Sciatic pain: a diagnostic pitfall

Neurological signs such as lower spinal cord lesions and/or femoral neuritis may be the presenting symptoms of a dissecting abdominal aortic aneurysm (AAA). We describe a patient in whom a severe sciatic pain was the presenting symptom of a non-dissecting AAA. The resection of the vascular mass resulted in dramatic relief of sciatic pain, thus indicating that the neurological impairment was caused by the non-dissecting aneurysm.     

Fine-needle aspiration cytology for diagnosis and management of palpable breast mass

BACKGROUND: The present study aims to clarify the use, in a developing country, of fine-needle aspiration cytology (FNA) instead of open biopsy as a cost-saving, reliable initial diagnostic and management tool for patients with breast mass. METHODS: A prospective study of 60 patients (71 breast masses) was carried out. The accuracy of physical diagnosis of the mass was compared with that obtained by FNA. The cytological results were analysed with the clinical profiles and pathological results. RESULTS: Physical examination was unreliable for the diagnosis of breast cyst (61.1% positive predictive value, 73.6% negative predictive value), which accounted for 35% of breast masses studied. Aspiration alone determined the diagnosis and management in 39% of masses. For solid breast masses benign cytological results (class I, II) were proved to be reliable (100% positive predictive value), as were malignant cytological results (class V; 100% positive predictive value). Inadequate cytology was reported for five masses (11.9%). CONCLUSIONS: Fine-needle aspiration should be routinely performed in all patients with breast masses. This would facilitate prompt diagnosis and treatment in one-third of patients with breast cyst, and the benign cytological result could facilitate definite management in the majority of patients with a low risk of malignancy. This could save cost, time and patient anxiety. For the patients with a high clinical suspicion of breast cancer, the positive cytological result could reliably confirm the diagnosis, while the equivocal result could be combined with mammography or open biopsy. Considering the ease, simplicity and low cost, FNA may be suitable for developing countries where other non-invasive procedures are unavailable or difficult to obtain, and it could replace open biopsy, which is still commonly done.     

Endobronchial fibroleiomyomatous hamartoma: a diagnostic pitfall

A 46 year-old man was found to have a polypoidal growth in the lumen of the right main bronchus. Fiberoptic bronchoscope-guided biopsy of the mass on two occasions showed acute-on-chronic inflammation. The origin of the polyp was the right upper lobe bronchus; and upper lobectomy with adequate resection margin was done. Histopathology examination of the polyp showed features compatible with benign fibroleiomyomatous hamartoma. True fibroleiomyomatous hamartoma arising primarily in the lung is rare and presents as a pulmonary parenchymal lesion. the endobronchial variant of this tumor is extremely uncommon and not well documented in the literature. A preoperative diagnosis is difficult, and a high index of suspicion is required for diagnosing this benign neoplasm.     

Epithelial misplacement in Peutz-Jeghers polyps. A diagnostic pitfall

Early difficulties with the interpretation of the histopathology caused overdiagnosis of cancer in the Peutz-Jeghers syndrome; and there is still controversy about the magnitude of risk of gastrointestinal carcinoma. Most workers now believe that there is a small but definite increase in the incidence of gastrointestinal carcinoma in Peutz-Jeghers polyps and most of these cancers occur in the upper gastrointestinal tract. In a review of 491 Peutz-Jeghers polyps in the records of St. Mark's Hospital Pathology department, misplacement of epithelium was found in approximately 10% of small intestinal polyps and closely mimicked adenocarcinoma. This "pseudoinvasion" was not observed in polyps of the stomach or colon. The epithelial misplacement may involve all layers of the bowel wall; and the most helpful histological discriminators include a lack of cytological atypia, the presence of the normal epithelial cell subtypes and a brush border, hemosiderin deposition, and intramural mucinous cysts. Epithelial misplacement may account for the overdiagnosis of carcinoma arising in Peutz-Jeghers polyps as reported in the literature.     

Analysis of residual cancer after diagnostic breast biopsy: An argument for fine-needle aspiration cytology

Background: Diagnostic breast biopsy (DxBx) requires an effective strategy for strategy for successful treatment of breast cancer by lumpectomy or mastectomy. Clearance of margins is required to achieve local control. Methods: We reviewed 844 malignant diagnostic biopsies. The strategy was to perform DxBx on all nonpalpable lesions and fine-needle aspiration (FNA) on all palpable lesions. When FNA was equivocal, DxBx was performed. After positive DxBx, either the biopsy cavity or FNA-positive breast mass was excised, and margins were documented with touch preparation cytology analysis (TPC) and frozen section (FS) as necessary to achieve negative margins. Results: Ourside institutions referred 430 excisional biopsies. Two hundred twenty-five (52.3%) were found to have residual cancer at surgical excision. Our institution performed 414 biopsies: 169 were performed on nonpalpable lesions in which 58% had residual tumor at resection; 245 were diagnosed by FNA of palpable lesions. Residual disease was found in 12 (5%). Conclusions: Of patients who undergo DxBx, >50% have residual breast cancer. It is recommended that (a) FNA be performed on all palpable masses or DxBx of nonpalpable masses; when cancer is diagnosed, proceed to surgical excision. (b) When lumpectomy is the option, margins should be reexcised and intraoperatively evaluated with TPC and FS at the time of axillary dissection.     

Hepatic 'pseudotumours': an important diagnostic pitfall.

Hepatic 'pseudotumours' are radiological abnormalities which give the appearance of tumour. They may be focal areas of disease such as fatty infiltration or areas of focal sparing in diffuse processes. We present four cases of hepatic 'pseudotumours' due to diffuse fatty infiltration with focal sparing and emphasise the need for further radiological assessment of focal lesions found on ultrasound scanning. Measurement of CT attenuation allows a confident diagnosis of fatty infiltration with focal sparing, thus preventing unnecessary investigation. Other forms of hepatic pseudotumour may require further investigation.