Distant cutaneous metastasis of pleural malignant mesothelioma.

We report a facial tumor that was proven to be a metastatic mesothelioma. The diagnosis was not established pre-mortem. The patient died shortly after the facial biopsy, and an autopsy revealed a large pleural-based mass which had the gross appearance typical of a mesothelioma. Electron microscopic examination of tissue from the pleural tumor was diagnostic for mesothelioma. The patient had extensive visceral metastatic disease. Inclusion of this entity in the differential diagnosis of certain cutaneous tumors is important, in part because this lesion may be confused with angiosarcoma, particularly when it occurs in the skin of the face or head in older patients.

Stratified diagnostic approach to fine needle aspiration of the breast.

The clinical value of fine needle aspiration (FNA) of the breast is enhanced by incorporating into the cytologic diagnosis explicit comments on the level of diagnostic certainty. This stratification of diagnostic certainty is based predominantly on the cytologic features but occasionally also takes into consideration the clinical situation. Strong clinical and mammographic suspicion of mammary carcinoma associated with FNA, diagnostic of typical, intermediate to high-grade mammary carcinoma, warrants proceeding to definitive therapy without further diagnostic studies. False-positive results are virtually eliminated by placing cases with any uncertainty into a "probable" category, which does not support definitive therapy. In addition, oversimplified "benign versus malignant" approaches to FNA diagnoses ignore the heterogeneity of breast masses, with in situ and low-grade carcinomas warranting special clinical management and usually being placed in the "probable" category. Thus, malignant diagnoses are stratified into "definite" and "probable," with only the former supporting definitive therapy. Within our recent series of 1,005 FNAs of the breast, we were able to confirm the diagnosis in all 62 patients with a "definite" carcinoma diagnosis, and only 3 of 25 "probable" cancer diagnoses were benign at tissue biopsy. Thus, false-positive results were successfully avoided in the "definite" category. Furthermore, a much greater incidence of unusual and good prognosis tumor types were identified by the "probable" category. If the clinical setting is relatively suspicious only, a definitive diagnosis of cancer by FNA is rare and not necessary because the clinical question to be addressed is only whether to biopsy. This approach to FNA diagnosis, unlike the oversimplified "benign versus malignant" scheme, provides an approach that is more likely to result in optimal therapy for breast neoplasms, with low-grade or in situ carcinomas requiring special clinical management since these types of cancers are found predominantly in the "probably malignant" category. It also provides additional security against false-positive diagnoses by incorporating clinical level of certainty statements into FNA diagnostic categories, which more closely reflect the diversity and inherent complexity in the appropriate diagnosis and therapy of mammary carcinomas.

Occurrence of ovarian malignancy in childhood and adolescence: a community-wide evaluation.

During childhood and adolescence, the rate of malignancy in ovarian enlargement is reported to be high-approximately 35% in many large series from tertiary centers. To assess whether this represents an overestimation because of the referral patterns of these institutions, a retrospective review was conducted at five hospitals in Nashville, Tennessee. In females 21 years of age and under, borderline or malignant ovarian neoplasms were identified in only eight (5.8%) of 137 individuals with ovarian enlargement and eight (9.8%) of 82 females with ovarian neoplasms. All six malignant neoplasms were of germ-cell origin. The borderline neoplasms were of epithelial origin, and occurred in females in their late teens. We conclude that the frequency with which ovarian enlargement represents malignancy in this age group appears to be much smaller than previously suggested. Nevertheless, because of the potential for malignant ovarian neoplasia in young females, the presence of an abdominal-pelvic mass requires prompt and thorough attention.

Neuroleptic malignant syndrome presenting as adult respiratory distress syndrome and disseminated intravascular coagulation.

We have reported a case of neuroleptic malignant syndrome (NMS) in a patient with historical and clinical features suggestive of heat stroke or sepsis and adult respiratory distress syndrome (ARDS). ARDS and disseminated intravascular coagulation may be important, atypical signs encountered early in NMS and complicating its recognition.

Myometrial invasion by endometrial carcinoma: sonographic assessment.

The depth of myometrial invasion by endometrial carcinoma was evaluated using real-time sonography (US) in 20 patients with histologically proved adenocarcinoma of the endometrium. In 14 of 20 (70%) cases, US-based estimation of the depth of myometrial invasion was within 10% of the actual measurement in the gross specimen. The US-based estimation of tumor invasion was low in seven patients, high in four patients, and agreed with pathologic findings (+/- 5%) in nine patients. In four patients with polypoid intraluminal extension of tumor, a deeply invasive tumor was suspected on US but was not found on pathologic examination. In 12 superficially invasive tumors, the continuity of the demarcating subendometrial halo was intact in nine and incomplete in three. In six patients with deeply invasive tumors, this zone was partially disrupted in four, totally disrupted in one, and intact in one. Errors of estimation of the depth of myometrial invasion on US most frequently occurred when a tumor had a significant intraluminal polypoid extension. Demonstration of a subendometrial halo usually indicated superficial invasion, whereas the absence of a halo was frequently associated with deep invasion.

Breast sonotomography and high-frequency, hand-held, real-time sonography: a clinical comparison.

The diagnostic quality of breast sonography as performed with a dedicated tomographic unit (ST) and a hand-held, high-frequency, real-time transducer (RT) was evaluated in 76 patients. In 38 per cent of cases, ST was found to be of equal diagnostic quality to RT. The number of instances in which ST was judged to be better than RT was slightly greater than those in which RT was considered better than ST (34 vs. 24 per cent) (P less than or equal to 0.10). In 3 per cent of cases, the diagnostic quality of both ST or RT was considered to be poor. The majority of instances when the diagnostic quality of ST was judged to be better than RT occurred in establishing a negative diagnosis, whereas RT seemed to have greater diagnostic quality than ST in the evaluation of a palpable mass.

Prior cesarean section. A risk factor for adenomyosis?

Four hundred eighty-five cases of histologically proven adenomyosis were reviewed to determine if that condition might have been induced by transplanted endometrium at the time of cesarean section. The rate of cesarean section in the study group was 6.4%. Evidence of the cesarean scar was noted histologically in 13 of 31 patients (42%) who had undergone cesarean section, and 2 of the 13 (15%) had evidence of glands and stroma within the scar. Both patients had other pathology that could account for their symptoms. Prior cesarean section does not appear to be a risk factor for symptomatic adenomyosis.

Auditing the quality of care of a crisis center.

The purpose of this paper is twofold: First, it defines and describes different types of audits and areas of patient care which lend themselves to a quality of performance review. Second, it describes an audit application at a hospital-based crisis intervention center and the corrective action taken on the basis of the findings. The major emphasis of the audit was to determine the quality of medical-psychiatric consultation and to develop criteria for its initiation.