Progressive histopathologic abnormalities in the persistent generalized lymphadenopathy syndrome

Using a quantitative classification, we evaluated serial lymph node biopsies in 20 homosexual men with Persistent Generalized Lymphadenopathy (PGL), and correlated the results with peripheral blood lymphocyte counts and clinical findings. In a median follow-up interval of 19 months, ten patients (50%) had progression from one histologic subtype of this disorder to another. Lymph nodes from the other 10 patients also demonstrated decreased numbers of organized follicles in the most recent specimens, in addition to progressive abnormalities of other histologic parameters and peripheral blood T4 counts. This suggests that these patients do not have stable disease. However, in a median follow-up interval of 19 months, only one (5%) of the patients had developed AIDS. We conclude that progressive lymph node histopathologic subtypes do not correlate well with decreased T4 lymphocyte counts or clinical course over a short time interval.     

超声造影引导浅表淋巴结穿刺活检的应用

目的评价CEUS引导浅表淋巴结穿刺活检的应用价值。方法将157例因淋巴结肿大拟行穿刺活检患者分成造影组（81例）和对照组（76例）。比较两组穿刺取材的满意率及病理诊断准确率。结果造影组获取满意的穿刺标本289条,对照组获取233条;造影组标本满意率高于对照组（98.30%vs 87.27%,P〈0.001）,造影组病理诊断准确率高于对照组（97.53%vs 88.16%,P〈0.05）。结论 CEUS有助于在活检前发现病理标本,提高穿刺病理诊断准确率。     

Prostate adenocarcinoma manifesting as generalized lymphadenopathy

Generalized lymphadenopathy is a rare manifestation of metastatic prostate cancer. Here, we report the case of a 65-year-old patient with supraclavicular, mediastinal, hilar, and retroperitoneal lymphadenopathy and pulmonary infiltration, which suggested the diagnosis of lymphoma. There were no urinary symptoms, and the serum prostate-specific antigen (PSA) was only mildly increased with a normal free PSA. A biopsy of the supraclavicular lymph node was compatible with adenocarcinoma, whose prostatic origin was shown by immunohistochemical staining with PSA. The origin of the primary tumor was confirmed by directed prostate biopsy. We emphasize that a suspicion of prostate cancer in men with adenocarcinoma of undetermined origin is important for an adequate diagnostic and therapeutic approach.     

Fine needle aspiration biopsy of tuberculous cervical lymphadenopathy

Fine needle aspiration biopsies of 42 histologically confirmed tuberculous cervical lesions were studied. Thirty-four patients had subsequent excision of cervical lymph nodes and eight had incision and drainage of cervical abscesses. All aspirates except two (which were inadequate) were satisfactory for diagnosis and contained inflammatory cells. Twenty-seven smears revealed cells typical of granulomatous lymphadenopathy, that is, epithelioid and multinucleated giant cells. Of all aspirates, 17 smears had bacteriological staining by Ziehl-Nielsen technique, nine of which (53%) were positive for acid-fast bacilli. An aspiration biopsy diagnosis of granulomatous or tuberculous cervical lymphadenopathy was made in 30 patients (71%). In regions where mycobacterial infection is common, the presence of granulomatous changes in lymph node aspirates is highly suggestive of tuberculosis. When the aspirates contain purulent material or when tuberculosis is suspected, staining and culture for mycobacteria should be performed. FNA biopsy is a sensitive, specific and cost-effective way to diagnose tuberculous cervical lymphadenopathy and is recommended.     

Surgical biopsy in lymphoma

The term 'lymphoma' describes malignant lymphoproliferative diseases that originate from B- and T-cells in the lymphatic system. The majority of lymphomas arise from lymph nodes, while some may originate in extranodal sites. Lymphoma is a common cancer, affecting approximately 4000 people in Australia per year, and constituting 4% of newly diagnosed cancers. Lymphoma is primarily a disease of adults, and is the sixth most common cancer in men, after prostate, colorectal, lung, melanoma and bladder, and the fifth most common cancer in women, after breast, colorectal, melanoma and lung.     

Role of laparoscopic biopsy in the management of intra-abdominal lymphadenopathy

Intra- or retroperitoneal lymphadenopathy is often a diagnostic challenge Surgical radiology techniques, such as fine needle aspiration and core needle biopsy, are useful but frequently inadequate and sometimes difficult and dangerous to perform. Deep abdominal lymph node sampling can be done laparoscopically, avoiding the risks of a large laparotomy. The objective of this study was to assess the safety, efficacy and diagnostic accuracy of laparoscopic biopsy, when compared with historic needle biopsy studies reported in the literature. From January 1999 to June 2001, 19 laparoscopic biopsies were performed for 18 patients with intra- or retroperitoneal lymphadenopathy. Clinical and technical characteristics and histopathological findings for each laparoscopic biopsy performed were analysed retrospectively. In 15 patients the biopsy was performed in order to achieve the diagnosis. In the other 4 cases laparoscopic biopsy was required to confirm a relapse or the evolution of a lymphoma during treatment or follow-up. The conversion rate was nil. There were no major complications. None of the patients died postoperatively. The average hospital stay was 2.4 days (range: 1-6 days). In 94% of the cases, the laparoscopic biopsy supplied the necessary information for the correct diagnosis and consequent therapeutic decisions. These results confirm that laparoscopic biopsy is safe and effective. This procedure has a higher diagnostic yield than the percutaneous techniques and should be proposed as the gold standard biopsy approach in all cases of deep abdominal lymphadenopathy.     

Percutaneous CT-guided lung biopsy for the diagnosis of persistent pulmonary consolidation

PurposeThe primary objective of this study was to determine the diagnostic accuracy of percutaneous computed tomography (CT)-guided biopsy of persistent pulmonary consolidations. The secondary objective was to determine the complication rate and identify factors affecting diagnostic yield.Materials and methodsTwo radiologists retrospectively reviewed 98 percutaneous CT-guided biopsies performed in 93 patients (60 men, 33 women; mean age, 62 ± 14.0 (SD) years; range: 18–88 years) with persistent pulmonary consolidations. Final diagnoses were based on surgical outcomes or 12 months clinical follow-up findings. Biopsy results were compared to the final diagnosis to estimate diagnostic yield.ResultsA final diagnosis was obtained for all patients: 51/93 (54.8%) had malignant lesions, 12/93 (12.9%) specific definite benign lesions (including 9 infections, two pneumoconiosis and one lipoid pneumonia) and 30/93 (32.3%) non-specific benign lesions. CT-guided biopsy had an overall diagnostic yield of 60% (59/98) with a correct diagnosis for 50/51 malignant lesions (diagnostic yield of 98% for malignancy) and for 9/47 benign lesions (diagnostic yield of 19% for benign conditions). Major complications occurred in 4/98 (4%) of lung biopsies (four pneumothoraxes requiring chest tube placement).ConclusionPercutaneous CT-guided biopsy is an alternative to endoscopic or surgical biopsy for the diagnosis of persistent consolidation with a low risk of severe complication.     

Surgical complications of pancreatectomy for persistent hyperinsulinaemic hypoglycaemia of infancy

Purpose: The aim of this study was to review the surgical complications of pancreatectomy for persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI). Methods: A retrospective review was conducted of patients undergoing pancreatectomy for PHHI in one institution over the past 13 years. Results: The records of 48 patients were reviewed; the age at operation ranged from 10 days to 30 months (median, 8 weeks). Weight at operation ranged from 1.97 to 11.4 kg (median, 5.2 kg). There were no deaths. Intraoperative complications comprised bleeding in 7, (major in 2), splenic injury in one, bile duct injury in 2 (1 oversewn, 1 choledochoduodenostomy), and 1 small bowel injury. Postoperatively, 5 children underwent choledochoduodenostomy: 2 for biliary leak and 3 for delayed bile duct stricture. Other postoperative complications included wound infection (n = 3), prolonged ileus (n = 1) and adhesion obstruction (n = 1), and wound leakage (n = 1). Renal failure developed in one child owing to acute tubular necrosis. Nine patients required further pancreatic resection because of continued hypoglycaemia. Three patients continued to require medication for hyperinsulinism despite surgery, 20 required insulin, and 13 required pancreatic enzyme replacement at the time of the last review. Conclusions: Pancreatectomy resulted in resolution of hyperinsulinism in 45 of 48 patients. Sixteen patients required no further surgery or medication. Pancreatectomy for PHHI may be associated with major intra and postoperative morbidity. J Pediatr Surg 38:13-16.     

Surgical margins after needle-localization breast biopsy

: The use of needle-localization breast biopsy (NLBB) for the early diagnosis of breast cancer is common. The therapeutic adequacy of tumor-free margins following NLBB is unknown. We hypothesized that the presence of residual tumor after reexcision (mastectomy, tylectomy, or quadrantectomy) does not depend on the margin status following NLBB. : Retrospective cohort analysis was performed on 890 consecutive NLBBs executed between January 1990 and June 1994. Patients with invasive breast neoplasia were divided into two groups based on the tumor margins after NLBB. Group 1 were the women with positive margins, and group 2 had negative margins. Breast specimens after reexcision were reviewed for evidence of residual invasive carcinoma. : Invasive neoplasia was present in 107 patients (12%). Surgical margins and definitive records of care were avaliable for 96 of them (90%). All 45 patients in group 1 and 38 (75%) of 51 patients in group 2 underwent reexcision of the initial biopsy site (P = 0.36). Residual invasive carcinoma was present in 10 patients (22%) in group 1 and 3 (8%) in group 2 (P = 0.13). : Invasive breast neoplasia diagnosed by NLBB requires reexcision regardless of tumor margins to achieve complete local surgical eradication of tumor.     

Surgical treatment of persistent elbow epicondylitis.

From 1978 through 1987, 86 patients with epicondylitis were admitted for surgery after failed conservative treatment. The Wilhelm technique was performed either alone or in combination with an intraarticular procedure. The Wilhelm technique involves denervation of the epicondyle. The intraarticular procedure described by Bosworth or Boyd involves a one-third resection of the orbicular ligament and resection of a synovial fold. Before surgery a local anesthetic was injected at the sore spot of the epicondyle. After almost complete pain relief after injection, a sole Wilhelm procedure was performed at the lateral epicondyle in 34 patients and at the medial epicondyle in 17 patients. For 27 patients in whom the pain persisted after the injection, a combined Wilhelm and intraarticular procedure using the Bosworth or Boyd method was used. Degeneration of the orbicular ligament or a redundant synovial fold was reported in 77% of the intraarticular operation reports. At a follow-up examination, a minimum of two years and an average of four years nine months after surgery, 85% had good and excellent results after lateral and medial Wilhelm and 56% after combined surgeries while the poor results were 3% and 7% respectively. The results of combined surgery worsened from discharge to follow-up examination, and they show fewer good results than those where a sole Wilhelm procedure was performed. Therefore, intraarticular surgery should be considered for patients with incomplete pain relief after a test injection, but it should not routinely be performed.     

The role of fine-needle aspiration cytology in children with persistent or suspicious lymphadenopathy

PURPOSE: The aim of this study was (1) To determine the value of fine-needle aspiration cytology (FNAC) in children with persistent or suspicious peripheral lymphadenopathy and (2) to analyze whether a history of previous malignancy influenced the accuracy of FNAC. METHODS: A retrospective study in an Academic Children's Hospital of 73 FNACs of peripheral lymph nodes in 64 patients (35 boys and 29 girls; median age, 9 years; range, 15 months to 20 years) was performed between 1992 and 1997. Eleven patients were excluded because aspirated material appeared inadequate. Outcome was compared with results of subsequent surgical biopsies, clinical follow-up, or both. Patients were divided into group A "de novo" lymphadenopathy (n = 39) and group B lymphadenopathy and a history of previous malignancy (n = 23). RESULTS: Group A: FNAC showed a benign diagnosis in 25 cases, a malignancy in 13, and was inconclusive in 1. Outcome was false-negative in 2 and false-positive in 1. Sensitivity and specificity were 86% and 96%, respectively. FNAC helped avoid additional surgical procedures in 27 cases (61%). However, if FNAC showed malignant lymphoma, open biopsy was inevitable (8 of 13) to establish proper classification. Group B: FNAC showed a benign diagnosis in 10 cases and a malignancy in 13. Outcome was false-negative in 1, and false-positive in 1. Sensitivity and specificity were 92% and 90%, respectively. FNAC helped avoid additional surgical diagnostic procedures in 25 cases (86%). CONCLUSIONS: (1) Fine-needle aspiration cytology is a rapid, simple and accurate diagnostic procedure to differentiate between benign and malignant peripheral lymphadenopathy in children. FNAC can avoid open biopsy in at least 60% of cases. (2) A history of previous malignant disease does not influence the accuracy of the test.     

Surgical indications in persistent atelectasis in early childhood

Between 1980 and 1989 46 lung resections were performed in 45 children (0-9 years of age) for recurrent or persistent "atelectasis". Indications for surgery were intralobar sequestration (6), bronchial malformations and stenoses (7), chronic pneumonia following infection or aspiration (11), bronchiectases (4), pyocele associated with pulmonary artery ligation (1), upper lobe torsion (1), compression by cysts (6) or lobar emphysema (10). Overall mortality: 4/45 (2 of them within 4 weeks postoperatively) secondary to long-term artificial ventilation and associated or intercurrent disturbances.     

Surgical management of persistent post-traumatic trans-tentorial brain hernia

IntroductionTemporal engagement may persist after etiologic surgical treatment of acute subdural hematoma (ASH) without clinical improvement despite normalized intracranial pressure (ICP). The aim of this study was to assess the feasibility of secondary direct temporal lobe disengagement (DTLD) after surgery for supratentorial ASH and to evaluate clinical outcome.Materials and methodsThis was a retrospective analysis of 4 patients undergoing secondary DTLD. Patient data were recorded at admission, pre- and postoperatively and at 6 months’ follow-up (FU): age, gender, Rotterdam score, Glasgow Coma Scale (GCS), neurological deficits, oculomotor nerve palsy (ONP), ICP, midline shift, complications and Extended Glasgow Outcome Scale (GOS-E).ResultsAt postoperative evaluation 48 h after DTLD, we observed a significant improvement in GCS score (initial 6 ± 3, preoperative 7 ± 3, postoperative 14 ± 1; P = 0.02), midline shift (initial 16 ± 3 mm, preoperative 13 ± 5 mm, postoperative 9 ± 2 mm; P = 0.049) and ONP (P = 0.01). In all cases, early postoperative imaging documented visualization of a patent ipsilateral peri-mesencephalic cistern. At 6-month FU, GOS-E showed 75% good recovery and 25% disability. Complete ONP recovery was observed in 75% of patients (P = 0.01). Neurological deficits were present at FU in 25% of patients. No surgery-related complications or mortality were recorded.ConclusionsIn traumatic brain injury, secondary DTLD may allow simple, effective and safe management of trans-tentorial uncal herniation, avoiding more challenging procedures. Clinical results are promising, as this technique seems to favorably influence neurological outcome in this selected subgroup of patients with persistent clinical and radiological signs of temporal engagement after etiological treatment with normal ICP values.