Diagnostic dilemmas in intraductal papillomas of the breast - experience at Sultan Qaboos University Hospital in the Sultanate of Oman

The aim of this retrospective study was to correlate the significance and accuracy of the colour of nipple discharge and breast ultrasound imaging in the diagnosis of intraductal papilloma. This is a retrospective study of 34 patients who underwent 36 microdochectomies in Sultan Qaboos University Hospital [SQUH] in the Sultanate of Oman, over a 4 year period of January 2009 till December 2012. The confounders considered were patient age, physical examination findings, nipple discharge cytology result, ultrasound results and biopsy report following microdochectomy. Comparisons analysis, charts and graphs were made using the SPSS software [version 20]. The mean age of the patients was 44 [27-73] years old. Twenty-seven out 36 [75%] patients had presented with nipple discharge, 14 out 27 [52%] had blood stained nipple discharge and 13 [48%] with coloured discharge [yellow, brown and green], 9 patients had no discharge. The final histopathology showed intraductal papilloma 13 [36%], duct ectasia 18 [50%], DCIS 1 [2.7%], fibrocystic disease 3 [8.3%] and LCIS 1 [2.7%]. Thirteen out of 36 had intraductal papilloma on final histopathology. The correlation between blood stained discharge and final histopathology of intraductal papilloma was insignificant [p=0.44]. Nipple discharge is irrelevant to the diagnosis of intraductal papilloma. Spontaneous nipple discharge regardless of color is to be referred to breast surgeon and to be assessed with triple assessment. Surgery remains the mainstay of treatment

Clinically significant anatomical variants of the paranasal sinuses

Anatomic structural variations of the paranasal sinuses have a practical significance during surgical procedures conducted on the sinuses by otolaryngologists. This study aims to evaluate the prevalence of clinically significant anatomical variations of the paranasal sinuses. A prospective analysis of 435 computed tomography [CT] examinations of adult Omani patients was conducted to determine the prevalence of clinically significant anatomical variations of the paranasal sinuses. A total of 360 CT scans were included from January 2009 to January 2010. The findings showed abnormal Agger nasi cells in 49% of cases [95% CI: 44-54%], concha bullosa in 49% [95% CI: 44-54%], Haller cells in 24% [95% CI: 18-31%], asymmetry in anterior ethmoidal roof 32% [CI: 29-37%], Onodi cells in 8% [CI: 5%-10%]. The type of skull base were as follows; Type 1 was 30% [n=107; 95% CI: 25-35%], Type 2 was 34% [n=123; 95% CI: 29-39], and Type 3 was 36% [n=130; 95% CI: 31-41%]. Many other surgically significant anatomical variations in small numbers [1-3] were incidentally identified. Knowledge of the presence of anatomical variations of the sinuses has a clinical significance as it minimizes the potential for surgical complications. There is an ethnical difference in the prevalence of anatomical variations. Further studies of anatomical variations with clinical disease correlations are needed.

Metastatic invasive lobular carcinoma of the breast masquerading as a primary renal malignancy

Breast cancer is known to metastasise to different organs in the body, but an initial presentation of breast cancer with loin pain secondary to a metastatic renal mass is extremely rare. We report a 58-year-old woman who presented with recurrent left loin pain due to a metastatic deposit of invasive lobular carcinoma of the breast. The detection of a renal mass on computed tomography led to the assumption of a renal pelvic malignancy. The diagnostic dilemma posed by the detection of a breast mass during staging and the usefulness of immunohistochemistry in the confirmation of diagnosis are discussed

Idiopathic granulomatous mastitis. Diagnostic strategy and therapeutic implications in Omani patients

Idiopathic granulomatous mastitis [IGM] is a rare benign disorder of the breast whose aetiology is controversial, and is often misdiagnosed clinically and radiologically as mammary malignancy; as a result, it may be incorrectly treated. Although no standard treatment is available for this chronic disease, surgery with or without corticosteroids has been tried with controversial results. This study discusses the clinical presentation, diagnosis, management, recurrence, and follow-up data of IGM with a review of relevant literature. From 2009-2012, the Breast Unit at Sultan Qaboos University Hospital, Oman, conducted a clinical study on 20 patients with breast lumps. Their clinical and radiological examinations were indeterminate, and a diagnosis of granulomatous mastitis was established only by histopathology. The majority of the patients were cases of unknown aetiology, who presented with a unilateral breast mass. A few patients had a mass with an abscess, along with axillary lymphadenopathy. A total of 4 patients were suspected of malignancy using radiology. In all patients, sterilised pus was sent for culture and sensitivity. Microscopy showed the characteristic pattern of granulomatous inflammation. All patients were treated with antibiotics for 6 weeks, and the mean follow-up period was 15 months [11-33 months]. All patients had complete remission with no further recurrence. This single largest study of cases of IGM in Oman highlights the pitfalls in diagnosing this non-neoplastic disease of unknown aetiology and uncertain pathogenesis. It emphasises IGM's excellent response to antibiotics, which is crucial, as IGM is a disease which is notoriously difficult and controversial to treat

Marjolin's Ulcer: radiographic and magnetic resonance appearances in two cases

Marjolin's ulcers are malignancies that arise in chronic venous ulcers, scars, burns, long standing wounds or sinuses. Radiography provides important information regarding bone destruction and periosteal reaction, and magnetic resonance [MR] imaging provides excellent soft tissue detail, like tumour extent, depth, margins, any underlying bone cortical or marrow involvement, or involvement of adjacent neuro-vascular structures. We report two cases of Marjolin's ulcer and describe their radiographic and MR appearances

Gastric adenocarcinoma in association with tuberous sclerosis case report

We report the first case of gastric cancer in association with tuberous sclerosis. Tuberous sclerosis is an autosomal dominant disorder which presents with a constellation of signs including benign tumours in the brain and in other vital organs such as the kidneys, heart, eyes, lungs, and skin. A combination of symptoms may include seizures, developmental delay, behavioural problems, skin abnormalities, and lung and kidney disease. It is caused by mutations on either of two genes, tuberous sclerosis genes, TSC1 or TSC2, which encode for the proteins hamartin and tuberin respectively. These proteins act as tumour growth suppressor agents that regulate cell proliferation and differentiation. Tuberous sclerosis has been associated with hamartomatous growths and angiomyolipomas, an association with gastric cancer has not been reported; however, this could be a co-incidental finding and further cases need to be reported

Metastatic malignant melanoma during pregnancy: case report and a review of the literature

Malignant melanoma is one of the most rapidly increasing cancers and, when it occurs during pregnancy, it can frequently metastasise to the placenta and the foetus. Earlier reports suggested a rapid progress of the disease during pregnancy with a poor prognosis; however, recent controlled studies found that stage for stage, the prognosis of melanoma during pregnancy is similar to that in a non-pregnant state. Early diagnosis and prompt treatment can avoid a tragic outcome

Tc-99m tetrofosmin scintimammography for the detection of recurrent breast cancer in a patient with equivocal mammography study

This is a case report describing a patient at Sultan Qaboos University Hospital, Oman, with recurrent local breast cancer and axillary lymph node metastasis. The cancer was detected with 99Tc-m tetrofosmin scintimammography after an equivocal mammography study

Pulmonary infarction. A rare case of adrenal carcinoma

A case report of unsuspected adrenal carcinoma with pulmonary artery obstruction in a young girl who was admitted with recurrent episodes of hypotension is presented. Computed tomography [CT] scans demonstrated a large right adrenal mass extending into the inferior vena cava [IVC], right atrium, right ventricle and right pulmonary artery. There are many case reports in literature documenting IVC and right atrial thrombus in patients with adrenal carcinoma. To our knowledge, this is the first case report specifically documenting pulmonary infarction secondary to tumour extension into the pulmonary artery