A rare and interesting case of primary mammary tuberculosis mimicking breast carcinoma

Introduction

Mammary tuberculosis (MT) is an extremely rare form of extrapulmonary tuberculosis (TB), which is uncommon even in countries where TB is considered to be endemic. It can occur in primary and secondary forms, clinically and radiologically, both of which can mimic breast carcinoma or persistent breast abscess.

Case presentation

A 35-year-old multigravida presented with a history of swelling in the right breast and axilla that had begun six months earlier, to be followed three months later by a yellowish dirty discharge, and five months later by blackish discolouration of the overlying skin. Ultrasonography (USG) showed cutaneous oedema and lymphatic dilatation in the right breast with a lump measuring 6 cm × 7 cm, as well as three significantly enlarged pectoral lymph nodes in the right axilla.

Discussion

The most common type of MT is the nodular pattern which may be mistaken for carcinoma or fibroadenoma. MT may present as multiple heterogeneous, hypoechoic masses with irregular margins, or on USG as thickwalled cystic lesions with septa and sinus tracts. It can only be accurately diagnosed by histological identification of typical necrotising granulomas in the tissue sections. Conservative surgery (local excision of the mass) if needed, followed by antitubercular therapy is the standard treatment protocol.

Conclusion

An atypical rare entity, primary MT may mimic adenoma or carcinoma and may often be misdiagnosed without formal histopathology due to its intriguing clinical and radiological features.     

Scrotal cancer survival is influenced by histology: a SEER study

Introduction

Due to the scrotum’s multiple layers of different tissues, scrotal cancer can present with several unique histologies. Historically, outcome arising from these different sources has been historically aggregated together. However, it remains unclear whether survival differs by histology of scrotal cancer.

Methods

We queried the seventeen registries of the Surveillance, Epidemiology, and End Results database for patients diagnosed with primary scrotal cancer from 1973 to 2006. Patients were initially grouped by the following histologies: basal cell carcinoma, Extramammary Paget’s Disease (EMPD), sarcoma, melanoma, squamous cell carcinoma, and adnexal skin tumors. For some analyses, the former three histologies were reclassified as Low-Risk scrotal cancer and the latter three histologies as High-Risk scrotal cancer. Kaplan–Meier survival analyses were conducted to assess the impact of histology on overall survival (OS).

Results

The cohort consisted of 766 patients. Median (95% CI) OSs by histologies were basal cell carcinoma—143 (116–180), EMPD—165 (139–190), sarcoma—180 (141–219), melanoma—136 (70–203), squamous cell carcinoma—115 (97–133), and adnexal skin tumors—114 (55–174). Patients with Low-Risk scrotal cancer experienced a median (95% CI) OS of 166 (145–188) months, while patients with High-Risk scrotal cancer experienced a median (95% CI) OS of 118 (101–135) months.

Conclusions

Survival of scrotal cancer depends on tumor histology. Classification of histologies into Low and High Risk can be clinically useful for counseling and clinical decisions.     

Role of US in acute scrotal pain

Background

The acute scrotum is a common emergency department (ED) presentation and can be defined as any condition of the scrotum or intrascrotal contents requiring emergent medical or surgical intervention. Although rarely fatal, acute scrotal pathology can result in testicle infarction and necrosis, testicular atrophy, infertility, and significant morbidity.

Methods

Scrotal US is best performed with a linear 7.5- to 12-MHz transducer. In addition to imaging in the longitudinal and transverse planes, it is helpful to obtain simultaneous images of both testes for comparison. Color Doppler is used to evaluate for abnormalities of flow and to differentiate vascular from nonvascular lesions. Attention to appropriate color Doppler settings to optimize detection of slow flow is critical.

Results

The evaluation of acute scrotal pain can be challenging for the clinician initially examining and triaging the patient. Acute scrotal conditions due to traumatic, infectious, vascular, or neoplastic etiologies can all present with pain as the initial complaint. Additionally, the laboratory and physical examination findings in such conditions may overlap; this, coupled with potential patient guarding and lack of collaboration, may result in a limited, non-specific physical examination. Therefore, scrotal ultrasound has emerged to play a central role in the evaluation of the patient presenting with acute scrotal pain.

Conclusions

In conclusion, we are firmly convinced that a scrotal ultrasound should always be performed in the presence of acute scrotal pain. Moreover, urologist should be able to perform a scrotal ultrasound but, if imaging does not supply a clear diagnosis, surgical exploration is still mandatory.     

The burden of prolonged indwelling catheter after acute urinary retention in Ikeja – Lagos, Nigeria

Background

Scrotal schwannoma is a rare neoplasm and poses a diagnostic challenge to urologists. This article describes a rare case of ancient scrotal schwannoma and reviews the current modality of investigation and treatment of this tumour.

Case report

A 28 year old man presented with a 3-month history of an asymptomatic scrotal swelling. Ultrasonography and computer topography revealed an intra-scrotal and extra-testicular mass without local invasion. Surgical excision was undertaken and histology was an ancient schwannoma of the scrotum.

Conclusion

Schwannoma is a benign encapsulating neoplasm with an overall low incidence, occurring mostly in the head and neck region and seldom in the scrotum. Histology shows two distinctive patterns, Antoni type A and B areas. Variations of schwannoma such as cellular, ancient, glandular and epithelioid are observed based on the appearances. Ancient schwannoma exhibits pleomorphism without mitosis as the result of cellular degeneration, which can lead to an erroneous diagnosis of malignancy. Imaging modalities are non-specific for schwannomas, but can define tumour size, site and extension. The mainstay treatment is complete excision, although local recurrence may occur in large and incompletely excised lesions. Malignant change is exceedingly rare.     

Gutartige Knochentumoren und „tumor-like lesions“

Purpose

Benign bone tumors are relatively seldom compared to degenerative and inflammatory skeletal diseases. There are usually diagnostic difficulties because of their markedly high differential diagnostic potential. This leads to problems regarding the further procedure.

Problem

Evaluation of the significance of radiology in the management of benign skeletal lesions.

Material and methods

Significant diagnostic elements of benign bone tumors are presented by means of data from the well-known literature and personal experiences.

Results

The tasks in radiology when diagnosing primary bone tumors or tumor-like lesions are firstly, detection or exclusion of a lesion, secondly, limiting the differential diagnostic possibilities or reaching a certain diagnosis and thirdly, staging of bone tumors in cases where the disease needs further diagnostic measures. In particular circumstances the diagnostics of disease recurrence can additionally be necessary.

Conclusion

The diagnostics of primary and secondary benign (and malignant) bone tumors requires a specialized osteoradiological expertise because of their rarity and the differential diagnostic and differential therapeutic potential. Radiology and pathology are the basis of diagnosing bone tumors and tumor-like lesions. Benign bone tumors and tumor-like lesions can often be diagnosed radiologically; therefore, the choice between a conservative (surveillance) or interventional (surgery) procedure will be correct in most cases.     

Potential role of F18 FDG PET-CT as an imaging biomarker for the noninvasive evaluation in uncomplicated skeletal tuberculosis: a prospective clinical observational study

Purpose

This is a prospective non-randomized observation study done on 33 patients with uncomplicated spinal tuberculosis to observe the imaging characteristics on sequential F-18 FDG PET CT scans.

Methods

33 consecutive patients with pathologically proven spinal tuberculosis underwent a baseline contrast-enhanced whole body FDG PET scan before initiation of antitubercular therapy, 6 and 12 months and at 18 months or the end of antitubercular therapy.

Result

The baseline peak SUVmax of lesions in our 33 cases had values ranging from 5.9 to 30.3 (mean 14.8). 63.6 % patients had clinically occult non-contiguous multifocal skeletal involvement at the time of the baseline whole body PET CT scanning. The mean change in SUVmax at various time points was highly significant (p value < 0.001).

Conclusion

SUVmax can be taken as a reliable marker for serial quantification of metabolic activity in spinal tuberculosis. This may translate into a potential role for FDG as an imaging biomarker for noninvasive response evaluation in skeletal tuberculosis.     

Solitary fibrous tumour of the pleura: Recurrence presented with severe clinical hypoglycaemia

Aim

To highlight an interesting case report of a rare cause of surgically treated hypoglycemia.

Background

Solitary fibrous tumors of the pleural are rare tumors, accounting for less than 5% of all pleural tumors. Interestingly, they are associated with hypoglycemia due to secretion of insulin growth factor II.

Case report

An 80 year old female who had been operated in the past for solitary fibrous tumor of the pleura in the right pleural cavity, developed severe symptomatic episodes of hypoglycemias. Her diagnostic workup revealed multiple ipsilateral intra-thoracic masses. She had been re-operated for and, indeed, multiple tumors were found and excised.

Results

The histologic identity of these tumors were in accordance with histology of the tumors which had been excised at her first operation.The patient recovered well and the hypoglycemic episodes have been completely subsided thereafter.

Conclusion

Hypoglycemia, which is considered a common though sometime severe symptom, needs a thorough diagnostic workup and when assessing it with an intrathoracic mass, solitary fibrous tumor of the pleural should always be kept in mind, since it is reversible cause.     

Surgical repair of giant inguinoscrotal hernias in an austere environment: leaving the distal sac limits early complications

Purpose

Giant inguinoscrotal hernias represent a real public health problem in the Ivory Coast that can dramatically impair patients’ quality of life. Limited resources require a simplified surgical strategy including, in our experience, not using a mesh and leaving the distal hernia sac. The aim of this study was to evaluate the benefits of this technique in terms of complications (seroma, haematoma, trophic troubles) and the ability to recover from surgery and return to work at 1 month postsurgery.

Methods

Between January and May 2012, all patients who presented with a giant primary inguinoscrotal hernia that was spontaneously reducible in the decubitus position and who did not have any trophic changes in the scrotal skin were prospectively studied. The surgical procedure was a herniorrhaphy as described by Bassini. All patients received follow-up examinations on postoperative days 5, 12 and 30.

Results

Twenty-five males with a median age of 42 years (range 18–60) underwent surgery. Three patients (12 %) presented with a superficial skin infection and four (16 %) with early scrotal swelling without seroma, spontaneously resolved by postoperative day 30. Three patients (12 %) presented with scrotal swelling and seroma; two required aspiration. No early recurrence was observed at the end of follow-up, and all patients were able to return to work.

Conclusion

Leaving the distal hernial sac in the scrotum does not interfere with the type of hernia repair and can limit the occurrence of complications. This technique is reliable, reproducible and does not incur additional morbidity when used in selected patients.     

Comparison of platelet count in tuberculosis spine to other spine pathology

Purpose

Haematological markers currently used to investigate TB spine vary from WCC, Anaemia, ESR and CRP. Platelet count in TB spine as a marker has been inadequately investigated.

Method

In this retrospective review, Platelet count in TB spondylitis on admission was compared to patients undergoing other elective spinal surgery (control) preoperatively. Comparisons of the platelets with ESR and the effect of HIV on platelet count in TB spine were also evaluated.

Results

160 TB spine patients showed statistically significant higher platelet count when compared to 210 patients in the control group (p < 0.001). 52.5 % patients had a raised platelet count in the TB spondylitis group. Raised Platelet count had a sensitivity and specificity of 52.5 % and 86.2 %, respectively in TB spondylitis. ESR and platelet count had a Pearson correlation r = 0.31 (p < 0.001). HIV however did not statistically show any difference in the platelet count (p = 0.12).

Conclusion

A raised platelet count in spinal pathology may be used as an inflammatory marker of TB spondylitis.     

Coverage of circumferential penile shaft defects with the bipedicled scrotal flap: a case series

Background

Reconstruction of circumferential penile skin defects should address both cosmetic and functional concerns. Scrotal skin is an ideal replacement because its inherent elasticity allows erection. This characteristic also allows primary closure of the donor site. The purpose of this paper is to describe our use of a bipedicled scrotal flap and our modifications.

Methods

Five patients (age range, 19 to 76 years) over the last 7 years underwent reconstruction of circumferential defects with this technique. The underlying pathologic condition was siliconoma/paraffinoma (n?=?2), full-thickness burn (n=1), overly aggressive circumcision (n=1), and traumatic avulsion (n=1). Follow-up ranged from 2 to 6 years. A bipedicled flap was elevated from the scrotum and inset over either the dorsal or ventral aspect of the penile defect. Flap delay was carried out before final division at 3 weeks. The junction line on the penile shaft was designed as a Z-pattern which was off-center.

Results

Four patients healed uneventfully. One patient had flap tip necrosis due to insufficient delay, which resulted in mild ventral scarring. All were able to have normal erection.

Conclusions

We have used the bipedicled scrotal flap in a staged manner for circumferential penile defects. The advantages of this technique were reliable coverage with an inconspicuous donor site, provision of expansile skin allowing normal erection and preservation of the penile–scrotal junction. The disadvantages were multistaged procedure, skin mismatch because of rugosity, and hair growth. Level of Evidence: Level V, therapeutic study.     

Combined laparoscopic and open extraperitoneal approach to scrotal hernias

Background

Laparoscopic repair of scrotal hernias is often a difficult endeavor to successfully complete. The longstanding nature of these hernias often results in significant adhesions and anatomic distortion of the inguinal floor. These two issues make reduction of the hernia arduous and subsequent reinforcement of the parietal sac difficult. We have previously described techniques to increase the chances of success when attempting laparoscopic repair of scrotal hernias. Here, we describe some of those techniques as well as a combined laparoscopic and open approach to achieve a robust preperitoneal repair of incarcerated scrotal hernias when the usual totally extraperitoneal approach does not work.

Patients and methods

We performed a retrospective review of 1890 TEP hernia repairs we performed from 1990 to 2010. Rate of conversion to an open approach or a combined laparoscopic and open approach was examined. Incidence of complications or recurrences was assessed over a 12-month follow-up period.

Results

Among the 1890 TEP repairs, 94 large scrotal hernias were identified. Of these, nine cases (9.5 %) required conversion to an open procedure due to an incarcerated and indurated omentum. Three were completed with a conventional open preperitoneal whereas six patients (6.4 %) underwent repair with the combined approach. In this group, no recurrences or complications were found over a 12-month period.

Conclusion

In cases where a large scrotal hernia may be difficult or dangerous to reduce laparoscopically, immediate conversion to an open repair may not be necessary. A combined laparoscopic and open approach can greatly assist in the visualization and dissection of the preperitoneal space, thereby facilitating reduction of the hernia and placement of the mesh.     

Management of Non-Parasitic Splenic Cysts: Does Size Really Matter?

Background

Splenic cysts are relatively rare clinical entities and are often diagnosed incidentally upon imaging conducted for a variety of clinical complaints. They can be categorized as primary or secondary based on the presence or absence of an epithelial lining. Primary cysts are further subdivided into those that are and are not secondary to parasitic infection. The treatment of non-parasitic splenic cysts (NPSC) has historically been dictated by two primary factors: the presence of symptoms attributable to the cyst and cyst size greater or less than 5 cm. While it is appropriate to resect a symptomatic lesion, the premise of recommending operative intervention based on size is not firmly supported by the literature.

Methods

In the current study, we identified 115 patients with splenic cysts and retrospectively reviewed their management that included aspiration, resection, or observation.

Results

Our data reveal a negative overall growth rate of asymptomatic cysts, a high recurrence rate after percutaneous drainage, as well as demonstrate the safety of observing asymptomatic lesions over time.

Conclusion

We conclude that observation of asymptomatic splenic cysts is safe regardless of size and that aspiration should be reserved for those who are not surgical candidates or in cases of diagnostic uncertainty.     

Warthin-like tumour papillary thyroid carcinoma

Aim-Background

With less than 100 cases reported in the English literature to date, Warthin-like tumour papillary thyroid carcinoma is a relatively uncommon variant of papillary thyroid carcinoma (PTC). This term was first coined on the basis of its close morphological resemblance to the Warthin tumour that characteristically occurs in the salivary glands.We present a case of this uncommon variety of PTC, and through a brief literature review we describe the diagnostic challenges presented in distinguishing between several varieties of PTC and benign lesions to provide optimal treatment.

Case Report

A 48-year-old woman was referred to our department for surgical treatment of an enlarged goitre that had presented over the last year. Dominant nodule FNA revealed suspicion of a follicular neoplasm, and she was submitted to total thyroidectomy.

Results

Histopathology showed multifocal PTC on chronic lymphocytic thyroiditis ground. Left lobe foci of 0.3 cm follicular variant of PTC, 0.6 cm isthmus foci of Warthin-like tumour PTC and 1.5 cm of conventional PTC with extrathyroidal extension were reported.

Conclusion/Discussion

Previous studies showed prognosis to be similar to that for conventional PTC. Distinction between Hurthle cell tumours, tall cell and oncocytic variants of PTC or medullary carcinoma, or even lymphocytic thyroiditis and this entity, is intriguing and poses diagnostic difficulties. Data from new studies will reveal more on this uncommon tumour.     

Forked osteotomy arthroplasty for elbow tuberculosis: six years of follow-up

Background

Elbow tuberculosis (TB) is not rare in China. Most patients are diagnosed when it is at an advanced stage and with bony ankylosis complications. For a developing country, such as China, it is important for there to be safe and cost-effective procedures.

Materials and methods

A retrospective study was designed to assess the effects of improved forked excision arthroplasty for treating elbow TB. There were 20 patients (average age, 48.45 years). For all patients, the preoperative diagnosis was elbow TB at an advanced stage. All patients underwent forked excision arthroplasty. Patients were evaluated preoperatively and postoperatively with the Mayo’s elbow performance score (MEPS). Mean follow-up was at 74.4 months.

Results

At the last follow-up, the mean postoperative MEPS was 83.7 compared with the preoperative MEPS of 20.25. Results of Mayo’s elbow performance index were excellent in seven patients, good in 12 and fair in one, and none were poor. The range of elbow motion also improved significantly.

Conclusion

This study of forked elbow excision arthroplasty has shown promising results for treating elbow TB. Most patients had ideal postoperative outcomes and exhibited painless elbow joints, with satisfactory functional recovery at medium-term follow-up. Further studies with longer follow-up are warranted.

Level of evidence

III.     

Safety and efficacy of new integrated bipolar and ultrasonic scissors compared to conventional laparoscopic 5-mm sealing and cutting instruments

Background

Hemostasis is a central issue in laparoscopic surgery. Ultrasonic scissors and bipolar clamps are commonly used, with known advantages with each technique.

Methods

The prototype of new surgical scissors, delivering ultrasonically generated frictional heat energy and bipolar heat energy simultaneously (THUNDERBEAT^? [TB]), was compared to ultrasonic scissors (Harmonic ACE^? [HA]) and an advanced bipolar device (LigaSure^? [LS]) using a pig model. As safety parameters, temperature profiles after single activation and after a defined cut were determined. As efficacy parameters, seal failures and the maximum burst pressure (BP) were measured after in vivo sealing of vessels of various types and diameters (categories 2–4 and 5–7 mm). Moreover, the vertical width of the tissue seal was measured on serial histological slices of selected arteries. The cutting speed was measured during division of isolated arteries and during dissection of a defined length of compound tissue (10 cm of mesentery). Burst-pressure measurement and histological analysis were performed by investigators blinded to the used sealing device.

Results

Using the TB, the burst pressure in larger arteries was significantly higher (734?±?64?mmHg) than that of the HA (453?±?50?mmHg). No differences in the rate of seal failures were observed. The cutting speed of the TB was significantly higher than that of all other devices. Safety evaluation revealed temperatures below 100?°C in the bipolar device. The maximum temperature of the HA and the TB was significantly higher. No relevant differences were observed between the HA and the TB.

Conclusions

The ultrasonic and bipolar technique of the TB has the potential to surpass the dissection speed of ultrasonic devices with the sealing efficacy of bipolar clamps. However, heat production that is comparable to conventional ultrasonic scissors should be minded for clinical use.     

Olecranon fractures: factors influencing re-operation

Purpose

We evaluated factors influencing re-operation in tension band and plating of isolated olecranon fractures.

Methods

Four hundred eighty-nine patients with isolated olecranon fractures who underwent tension band (TB) or open reduction internal fixation (ORIF) from 2003 to 2013 were identified at an urban level 1 trauma centre. Medical records were reviewed for patient information and complications, including infection, nonunion, malunion, loss of function or hardware complication requiring an unplanned surgical intervention. Electronic radiographs of these patients were reviewed to identify Orthopaedic Trauma Association (OTA) fracture classification and patients who underwent TB or ORIF.

Results

One hundred seventy-seven patients met inclusion criteria of isolated olecranon fractures. TB was used for fixation in 43 patients and ORIF in 134. No statistical significance was found when comparing complication rates in open versus closed olecranon fractures. In a multivariate analysis, the key factor in outcome was method of fixation. Overall, there were higher rates of infection and hardware removal in the TB compared with the ORIF group.

Conclusions

Our results demonstrate that the dominant factor driving re-operation in isolated olecranon fractures is type of fixation. When controlling for all variables, there is an increased chance of re-operation in patients with TB fixation.     

Maximum urethral closure pressure in women: normative data and evaluation as a diagnostic test

Introduction and hypothesis

Our goal was to identify correlates of maximum urethral closure pressure (MUCP) and MUCP as a diagnostic test for stress urinary incontinence (SUI).

Methods

This study was a retrospective review of women with non-neurological referrals for urinary incontinence between1995 and 2006.

Results

We studied the characteristics of 8,644 women who underwent urodynamics for non-neurological referrals. Mean MUCP was 48?cm?H₂O in urodynamic stress incontinence (USI), 50?cm?H₂O in mixed urinary incontinence (MUI), 65?cm?H₂O in detrusor overactivity incontinence (DOI) and 67?cm?H₂O for continent women . Age and MUCP were negatively correlated in all groups. Multiple regression analysis showed lower levels of MUCP in women with USI who also had previous hysterectomy or anti-incontinence surgery or who were in an older age group. Previous anti-incontinence surgery and older age were risk factors for lower MUCP in women with MUI and DOI. Receiver operator curves did not show MUCP to have utility as a diagnostic test despite age and parity stratification. MUCP?<?20?cm?H₂O showed a sensitivity of 5?% and specificity of 98?% in diagnosing USI.

Conclusions

MUCP failed to meet the criteria for a diagnostic test. Women with USI and MUI have lower MUCP than women with DOI and continent women in each decade of life. MUCP decreases with age.