A feasibility study of using a high-definition intra-operative exoscope in teaching septorhinoplasty

OBJECTIVE

This pilot study aimed to assess the feasibility of using a high-definition intra-operative exoscope in teaching septorhinoplasty.

METHODS

The exoscope was used in septorhinoplasty cases with different trainers and trainees. A high-definition screen displayed real-time, magnified images. Post-procedure, a questionnaire was completed by trainer and trainees, assessing the feasibility, safety and content validity of the exoscope as a septorhinoplasty training tool.

RESULTS

Trainees and trainers assigned favourable ratings to all aspects of the exoscope as a training tool, particularly with regard to teaching anatomy and improving visualisation.

CONCLUSION

The exoscope is a potentially effective training tool in septorhinoplasty, and is especially useful in improving visualisation, without restricting the operator. Annotatable intra-operative photographs and videos allow trainees to study cases outside of the operating theatre environment. The use of an exoscope for septorhinoplasty in the UK may facilitate increased hands-on involvement earlier in training than is currently typical.

Novel CD44-downstream signaling pathways mediating breast tumor invasion

CD44, also known as homing cell adhesion molecule is a multi-structural cell molecule involved in cell-cell and cell-extracellular matrix communications. CD44 regulates a number of central signaling pathways, including PI3K/AKT, Rho GTPases and the Ras-MAPK pathways, but also acts as a growth/arrest sensor, and inhibitor of angiogenesis and invasion, in response to signals from the microenvironment. The function of CD44 has been very controversial since it acts as both, a suppressor and a promoter of tumor growth and progression. To address this discrepancy, we have previously established CD44-inducible system both in vitro and in vivo. Next, using microarray analysis, we have identified and validated Survivin, Cortactin and TGF-β2 as novel CD44-downstream target genes, and characterized their signaling pathways underpinning CD44-promoted breast cancer (BC) cell invasion. This report aims to update the literature by adding and discussing the impact of these novel three signaling pathways to better understand the CD44-signaling pathways involved in BC tumor cell invasion.

Optimising outcomes in the management of spontaneous cerebrospinal fluid rhinorrhoea

BACKGROUND

To describe our experience of the management of spontaneous cerebrospinal fluid (CSF) rhinorrhoea in a large case series focusing on surgical approach, peri-operative management and outcomes; to evaluate the efficacy of endoscopic CSF leak repairs.

METHODOLOGY

Retrospective chart review was performed for all patients with spontaneous CSF rhinorrhoea managed from 2003 to 2011 at a tertiary referral centre. Data regarding demographics, presentation, site of leak, peri-operative management, surgical approach, body mass index (BMI), follow up and success rates was collated.

RESULTS

Thirty-six patients were identified: 9 male and 27 female with a mean age of 50.4 years. Eight patients had previous failed repairs in other units. Success rate after first surgery was 89 % and after second surgery was 100 %. Four patients had recurrences, 3 underwent successful revisions and the fourth had complete cessation of the leak after gastric bypass surgery and weight reduction. All failures were before 2004 prior to instigation of an anatomic three-layered repair with no further failures in the following 7 years. Mean follow up was 21.5 months. Mean body mass index was 34.0 kg/m2. Fifty percent of spontaneous leaks were from the cribriform plate, 22 % sphenoid, 14 % ethmoid and 14 % frontal sinus.

CONCLUSION

Endoscopic CSF fistula closure has become the gold standard of care. In order to optimise the outcome, we recommend a multidisciplinary approach to manage the associated idiopathic intracranial hypertension and an anatomic three-layered closure technique for recalcitrant cases.

The menthol and cold sensation receptor TRPM8 in normal human nasal mucosa and rhinitis

BACKGROUND

Menthol and cold sensation trigger symptoms and reflex responses in the upper airway, but the underlying molecular mechanisms are unknown. We have therefore studied nerve fibres expressing the menthol and cold receptor TRPM8 in normal human mucosa, and in rhinitis. TRPM8 nerve fibres were compared with those expressing other TRP receptors including TRPV1 (capsaicin and heat receptor), and TRPA1 (mechano-cold receptor).

METHODS

Immunohistology and image-analysis were used to study TRP receptors in biopsies of nasal turbinate from control subjects, patients with allergic rhinitis, and non-allergic rhinitis.

RESULTS

TRPM8-immunoreactive nerve fibres were observed in the sub-epithelium, and were profuse around blood vessels in deeper regions, where they were markedly greater in number than TRPV1+ fibers. Image analysis of TRPM8 in sub-epithelial and vascular regions showed no significant differences between control and the rhinitis patient groups. TRPA1-immunoreactivity was weak and seen rarely in nerve fibres.

CONCLUSION

We show that TRPM8 nerve fibres are abundant in nasal mucosa particularly around blood vessels, and may mediate neurovascular reflexes. TRPM8 antagonists deserve consideration for therapeutic trial in rhinitis.

Estimating the effect of nasal steroid treatment on repeat polypectomies: survival time analysis using the General Practice Research Database

BACKGROUND

Intranasal steroids are effective in preventing or delaying recurrence of nasal polyps. However, their effectiveness in delaying a need for repeat polypectomy in clinical practice is unknown.

OBJECTIVES

To compare time to a repeat polypectomy between post-polypectomy intranasal steroid users and non-users. METHODOLOGY/PRINCIPLE: Our cohort consisted of patients in GPRD who had undergone at least one nasal polypectomy procedure in or after the year 2000. These patients were followed for up to 4 years and the time to next polypectomy was estimated. Cox`s proportional hazards regression was used to estimate the effect of post polypectomy intranasal steroid treatment on time to the next polypectomy after controlling for other respiratory conditions and their treatment.

RESULTS

The cohort consisted of 1,675 patients with a mean age of 59 years and 68% males. Of these, 576 patients were post-polypectomy steroid users and 1,099 patients were steroid non-users. The median time to repeat polypectomy was 812 days among the steroid users and 736 days among steroid non-users. Significantly less proportion of intranasal steroid users experienced a repeat polypectomy compared to steroid non-users. This difference was consistent among subgroups of females and concomitant rhinitis treatments users. Patients with post polypectomy intranasal steroid use showed lower risk for a repeat polypectomy compared to steroid non-users. Concomitant rhinitis medication users showed a higher risk whereas other confounders were not significant.

CONCLUSIONS

Intranasal steroids were effective in delaying a repeat polypectomy. However, further research using a prospective design is necessary to quantify the benefit of ongoing steroid treatment.

Image guidance removal of a foreign body in the orbital apex

Retrieval of foreign bodies lodged in the orbit present a challenging surgical problem. The trans-nasal approach when combined with image-guided navigation allows clear identification of structures and increased safety. We report a case of a successful removal of a foreign body under image-guidance using a trans-nasal approach.

Endonasal endoscopic approach to the petrous apex: an image-guided quantitative anatomical study

BACKGROUND

The petrous apex is a relatively inaccessible region, deeply situated within the skull base. Removal of lesions from this area, traditionally accomplished via lateral approaches, can cause significant morbidity. We undertook an anatomical study to investigate the surgical anatomy of the petrous apex through an endonasal endoscopic approach, which has been sporadically described in the literature, to investigate its feasibility and to characterise clear and consistent surgical landmarks for access.

METHODS

Cadaveric dissections were performed on five heads. Pre-dissection computed tomography scans were used, with the BrainLab navigation system, to verify entry into the petrous apex. Surgical landmarks were characterised in relation to fixed sphenoid sinus structures, and surgical access before and after drilling the sphenoid sinus rostrum was quantitatively compared.

RESULTS

The landmark for entry into the petrous apex was the intersection of a vertical line halfway between the medial surface of the internal carotid artery and the midline, with a horizontal line one-third of the way up from the postero-inferior floor of the sphenoid sinus. The dimensions of the postero-superior sphenoid sinus were characterised by the inter-carotid distance, pituitary-to-sphenoid-floor distance and the width of the sphenoid sinus floor, which were 15 +/- 3 mm, 16 +/- 3 mm and 26 +/- 1.6 mm respectively. The surface area of surgical access was 193 +/- 28 mm(2), increasing to 316 +/- 39 mm(2) after drilling of the sphenoid rostrum (P < 0.001; paired t-test).

CONCLUSIONS

Endoscopic approach to the petrous apex is anatomically feasible, and, aided by image navigation, could extend the scope of endonasal surgery to access highly-selected lesions in the middle cranial fossa.

Fine needle aspiration cytology of lung lesions: a clinicopathological and cytopathological review of 150 cases with emphasis on the relation between the number of passes and the incidence of pneumothorax

OBJECTIVE

The aim of this study was to review the lung fine needle aspirations (FNA) that were done in our hospital between January 1998 and April 2004. Interobserver agreement, sample adequacy and the relation between the number of passes and the occurrence of pneumothorax are presented.

STUDY DESIGN

One hundred fifty cases of lung FNA from the department of pathology files were identified and the available specimens and patient charts were reviewed. The interobserver agreement was calculated. The relation between the number of passes and the subsequent development of pneumothorax was tested using Mann-Whitney U-test.

RESULTS

The material of 132 patients (88%) out of 150 were retrieved and reviewed. There were 85 cases of non-small cell lung cancer (NSCLC) (64.4%), nine cases of small cell lung cancer (6.8%), five cases of metastatic cancer (3.8%) and 33 cases were reported negative for cancer (25%). The NSCLC included 36 cases of adenocarcinoma (27.3%), 32 cases of squamous cell carcinoma (24.2%), and 17 cases of large cell undifferentiated carcinoma (12.9%). The interobserver agreement k was 0.93, (95% CI 0.87-0.98). The majority of cases (95.5%) were considered adequate for interpretation. The charts of 138 patients (92%) were reviewed for postprocedure radiologically confirmed pneumothorax. Sixteen patients (11.6%) developed pneumothorax only three of whom (2%) required a chest tube for treatment. The number of passes was identified in 118 patients (85.5%). The number of passes did not have a statistically significant association with the development of a pneumothorax (P = 0.747).

CONCLUSION

Fine needle aspirations to diagnose lung lesions is a safe procedure with a low incidence of pneumothorax. Its findings are reproducible with high interobserver agreement. Immediate adequacy evaluation and triage by a pathologist guarantees adequate sample in most instances. The number of passes was not associated with an increased incidence of pneumothorax.

Differential expression of HER-2/NEU receptor of invasive mammary carcinoma between Caucasian and African American patients in the Detroit metropolitan area. Correlation with overall survival and other prognostic factors

GOALS

HER-2/neu overexpression in invasive mammary carcinoma is associated with more aggressive biologic behavior. Breast cancer in African American (AA) women has been associated with a shorter survival rate than that seen in Caucasians (C). This study evaluated the frequency of HER-2/neu overexpression in C compared to AA patients and the association of HER-2/neu expression with overall survival and other prognostic factors.

METHODS

A retrospective review of the SEER data of Karmanos Cancer Institute for patients with invasive mammary carcinoma was conducted between 1998 and 2001. Pathology reports and pathology slides were obtained for those patients with missing data. Available data and material on 608 patients were found. The median follow-up interval was 35 months with a range of 1-91 months. 46.7% of the study population was C while 53.3% was AA. The differential of HER-2/neu expression in C and AA was evaluated. The association of HER-2/neu expression and other prognostic factors with overall survival was carried out by univariate and multivariable analyses using Cox's proportional hazards regression model.

PRINCIPLE RESULTS

No statistically significant difference was found in HER-2/neu expression between C and AA patients. Overexpression of HER-2/neu did not correlate with decreased overall survival in this analysis.

MAJOR CONCLUSIONS

Breast cancer HER-2/neu expression in AA patients is not statistically different from that of Caucasians. HER-2/neu expression is not associated with overall survival. Among the other prognostic factors analyzed, ER status and histologic grade were not statistically significant.

A new combined approach to the nasopharynx in head and neck plastic surgery: technique and application

This article presents a combined approach to the nasopharynx, which has not been previously described. The technique is applicable to cases of recurrent nasopharyngeal carcinoma which exhibit lateral extension. We describe the technique and report a case in which it was used. A review is presented of all other techniques currently described. The authors would not advocate the use of a combined approach to the nasopharynx in all cases, but there certainly appears to be a place for this technique.

Nasal nitric oxide in objective evaluation of chronic rhinosinusitis therapy

BACKGROUND

The assessment of the response of chronic rhinosinusitis (CRS) to therapy is difficult. Computerized tomographic (CT) scans cannot be repeatedly used so measures such as symptom scores, endoscopic findings, and parallel measures such as saccharin clearance time are employed instead.

OBJECTIVE

To study the effect of CRS therapy on nasal nitric oxide and to see whether nasal nitric oxide level changes correlate with other assessments.

METHODS

The study was a prospective randomized trial of patients with CRS, with or without polyps, who had failed initial medical therapy with douching and nasal corticosteroids and who then had abnormal CT scans. They were treated either medically or surgically, with follow up at 6 and 12 months whilst still taking nasal corticosteroids. Nasal nitric oxide was measured initially and at 6 and 12 months as well as symptom scores, endoscopy, polyp grading, and saccharin clearance time.

RESULTS

Initial absolute nasal nitric oxide levels correlated inversely with CT scan changes, (P<0.001). The percentage rise in nasal nitric oxide seen on both medical and surgical treatment correlated with changes in symptom scores (P<0.001), saccharin clearance time (P<0.001), endoscopic changes (P<0.001), polyp grades (P<0.05 at 6 months, P<0.01 at 12 months) and surgical scores (P<0.01). There was no significant correlation with age, sex, smoking or allergy.

CONCLUSION

Nasal nitric oxide, which is easily measured, provides a valuable non-invasive objective measure of the response of CRS to therapy. Topical nasal corticosteroids may be needed to reduce the contribution of nasal epithelial nitric oxide and allow that emanating from the sinuses to be measured.

Prostatic metastases in the nose and paranasal sinuses

Prostatic metastases in the nose and paranasal sinuses are rare. Seven cases have previously been reported in the world literature. We describe the clinical presentation of a patient with prostatic metastases and the use of prostate specific antigen in confirming the diagnosis. We also review the literature about metastases involving the nose and paranasal sinuses.

Ball valve nasal obstruction following incomplete inferior turbinectomy

An interesting case is presented of a 53-year-old male who was seen with a 10-year history of intermittent, unilateral nasal obstruction following a bilateral total inferior turbinectomy. A pedunculated mass was seen in the right posterior nasal space acting as a ball valve. This was removed and found to be residual turbinate tissue.

Treatment of chondrodermatitis nodularis with removal of the underlying cartilage alone: retrospective analysis of experience in 37 lesions

Most otolaryngologists treat patients with chondrodermatitis nodularis (CDN) by wedge excision. Although the results of this technique are generally good, it can leave the patient with an asymmetric, deformed ear. In the dermatological literature, a relatively straightforward technique has been described for the treatment of CDN by smoothing only the underlying cartilage. This is based on the assumption that CDN is caused by pressure necrosis of protuberant cartilage, and thus is primarily not a skin disease. Reports on this technique claim excellent cosmetic results with only a small chance of recurrence. In the present study we analyse the application of this technique to 34 patients with 37 CDN lesions. All patients were symptom-free with a minimum follow-up of three months according to their medical reports. Seventeen patients with 19 lesions were interviewed later by telephone. In a mean follow-up of 30.7 months, 34 of these patients remained symptom-free and only one required revision surgery. The authors recommend this safe and simple technique to other physicians who treat patients with CDN.

Bone resorption after alloplastic augmentation of the mandible

Augmentation mentoplasty is a commonly performed operation especially in conjunction with rhinoplasty. While various materials have previously been used for this procedure, silastic has been the implant of choice for the last three decades. Concerns have been raised due to the occurrence of bone resorption beneath these implants. Controversy prevails as to the cause and the long-term effects of the resorption. It has been suggested by some that the resorption is self-limiting although this has not been confirmed in clinical studies. In total, 40 patients with silastic implants, who had a mean follow-up of 20 months (8-60 months), were studied radiologically. In 21 of them (52%), a degree of resorption from 0.5 to 2 mm was observed. Spearman's rank correlation showed a statistically significant relationship between the degree of resorption and the time lapse since surgery (P = 0.048).

Assessing the quality of life for patients with chronic rhinosinusitis using the "Rhinosinusitis Disability Index"

Quality of life studies are increasingly being use as the primary outcome measure in chronic rhinosinusitis. The Rhinosinusitis Disability Index (RSDI) is a recently designed validated measure that has not been used in clinical studies. We have used the RSDI on 53 patients with chronic rhinosinusitis and compared the results to their endoscopic score and self-rated symptom score. Our data showed that the mean total quality of life score was 42 with a range of 5 to 69 (SD 17). The means of the functional, emotional and physical domains were 13 (range 0 to 27, SD 6), 13 (range 0 to 25, SD 7) and 16 (range of 2 to 32, SD of 7) respectively. There was no correlation between endoscopic score and either the patient's self-rated symptom score or RSDI score. The correlation between the self-rated symptom score and total quality of life score was significant (p = 0.02). Various areas of the patients' quality of life were shown to be affected by chronic rhinosinusitis.

A new presentation of angiopathy in neurofibromatosis type 1

Neurofibromatosis is a genetic condition characterized by localized over-growth of mesodermal and ectodermal tissues. Neurofibromatosis type 1 is characterized by cutaneous and skeletal abnormalities. Angiopathy is rare. We describe a new presentation of angiopathy in neurofibromatosis type 1. The patient presented with extensive bruising of the right side of her neck together with intra-oral and pharyngeal submucosal haemorrhage. Radiological investigation confirmed that an aneurysm of the right ascending pharyngeal artery had ruptured. This was successfully embolized without complication.

A randomised controlled trial of the effect of regional nerve blocks on immediate post-tonsillectomy pain in adult patients

Post-operative pain is the main cause of morbidity following tonsillectomy. The efficacy of glossopharyngeal and lesser palatine nerve blocks in controlling postoperative pain in adult patients was investigated prospectively. Patients 16 years and older admitted for elective tonsillectomy were randomised to one of three groups to receive a pre-incisional oropharyngeal injection of 0.5% bupivicaine, a 'dummy' injection of saline or no injection. Dissection tonsillectomy and general anaesthetic techniques were standardized. Postoperative pain was monitored for 24 h. ANOVA, chi2 and Fisher's exact test were used for intergroup comparisons. Ninety-two patients (72 women and 20 men), mean age 22 years were studied. Twenty-nine patients received 0.5% bupivicaine, 30 saline and 33 no pre-incisional injection. The overall mean pain scores of 2.1, 1.9 and 1.9 in the bupivicaine, saline and no injection groups were similar. Glossopharyngeal and lesser palatine 0.5% bupivicaine nerve blocks are not effective in reducing early post-tonsillectomy pain.

Endoscopic endonasal ligation of the sphenopalatine artery

Internal maxillary artery ligation for persistent posterior epistaxis is traditionally performed via the transantral approach. Although usually effective in controlling the bleeding it carries significant risks, including damage to the infraorbital nerve, damage to dentition and oro-antral fistula formation. The alternative procedure of endoscopic ligation of the sphenopalatine artery at its exit from the sphenopalatine foramen avoids the morbidity associated with the transantral approach. The technique we describe involves the use of standard FESS instruments and a Ligge Clip applicator. This operation is well within the capability of the Otolaryngologist/Rhinologist experienced in endoscopic sinus surgery.

Immunohistochemical expression of bcl-2 and p53 oncoproteins: correlation with Ki67 proliferation index and prognostic histopathologic parameters in colorectal neoplasia

The bcl-2 oncogene plays an important role in carcinogenesis by inhibiting cell death (apoptosis). It was initially discovered in follicular B cell lymphoma with t(14,18) and subsequently found in other malignant and premalignant lesions. Alteration of the normal controls of cell proliferation is also a significant factor in the multistep process of tumorigenesis. The proliferative activity of a given lesion is commonly evaluated by MIB 1, a monoclonal antibody to Ki67 proliferation antigen. Mutation of the p53 gene is considered the most common genetic aberration in colorectal cancer. Immunohistochemical (IHC) staining expression of bcl-2, Ki67, and p53 was retrospectively investigated in a series of 52 colorectal carcinomas and 56 adenomas. The aim of the study was twofold: (i) to investigate any correlation between MIB 1, p53, and bcl-2 immunostaining expression in colonic adenomas and carcinomas and (ii) to identify any relation between these markers and several histopathologic parameters including tumor size, pathologic stage, lymph node metastasis, angiolymphatic invasion, tumor grade, and differentiation in colon carcinomas. bcl-2 was consistently higher in adenomas than in carcinomas. There were 44 of 56 (78.6%) adenomas and 27 of 52 (51.9%) carcinomas positive for bcl-2 (P = 0.004). The mean Ki67 labeling index (LI) was 30.05 +/- 7.6 and 38.12 +/- 11.01 in adenomas and carcinomas, respectively (P = 0.0001). p53 was significantly higher in carcinomas (35 of 52 [67.3%]) than in adenomas (18 of 56 [32.1%]) (P = 0.0004). Expression of bcl-2 in carcinoma was associated with a lower p53 levels and lower mean Ki67 LI and with favorable histopathologic parameters. Higher p53 and Ki67 values were associated with prognostically poor histopathologic features (differentiation and Duke's stage). We conclude that, in contrast to p53 and Ki67, bcl-2 oncoprotein expression is probably an early step in the process of colon carcinogenesis, and its expression may be associated with favorable pathologic parameters. Furthermore, an inverse relation exists between p53 and Ki67, and bcl-2 IHC expression in colonic neoplasia. Evaluation of bcl-2, p53, and Ki67 IHC expression in colonic carcinoma may be of value in predicting the clinical course in these patients.

Correlation of bcl-2 oncoprotein immunohistochemical expression with proliferation index and histopathologic parameters in colorectal neoplasia

Thebcl-2oncogene plays an important role in carcinogenesis by inhibiting cell death (apoptosis). It was initially discovered in follicular B cell lymphoma with t(14,18), and subsequently found in other malignant and premalignant lesions. Alteration of the normal controls of cell proliferation is also a significant factor in the multistep process of tumorigenesis. The proliferative activity of a given lesion is commonly valuated by MIB1, a monoclonal antibody to Ki67 proliferation antigen. Immuno-histochemical (IHC) staining expression of bcl-2 and Ki67 was retrospectively investigated in a series of 52 colorectal carcinomas and 56 adenomas according to the avidin-biotin-complex method. The aim of the study was twofold: 1) to investigate any correlation between MIB1 and bcl-2 immunostaining expression in colonic adenomas and carcinomas, 2) to identify any relationship between either marker and several histopathologic parameters including tumor size, pathologic stage, lymph node metastasis, angio-lymphatic invasion, tumor grade and differentiation in colon carcinomas. Bcl-2 was consistently higher in adenomas than in carcinomas. There were 44/56 (78.6%) adenomas, and 27/52 (51.9%) carcinomas positive for bcl-2 (p=0.004). The mean Ki67 labeling index (LI) was 30.05+/-7.6 and 38.12+/-11.01 in adenomas and carcinomas, respectively (p=0.0001). Expression of bcl-2 in carcinoma was significantly associated with a lower mean Ki67 LI and with favorable histopathologic parameters. We conclude that bcl-2 oncoprotein expression is probably an early step in the process of colon carcinogenesis, and its expression may be associated with a favorable clinical course. Furthermore, an inverse relationship exists between bcl-2 and Ki67 in colonic neoplasia. Evaluation of bcl-2 and Ki67 IHC expression in colonic carcinoma should be performed prospectively to determine if their expression is of value in predicting the clinical course in these patients.

First branchial cleft sinus presenting with cholesteatoma

Disorders of the first branchial cleft are rare and often present difficulties in diagnosis. A case is reported that presented with the clinical and histological features of cholesteatoma. The embryology, diagnosis and treatment of branchial arch defects are also reviewed. The case highlights the fact that a high index of suspicion should be aroused for patients with a discharging ear in the presence of an intact tympanic membrane.

Classification and staging of cholesteatoma

No staging system for cholesteatoma has been universally adopted. All previous attempts failed to gain acceptance because of the lack of clinical relevance. We have devised a simple system to stage cholesteatoma which is based on the extent of lesion, ossicular condition and the preoperative complications. To illustrate the systems potential value, data from 119 new patients with cholesteatoma are presented and classified according to our proposed scheme. This shows a relationship between the stage of disease, ossicular damage and the occurrence of complications. The proposed staging system is potentially useful when considering the type of surgery required and when comparing published data reporting the results of tympanomastoid surgery.

Fine needle aspiration diagnosis of extraadrenal myelolipoma presenting as a pleural mass. A case report

BACKGROUND

Myelolipoma is a benign tumor composed of mature adipose tissue and hematopoietic cells. Although they are commonly found in adrenal glands, extraadrenal myelolipomas (EMLs) are rare but well documented. They have been found in various sites, including mediastinum, liver, stomach, lungs, pelvis, spleen, retroperitoneum, presacral region and mesentery. EMLs must be distinguished from extramedullary hematopoieses, which are also composed of hematopoietic elements but may lack adipose tissue and are associated with anemia and marked bone marrow hyperplasia.

CASE

We describe a case of a pleura-based, extraadrenal myelolipoma in a 53-year-old female with unremarkable bone marrow findings that were initially encountered on fluoroscopy-guided fine needle aspiration (FNA). One year later the mass was removed via open thoracotomy. It showed typical EML features histologically.

CONCLUSION

EML manifests on aspiration cytology as a cellular specimen with numerous trilineage hematopoietic cells and a variable proportion of mature adipose cells. To our knowledge, FNA cytology of EML has not been found in this location before. Aspiration biopsy offers a simple and reliable method for the diagnosis of EML in the presence of appropriate clinical settings.

Bipolar scissor tonsillectomy

We describe a new technique for tonsillectomy using dual-function scissors that cut and bipolar coagulate at the same time. The technique shortens operating time and decreases intra-operative blood loss. Forty patients had their tonsillectomy performed using this technique. The mean operating time was 5.5 min (SD 2.1) and mean blood loss was 1.3 ml (SD 3.6). All patients were able to eat and drink on the same postoperative day and all were discharged the following morning. None of the patients had primary haemorrhages and two patients (5%) had minor secondary haemorrhages. We found bipolar scissor tonsillectomy to be a safe technique that shortens surgery and minimises blood loss without causing increased postoperative morbidity.

Fluid phase endocytosis within buccal mucosal cells of alcohol misusers

The structure of the oral mucosa is now well characterised, although studies on oral epithelial cell function have received less attention. The aims of this study were to see whether endocytosis could be demonstrated in cells from oral smears and if so, to assess the effect of chronic high alcohol intake on such uptake. Buccal mucosal smears were collected from 135 patients (91 non- or social drinkers, and 44 patients with harmful alcohol use). Name, age, sex, and alcohol history (for alcohol problem patients) were recorded. Cell suspensions were incubated in a solution of bovine serum albumin (BSA)-coated fluorescently labelled latex microspheres (0.02 micron diameter) in Ham's F-10 culture medium for 1 h at 37 degrees C as a marker of fluid phase endocytosis. Uptake of microspheres was confirmed by confocal microscopy, and mean endocytosed fluorescence levels determined by flow cytometry. A repeat smear from 11 of the alcohol patients was taken 9-14 days later. Endocytosis was significantly reduced in both male (P < 0.01) and female (P < 0.01) alcohol problem patients compared to controls. Units of alcohol consumed and cigarettes smoked per day did not show a dose-response correlation with endocytosis in the alcohol problem patients. Apparent abstinence from alcohol had no further effect on endocytic uptake at days 9-14. This study shows that normal oral squamous cells removed as buccal smears readily endocytose fluorescent microspheres and that this capacity can be affected by alcohol. Chronic high alcohol intake would appear to down regulate endocytosis in buccal cells even up to 14 days of abstinence. This may have implications for the pathogenesis of oral mucosal disorders in long-term users.

Improved detection of adenocarcinoma of serous fluids with p53 immunocytochemistry

OBJECTIVE

To investigate the potential value of p53 protein immunostaining in identifying malignant cells in serous fluids.

STUDY DESIGN

We applied p53 immunostaining to 26 cytologically malignant, 8 suspicious and 34 benign specimens of serous fluids from 68 patients. For comparison, staining for carcinoembryonic antigen (CEA) was also done on all the specimens.

RESULTS

CEA was positive in 23 of 26 (88%) cytomorphologically malignant, 3 of 8 (38%) suspicious and 1 of 34 benign cases. p53 Nuclear immunostaining was positive in 12/26 (46%) malignant, 2/8 (26%) suspicious and no benign cases. Correlation between p53 staining and serous fluid type (benign, suspicious or malignant) was significant. The P based on Fisher's exact test was < .0001. Two cases that were reported cytomorphologically as suspicious stained positively with p53; further investigation in those cases confirmed the diagnosis of metastatic adenocarcinoma.

CONCLUSION

p53 Immunostaining of serous fluids seems to be of value in identifying carcinoma cells, especially in those cases that show inconclusive or bland cytologic features. Combining p53 with CEA immunostains in clinically or cytologically suspicious cases may assist in recognition of carcinoma cells and in pursuing an appropriate therapeutic approach.

Lipomatosis of the minor salivary glands

Lipomatosis has not previously been reported in minor salivary glands. Its occurrence in the parotid gland is well recognized. We present the first reported case of lipomatosis of the minor salivary glands in the nasal cavity. We also review the tumours of the minor salivary glands, lipomas and lipomatosis of the parotid, and the few reported cases of lipomas of the sinonasal tract.

P53 protein immunohistochemical expression in colonic adenomas with and without associated carcinoma

OBJECTIVES

P53 protein immunohistochemical (IHC) expression was investigated in a series of colonic adenomas and carcinomas to determine the p53 immunohistochemical expression of adenomas in general compared with carcinomas, the difference in staining pattern between adenomas with associated carcinoma and those without associated carcinoma, and the difference in p53 staining in the usual adenomas (low-grade dysplasia) compared with those harboring high-grade dysplasia.

METHODS

The study involved a series of 20 adenomas without concurrent carcinoma (group 1 adenoma), 29 adenomas with concurrent carcinoma (group 2 adenoma), and 20 carcinomas. Sections of the paraffin-embedded tissues were stained with DO-7 p53 monoclonal antibody after microwave antigen-retrieval method. Cases with nuclear staining in > or = 20% of the tumor cells were considered positive.

RESULTS

Analysis of results showed that 65% of carcinomas and 37% of all adenomas were reactive with p53 IHC staining (p = 0.03). With respect to the adenomas, 30% of group 1 and 41% of group 2 adenomas were reactive for p53 protein (p = 0.42).

CONCLUSIONS

Our data demonstrate a statistically significant higher p53 expression rate in colonic carcinomas than in adenomas, and that adenomas with concurrent carcinomas are more frequently p53 positive than those without concurrent carcinoma, but this was not statistically significant. Also, p53 expression is more frequent and intense in adenomas with high-grade dysplasia (10/20, 50%) than in ordinary adenomas with low-grade dysplasia (8/29, 28%), which suggests a strong correlation between the degree of dysplasia in colonic neoplasia and p53 expression pattern.

Verrucous carcinoma of the maxillary antrum

Verrucous carcinoma is a distinct variant of well differentiated squamous cell carcinoma. Its occurrence in the maxillary antrum is rare. Only three cases have previously been documented. We present a case report of verrucous carcinoma in the maxillary antrum and a review of the literature.

Bronchioloalveolar carcinoma: diagnostic pitfalls and immunocytochemical contribution

Because bronchioloalveolar carcinoma (BAC) commonly displays bland cytologic appearance, there is a good potential for misinterpretation. The aim of this study was twofold: one was to identify the most reproducible cytomorphologic features to distinguish BAC from conventional lung adenocarcinoma (CLA) on fine-needle aspiration (FNA), and the other was to investigate the staining characteristics of these two variants of lung carcinoma with P53 tumor suppressor gene immunostain and their potential value in the distinction between the two entities. Cytology records of 13 histologically documented BACs was retrieved: 7 FNA, 3 bronchial washing/bronchial brushing (BW/ BB), and 3 scraping smears of surgical specimens. Two cases had both FNA and BW/BB material. Immunostains for P53 protein, carcinoembryonic antigen (CEA), and Ki67(MIB-1) monoclonal antibodies were performed on 13 BACs (FNA cell blocks and tissue) and on 11 FNA cell blocks of CLA. Cytologically, BAC showed uniform cells with abundant, lacy cytoplasm, and bland, folded nuclei arranged singly, in papillary clusters, and sheets. Immunocytochemically, one BAC and one CLA were technically unacceptable. Of the 12 remaining BAC cases, 10 were reactive with CEA, 9 reactive with Ki67 (> 5%), and 4 reactive with P53. Of the 10 remaining CLAs, 9 were positive with CEA, 9 were reactive with Ki67 (> 5%), and 8 were reactive with P53. We conclude that BAC demonstrates distinctive cytologic features, but difficulty may be encountered with well-differentiated CLA, metastatic adenocarcinoma, and other lesions. Immunocytochemically, CEA and Ki67 do not appear to be discriminate, but P53 may be of value in distinguishing BAC from CLA. Attention to subtle nuclear changes, characteristic grouping, cellular arrangement, and P53 reactivity could enable cytopathologists to accurately diagnose BAC.

Hepatic angiosarcoma: aspiration biopsy cytology and immunocytochemical contribution

In the absence of previously documented sarcoma, the initial diagnosis of angiosarcoma (AS) on fine-needle aspiration (FNA) biopsy of the liver is difficult. However, awareness of its occurrence and the assistance of immunocytochemical stains may aid in arriving at the correct diagnosis. In this paper, a 59-yr-old smoker and alcoholic woman presented after a syncopal episode and was found to have a palpable right abdominal mass. An abdominal CT scan confirmed multiple centrally necrotic liver masses, from which an FNA biopsy was obtained. The smears were bloody with groups of relatively dishesive and singly dispersed spindle cells in a somewhat necrotic background. The nuclei were elongated to ovoid-round with small nucleoli. The cytoplasm was ample and ill-defined. The cells were reactive for factor VIII-related antigen and CD31 but negative for cytokeratin immunocytochemical stains, and a diagnosis of "suspicious for angiosarcoma" was entertained. The patient declined further studies or treatment but presented 4 mo later with light-headedness and hypoglycemia. Laparoscopic tissue biopsies of the liver/abdominal masses were obtained and revealed AS. Rarely, liver masses may represent AS. Pathologists should be aware of their cytomorphology and characteristic immunostaining to avoid their misinterpretation.

Double oocyte aspiration may be a solution for empty follicle syndrome: case report

OBJECTIVE

To assess the possibility of salvaging the cycle in a case of empty follicle syndrome by scheduling a second retrieval.

SETTING

Miami IVF/Intracytoplasmic Sperm Injection Center, Alexandria, Egypt. It is a private center.

PATIENT(S)

A 24-year-old female with a 6-year history of primary infertility. Intracytoplasmic sperm injection was performed because of her partner's obstructive azoospermia. No oocytes could be retrieved despite normal ultrasonic and hormonal responses and the presence of 25 mature follicles.

INTERVENTION(S)

Serum hCG on the day of the first retrieval. A second dose of hCG was given after the first retrieval, and a second retrieval was scheduled 24 hours later.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved, fertilization and cleavage rates, and pregnancy outcome.

RESULT(S)

Serum beta-hCG level on the day of the first retrieval was 300 IU/mL. Eleven oocytes were retrieved, (7 were metaphase II, 3 fertilized, and 2 cleaved) and two embryos were transferred. No pregnancy resulted.

CONCLUSION(S)

In a variant of empty follicle syndrome, the cycle could be salvaged by giving another dose of hCG and scheduling another retrieval 24 hours later.

Invasive aspergillosis of the paranasal sinuses: a medical emergency

A rare case of invasive aspergillosis of the paranasal sinuses in a previously healthy individual is presented. The disease caused severe complications and proved fatal. Classification, aetiology and presentation of sinus aspergillosis are discussed. Early diagnosis and management is stressed to avoid the high incidence of morbidity and mortality.

Clicking hyoid

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Cytomorphology of adenocarcinoma of lung presenting as submandibular salivary gland mass: report of a case diagnosed by fine-needle aspiration biopsy

BACKGROUND

Primary malignant neoplasms of the submandibular salivary gland (SMG) are rare, and metastatic tumors are rarer. Most of the metastases are discovered months or years after the diagnosis of the primary malignancy. Despite the increasingly used fine-needle aspiration biopsy (FNAB) in the evaluation of major salivary gland masses, diagnosis of metastases by FNAB has been only rarely studied.

CASE

We report a case of lung carcinoma initially presented as a SMG swelling diagnosed by aspiration biopsy. The patient is a 52-yr-old man, a 40-pack/year smoker who also complained of weight loss and blood-streaked cough. An FNAB of the mass was consistent with metastatic adenocarcinoma with prominent signet ring-cell component of unknown primary. Subsequent studies revealed a left lung mass and left pleural effusion. The effusion cytologic examination showed malignant cells consistent with carcinoma. The patient's condition deteriorated rapidly, and he died within a few days. An autopsy revealed adenocarcinoma of lung with prominent signet ring-cell component.

CONCLUSION

FNAB is a rapid, safe, reliable, and cost-efficient technique for evaluation of major salivary glands lesions. To our knowledge, this case is the first lung carcinoma presenting as SMG mass initially diagnosed on FNAB.

Recurrent canalicular adenoma of the minor salivary glands in the upper lip

Canalicular adenoma is a recently classified uncommon salivary gland neoplasm. This biologically benign growth tends to be multifocal and occurs most often in the upper lips of elderly people. Histologically and clinically it differs from the basal cell adenoma, for which it may be mistaken, in a number of ways. Its clinical importance lies in the fact that it may be confused with malignancy. Little information is available regarding the recurrence and long-term follow-up of these tumours, and where available it covers only relatively short periods. We report the recurrence of a canalicular adenoma after an 11.2 year disease-free period.

Aspiration biopsy cytology of malignant hemangiopericytoma metastatic to the lungs. Cytomorphologic and immunocytochemical study of a case

BACKGROUND

Hemangiopericytoma (HP) is an uncommon, slowly growing tumor that originates in "pericyte" cells. Biologically it can be benign or malignant; however, it is difficult to predict tumor behavior based on histomorphology alone. The cytomorphology of this tumor has been described only rarely. Other spindle cell mesenchymal tumors can mimic HP on fine needle aspiration biopsy (FNAB).

CASE

A 60-year-old man presented with cough and a left lung mass on chest roentgenography and multiple smaller bilateral lung nodules on computed tomographic scan. FNAB of the dominant left lung mass showed a moderately cellular aspirate with clusters and single spindle-shaped cells morphologically similar to those of hemangiopericytoma excised from the posterior part of the neck 11 years previously. With immunocytochemical studies, the tumor cells were negative for cytokeratin, factor VIII-related antigen, S-100 protein and HHF35 but positive for vimentin and CD34.

CONCLUSION

FNAB is a valuable tool in evaluating nonepithelial metastatic lung tumors. In the appropriate clinical setting, it is possible to render a diagnosis of HP on FNAB in patients with previously documented HP based on morphologic comparison and ancillary studies, especially immunocytochemical stains.

Fatal gastrointestinal bleeding as the primary manifestation of granulocytic sarcoma in a patient with myelodysblastic syndrome

Granulocytic sarcoma (GS), or chloroma, is a rare extramedullary tumor composed of immature myeloid cells. It most commonly involves bone, soft tissue, lymph nodes and skin and develops during the course of or preceding myelogenous leukemia (ML). Involvement of other organs has been rarely reported including ovary, uterus and cervix, lung and the gastrointestinal tract; however, GS presenting as upper and lower gastrointestinal (GI) bleeding from ulcerated gastric mass and concurrent bleeding vaginal mass is an unusual rare manifestation of GS. We describe a case of GS in a 70 year old black woman who presented with a bleeding "lump" in the vaginal wall and suffered fatal GI bleeding from an ulcerated gastric lesion. She was diagnosed with myelodysblastic syndrome a few months earlier. From the review of the available English literature, this is a unique presentation of GS. It is important to include this entity in the differential diagnosis when encountering GI bleeding particularly in a patient previously diagnosed with myeloid leukemia or preleukemia. The importance of Naphthol Chloracetate Esterase (NCAE) stain and lysozyme immunoperoxidase stain in establishing the diagnosis is breifly discussed.

Positive economic and diagnostic accuracy impacts of on-site evaluation of fine needle aspiration biopsies by pathologists

OBJECTIVE

To investigate the impact of pathologists' immediate evaluation of fine needle aspiration biopsy (FNAB) on increasing diagnostic yield and decreasing related expenses.

STUDY DESIGN

All FNABs performed at our 420-bed hospital between January 1992 and December 1994 were reviewed. The 1992-1993 FNABs were all performed without pathologist attendance. Smears were wet fixed in 95% alcohol and later stained by the Papanicolaou or hematoxylin and eosin methods. The remaining aspirated material was collected in Saccomano's preservative, and a cell block was made. Nearly all the 1994 FNABs were performed with the pathologist present; he examined air-dried, Diff-Quik-stained smears for preliminary evaluation of the aspirate. An average of three passes were done. The rest of the procedure was as usual.

RESULTS

The total number of 1992-1993 FNABs was 227 (108 + 119); of them, 104 (46%) were inadequate for diagnosis. In contrast, the 1994 FNABs totaled 169, with only 40 (24%) inadequate for diagnosis. The vast majority of the aspirates were done on deep-seated lesions under computed tomography (CT) guidance.

CONCLUSION

The results of our experience indicate that on-site evaluation by a pathologist greatly increases the diagnostic yield. Another advantage is the significant financial savings as compared to excisional tissue biopsy. In general, the expenses of a CT-guided FNAB (e.g., pancreas) average around $1,400, while charges for excisional biopsy under general anesthesia with a subsequent two- to three-day hospitalization average about $7,720.

Endometrial unresponsiveness: a novel approach to assessment and prognosis in in vitro fertilization cycles

OBJECTIVE

To categorize endometrial responsiveness to orally administered estriol in natural cycles of patients with thin endometrium. The value of endometrial responsiveness in predicting the outcome of subsequent IVF-ET cycles was evaluated.

DESIGN

Prospective clinical study.

SETTING

Miami IVF-ICSI Center, Alexandria, Egypt, a private center.

PATIENTS

Forty-two patients undergoing IVF-ET. All had endometrial thickness < or = 7 mm at the time of maximal follicular diameter in natural cycle.

INTERVENTION

Estriol was orally administered in subsequent unstimulated cycle. Patients were categorized into responsive and unresponsive groups (those with improved and unimproved endometrial thickness, respectively). Lastly, controlled ovarian hyperstimulation (COH) with or without estriol was started in the IVF-ET cycles.

MAIN OUTCOME MEASURES

The endometrial thickness during COH with or without estriol, fertilization, pregnancy, and abortion rates.

RESULTS

The responsive group compared with the unresponsive group had a significantly higher rate of improved endometrial thickness, a similar number of oocytes retrieved, a similar fertilization rate, and a significantly higher pregnancy rate.

CONCLUSION

Patients with endometrial unresponsiveness to estriol in their natural cycles rarely improve by COH and have a poor pregnancy rate in IVF cycles.