgical condition suffered from excessive delay (greater than 12 hours) before surgery. There was no correlation between time of admission and operation and accuracy of diagnosis, but a considerable variation in accuracy between different surgeons. The difficulty in obtaining a correct pre-operative diagnosis in patients with suspected acute appendicitis is still a clinical problem of major concern.

Carcinoma of the stomach. A ten-year material.

1959-68 220 patients from Aust-Agder County were admitted to the Central Hospital with carcinoma of the stomach. The material is analysed and discussed. The average age of the patients was 69.4 years. A palpable tumour was found in 96 patients (46%); of these 6 survived 5 years. A short case history is connected with a better prognosis. One hundred and forty-nine patients (71.3%) underwent laparotomy, and the tumour could be removed in 94 cases (45%). The standard treatment has been partial gastrectomy according to Billroth II. Better results can possibly be achieved if the diagnosis is made at an earlier stage, which means before the tumour causes classical symptoms. Early gastrectomy is recommended in cases of ulcer of the stomach or X-ray negative dyspepsia.