Sonographic Features of Atypical and Initially Missed Parathyroid Adenomas: Lessons Learned From a Single-Center Cohort.

CONTEXT: Awareness of typical and atypical ultrasonographic (US) features of parathyroid adenomas (PAs) is crucial since US is the most widely used first-line imaging modality. OBJECTIVE: The purpose of this study was to describe the atypical features of PAs on US and other possible factors leading to a false negative examination in a large single-center cohort. MATERIALS AND METHODS: The US records of 457 PAs in 445 patients with biochemically proven primary hyperparathyroidism (PHPT) were evaluated in a prospectively maintained database. Atypical size, composition, shape, echogenicity, location, and vascular pattern on US were noted. For patients who previously had at least one negative US examination in referring centers, the main possible reason was defined accordingly. RESULTS: The study group included 359 female and 86 male patients with PHPT. Typical sonographic features were observed in 231 PAs (51%), whereas 226 (49%) had at least one atypical US feature. The most common atypical features were atypical size (29%), followed by atypical echogenicity (19%), shape (8%), location (7%), and composition (7%), respectively. There were 122 initially missed PAs in all groups. The most frequent main atypical US features leading to false negative examinations were atypical size (22.1%) and atypical location (18.8%). Inexperience was third most common reason (16.3%) for false negative US examinations. CONCLUSIONS: Almost half of PAs have at least one atypical feature on US. Awareness of the high prevalence of atypical US features could increase the accuracy of US examination and potentially decrease demand for more expensive second-line imaging modalities.

The sonographer's and pathologist's perspective of echogenic microfoci in papillary thyroid carcinoma.

Objective: Punctate echogenic foci (PEF)/microcalcifications are thought to represent psammoma bodies (PB) in histopathology. However, there are few and contradictory data on this. Different types of sonographic echogenic microfoci (EMF) are seen in papillary thyroid carcinoma (PTC), and their histopathological equivalents are not clearly known. There is also conflicting data on the interobserver agreement between the sonographers on EMF. Methods: We prospectively collected US video records of PTC nodules with and without EMF in two large thyroid centers. All video recordings were independently interpreted by three blinded, experienced sonographers. EMF were classified as true microcalcifications (punctate echogenic foci (PEF) ≤1 mm long), linear microechogenities (>1 mm long, posterior acoustic enhancement of the back wall of a microcystic area), comet-tail artifacts/reverberations or linear microechogenities with comet-tail artifacts/reverberations, non-shadowing coarse echogenic foci (>1 mm nonlinear areas) and unclassifiable. Histopathological evaluation was performed by two blinded, qualified pathologists. Results: A total of 114 malignant nodules were included. The average Cohen's kappa (κ) of three sonographers for the EMF presence was 0.775, indicating substantial agreement. A substantial agreement for PEF with 0.658 κ, only fair agreement for other types of EMF with 0.052 to 0.296 κ were detected. EMF were significantly associated with PB and papillae. PEF had an evident relationship with PB in multivariate analysis. There was a strong positive correlation between the amount of PEF and PB (r = 0.634, P < 0.001). Conclusions: PEF in PTC mainly correspond to PB on histopathology. Although observation of EMF varies among sonographers, this inconsistency can be reduced by classifying EMF into subgroups and keeping the term 'PEF' only for true microcalcifications.

Effects of Intracameral Drugs and Dyes on Corneal Endothelial Cell Apoptosis in a Rat Model: An In Vivo and In Vitro Analysis.

Objectives: To evaluate the effects of intracameral drugs and dyes on rat corneal endothelial apoptosis and cell morphology. Materials and Methods: The right eyes of 72 rats were injected intracamerally with 1% lidocaine, 0.01% adrenaline, triamcinolone acetonide (TA) 4 mg/mL, 1% trypan blue (TB), 0.5% indocyanine green (ICG), and fortified balanced salt solution as control. Corneal samples were taken 1 day and 1 week post-injection. Corneal endothelial apoptosis was assessed by the TUNEL technique, and the ratio of apoptotic cells in each group was compared with the control. Corneal endothelial cell morphology was evaluated in each specimen by transmission electron microscopy. Results: The mean apoptotic endothelial cell ratio was significantly higher at 1 day and 1 week after intracameral adrenaline injection when compared to controls (p=0.03 and 0.021, respectively). TB caused a significantly higher apoptotic cell ratio when compared to controls at 1 week after injection (p=0.043). Lidocaine caused a higher apoptotic cell ratio compared to TA and ICG at 1 week, although not statistically significant (p=0.058, 0.09, 0.69, respectively). In all experimental specimens, transmission electron microscopy showed morphological changes associated with apoptosis. Conclusion: This study showed that intracameral adrenaline, TB, and lidocaine injections may have toxic effects on corneal tissue, as indicated by ultrastructural and histopathological alterations. Therefore, these agents should be used with caution in intraocular surgery.

Value of the Likert dyspepsia scale in differentiation of functional and organic dyspepsia in children.

AIM: Dyspeptic symptoms may not allow clinicians to differentiate organic and functional gastrointestinal disorders. According to our dyspeptic patients' answers to dyspepsia questionnaire, we aimed to define the symptom scores directing organic dyspepsia (OD) before upper gastrointestinal endoscopy. PATIENTS AND METHODS: One hundred sixty-one patients (ages 10-17 years, mean 13.5 ± 2.3 years, male/female: 2/3) with chronic upper gastrointestinal system symptoms lasting for at least 3 months were enrolled. Patients with predominated reflux symptoms were excluded by 24-hour pH monitoring. Before upper gastrointestinal endoscopy, severity and incidence of 8 gastrointestinal symptoms (epigastric pain, upper abdominal discomfort, retrosternal pyrosis, bitter or sour taste in mouth, halitosis, belching, nausea, and early satiety) were measured by 5-point Likert scale. Total score indicated severity score multiplied by incidence score. Antral biopsy samples were obtained. OD is defined as peptic ulcer, erosive esophagitis, erosive or nodular gastritis, and erosive duodenitis in endoscopy and/or moderate to severe antral gastritis in histology. Functional dyspepsia (FD) is defined as normal findings/mucosal hyperemia in endoscopy and/or mild antral gastritis in antral histology. We evaluated the relation among severity and incidence scores of each dyspeptic symptom in patients with OD or FD. Age, sex, body mass index, drug history, nutritional habits, the quality of life related to dyspepsia were also investigated in patients with OD and FD. RESULTS: According to patients' histological and endoscopic findings, 100 (62%) patients were in the OD group and 61 (38%) patients were in the FD group. Of the dyspeptic complaints, the severity, incidence, and total scores of epigastric pain were significantly correlated with dyspepsia type (respectively, P = 0.042, P = 0.028, and P = 0.005). Of 93 patients who had an epigastric pain severity of 4 and 5 (namely, moderate to severe pain), 65 (70%) patients were in the OD group and 28 (30%) patients were in the FD group. Of 68 patients who had an epigastric pain severity of 0 to 3 (no epigastric pain or mild pain), 33 (48.5%) were in the OD group and 35 (51.5%) were in the FD group, and the difference was statistically significant (P = 0.042). After analyzing the total scores of 8 dyspeptic symptoms, one by one or in different combinations, we could not find a threshold (cutoff) score value that was able to indicate OD definitely. Age, sex, body mass index, and nutritional habits were not significantly different between patients with OD or FD. Nocturnal abdominal pain, pain before meals, and resolution of symptoms after meals or ingestion of antacid drugs were not significantly related to OD. Nocturnal abdominal pain was observed to be higher in the group with moderate to severe gastric inflammation. CONCLUSIONS: In the present study, the severity, incidence, and total scores of epigastric pain were significantly related to OD; however, a cutoff value of dyspepsia symptom score for differentiation of OD and FD could not determined. In our study, Likert dyspepsia scale was not beneficial in differentiation of the OD/FD groups. We suggest that the Likert dyspepsia scale should be redesigned for children or the same scale should be applied in a larger cohort of dyspeptic children.

Radioguided occult lesion localization for minimally-invasive parathyroidectomy without quick PTH monitoring and frozen section: impact of the learning curve.

OBJECTIVES: Minimally-invasive parathyroidectomy (MIP) is a surgical procedure that reduces the duration of operation, hospital costs, and hypocalcemia, and shortens the length of hospital stay. This study addressed the important procedural details of the radioguided occult lesion localization (ROLL)-MIP technique and evaluated the consequences of the learning curve from a series of patients. PATIENTS AND METHODS: A total of 80 patients who underwent ROLL-MIP for a single parathyroid adenoma were included into this retrospective study. In order to analyze the effect of the learning curve, these subjects were then divided into 2 groups per time period and the operative times were compared. Group A consisted of 22 previously reported patients who served as the control group. Group B consisted of 58 consecutive patients. RESULTS: Serum calcium and parathyroid hormone (PTH) levels were normalized in all of the patients within 2 days and remained normal during the follow-up period (31 ± 18.5 months). None of the patients who underwent ROLL-guided parathyroidectomy suffered temporary or permanent recurrent laryngeal nerve injuries. Mean operation time (time from incision to excision of the adenoma) was 23 ± 6 min in Group A and 18 ± 7 min in Group B. Mean operative times were significantly shorter in group B. CONCLUSION: The success of MIP administered with the ROLL technique in a single adenomatous patient was quite high. This method seems especially valuable in patients with atypically located or small adenomas.

Ciliary body toxicity of subconjunctival suramin compared with mitomycin-C in the rabbit eye: determining the toxic concentration.

BACKGROUND/AIMS: To evaluate the safety of suramin compared with mitomycin-C (MMC) as an adjunctive agent in trabeculectomy by determining its ciliary body toxicity at predetermined effective dosages in rabbit eyes. METHODS: Thirty-two New Zealand albino rabbits received either suramin (200, 300, 400, or 800 mg/ml) or MMC (0.2, 0.3, 0.4, or 0.8 mg/ml) injections subconjunctivally in the right eye. Enucleations were performed on the 1st, 3rd, 7th and 28th day. Untreated left eyes were injected with balanced salt solution and served as controls. The injection-exposed ciliary body specimens were processed to be investigated under the light microscope and transmission electron microscope. RESULTS: There was no pathologic abnormality in specimens under light microscopy. The morphologic evaluation with transmission electron microscopy showed severe changes in structure, except for eyes treated with 200 mg/ml suramin and 0.2 mg/ml of MMC. These changes were more prominent in eyes exposed to MMC, and appeared earlier compared to suramin-treated eyes. CONCLUSIONS: Suramin 200 mg/ml and MMC 0.2 mg/ml seem to be comparatively nontoxic to the ciliary body of the rabbit eye. Concentrations higher than these values caused severe damage.

An alternative method of using an interpositional silicone sheet in tissue expansion.

To reduce the rate of complications in tissue expansion, we placed a silicone sheet between the expander and the tissue above it in a rat model. In the rats in group 1 (n = 10), the expanders were placed under the dorsal skin. The expanders were inflated with up to 45 mL of saline solution. In group 2 (n = 10), a silicone sheet was inserted between the tissue expander and the skin, after which the procedure used in group 1 was performed. The blood flow was reduced at the dome (center [C]) of the expanders in groups 1C and 2C to a degree greater than that in the expanded skin in groups 1 and 2 far periphery. However, the flow was significantly better in group 2C than in group 1C. Histologic analysis showed that the dermal and capsular tissues were significantly thicker in group 2C than in group 1C. In our opinion, placing a silicone sheet between the expander and the tissue above it seems to be beneficial. This may reduce the incidence of complications, especially the expander extrusion in this model.

Value of an individual liver biopsy in the preoperative evaluation of apparently healthy potential liver donors.

Living donor liver transplantation has acquired widespread acceptance. A thorough workup of the potential living donor is guided by 2 objectives: the first is ensuring the safety of the surgical procedure for the donor, and the second is identifying donor grafts that pose potential risks for the recipient. Of 305 living-related liver donors, liver biopsy was performed in 201. The results of those patients' liver function tests and serologic tests were within normal limits. Forty-one of the 201 patients had steatosis on abdominal ultrasonography or tomography. Of 201 liver biopsies, 94 (46.8%) demonstrated normal findings, whereas 107 (53.2%) showed abnormal findings on pathology. Of 107 patients with abnormal pathological findings, 32 (29.9%) had fatty changes, 4 (3.7%) had steatohepatitis, and 71 (66.4%) had nonsteatotic histologic findings including fibrosis, hepatitis, and granulomatous reactions. In conclusion, our data show that half of the living-related liver donors, appearing absolutely healthy, had biopsies with abnormal pathology results. As it is well known that increasing percentages of steatosis may reduce the functional mass of the graft and occult liver diseases may not be detected without liver biopsy, we recommend that liver biopsies be part of the routine evaluation protocol for living-related liver donors in all transplantation institutions.

Determination of HER-2/Neu status in hepatocellular carcinoma cases.

Specific chromosome abnormalities and genetic changes in hepatocellular carcinoma (HCC) have been demonstrated by conventional cytogenetic studies or molecular cytogenetic approaches like comparative genomic hybridization and loss of heterozygosity analyses. HER-2/Neu amplification and expression has been studied as a molecular target for treatment of HCC, and there are conflicting results. We aimed to determine HER-2/Neu status in archive materials of HCC patients by fluorescence in situ hybridization (FISH). Among the 35 patients, 2 had HER-2/Neu amplification and 3 had increased chromosome 17 copy number. All these patients had grade 2 or 3 tumor with a diameter of 3-12 cm. We conclude that although HER-2/Neu amplification is not the primary mechanism in the development of liver tumors, it might play a role in one of the steps of multistage carcinogenesis.

Total colonic polyp diameter: a marker for the risk of malignancy?

BACKGROUND/AIMS: The correlation of the risk of malignancy with the sum of the diameters of small colonic polyps is unknown, and data regarding this topic are lacking. In this study, the relationship between the sum of the diameters of the total number of colonic polyps and poor histopathologic characteristics was examined. METHODS: A total of 920 neoplastic colon polyps were evaluated in 480 patients. The "total polyp diameter" (i.e. the sum of all polyp diameters identified during colonoscopy), which was calculated in each patient by adding the diameter of each polyp to a sum, was categorized as "small" (<10mm in diameter) or "large" (> or =10mm in diameter). The polyps were further categorized by histopathologic component as "unfavorable" or "favorable" and were divided into 2 groups: group 1 (those identified as carci noma, carcinoma in situ, villous adenoma, and tubulovillous adenoma with a villous component of more than 25%) and group 2 (mixed adenomatous polyps with various degrees of hyperplastic or inflammatory components and adenomas with a tubular component of more than 75%). RESULTS: Large polyps that had a total diameter greater than or equal to 10mm tended to have poor histopathologic characteristics (p<0.05). Polyps generally tended to localize in the left portion of the colon, and malignant polyps or those at risk for malignancy in particular tended to localize in the left colon (p<0.05). CONCLUSIONS: Polypectomy is recommended for patients in whom the sum of the diameter of all colonic polyps exceeds 10mm.

Ménétrier's disease and severe gastric ulcers associated with cytomegalovirus infection in an immunocompetent child: a case report.

In pediatric patients, Ménétrier's disease is an uncommon clinical entity that has been rarely described only as sporadic cases, and the etiology is unclear. These patients usually have a self-limiting clinical course. Cytomegalovirus is an important pathogen in the immunocompromised host. However, cytomegalovirus infection can be detected in non-immunocompromised children. We discuss the possible role of cytomegalovirus infection in both Menetrier's disease and severe gastric ulcers in an immunocompetent child.

Ginger (zingiber officinale) might improve female fertility: A rat model.

BACKGROUND: Ginger (Zingiber officinale) is a well known and extensively used antioxidant in traditional remedies. In this study, we aimed to investigate the effects of ginger powder on ovarian folliculogenesis and implantation in rats. METHODS: There were two study groups. In the 5-day treatment group (one estrous cycle), 100 mg ginger powder, 200 mg ginger powder or distilled water was given for 5 days to the three subgroups each containing seven rats. In the 10-day treatment group, same doses were given for 10 days (two estrous cycle) to the three subgroups each containing seven rats. At the end of the 5th and 10th days, ovarian volumes, ovarian weights, primordial follicles, antral follicles, atretic follicles, and corpus luteum counts were assessed. To evaluate the angiogenic effects of ginger, vascular endothelial growth factor (VEGF) and for the antioxidant effects of ginger endothelial nitric oxide synthase (eNOS) were examined in the ovaries and in the endometrium immunohistochemically. RESULTS: In the 5-day treatment group, antral follicle count and ovarian stromal VEGF were significantly high in the 100 mg ginger subgroup in comparison to the control group (p < 0.05). In the 10-day treatment group, endometrial VEGF and ovarian stromal eNOS were significantly high in the 100 mg ginger subgroup in comparison to the control group (p < 0.05). There was no statistically significant difference at 200 mg ginger dose both in 5-day and 10-day treatment groups. CONCLUSION: The increases in the antral follicle count and ovarian stromal VEGF in the 100 mg/5-day treatment subgroup indicate that ginger have positive effects on folliculogenesis in short term with low dose. Additionally, ginger may enhance implantation in rats in long term with low dose.

Invasive Candida albicans infection mimicking leukemia in a neonate.

Congenital leukemia is rare, and is frequently diagnosed as a form of acute myeloid leukemia at, or immediately after birth. Some infections, viral in particular, can mimic clinical signs and/or laboratory findings of congenital leukemia. This is the first documented case of candidemia resembling leukemia.

Expanded criteria for hepatocellular carcinoma and liver transplantation.

In this study, we evaluated our early results of liver transplantation for hepatocellular carcinoma. Between January 2003 and June 2006, 26 patients (4 women and 22 men; age, 1.1-65 years) with preoperatively diagnosed or incidental hepatocellular carcinoma (HCC) underwent liver transplantation at our center. Inclusion criteria (independent of tumor size and number of tumor nodules) were no invasion of major vascular structure and no evidence of extrahepatic disease. In 13 of the patients, tumors were beyond the Milan criteria. At this writing, with a mean follow-up of 16.5 months (range, 1-31 months), all patients are doing well with excellent graft function. The longest survival is 2.5 years, and our patient survival rate is 100%. There has been only one tumor recurrence that was 4 months after liver transplantation. Liver transplantation provides long patient and disease-free survival, even in patients with HCC that exceeds the Milan criteria.

Hepatitis A super infection as a cause of liver failure in a child with Wilson's disease.

Infection with hepatitis A virus can cause severe or even fatal illness in patients with chronic liver disease. Here we describe a seven-year-old girl who presented as acute liver failure and was diagnosed with Wilson's disease and later with coexistent hepatitis A infection. Wilson's disease was demonstrated on the basis of low ceruloplasmin, high urinary copper excretion, histological evidence of cirrhosis, and high biochemical estimation of liver copper concentration. Hepatitis A was diagnosed serologically. Our case suggests that acute hepatitis A may play a part in the acute decompensation seen in some cases of unrecognized Wilson's disease. We also emphasize the importance of prevention measures of hepatitis A infection in patients with chronic liver disease.

Smoking associated with damage to the lipid layer of the ocular surface.

PURPOSE: To evaluate the effects of smoking on ocular surface. DESIGN: Prospective, comparative, interventional case series. METHODS: setting: Institutional. study population: Sixty smokers (33 men, 27 women) and 34 healthy subjects (18 men, 16 women) were enrolled into this study. Patients with associated ophthalmic or systemic diseases, and history of contact lens use and ocular surgery were excluded. The duration of average smoking was 13.1 years (range 5 to 35 years). INTERVENTION: Ocular surface was evaluated by measuring corneal and conjunctival sensitivity, surface staining with fluorescein, tear film breakup time, Schirmer 1 test, and conjunctival impression cytology. Dry eye symptoms were scored by questionnaire. Kinetic analysis of sequential tear interference images obtained by a DR-1 tear lipid layer interferometry was used to investigate the precorneal lipid layer spread. Results were compared with a control group. MAIN OUTCOME MEASURES: Comparison of subjective complaints with objective parameters in cigarette smokers and normal subjects. RESULTS: In the smoker group, the mean Schirmer 1 test value was 10.8 mm (range 8 to 14 mm). The mean breakup time was 5.3 seconds (range 1 to 10 seconds), the average conjunctival sensitivity was 26.2 mm (range 0 to 45 mm), and the average central corneal sensitivity was 37.6 mm (range 5 to 60 mm). There was no statistically significant difference in goblet cell densities or in Schirmer 1 test values between smokers and controls (P > .05). Higher grades of lipid layer changes were observed in smokers by DR-1 interferometry kinetic analysis. CONCLUSIONS: Smoking has deteriorating effects on the lipid layer of precorneal tear film.

Frontal mucocele with an accompanying orbital abscess mimicking a fronto-orbital mucocele: case report.

BACKGROUND: Mucoceles are slowly expanding cystic lesions with respiratory epithelium containing mucus most commonly affecting the frontal and ethmoidal sinuses. They are caused by obstruction of sinus ostium. Mucoceles exert pressure on the bony boundaries and due to the proximity to the brain and orbit extension to these areas are common. CASE PRESENTATION: A case of a frontal mucocele with an accompanying orbital abscess mimicking a fronto-orbital mucocele is reported. A 77 year old female patient suffering from left sided proptosis and pain around the left eye was admitted to our department. She had a history of left frontal sinus mucocele one year ago that was offered an osteoplastic frontal sinus surgery that the patient refused. Patient had limitation of eye movements. Fundoscopic examination revealed a minimal papilledema. Coronal computerized tomography and orbital magnetic resonance imaging showed a frontal mucocele with suspicious erosion of the orbital roof and a superiorly localized extraconal mass displacing the orbit lateroinferiorly. Frontal and orbital masses had similar intensities. Thus surgery was planned for a fronto-orbital mucocele. During surgery no defect was found on the orbital roof. Frontal mucocele and orbital cystic mass was removed separately. Pathological examination showed a frontal mucocele and an orbital abscess wall. Postoperatively eye movements returned to normal and papilledema resolved. CONCLUSION: Fronto-orbital mucoceles are commonly encountered pathologies, but frontal mucocele with an orbital abscess is a rarely seen and should be kept in mind because their treatments differ.

Slowly Growing Nodule on the Trunk: Cutaneous Granular Cell Tumor.

Granular cell tumor (GCT) is a rare benign neoplasm of the skin that accounts for 0.5% of all soft-tissue tumors. The tumor mostly presents with a symptomatic slowly growing solitary nodule and overlying normal skin; therefore, it is not always considered in the differential diagnosis. Here, we report a 58-year-old female patient who presented with a 4-year history of a slowly growing mass, with a dimension of 5 × 4 cm on her left waist, diagnosed as a GCT at the histopathological examination. The neoplastic cells had centrally located nuclei and granular eosinophilic cytoplasm and stained positively for S100, neuron-specific enolase, and CD68 antibodies. Fifteen months after surgery, the patient still showed no signs of local recurrence or metastases. Although a large diameter is a feature of malignant GCT, our case with cutaneous GCT was localized on the trunk and did not present malignant features clinically and histopathologically.

Primary intrarenal neuroblastoma in a 13-month-old girl presenting as a Wilms' tumor with pulmonary metastasis.

We report a 13-month-old girl with primary intrarenal neuroblastoma initially diagnosed as Wilms' tumor. Intrarenal neuroblastoma is exceedingly rare in pediatric age that may masquerade as Wilms' tumor clinically and radiographically and it is important to differentiate for management.

Primary squamous cell carcinoma of the stomach: a case report.

Squamous cell carcinoma (SCC) originating from the stomach is a relatively rare entity. There are theories regarding the development of this rare tumor, but its exact pathogenesis remains obscure. Fewer than 100 cases of primary SCC of the stomach have been presented in the literature. Due to the advanced stage at the time of diagnosis in most of these cases, the prognosis is generally poor. In the case presented here, dissemination of the tumor to the transverse colon, gallbladder and omentum was present at diagnosis. Despite the tumor's advanced stage, complete remission was achieved after six courses of adjuvant chemotherapy with 5-flourouracil and cisplatin. No recurrence has been detected during follow-up. The patient has been healthy with no sign of the disease for three years.