Corneal stromal sequestration and keratoconjunctivitis sicca in a horse.

A 19-year-old Shetland pony presented with unilateral ocular discomfort and abnormal ocular appearance. Keratoconjunctivitis sicca, ulcerative keratitis and brown discoloration of the corneal stroma were identified on ophthalmic examination. The etiology of keratoconjunctivitis sicca was not determined in this case. For practical and financial reasons, the owners requested enucleation of the affected eye. Histopathologic examination revealed extensive loss of corneal epithelium overlying a zone of hypereosinophilic, degenerate, and necrotic corneal stroma. This well-circumscribed region of corneal stromal sequestration was surrounded by stromal vascularization, and an intense inflammatory, predominantly polymorphonuclear, cellular infiltrate. The clinical and histopathologic features of this case were considered remarkably similar to those observed in feline corneal stromal sequestration.

Renal peripelvic lymphangiectasia: appearance at CT.

In a patient who had undergone emergency nephrectomy during exploratory surgery, a pathologic diagnosis of peripelvic lymphangiectasia was made. Subsequent computed tomographic examination of the remaining kidney showed large multilocular renal sinus cysts, renal capsular cysts, and regions of fluid attenuation surrounding the mesenteric vessels, findings consistent with peripelvic lymphangiectasia. A brief discussion of cystic disease of the renal sinus is presented.

Application of estrogen receptor immunocytochemical assay to aspirates from mammographically guided fine needle biopsy of nonpalpable breast lesions.

The importance of hormone receptors in the management and prognosis of breast cancer is well established, but difficult to apply to the growing numbers of very small breast cancers being detected. To assess the feasibility of applying estrogen receptor immunocytochemical assay (ER-ICA) to cytologic specimens, we prospectively studied 100 patients who had fine needle aspiration biopsy (FNAB) of mammographically detected nonpalpable breast lesions. All 100 patients also had surgical excision of these nonpalpable lesions immediately after cytologic aspiration. Twenty malignancies were ultimately diagnosed by histology; 17 of them had been cytologically diagnosed. Using specific monoclonal antibody for estrogen receptor, we applied ER-ICA to cytologic preparation of 15 malignant neoplasms with sufficient cellular material available for the assay. Positive immunostaining was demonstrated in nine cases. No ER expression was seen in six cases. Immunocytochemical assay was also done on frozen tissue of the corresponding surgically removed tumors, with 86.6% concordance between the two results. This study is the first to demonstrate that ER-ICA can be effective in assessing hormone receptor content of mammographically directed cytologic aspirates.

Cytologic differentiation between proliferative and nonproliferative breast disease in mammographically guided fine-needle aspirates.

Fine-needle aspiration biopsy (FNAB) is considered a valid diagnostic procedure in management of patients with breast lesions. It is also important to differentiate benign nonproliferative change from proliferative breast changes, since the risk of development of breast carcinoma in patients with atypical hyperplasia is 4-5 times that of general population. Therefore, the recognition of proliferative breast disease with atypia significantly impacts on the patient's subsequent management. To assess the feasibility of a cytologic grading system to further characterize benign breast lesions, cytologic preparation of 87 mammographically guided FNABs were studied. Cellular aspirates were evaluated for the cellular arrangement, the degree of cellular pleomorphism and anisonucleosis, presence of myoepithelial cells and nucleoli and the status of the chromatin pattern. Values ranging from 1 to 4 were assigned to each cytologic criterion, and a score based on the sum of the individual values was calculated for each case. The minimum score attainable was thus 6. In our chosen criteria cytologic diagnosis of nonproliferative disease was entertained when the total score ranged from 6 to 10. Proliferative disease without atypia was diagnosed with a total score ranging from 11 to 14. Atypical hyperplasia was reported when the total score ranged from 15 to 18. A cytologic diagnosis of malignancy was entertained when the total score ranged from 19 to 24. The cytologic diagnosis was then compared to the reported histologic diagnosis from the excisional biopsies and the data were statistically analysed. A high degree of concordance was found between the cytologic findings and the histologic diagnosis. This study suggests that it is possible to apply a cytologic grading system to further subclassify benign breast disease and distinguish these forms from neoplastic lesions.

Prospective evaluation of radiologically directed fine-needle aspiration biopsy of nonpalpable breast lesions.

The application of fine-needle aspiration biopsy (FNAB) to the diagnosis of nonpalpable breast lesions was evaluated with a new method which uses standard needle localization under mammographic guidance to assure accurate sampling by FNAB. This method was prospectively applied to 100 mammographically detected breast lesions in 100 women (mean age, 53 years). All 100 patients underwent surgical excision of these nonpalpable lesions after cytologic aspiration. Sufficient aspirated material was obtained for cytologic diagnosis from 91 patients (91%). The histologic and cytologic interpretations were then compared. Twenty malignancies were ultimately diagnosed by histology (12 invasive ductal carcinoma, six ductal carcinoma in situ, and two lobular carcinoma in situ), of which 17 had been cytologically diagnosed. There were no false-positive diagnoses of malignancy by FNAB. False-negative readings (3.3%) included two cases of lobular carcinoma in situ and one case of ductal carcinoma in situ. This technique thus demonstrated a sensitivity of 85%, specificity of 100%, and overall diagnostic accuracy of 96.7% for the nonsurgical detection of malignancy in nonpalpable breast lesions. These results suggest that the established safety, reliability, and cost-effectiveness of FNAB can be maintained in this clinical setting. This procedure may obviate the need for open surgical biopsy in those patients with an unequivocal diagnosis of malignancy. It can also be done using standard techniques and equipment available in many community hospitals.

A reassessment of the role of arteriography in penetrating proximity extremity trauma: a prospective study.

Penetrating proximity extremity trauma (PPET) was prospectively studied to clarify the role of routine arteriographic evaluation (AG). Over a 24-month period, 135 patients were identified with 152 injuries from PPET. All patients underwent AG and were randomized to either immediate or delayed timing. There were 27 arteriographic abnormalities from these 152 wounds, of which 16 (10.5%) were in major arteries. One acute arteriovenous fistula underwent immediate surgery. The remaining 15 major vessel injuries were nonoperatively observed, including seven cases of segmental arterial narrowing, six intimal flaps, and two small pseudoaneurysms (one of which enlarged and underwent surgical repair after 10 weeks of followup). Nine of the remaining 14 lesions resolved; two improved and three remained clinically unchanged over a mean followup interval of 2.7 months. Shotgun trauma was the mechanism which carried the greatest risk of significant vascular injury. Although "soft" clinical signs were significantly more predictive of vascular injury following PPET than proximity alone (p less than 0.0005), 50% of all injuries to major arteries did not manifest soft signs. No extremity morbidity resulted from delayed AG or from vascular injury management. We conclude from our study population: 1) the natural history of clinically occult arterial injuries was predominantly benign; 2) AG could be safely delayed up to 24 hours; 3) "soft" signs were not clinically useful predictors of vascular injury; and 4) with the exception of shotgun wounds, AG did not appear to be a cost effective screening modality, since detection of a single vascular injury requiring surgery cost $66,420.00.

The potential value of mammographically guided fine-needle aspiration biopsy of nonpalpable breast lesions.

Nonpalpable breast lesions in 20 female patients were prospectively evaluated with a new technique of fine-needle aspiration biopsy (FNAB) under mammographic guidance. The patient age range was 37-82 years (mean: 60 years), and the mammographic indications for biopsy were microcalcifications (30%), mass (30%), mass with calcifications (25%), and asymmetric density (15%). Seven (35%) patients had significant risk factors for breast cancer. Prototype coaxial 19-gauge/22-gauge and 18-gauge/20-gauge needle systems (Cook, Inc., Bloomington, IN) were used for localization and biopsy. The technique involved needle localization of the target lesion with FNAB performed through the localizing needle after radiologic confirmation of position. A localizing wire then was inserted to allow each patient to proceed directly to the operating room for a standard needle localization open biopsy. Successful localization and aspiration was possible in 18 (90%) patients. Surgical excision was performed in all 20 patients and confirmed by specimen radiography in 17 (85%). A significant concordance of 94 per cent was found between the histologic results of the open biopsy specimens and the cytologic findings of aspirated specimens. These findings suggest that mammographically guided FNAB may offer a safe, reliable, and cost-effective alternative to open biopsy of nonpalpable breast lesions. Further study of this procedure is warranted to confirm its potential in this area.

Aneurysm of the internal iliac vein as a rare source of pulmonary thromboembolism.

This is the first reported case of internal iliac vein aneurysm, manifested by recurrent pulmonary embolism. The case emphasizes the importance of searching for unusual sources of unexpected and unexplained pulmonary emboli. Venous aneurysms may have various manifestations and sequelae. Antecedent trauma and arteriovenous fistulas should be excluded.

Pulmonary artery catheterization: a modified technique.

A modified technique for catheterization of the pulmonary artery was developed. It involves the passage of a tapered, movable-core, J-tipped guide wire across the right ventricle into the pulmonary artery followed by the advancement of a straightened Grollman pigtail catheter. The technique was successful in 34 of 34 pulmonary artery catheterizations. The method avoids prolonged catheter manipulation within the right ventricle. In addition, since the catheter does not cross the tricuspid valve until the guide wire has been advanced, the occasional complication of the pigtail "hooking" on a tricuspid valve leaflet or chordae tendineae during catheter withdrawal and manipulation is prevented.

Screening and early diagnosis of breast cancer.

Long-term survival in breast cancer currently rests on detection and appropriate therapy at the earliest possible stage, with survival being excellent in patients whose cancers are discovered at a small size and without dissemination. Discovery of lesions at the smallest possible size is therefore desirable. Of the available imaging modalities, only modern mammography has been shown consistently to detect small breast lesions. The efficacy of screening mammography in asymptomatic women has been demonstrated in large-scale trials in women older than 49 years of age and has been strongly supported by follow-up results in the Breast Cancer Detection and Demonstration Project in women aged 40 to 50 years. Mammographic screening has been advocated by the American Cancer Society (ACS) beginning at 40 years of age, while the National Cancer Institute recommends mammographic screening beginning at 50 years of age. The ACS recommends also that breast self-examination begin at 20 years of age. Unfortunately, a great majority of women do not practice breast self-examination, nor do they know that mammography is useful in detecting breast cancer. Further, only a minority of physicians recommend screening mammography, although most recommend breast self-examination and perform physical examination of the breast. Physicians are therefore urged to recommend regular screening to their patients.

Persistent sciatic artery: clinical, surgical, and angiographic aspects.

The sciatic artery is a persistent fetal vessel that usually constitutes the end arterial supply to the lower extremity and replaces the femoral artery, which is usually present but hypoplastic. It is prone to vascular disease, such as aneurysm and arteriosclerosis. The artery can be demonstrated angiographically by transfemoral catheterization or translumbar aortogram with peripheral studies. Bilateral aortoperipheral studies are necessary because the anomaly is often bilateral. Surgical therapy was carried out on ten of 18 patients. The recommended technique is a femoropopliteal vein bypass. When an aneurysm is present, either ligation of the aneurysm or aneurysmorrhaphy accompanied by femoral popliteal bypass is the recommended procedure.