Ultrasound for suspected Baker's cyst: A test of limited clinical value?

Introduction

Patients with posterior knee swellings are commonly encountered in clinical practice with the vast majority referred for an ultrasound scan to assess for a clinically suspected Baker's cyst.

Aims

Our aim was to determine the incidence of different pathologies in patients investigated for a posterior knee swelling of a clinically suspected Baker's cyst using ultrasound. We also wanted to investigate the incidence of significant pathologies in the popliteal fossa to assess whether the ultrasound scan findings influenced patient management.

Methodology

Retrospective analysis was performed on all patients who underwent an ultrasound scan for a suspected Baker's cyst or posterior knee swelling at our institution, between January 2017 and December 2018. Patient demographics, ultrasound findings, further imaging investigations and histopathology were recorded. Patient records were followed up for a minimum period of 3 years after ultrasound.

Results

A total of 680 patients had a posterior knee ultrasound scan. Of that, 51% (347/680) had a Baker's cyst and 40% (273/680) had a normal ultrasound scan. Sixty (9%) patients had other abnormalities identified within the popliteal fossa. Four patients had significant findings on ultrasound that required a change of management. No malignancies identified.

Conclusion

This study confirms the high incidence of Baker's cysts in patients presenting with a posterior knee swelling. In the absence of red flag symptoms, ultrasound of the posterior knee for a clinically suspected Baker's cyst is of limited clinical value.

Ultrasound Assessment of an Isolated Rupture of the Medial Bundle of a Bifid Distal Biceps Tendon

This case study describes a patient with a clinically ruptured distal biceps tendon, with ultrasound detecting an isolated rupture of the medial bundle of a bifid distal biceps tendon. A 45-year-old male presented to the accident and emergency department with a week-old history of a right elbow injury. The ultrasound scan demonstrated a hypoechoic, corrugated distal biceps tendon with a tendon stump close to the radial tuberosity insertion in keeping with a rupture. However, a small caliber accessory or bifid distal biceps tendon was also identified and was intact. Typically, distal biceps tendon ruptures occur following a traumatic event with most detected clinically although imaging is required to confirm the diagnosis. Ultrasound is utilized to assess these injuries, and several different techniques or approaches are described in the literature. A combination of these approaches is required to make an accurate diagnosis. Detection of bifid distal biceps tendons is important for patient management, especially if a surgical repair is considered. This case highlights the anatomical variant of a bifid distal biceps tendon, which was ruptured clinically. The ultrasound diagnosis of distal biceps tendon ruptures can be challenging, especially when there is limited tendon retraction. This case also demonstrated the importance of dynamic ultrasound in the assessment of tendon ruptures.

Primary lung tumour invading the chest wall

Introduction

This case study describes a primary lung tumour invading the chest wall, that clinically was thought likely to be a lipoma, and was imaged first using ultrasound.

Case Report

A 67 year old male presented to his GP with a six month history of a lump increasing in size on the left upper chest wall. The ultrasound scan demonstrated a hypoechoic and hypervascular soft tissue mass, extending out of the chest into the subcutaneous tissue and starting to erode the overlying rib. The appearances were highly suspicious for a chest malignancy. Further imaging and an ultrasound guided biopsy confirmed the diagnosis of a squamous cell carcinoma.

Discussion

The majority of patients who present to their general practitioner with a soft tissue mass commonly have benign abnormalities such as a lipoma or epidermoid cyst. Tumours of the chest wall are varied and are divided into benign and malignant tumours, and those that arise from the rib cage. Primary lung tumours are uncommonly seen on ultrasound. Lung cancers account for around 20% of all cancer deaths and the chest wall is involved in around 5% of primary lung tumours.

Conclusion

This case highlights the need for prompt investigation of enlarging superficial masses. Ultrasound imaging offers excellent detail for superficial structures and in this case, due to the location of the mass, identified a primary lung tumour.

Soft-Tissue Sarcoma Masquerading as a Haematoma

Sarcomas commonly occur in the buttock and thigh, although the clinical presentation varies with no specific symptoms other than a painless lump. This case study reports on a soft-tissue sarcoma that was initially thought to be a haematoma on ultrasound, despite being rescanned 6 weeks later. The patient presented back to their general practitioner 8 months later with the subsequent ultrasound showing an irregular and hypervascular soft-tissue mass. Further imaging and ultrasound-guided biopsy led to a surgical excision of a myxofibrosarcoma. This case demonstrates the difficulty of differentiating between a haematoma and sarcoma, especially in patients presenting with a history of trauma.

A Multicenter Phase I Gene Therapy Clinical Trial Involving Intraperitoneal Administration of E1A-Lipid Complex in Patients with Recurrent Epithelial Ovarian Cancer Overexpressing HER-2/neuOncogene

PURPOSE

HER-2/neu oncogene is overexpressed in 10-30% of epithelial ovarian cancers and is associated with a poor prognosis. The E1A gene product of adenovirus type 5 down-regulates HER-2/neu and causes tumor regression in animal models. In the current study, we sought to determine the toxicity and biological activity of E1A-lipid complex in ovarian cancer patients.

EXPERIMENTAL DESIGN

A Phase I trial involving intraperitoneal (i.p.) administration of E1A-lipid complex was initiated in ovarian cancer patients to assess biological activity (E1A gene transfer/transcription/translation and HER-2/neu expression) and to determine the maximum tolerated dose. Successive cohorts received E1A-lipid complex at doses of 1.8, 3.6, and 7.2 mg DNA/m(2), given as weekly i.p. infusions for 3 of 4 weeks (each cycle) up to a maximum of six cycles. Peritoneal fluid was sampled at baseline and twice monthly for cellularity, cytology, CA-125, and biological activity

RESULTS

Fifteen patients, with a median age of 57 years (range, 43-81) were recruited. Three (1.8 mg DNA/m(2)), 4 (3.6 mg DNA/m(2)), and 8 patients (7.2 mg DNA/m(2)) received i.p. E1A. A total of 91 infusions (range, 1-18) was administered. Abdominal pain was the dose-limiting toxicity, and the maximum-tolerated dose was 3.6 mg DNA/m(2). E1A gene transfer and expression was observed in all of the patients and at all of the dose levels. HER-2/neu down-regulation could be demonstrated in the tumor cells of 2 patients (18%). There was no correlation between dose and biological activity.

CONCLUSIONS

I.P. EIA-lipid complex gene therapy is feasible and safe. Future studies, either alone or in combination with chemotherapy, particularly in patients with minimal residual disease, should be evaluated.

Distribution of transforming growth factor-beta isoforms TGF-beta 1, TGF-beta 2 and TGF-beta 3 and vascular endothelial growth factor in vulvar lichen sclerosus

OBJECTIVE

To study the distribution of transforming growth factor beta (TGF-beta) isoforms TGF-beta 1, TGF-beta 2 and TGF-beta 3 and vascular endothelial growth factor (VEGF) in vulvar lichen sclerosus.

STUDY DESIGN

Biopsies were obtained from 10 patients with vulvar lichen sclerosus, snap frozen and stained with polyclonal antibodies to TGF-beta 1, TGF-beta 2, TGF-beta 3 and VEGF. Control tissues used were uninvolved thigh tissue from two of the lichen sclerosus patients and normal vulvar tissue obtained from eight patients during gynecologic procedures. Two specimens of morphea were also examined.

RESULTS

Weak TGF-beta 1 staining was demonstrated in the epidermis of all the lichen sclerosus, morphea, thigh and five of the eight normal vulvar specimens. Slight increase in TGF-beta 1 staining was seen in the upper and middermis in 6 of the 10 lichen sclerosus specimens and in the morphea specimens as compared to the control tissue, and this staining was localized within cells. TGF-beta 2 staining was present throughout the epidermis in all the normal thigh, normal vulva, lichen sclerosus and morphea specimens. TGF-beta 2 staining was increased within cells in the upper and middermis of the lichen sclerosus and morphea specimens. TGF-beta 3 staining occurred in the basal half of the epidermis of all the control, lichen sclerosus and morphea specimens, and only slight upper dermal staining of a few individual cells was seen in 3 of the 10 lichen sclerosus specimens. VEGF staining was similar in the normal tissues, lichen sclerosus and morphea.

CONCLUSION

These results suggest that TGF-beta may.

CD44 expression in cervical intraepithelial neoplasia (CIN) and carcinoma

BACKGROUND

The expression of the CD44 gene is markedly changed in many neoplastic tissues. The identification of tumor-specific CD44 expression patterns may aid tumor diagnosis.

METHODS AND RESULTS

The transcription and translation of the CD44 gene were analyzed by reverse transcription polymerase chain reaction (RT-PCR), in situ hybridization and by immunohistochemistry. Samples were obtained from 24 normal and 24 neoplastic or malignant human cervical tissues. Southern blot hybridization analysis of RT-PCR products revealed an increase in the size and number of CD44 standard and variant transcripts in malignant cervical tissues compared with corresponding normal tissues. Misprocessing of mRNA was indicated in cervical carcinoma cells by the retention of intronic sequences. Multiple CD44 mRNA and protein isoforms were present throughout carcinoma tissues, whereas localization was restricted to the basal epithelium in normal cervical tissue. Analysis of desquamated cervical cells from cases of cervical intraepithelial neoplasia stages I-III showed progressively deranged patterns of CD44 expression, with more alterations being detected in the more advanced stages.

CONCLUSIONS

Marked alterations in CD44 expression occur in cervical tissues during progression to malignancy. CD44 expression analysis could aid the early diagnosis of cervical malignancy using minimally invasive methods.

Telomerase activity in human gynaecological malignancies

AIM

To evaluate whether increased telomerase activity can be clinically useful for detecting malignant cells in a variety of gynaecological specimens.

METHODS

Telomerase activity was examined in frozen tissue samples of histologically confirmed lesions of the endometrium, ovary, and cervix. It was also assessed in exfoliated cells in cervical smears from patients with premalignant and malignant lesions and in ascitic fluid obtained from cases with malignant or non-malignant ovarian tumours.

RESULTS

Solid tissues from carcinomas were telomerase positive in all specimens of endometrial (6/6) and cervical (6/6) origin, and in almost all from the ovary (12/13). Normal tissues from the cervix (0/5) and the ovary (0/5) were telomerase negative, but samples from normal endometrium were found to show telomerase activity, possibly due to the cyclical regenerative nature of this tissue. Conversely, dissociated cells in cervical smears from preneoplastic and frankly neoplastic lesions rarely showed detectable telomerase activity. Thus smears from patients with malignant tumours were only positive in one of two patients, whereas those from CIN-2 (0/5) and CIN-3 (1/17) lesions and from normal (0/10) samples were almost all negative. Telomerase activity was also scarcely detectable in cells obtained from ascitic fluid from patients with ovarian tumours.

CONCLUSIONS

As in many other organs, telomerase activity is increased in solid tissue specimens from malignant tumours of the female reproductive tract, but it is not yet a reliable indicator of the presence of exfoliated cancerous or precancerous cells in clinical specimens from such lesions. Interpretation should be guarded until more extensive studies have been conducted. The data on solid tissues presented here confirm that activation of this enzyme is a major hallmark of the neoplastic process.

The basement membrane zone in lichen sclerosus: an immunohistochemical study

The alteration in expression of basement membrane zone (BMZ) components in lichen sclerosus was investigated by immunohistochemical staining of skin biopsies from seven patients with histologically confirmed disease compared with controls. Monoclonal antibodies and polyclonal sera directed against proteins of the hemidesmosomes, anchoring fibrils, lamina lucida, lamina densa and BMZ collagens were used. Characteristic histological appearances at the dermo-epidermal junction were reflected in widespread alterations in antigen expression in the epidermal basement membrane and the papillary dermis. Expression of the proteins which constitute the structural scaffold (collagen IV and VII) were increased in lichen sclerosus. Expression of hemidesmosomal proteins which mediate adhesion and cell to matrix interaction (alpha 6 beta 4 and bullous pemphigoid antigen) and expression of anchoring filament components were markedly reduced, suggesting that the epidermal cells are exposed to selective damage.

Detection and typing of human papillomavirus infection of the uterine cervix by dot blot hybridisation: comparison of scrapes and biopsies

Paired scrapes and biopsies from 100 women attending a routine colposcopy clinic were examined by dot blot DNA hybridisation for infection with human papillomavirus (HPV) types 6/11, 16, 18, and 31; 51% of the scrapes and 50% of the biopsies were positive for HPV infection. Scrapes detected more HPV 18 (10% vs. 2%, P = less than 0.05) and HPV 31 (7% vs. 3%, not significant) than did the biopsies, but biopsies detected more HPV 16 (42% vs. 33%, not significant). Comparison of the results for each patient revealed that the correlation between scrapes and biopsies was not very close: only 34 patients were HPV-positive by both sampling methods, whereas 67 were positive if the results were combined. This report discusses the implications of these findings.

Use of immunocytochemical staining to identify cells in peritoneal fluid and washings at laparoscopy and laparotomy

Specimens of peritoneal fluid or peritoneal washings from a series of 106 patients who had had laparotomy or laparoscopy for gynaecological complaints were studied "blind" by conventional cytology and immunocytochemical staining. The antibodies used were Ca 1 or Ca 2, anti-CEA, and HMFG-2 or E29. All these are directed against epithelial antigens and are expressed on most malignant epithelial cells and weakly or not at all on mesothelial cells. It was hoped that these reactions would confirm diagnoses made by conventional cytology and possibly show malignant cells which had not already been identified. Of 28 patients with malignant disease (chosen to exclude any with frank ascites), eight gave positive immunochemical reactions, only four having been reported positive from conventional examination. Of 77 patients without malignant disease, HMFG-2 or E29 gave positive reactions in seven, Ca 1 or Ca 2 in two, and anti-CEA in two (reactions with plasma cells being disregarded). Some misleading reactions were probably due to endometrial cells. It was concluded that the antibodies used in this study are not sufficiently specific or sensitive to allow immunocytochemical staining to replace conventional cytological diagnosis but are a useful supplementary aid.

Evaluation of colposcopy in the postmenopausal woman

Cytology, colposcopy and histology findings in 121 postmenopausal and 120 premenopausal women referred to the Oxford colposcopy clinic were compared; 88% of postmenopausal and 69% of premenopausal women were referred by their general practitioners. Cervical smear reports, within the preceding 5 years, were available for 21% of the postmenopausal and 54% of the premenopausal women. Colposcopic assessment was technically unsatisfactory in 53% of the postmenopausal women because the transformation zone was not completely visible, this contributed to a cone biopsy rate of 71% in this group. Only 17% of postmenopausal women with cervical intraepithelial neoplasia (CIN) were managed with local ablative techniques compared with their use in 61% premenopausal patients overall and in over 70% of the women under 35 years. Local ablation was used in 10 of 14 women using hormone replacement therapy. The cytological false negative rate for postmenopausal Papanicolaou class III, IV and V smears was 9% but for persistent class II inflammatory smears it was 43%. Nine of 23 postmenopausal women with persistent inflammatory dyskariosis despite antibiotic or antifungal treatment were found to have colposcopic appearances of CIN and four had microinvasion or invasion. Colposcopy revealed probable microinvasive or invasive disease in 17 postmenopausal women, seven of whom had class II or III cytology.

Cervical wart virus infection, intraepithelial neoplasia and carcinoma; an immunohistological study using a panel of monoclonal antibodies

The pattern of epithelial antigen expression has been examined in normal and disordered cervical squamous epithelium using immunohistological methods and a range of monoclonal antibodies. It was demonstrated that wart virus infection (WVI) is associated with disordered staining for a keratin-associated component and for HLA-DR antigen. Furthermore, wart-infected epithelium shows strong labelling for carcinoembryonic antigen (CEA) and for human milk fat globule antigens 1 and 2 (HMFG1 and 2). In addition these antigens (CEA, HMFG1 and 2) are also expressed in mixed WVI and cervical intraepithelial neoplasia (CIN), CIN III and in carcinoma. While these findings do not allow immunohistological discrimination between non-neoplastic and neoplastic cervical epithelia, they do provide support for the view that cellular proliferation of the type induced by papilloma virus may represent an initiator stage in the process of neoplastic transformation.

Endosalpingiosis in pregnancy. Case report

At caesarean section, an unusual cystic lesion was found on the anterior uterine surface and on both ovaries. Biopsy established a diagnosis of endosalpingiosis. The pathogenesis and possible significance of the lesion are discussed, this being the first time this condition has been described in pregnancy.

Placental protein 5 in fetal and maternal compartments

Placental protein 5 is produced by the syncytiotrophoblast and secreted into the maternal peripheral circulation reaching levels of approximately 30 micrograms per litre in normal pregnancy at term. In the present study the distribution of PP5 was examined in maternal and fetal compartments in 13 patients at delivery.

Sensitivity differences displayed by Drosophila melanogaster larvae of different ages to the toxic effects of growth on media containing aflatoxin B1

Using Drosophila melanogaster, the relative sensitivities of various larval stages to the toxic effects of growth on media supplemented with either 0.44 or 0.88 ppm aflatoxin B1 (AFB1) were determined. Two strains of fruit flies were tested: strain A-11 which is relatively resistant to AFB1 induced toxicity, and strain A-9 which is quite sensitive. Eggs, mid-first, mid-second and early-, mid- and late-third instar larvae were transferred onto AFB1 media and allowed to complete larval and pupal development and eclose as adults. At the 0.44 ppm concentration, strain A-11 showed no effect, while only first instar larvae of strain A-9 showed significant mortality rates for first instar larvae, but the A-9 larvae die at higher rates than the A-11 larvae. In addition, second and third instar larvae of strain A-9 show significant mortality rates when grown at 0.88 ppm AFB1, while these stages are not affected in strain A-11.