Thromboelastographic distinction of malignant from benign breast masses: a preliminary report

Thromboelastography is a newly applied tool for the detection of carcinoma. By comparing the thromboelastograph (TEG) of fresh whole blood (native) to that of blood to which celite has been added (celite activated), enhanced clotting is manifested which allows identification of individuals harboring carcinoma. Twenty women, obtained in a random sampling, entering the North Carolina Baptist Hospital for biopsy of breast masses were studied with routine clotting tests and TEGs preoperatively. TEG prediction of the biopsy result was correct in 16 of 20 patients (P less than 0.05). Thromboelastography may be a useful adjunct in screening for carcinoma in the evaluating persons with masses of unknown histology.     

Biopsy-negative malignant esophageal stricture: diagnosis by endoscopic ultrasound

Endoscopic ultrasound (EUS) of the esophagus has been used primarily in staging biopsy-proven cancers. Its use as a primary diagnostic modality for esophageal malignancy has not been previously described. We report our recent experience in four patients with dysphagia and endoscopic biopsies negative for malignancy, including one patient with clinical and manometric features suggestive of achalasia. In all cases, EUS revealed a large infiltrating tumor invading through the esophageal wall into the surrounding tissues, and in one case into the aorta. Computed tomography suggested the possibility of a tumor in only one of the cases. Two patients underwent esophagectomy and were found to have adenocarcinoma. Two patients underwent repeat biopsy with alternative aggressive biopsy techniques and were found to have squamous cell carcinoma. We conclude that EUS is useful in the diagnosis of esophageal cancer and should be performed in selected patients with esophageal strictures whose biopsies are negative for malignancy; i.e., those with suspicious endoscopic or radiographic appearance, atypical presentation (e.g., profound weight loss, short duration of symptoms, or advanced age), and failure to respond to treatment.     

Differentiation of benign from malignant nodules by accumulation of Tc-99m pertechnetate using TI-201 delayed scans

OBJECTIVE: To report the presence of an uncommon adverse effect, pain in the tumor location, during the administration of the cytostatic agent vinorelbine. METHOD: Twenty-seven patients with non operable relapses of epidermoid carcinomas of the head and neck were treated with two combinations of cytostatics: mitomycin-c 10 mg/m2 on day 1 plus vinorelbine 25 mg/m2 on days 1, 8 and 15 in twelve patients or carboplatin 300 mg/m2 on day 1 plus vinorelbine 25 mg/m2 on days 1, 8 and 15 in fifteen patients. RESULTS: Six patients had moderate/severe pain in the tumor location; concomitantly, one patient had chest pain. Four patients required major opiates. The clinical picture reverted and no patient had acute or chronic neurotoxicity. The readministration of vinorelbine triggered pain again, and all patients refused to continue the therapeutic program. CONCLUSION: Vinorelbine can cause pain at tumor location, a nonserious adverse effect which, nevertheless, prevented the continuation of therapy.     

Differentiation between benign and metastatic cervical lymph nodes with ultrasound

OBJECTIVE: The differentiation between benign and metastatic lymph nodes with ultrasound (US) is based primarily on the evaluation of size, shape, margin and internal echo structure. The aim of this study is to determine whether these parameters are reliable indicators and to correlate internal echo structure and histopathological findings. MATERIALS AND METHODS: Seventy-one nodes in 21 patients with pathologically proven oral squamous cell carcinoma were examined. The shortest diameter, the short/long diameter ratio (S/L ratio), margins and internal echo structure of the lymph node were evaluated by US. The internal echo structure was divided into six patterns: homogeneous hypoechoic, homogeneous hyperechoic, heterogeneous, eccentric hyperechoic, centric hyperechoic and anechoic pattern. In addition, internal echo structure was correlated with histopathological findings. RESULTS: In 71.4% of the metastatic nodes, the shortest diameter was more than 10 mm and the S/L ratio was higher than that of benign nodes (average 0.71). Eleven (84.6%) of the 13 lymph nodes with irregular margins were metastatic. Heterogeneous and anechoic patterns were observed in metastatic nodes, whereas homogeneous hypoechoic and eccentric hyperechoic patterns were present in benign nodes. On ultrasonography with the corresponding histopathological findings, echogenic areas in the homogeneous hyperechoic, heterogeneous and centric hyperechoic patterns of metastatic nodes proved to be necrosis or fibrosis. Eccentric hyperechoic areas in benign nodes corresponded to the hilus and surrounding fatty tissue. CONCLUSIONS: The shortest diameter, S/L ratio, margin and internal echo structure were considered to be critical indicators to differentiate between benign and metastatic nodes. Secondary changes caused by tumour infiltration, necrosis, or fibrosis should be assessed when metastatic lymph nodes are differentiated from benign ones by internal echo structure.     

Differentiation of benign and malignant cervical lymph nodes with color Doppler sonography

OBJECTIVE: This study proposed to evaluate the efficacy of color Doppler sonography in detecting possible differences in blood flow patterns between malignant and benign cervical lymph nodes. SUBJECTS AND METHODS: During a period of 12 months, the palpable cervical lymph nodes of 48 untreated patients were prospectively evaluated with color Doppler sonography and Doppler flow wave analysis. Histopathologic diagnoses were obtained by sonographically guided fine-needle aspiration biopsy and/or excisional biopsy. RESULTS: We found 16 benign lymph nodes (four were tuberculous lymphadenitis, four were reactive hyperplasia, and eight were unspecified) and 32 malignant lymph nodes (13 were squamous cell carcinomas, nine were adenocarcinomas, four were small-cell carcinomas, three were lymphomas, and three were miscellaneous). Color Doppler flow patterns were seen in six (38%) of the 16 benign lymph nodes and in 29 (91%) of the 32 malignant lymph nodes. Twenty-six (81%) of the 32 malignant lymph nodes had abnormal flow patterns, with resistance indexes less than 0.6. However, three (19%) of the 16 benign lymph nodes also had abnormal flow patterns, and only seven (54%) of 13 squamous cell carcinomas had abnormal flow patterns. CONCLUSION: Color Doppler sonography has limited clinical value in differentiating malignant from benign cervical lymph nodes and in obviating biopsy.     

Diagnostic features of chronic pancreatitis distal to benign and to malignant pancreatic duct obstruction

Differentiation between diffuse chronic pancreatitis and pancreatitis distal to a malignant or benign stenosis has important prognostic and therapeutic implications. We examined the retrograde pancreatograms of 64 patients with histologically confirmed diagnosis of diffuse chronic pancreatitis, chronic pancreatitis distal to a benign tumor and chronic pancreatitis distal to a malignant tumor. The nature of the stenosis was often difficult to determine from the shape of the pancreatic duct only. By using discriminant analysis it was possible to determine an allocation rule based on 8 criteria mainly derived from changes in the pancreatic ductuli. This allocation rule allowed the correct diagnosis to be made in 24 out of 26 patients with diffuse chronic pancreatitis (92%), 19 out of 20 patients with pancreatitis distal to a benign tumor (95%) and all 18 patients (100%) with pancreatitis distal to a malignancy.     

Differentiation of benign and malignant cervical lymph nodes: value of B-mode and color Doppler sonography

AIM: Acute mesenteric ischemia is difficult to diagnose and is combined with a high mortality. In a retrospective analysis it was investigated how to improve the poor prognosis of the disease. PATIENTS AND METHODS: Between January 1988 through December 1994 a total of 46 patients were operated on for acute mesenteric ischemia. Mesenteric artery occlusion was present in three quarters of the cases (n = 35). These were analysed according to symptoms, diagnosis, mechanism of occlusion, operative procedure and prognosis. Distribution of gender was almost balanced (19 women, 16 men) with a median age of 70.5 years. RESULTS: Embolic arterial occlusion was predominant (n = 22). Most frequently, the superior mesenteric artery was exclusively concerned (n = 22). Serum levels of lactate and leucocytes were preoperatively elevated in over 90% (median values: lactate 53 U/l, leucocytes 15050/ml). In 16 patients diagnosis was made on the ground of clinical parameters and/or angiography, but 19 patients were not diagnosed until operation. 19 patients were operated within 6 hours, 12 patients within 24 hours after admission (> 24 hours: n = 4). Vascular reconstructive procedures only, such as thrombectomy and/or aortomesenteric bypass were performed in 9 cases, in a further 7 cases combined with bowel resection. Bowel resection alone was done in 7 patients, 12 patients had only diagnostic laparotomy. 13 patients survived, 10 of them had been treated with vascular reconstruction. CONCLUSION: Acute mesenteric ischemia ought to be suspected in every patient with uncertain abdominal pain, because only early diagnosis can improve prognosis. Measurement of serum lactate is diagnostically helpful, although not proving. In case of elevated lactate levels and uncertain abdominal symptoms angiography of the mesenteric vessels should be performed early. At operation, blood flow in the mesenteric arteries should be restored whenever possible.     

Solitary thyroid nodules. Separating benign from malignant conditions

Although features found on history taking, physical examination, thyroid function tests, and imaging studies help categorize solitary thyroid nodules as benign or malignant, fine-needle aspiration biopsy is the diagnostic test of choice. Nodules found to be malignant on cytologic examination should be treated with surgery. Benign nodules may be followed clinically or treated with levothyroxine to suppress their growth. Intermediate nodules should be excised if there is clinical suspicion of malignancy. In suspect nodules, levothyroxine therapy with follow-up ultrasound assessment for size is appropriate. Nodules that do not shrink significantly within 6 months should be excised.     

Computer-derived nuclear features distinguish malignant from benign breast cytology

This article describes the use of computer-based analytical techniques to define nuclear size, shape, and texture features. These features are then used to distinguish between benign and malignant breast cytology. The benign and malignant cell samples used in this study were obtained by fine needle aspiration (FNA) from a consecutive series of 569 patients: 212 with cancer and 357 with fibrocystic breast masses. Regions of FNA preparations to be analyzed were converted by a video camera to computer files that were displayed on a computer monitor. Nuclei to be analyzed were roughly outlined by an operator using a mouse. Next, the computer generated a "snake" that precisely enclosed each designated nucleus. The computer calculated 10 features for each nucleus. The ability to correctly classify samples as benign or malignant on the basis of these features was determined by inductive machine learning and logistic regression. Cross-validation was used to test the validity of the predicted diagnosis. The logistic regression cross validated classification accuracy was 96.2% and the inductive machine learning cross-validated classification accuracy was 97.5%. Our computerized system provides a probability that a sample is malignant. Should this probability fall between 30% and 70%, the sample is considered "suspicious," in the same way a visually graded FNA may be termed suspicious. All of the 128 consecutive cases obtained since the introduction of this system were correctly diagnosed, but nine benign aspirates fell into the suspicious category.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnostic ultrasound in the evaluation of scrotal masses

Evaluation of 27 patients with scrotal masses was done with gray scale ultrasound. Given the clinical diagnosis ultrasound proved reliable in almost all cases.     

Preoperative differential diagnosis of benign and malignant pancreatic lesions--the value of pancreatic secretory trypsin inhibitor, procarboxypeptidase B, CA19-9 and CEA

BACKGROUND/AIMS: Pancreatic secretory trypsin inhibitor (PSTI). Procarboxypeptidase B (PCPB or Human pancreas-specific protein HPASP), CA19-9 and CEA were evaluated for their performance in preoperative differential diagnosis of benign and malignant pancreatic lesions. METHODOLOGY: Our prospective study included 92 patients with pancreatic lesions diagnosed by imaging techniques. In 45 of them (group I), the lesions turned out to be malignant tumors (35 pancreatic cancer, 10 other carcinoma of the pancreatic region); 47 patients (group II) had benign lesions (38 inflammatory disease of the pancreas, 9 other benign lesions). RESULTS: Statistical analysis showed significant differences between these two groups for PSTI, PCPB and CA19-9, but not for CEA. When only pancreatitis versus pancreatic cancer was analyzed, differences were more significant for PSTI and PCPB, but less significant for CA19-9. Because of a strong trend toward false positive values in patients with pancreatic inflammation, the specificity of CA19-9 in our selected patient group was only 67%, but in combination with normal PSTI (< 13.5 ng/ml), it reached 96%. CONCLUSION: In our study, PSTI and PCPB were useful markers for pancreatitis. PSTI also showed good correlation with the severity of the inflammation and provided additional preoperative information, in combination with CA19-9.     

Dissemination of pancreatic carcinoma following endoscopic sphincterotomy

Endoscopic sphincterotomy (ES) is sometimes advocated for the temporary decompression of an obstructed bile duct by a periampullary tumor. We report a 27-year-old woman with a small carcinoma of the pancreatic head who developed acute pancreatitis and a pseudocyst following ES. At operation, malignant spread was virtually confined to the walls of the resolving pseudocyst cavity. Despite radical resection, she died from recurrent carcinoma 7 months postoperatively.     

Comparison of benign and malignant follicular thyroid tumours by comparative genomic hybridization

DNA copy number changes were compared in 29 histologically benign follicular adenomas, of which five were atypical, and 13 follicular carcinomas of the thyroid by comparative genomic hybridization. DNA copy number changes were frequent in adenomas (14 out of 29, 48%). Most changes were gains, and they always involved a gain of the entire chromosome 7 (10 out of 29, 34%); other common gains involved chromosomes 5 (28%), 9 (10%), 12 (24%), 14 (21%), 17 (17%), 18 (14%) and X (17%). Losses were found only in four (14%) adenomas. Two of the five atypical adenomas had DNA copy number losses, and none had gains. Unlike adenomas, gains were rare and losses were frequent in carcinomas. A loss of chromosome 22 or 22q was particularly common in carcinomas (6 out of 13, 46%), whereas a loss of chromosome 22 was found in only two (7%) adenomas, one of which was atypical (P = 0.002). A loss of 1p was also frequent in carcinomas (31%), but gains of chromosomes 5, 7, 12, 14 or X that were common in adenomas were not found. Loss of chromosome 22 or 22q was present in six of the eight widely invasive follicular carcinomas, but in only one of the five minimally invasive carcinomas. We conclude that large DNA copy number changes are common in thyroid adenomas. These changes are strikingly different from those found in follicular carcinomas consisting of few losses and frequent gains, especially those of chromosome 7. A loss of chromosome 22 is common in widely invasive follicular carcinoma.     

Rapid development and spontaneous regression of pancreatic pseudocysts documented by ultrasound

Three cases of pancreatic pseudocyst were followed serially by ultrasound examination. The entity was found to be more dynamic than has been generally thought. The rapid development and spontaneous regression of pancreatic pseudocysts was documented. The timing of surgical intervention in these cases must be reevaluated.     

Clinical analysis of inflammatory masses of the pancreatic head region

BACKGROUND/AIMS: Inflammatory masses of the pancreatic head are a dilemma for surgeons, especially when the differences between these lesions and pancreatic head carcinoma are not so clear. The surgical management of these inflammatory benign lesions is also a topic with conflicting opinions. A clinical analysis was performed in an attempt to differentiate between these lesions and malignancy. The results of our observatory strategy of these lesions are also presented. METHODOLOGY: From 1992 to 1994, 73 patients with ultrasonographically (US) or computed tomographically (CT) heterogenous pancreatic head lesions were diagnosed at the Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan. Forty-nine of these lesions were neoplastic (Group I), but the remaining 24 patients had inflammatory non-neoplastic lesions (pancreatic inflammatory masses, IPM, Group II), which were diagnosed during laparotomy by core needle biopsy. Surgery and outcome were reviewed. Ten of the 24 patients in group II received biopsy only, and the remaining 14 patients received bypass procedures. At follow-up of at least 16 months of the surviving patients (n=21), only 9.5% were with residual lesions. All cases in group II revealed shrinkage of masses. We focused on the clinical features, hematology, biochemistry, image study, serum CEA and CA 19-9, and compared these variances between the 2 groups. RESULTS: Three clinical features were statistically different between groups I and II: mean age at presentation of disease (group I vs II = 53.3 vs 65.1), the tendency of a past history of alcoholism (Group II), and presence of abdominal pain (Group II). Group II also showed a higher level of serum alkaline phosphatase and a lower level of total bilirubin as well as a lower level of CA19-9. These inflammatory masses could not be distinguished from the true neoplasms pre-operatively on endoscopic appearance, US, or CT. CONCLUSIONS: Pre-operative differentiation between these pancreatic lesions may be difficult but laparotomy and core needle biopsy remain safe and reliable procedures. Our short-term follow-up justified the bypass surgery and that observatory strategy is enough for those patients with pancreatic head inflammatory masses.