Perineural spread of malignant melanoma of the head and neck: clinical and imaging features.
(17/1235)
BACKGROUND AND PURPOSE: Extension of malignant melanoma along cranial nerves is a little-known complication of malignant melanoma of the head and neck. We describe the clinical and MR imaging findings of perineural spread of malignant melanoma to cranial nerves, emphasizing that this entity occurs more commonly with desmoplastic histology and may have a long latent period following primary diagnosis. METHODS: At two institutions, we identified and retrospectively reviewed eight cases of malignant melanoma of the head and neck that had MR imaging evidence of perineural spread of disease. All patients underwent confirmatory tissue sampling. RESULTS: Seven patients had melanomas of the facial skin or lip, and one patient had a primary sinonasal lesion. By histopathology, these melanomas included five desmoplastic, two mucosal, and one poorly differentiated melanotic spindle-cell tumor. All patients developed symptomatic cranial neuropathy an average of 4.9 years from the time of initial diagnosis. MR imaging demonstrated postgadolinium enhancement of at least one branch of the trigeminal nerve in all cases and of at least one other cranial nerve in five cases. Other findings included abnormal contrast enhancement and soft tissue thickening in the cavernous sinus, Meckel's cave, and/or the cisternal segment of the trigeminal nerve. CONCLUSION: Although perineural spread of disease occurs most commonly with squamous cell carcinoma and adenoid cystic carcinoma, malignant melanoma must also be included in this differential diagnosis, particularly if the patient's pathology is known to be desmoplastic. Similarly, any patient with malignant melanoma of the head and neck who undergoes MR imaging should receive an imaging assessment focused on the likely routes of perineural spread. (+info)
Diagnosis of early chronic pancreatitis by endoscopic ultrasound. Are we there yet?
(18/1235)
The diagnosis of chronic pancreatitis at an early stage is a clinical challenge. A major limitation is the inability of clinicians to obtain a tissue or histological sample to confirm the clinical diagnosis. Currently available imaging modalities have limited sensitivity or specificity for diagnosing early chronic pancreatitis. Endoscopic ultrasonography (EUS), introduced in the early 1980's, was first developed to image the pancreas. It overcame many of the limitations (abdominal gas and fat) of transabdominal ultrasonography when evaluating patients for possible pancreatic diseases. To date, EUS represents the most promising imaging modality for diagnosing chronic pancreatitis. Contrary to endoscopic retrograde pancreatography (ERCP), EUS has a very low risk of complications and can detect abnormalities suggestive of chronic pancreatitis in the pancreatic parenchyma and ductal system which are not visible on any other imaging modality. The minimal changes in echotexture are difficult to interpret because there is no reliable gold standard confirmatory test. There is now some evidence in the literature suggesting that these early changes detected by EUS correlate with the histological changes of chronic pancreatitis and may predict progression to more advanced disease. The EUS diagnosis of chronic pancreatitis relies on quantitative (more than qualitative) parenchymal and ductal criteria found during evaluation of the pancreas. It is generally accepted that, in the absence of any criteria, chronic pancreatitis is unlikely, whereas in the presence of 5 or more criteria (out of 9-11) chronic pancreatitis is likely although ERCP and pancreatic function tests may still be normal. The diagnostic significance of patients with fewer (1-4) criteria found on EUS is currently unclear, particularly when other diagnostic tests such as ERCP and function testing are normal. In these cases, there is a potential for "over-diagnosis" of chronic pancreatitis, since the EUS changes cannot be confirmed by other modalities. How can we better understand the implications of EUS detected changes when other tests are normal? (+info)
Applications of endoscopic ultrasonography in pancreatic cancer.
(19/1235)
BACKGROUND: Accurate staging of pancreatic cancer is essential for surgical planning and for identification of locally advanced and metastatic disease that is incurable by surgery. Advances in endoscopic sonography (EUS), computed tomography (CT), and positron emission tomography have improved the accuracy of staging and reduced the number of incomplete surgical resections. Tissue acquisition is necessary in nonsurgical cases when chemoradiotherapy is considered. The complex regional anatomy of the pancreas makes cytologic diagnosis of malignancy at this region difficult without exploratory surgery. Although CT-guided fine-needle aspiration (FNA) is used for this purpose, reports of an increased risk of peritoneal dissemination of cancer cells and a false-negative rate of nearly 20% make this a poor choice. The ability to position the EUS-transducer in direct proximity to the pancreas by means of the stomach and duodenum, combined with the use of FNA, increases the specificity of EUS in detecting pancreatic malignancies. METHODS: The current literature regarding the accuracy of EUS with FNA in the evaluation of pancreatic cancer is reviewed. RESULTS: EUS accuracy ranges from 78% to 94% for tumor staging and from 64% to 82% for nodal staging. EUS also enables FNA of lesions that are too small to be identified by CT or MRI or too well encased by surrounding vascular structures to safely allow percutaneous biopsy. The accuracy for detecting invasion into the superior mesenteric artery and vein is lower than that for detecting portal or splenic vein invasion, especially for large tumors. EUS permits delivery of localized therapy such as celiac plexus neurolysis for pain control and direct intra-lesional injection of antitumor therapy. CONCLUSIONS: EUS in combination with FNA is a highly accurate method of preoperative staging of pancreatic cancer, especially those too small to be characterized by CT or MRI, and it has the ability to obtain cytological confirmation of pancreatic cancer. (+info)
Surgical management of early-stage pancreatic cancer.
(20/1235)
BACKGROUND: Pancreatic cancer remains a difficult disease to treat. Diagnosis at an early stage may allow curative treatment with resection. In the past, the mortality associated with surgical treatment of pancreatic carcinoma was prohibitive but mortality associated with resection is now commensurate with all other major oncologic resections. Thus, the focus of surgical management has shifted to address several issues: the diagnosis and evaluation of patients with suspected pancreatic cancer, the role of preoperative endobiliary stenting, the role of laparoscopy, the extent of resection, the role of adjuvant and neoadjuvant treatment, and the role of specialized centers in treating the disease. METHODS: The current literature is reviewed to address these issues and help guide physicians who first encounter patients with suspected pancreatic cancer as well as surgeons who ultimately resect them. Practical evidence-based information to guide the decision-making process is provided. RESULTS: Surgical morbidity and mortality have achieved parity with other types of major oncologic resection, and a distinct survival advantage is possible when such therapy is applied early in the disease stage. Issues regarding the use of stents, extent of resection, and pre- vs post-operative chemoradiation therapy are becoming clearer as our collective experience broadens. CONCLUSIONS: Surgical treatment of pancreatic cancer should be aggressively pursued given the clearly established survival advantage and relief of symptoms achieved when it is applied appropriately. (+info)
Cost-effectiveness of immediate specimen adequacy assessment of thyroid fine-needle aspirations.
(21/1235)
Pathologists and cytotechnologists often provide immediate specimen adequacy evaluation of thyroid fine-needle aspirations (FNAs) to ensure that diagnostic material is obtained. We assessed the cost-effectiveness of this practice. All patients who had a thyroid FNA specimen accessioned at the Beth Israel Deaconess Medical Center, Boston, MA, during a 6-month period were included and divided into 2 groups: (1) with or (2) without immediate adequacy assessment. Specimen adequacy from each group was compared. The time spent to perform the adequacy assessment was recorded. Compared with group 2, group 1 had more specimens with diagnostic cellular material (67.2% vs 47.0%) and fewer specimens with suboptimal (23.3% vs 38.1%) or nondiagnostic cellular material (9.5% vs 14.9%) (P = .002). At the time of adequacy assessment, 98% (60/61) of the adequate specimens were obtained with 3 or fewer passes. The improved rate of diagnostic material was achieved at a cost of 220 minutes of cytologists' time per additional diagnostic specimen compared with group 2. It may be most cost-effective to routinely obtain 3 passes and to perform immediate adequacy assessment under special circumstances such as repeated procedures. (+info)
Core needle biopsy of palpable breast lump: the influence of needle size.
(22/1235)
The diagnostic value of core needle biopsy is increasingly being preferred because of its better characterization of benign and malignant lesions and lower frequency of insufficient samples. The aim of this study was to determine the diagnostic accuracy and complication rates with 2 different gauges of core biopsy needle in the preoperative diagnosis of palpable breast lumps. A total of 150 consecutive core biopsies were included in this prospective non-randomised study of palpable breast lump from May 2000 to May 2001. The tissue diagnosis made from the core biopsy specimen was compared with the final histopathology reports from the excised specimen. However, if the lump is not excised, a presumptive diagnosis of benign lesion was made only after at least 6 months follow up with no change in the breast lump. The data were analysed for sensitivity, specificity, predictive values, diagnostic accuracy and complications. The results from the 2 different sizes of core needle biopsies were compared accordingly and a statistical analysis was performed using Chi-squared test. Ninety-six core specimens were acquired with 14 G needle while the other 54 with 16 G needle. There was no significant statistical difference between the accuracy of both needle sizes. However, 4 complications occurred with the larger size 14 G needle while none with the 16 G needle, but this was not statistically significant. In conclusion the size 16 G core biopsy needle provided an accurate diagnostic reliability that is comparable to the larger size 14 G needle in the preoperative diagnosis of palpable breast lump. (+info)
Sensitivity of noncommercial computer-aided detection system for mammographic breast cancer detection: pilot clinical trial.
(23/1235)
PURPOSE: To evaluate a noncommercial computer-aided detection (CAD) program for breast cancer detection with screening mammography. MATERIALS AND METHODS: A CAD program was developed for mammographic breast cancer detection. The program was applied to 2,389 patients' screening mammograms at two geographically remote academic institutions (institutions A and B). Thirteen radiologists who specialized in breast imaging participated in this pilot study. For each case, the individual radiologist performed a prospective Breast Imaging Reporting and Data System (BI-RADS) assessment after viewing of the screening mammogram. Subsequently, the radiologist was shown CAD results and rendered a second BI-RADS assessment by using knowledge of both mammographic appearance and CAD results. Outcome analysis of results of examination in patients recalled for a repeat examination, of biopsy, and of 1-year follow-up examination was recorded. Correct detection with CAD included a computer-generated mark indicating a possible malignancy on craniocaudal or mediolateral oblique views or both. RESULTS: Eleven (0.46%) of 2,389 patients had mammographically detected nonpalpable breast cancers. Ten (91%) of 11 (95% CI: 74%, 100%) cancers were correctly identified with CAD. Radiologist sensitivity without CAD was 91% (10 of 11; 95% CI: 74%, 100%). In 1,077 patients, follow-up findings were documented at 1 year. Five (0.46%) patients developed cancers, which were found on subsequent screening mammograms. The area where the cancers developed in two (40%) of these five patients was marked (true-positive finding) by the computer in the preceding year. Because of CAD results, a 9.7% increase in recall rate from 14.4% (344 of 2,389) to 15.8% (378 of 2,389) occurred. Radiologists' recall rate of study patients prior to use of CAD was 31% higher than the average rate for nonstudy cases (10.3%) during the same time period at institution A. CONCLUSION: Performance of the CAD program had a very high sensitivity of 91% (95% CI: 74%, 100%). (+info)
An interesting case of primary cutaneous actinomycosis.
(24/1235)
Actinomycosis is an infection commonly seen in tropical countries. It is characterized by chronic and progressive suppurative inflammation, typically presenting on the neck, thorax, and abdomen. Primary cutaneous actinomycosis is a rare entity, and the diagnosis requires a high index of clinical suspicion. Anaerobic cultures may be negative despite repeated attempts. Microscopic examination reveals the diagnosis in the majority of cases, and treatment requires administration of parenteral or oral penicillin for at least 6 weeks. We report a case of cutaneous actinomycosis affecting the arm. This patient was treated with phenoxymethylpenicillin. (+info)