Fine needle aspiration diagnosis of benign oncocytic lesions of the head and neck associated with false positive 18F-fluorodeoxyglucose uptake on positron emission tomography scan.

INTRODUCTION: 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) has become the mainstay for staging and post-therapy surveillance of cancer as malignant neoplasms generally demonstrate higher FDG uptake that benign entities. However, there are certain benign lesions, most notably oncocytic tumors, that can display very high uptake and fine needle aspiration (FNA) is usually done to confirm malignancy. Therefore, it is important to recognize that benign oncocytic lesions of the head and neck may also present as FDG-avid lesions to avoid a diagnostic pitfall. METHODS: Electronic search of institutional surgical and cytopathology archives was conducted to identify cases of benign oncocytic lesions involving the head and neck region diagnosed by FNA from January 2012 to April 2022. Chart review was used to assess whether lesions were initially discovered via PET scanning. RESULTS: One hundred and twenty-five cases of oncocytic lesions were identified; 12 (9%) PET positive lesions were identified in the head and neck region from patients being evaluated for metastasis or for suspicion of malignancy. Cytopathology of all 12 cases demonstrated benign oncocytic lesions; eight (67%) of these cases were consistent with Warthin tumor, one (8.3%) was a benign oncocytic lesion, and one (8.3%) was consistent wit a parathyroid adenoma. Most (58%) of the PET-positive lesions were in parotid region, two from thyroid gland (17%), one from submandibular gland (8%), one from paratracheal area (8%). The PET scan SUVs ranged from 3.3 to 19.5 g mL-1. CONCLUSIONS: Oncocytic lesions including Warthin tumors can result in false-positive FDG uptake on PET scans. Clinicians and cytopathologists should be aware of PET-positive benign oncocytic head and neck lesions.

Flow cytometry improves the diagnostic value of fine needle aspiration cytology in a spleen with neuroendocrine tumor: A case report.

Fine needle aspirations are infrequently performed on the spleen due to concerns for hemorrhagic complications. As a result, splenic lesions can be challenging to diagnose given the limited amount of available specimen. Metastasis to the spleen is rare and metastatic neuroendocrine tumors to the spleen are scarce in literature. The diagnosis of splenic lesions from fine needle aspirate entails processing which prolongs the turnaround time, particularly if the cytomorphology is non-typical and a limited sample can further complicate this process. We describe a case in which flow cytometry performed on fine needle aspiration of a splenic lesion suggested a diagnosis of neuroendocrine neoplasm involving the spleen. Further workup confirmed this diagnosis. Flow cytometry can recognize neuroendocrine tumors involving the spleen in a timely manner so that appropriate immunohistochemistry tests on limited specimens can be performed to aid in their accurate diagnosis.

Delays In Breast Cancer Diagnosis At A Tertiary Care Facility In Karachi, Pakistan.

BACKGROUND: Diagnostic delay of breast cancer is linked to poor prognosis and survival. It can be caused by patients or healthcare providers. Since there is no quantification of provider delay and total delay in Pakistan, the general picture of breast cancer diagnostic delay is poorly understood. This study was conducted to quantify total delay, provider delay, and patient delay, along with the factors contributing to each type of delay in breast cancer management. METHODS: This was a descriptive study conducted over 3 years at a hospital in Karachi. Convenience sampling was used. Breast cancer patients undergoing treatment were interviewed. Values for diagnostic delays extracted from literature were >12 weeks in seeking care as patient delay and >4 weeks in treatment initiation as provider delay. RESULTS: A total of 334 patients were included in the analysis. Mean total delay was 56±52 weeks, the median (IQR) patient delay was 4 (0-22) weeks, and the median provider delay was 17 (9-52) weeks. Patient delay was found in 149 (44.6%), and provider delay was found in 269 (80.5%) patients. Believing symptoms to resolve on their own was the most common reason (24.9%) for patient delay. Seeking multiple opinions (43.7%) and misdiagnosis (43.4%) were the most common reasons for provider delay. CONCLUSIONS: Patients and providers both caused diagnostic delay in breast cancer treatment. There is a need to increase awareness in the general population and enhance the training of providers regarding timely recognition in all patients presenting with breast-related symptoms.

Efficacy and safety of pembrolizumab based therapies in triple-negative breast cancer: A systematic review of clinical trials.

Breast cancer is the most common cause of cancer-related deaths among women. There are a limited number of targeted therapies available for triple-negative breast cancer (TNBC), and chemotherapy is the mainstay of treatment. Among checkpoint inhibitors, atezolizumab is the only drug approved for PD-L1+ TNBC patients. We performed a systematic review to assess the efficacy and safety of PD-1 inhibitor pembrolizumab in triple-negative breast cancer. We included 15 clinical trials in this review. Pembrolizumab was well tolerated by all patients with triple-negative breast cancer. Pembrolizumab was more effective in the treatment of early-stage TNBC patients as compared to placebo, regardless of PD-L1 status. In advanced-stage breast cancer, pembrolizumab was as effective as single-agent chemotherapy with a better safety profile. Pembrolizumab with chemotherapy showed significantly better median progression free survival as compared to chemotherapy in advanced TNBC.

Performing cytoreductive nephrectomy following targeted sunitinib therapy for metastatic renal cell carcinoma: a surgical perspective.

OBJECTIVE: To describe for surgeons contemplating performing cytoreductive nephrectomy (CRN) on patients after neoadjuvant sunitinib compared to a benchmark of open radical nephrectomy, describing technical difficulties, safety and feasibility. PATIENTS AND METHODS: We compared measurable surgical parameters and perioperative complications in 22 patients with metastatic renal cell carcinoma (mRCC) undergoing CRN after neoadjuvant sunitinib, with 28 patients who underwent open radical nephrectomy for non-metastatic disease (nmRCC). RESULTS: Median blood loss (320 vs. 775 ml), median operative time (128 vs. 195 min) and median length of stay (5 vs. 7 days) were greater in the mRCC group. Surgery after sunitinib was technically challenging due to fibrosis, loss of the tissue planes that usually facilitate radical nephrectomy and abnormal blood vessel formation. Side effects of sunitinib resulted in predictable complications. CONCLUSION: CRN after treatment with sunitinib is safe and feasible in our hands, although the surgery is more time-consuming and technically demanding. A multidisciplinary approach is mandatory.

Influence of age and bladder dysfunction on the contractile properties of isolated human detrusor smooth muscle.

OBJECTIVE: To test the hypothesis that the in vitro contractile properties of human detrusor smooth muscle are dependent on the age, gender and lower urinary tract pathology of the patient. MATERIALS AND METHODS: Contractions were elicited in isolated human detrusor smooth muscle preparations by nerve-mediated electrical field stimulation, agonist application (carbachol, α,ß-methylene ATP and high-K solutions) or direct muscle electrical stimulation. Biopsies (n = 227) were obtained from four groups of patients with: stable bladders (control), bladder outlet obstruction (BOO), idiopathic (IDO), or neurogenic (NDO) detrusor overactivity. RESULTS: The magnitude of nerve-mediated contractions declined as a function of patients' age in each of the BOO, IDO and NDO groups but not in the control group. Contractions elicited by direct muscle activation (10 µM carbachol or electrical stimulation with 20 ms pulses in the presence of 1 µM tetrodotoxin) did not vary with patient age. Carbachol contractions were significantly smaller in samples from NDO bladders. Atropine resistance was more prevalent in the pathology groups compared with the control group and was greatest in the IDO group. There was no influence of age in the prevalence or magnitude of atropine-resistant contractions in any group. Muscle excitability to direct electrical stimulation was similar in all groups. CONCLUSIONS: In the human bladder there is no evidence for a decline of detrusor smooth muscle contractility or excitability as a function of age, nor any gender difference or presence of pathology. In the pathology groups there was evidence for a decline of functional innervation with age.

Genital foreign bodies: more than the eye can see.

Genital foreign bodies constitute a diverse but surprisingly common means of presentation to emergency departments. Although the presentation usually means the initial diagnosis is easily made, we present a case here that stresses the importance of attention to history, clinical examination and radiological investigation. A 44-year-old gentleman presented with a history of pain and discharge from a self-inflicted scrotal wound. Further questioning revealed a history of genital foreign bodies, but the full extent of his condition was not apparent until plain pelvic radiographs were obtained. The initial management of genital foreign bodies follows basic surgical principles. Constricting bands must be removed, devitalized tissues debrided and the surgical field extensively irrigated. Underlying psychiatric illness may be present and a high index of suspicion is required in the initial assessment of such patients. A plain pelvic radiograph is recommended to fully identify all foreign bodies present.

The current role of the artificial urinary sphincter for the treatment of urinary incontinence.

PURPOSE: The introduction of the artificial urinary sphincter (AUS) in 1972 was heralded as a revolution for the treatment of genuine stress incontinence. Initial enthusiasm was tempered by disappointment as complications occurred. The device has now been in routine clinical use for more than 30 years, and the indications and surgical principles involved in its use along with short-term and long-term outcomes are more clearly defined. Hence, we reviewed the literature to clarify the role of the AUS and offer a possible solution to its problems in the guise of a new sphincter. MATERIALS AND METHODS: A MEDLINE search was performed and all articles relating to the role of the AUS for the treatment of urinary incontinence were reviewed. RESULTS: The AMS 800 (American Medical Systems, Minnetonka, Minnesota) provides urinary continence in 73% of cases (range 61% to 96%) and it has a complication rate of 12% (range 3% to 33%) for mechanical failure, 4.5% to 67% for early infection/erosion, 15% for late erosion and 7% for delayed recurrent incontinence. The literature supports the role of the AUS as an important and reliable treatment modality for stress urinary incontinence and intrinsic sphincter deficiency. However, it is not suitable in all patients and its use for the management of hypermobility is controversial. Hence, careful patient selection according to indication is required with full preoperative counseling. CONCLUSIONS: Despite its reliability for achieving urinary continence the AMS 800 is not perfect. Newer devices, such as that being developed at our institution, may offer improved outcomes and decreased complication rates.

Long-term results of a self-expanding wallstent in the treatment of urethral stricture.

OBJECTIVE: To report the long-term outcome over 12 years of using the urethral Urolume wallstent (AMS, Minnetonka, MI, USA) for treating recurrent bulbar urethral stricture disease. PATIENTS AND METHODS: The case-notes of 60 consecutive men with urethral Urolume wallstents placed for treating recurrent bulbar strictures were reviewed retrospectively. Information was collected on patient demographics, stricture aetiology, stent-related complications and the need for further surgery to treat stent- or stricture-related complications. RESULTS: The mean (range) age of the men was 58 (32-76) years. The most common cause of stricture was iatrogenic, arising after previous endoscopic surgery or after an indwelling catheter (45%). Thirty-five men had complications, with re-operation required in 27 (45%) of them. The most frequent nonsurgical complications were post-micturition dribble (32%) and recurrent urinary tract infections (27%). The most common surgical interventions required were transurethral resection of obstructing stent hyperplasia (32%), urethral dilatation or urethrotomy for stent obstruction or stricture (25%) and endoscopic litholapaxy for stent encrustation or stone (17%). CONCLUSIONS: The Urolume wallstent should only be used in patients who are unfit for or who refuse a bulbar urethroplasty.