New directions in breast biopsy: review of current minimally invasive methods and presentation of a new coaxial technique.

Minimally invasive core breast biopsy methods are replacing hook-wire-guided surgery wherever ultrasound and stereotactic equipment are available. Cost efficiency is improved, but sampling errors inherent in these techniques cause underestimations of malignancy and the degree of invasiveness in a small but significant number of patients. Diagnostic accuracy improves with increasing specimen weight. The trend is to take many cores. How much tissue is enough to enable a confident diagnosis? Recent research suggests that 1 g of tissue is sufficient. A new coaxial biopsy method presented here can retrieve a contiguous 1-g block of tissue from the center of a mammographic lesion, without stereotactic guidance. This specimen may be superior to multiple small cores obtained by biopsy guns and vacuum devices.

Imaging of hydrosalpinx with torsion following tubal sterilization.

Hydrosalpinx following tubal sterilization has been observed with increasing frequency. Women who have had PID or who have used IUDs might be at risk of developing this condition because they may already have occluded tubes from prior salpingitis. If a previously occluded tube is ligated or cauterized so that a second occlusion is created, hydrosalpinx may be anticipated. Often bilateral, hydrosalpinx may be present for years. Recurrent pelvic pain may signify intermittent noninfarctive torsion, but severe acute pain is a sign of torsion with impending infarction and gangrene in some patients. This condition has been detected by ultrasound and CT, enabling preoperative diagnosis. Presumably it will also be imaged by MR. Nontorsive hydrosalpinx is usually imaged as a thin-walled adnexal cyst. Torsion with infarction is seen as a larger cystic structure with thicker walls and internal debris from venous congestion and internal hemorrhage. Since 25 of 30 patients with post-tubal sterilization hydrosalpinx have presented with acute torsion, the significance of a nontorsive hydrosalpinx detected by any imaging modality should not be disregarded. Surgical removal or percutaneous puncture and drainage should be considered. Awareness of the patient's medical history is the key to diagnosis.

PIP: Tubal sterilization, most commonly by means of ligation or cauterization, is performed every year on over 500,000 women in the U.S. It is generally regarded as a safe and effective means of pregnancy prevention. It has been reported, however, that 3 of 1,000 women become pregnant with 2 years of sterilization. In a recent study, 12% of pregnancies occurring after tubal ligation and 51% of pregnancies following tubal cauterization were ectopic. After several years, surgically sterilized fallopian tubes exhibit pathologic changes. After 5 years of sterilization, 80% of patients develop dilation of the proximal stump lumen, which may be filled with blood and fragments of menstrual endometrium. 39% of patients develop fibrosis of the distal stumps after 5 years of sterilization. If the lumen becomes blocked at 2 sites, hydrosalpinx forms as a result of tubal epithelium secretions. This condition has increasingly been observed as a consequence of tubal sterilization. Since 1956, 30 cases of hydrosalpinx due to tubal ligation and cauterization have been reported. In 25 of these cases, torsion of the hydrosalpinx resulted in acute abdominal pain; in some cases, gangrene had developed. On average, 3.8 years elapsed between tubal sterilization and clinical presentation. Hydrosalpinx has been detected through both computerized tomography and ultrasound, allowing for preoperative diagnosis. It is usually imaged as a thin-walled adnexal cyst. Torsion is seen as a larger cystic structure with thicker walls. The key to diagnosis is awareness of a patient's medical history.

Hydrosalpinx and tubal torsion: a late complication of tubal ligation.

Two women who had been sterilized by tubal ligation or cautery experienced recurrent pelvic pain several years later, and cystic adnexal masses were recognized in both patients. Both patients had bilateral hydrosalpinges with unilateral torsion and gangrene. These cases suggest there may be a predisposition to hydrosalpinx and tubal torsion following tubal ligation if the fimbriated end of the fallopian tube becomes occluded. Awareness of this potential complication may lead to increased recognition and earlier intervention in patients who have undergone tubal ligation.

Renal oncocytoma: sonographic analysis of 14 cases.

The sonographic features of 15 histologically confirmed renal oncocytomas in 14 patients are presented. Lesions were evaluated for homogeneity, echogenicity, margination, venous invasion, and nodal enlargement. Nine were less than 5.5 cm in diameter, homogeneous, and well circumscribed. Three lesions were greater than 8 cm in diameter, contained areas of central necrosis or calcification, and were nonspecific for renal oncocytoma. One of these lesions (12 cm) contained a central scar. Two masses were slightly inhomogeneous and, at best, moderately circumscribed. In no case were metastatic nodes or venous invasion present. Since about 6% of renal cell carcinomas may have this appearance, the homogeneous, well marginated renal mass that is isoechoic with cortex and less than 5.5 cm in diameter is as likely to represent renal cell carcinoma as it is an oncocytoma. Although only present in one of the cases, the central fibrotic scar in a larger mass has been described in oncocytoma and may be the most specific feature. Preoperative investigation with fine-needle aspiration biopsy for cytology may be indicated in an attempt to avoid radical nephrectomy in selected patients.

Hip fracture: a review of 1,166 cases in a community hospital setting.

A consecutive series of 1,166 patients 50 years of age and older with acute hip fracture, treated at a community hospital over a 20-year period, is analyzed as to age, sex, type of fracture, associated diseases, and treatment in relation to mortality and morbidity. Mortality was 8.66% overall (6.58% for patients treated surgically, 30.39% for nonoperative patients). The postoperative complication rate for surgical patients was 21%. Associated diseases, type of treatment and delay prior to surgery were major factors contributing to mortality. It was found that a patient's survival chances are enhanced by adequate control of associated diseases prior to and following injury, early surgery, and competent treatment of the fractured hip. Also, the mortality rate for patients with fractured hips was found to be lower for patients treated in community hospitals than for patients treated in municipal or county hospitals.

Migration of left hip pin with involvement of left ureter.

This patient had hematuria and a history of hip fusion many years before. It was found that a left hip pin had broken, and its sharpened portion had migrated through the head of the femur into the adventitia of the left ureter. During exploratory surgery, a bonecutter was employed to cut off the tip of the pin flush with the pelvic wall. The patient has had no recurrence of hematuria. Review of the literature disclosed no report of a similar case.

Treatment of intertrochanteric and subtrochanteric fractures with Ender's intramedullary rods.

A series of 100 patients was treated with Ender's rods for intertrochanteric fractures, subtrochanteric fractures and intertrochanteric pathologic lesions. Healing occurred within 4 months in all 85 of the patients who could be followed, and fractures were prevented in all 4 of the patients with pathologic lesions. Every patient who was ambulatory preoperatively regained ambulation within 3 months after surgery. Inhospital mortality for the series was 3%, compared to 8.4% for a 20-year series of 1,204 hip fractures treated by conventional means. Other advantages of the Ender's rod method are simplicity of the insertion procedure, minimal trauma and blood loss, uniform distribution of stress, early ambulation and weight bearing, and lower morbidity.

Radionuclide imaging of intestinal infarction.

An acute small bowel infarction in a 57-year-old male alcoholic produced a dense positive image on a gallium-67 citrate scan. Radionuclide imaging may be useful in the diagnosis of this condition, which has a high mortality rate and is not often diagnosed premortem.

Multidirectional tomography in cervical spine injury.

Forty-one patients with acute cervical spine injury were examined by both conventional radiography and multidirectional tomography and the findings compared. Indications for tomography are given.

Unusual bone-scan findings in acute osteomyelitis: case report.

In osteomyelitis, bone-scan findings precede the appearance of bone changes on radiographs. In cases where focal ischemia occurs, the earliest scan finding may be a "cold" area that later becomes "hot" as active periostitis develops.

Lumbar spinal stenosis. Radiographic diagnosis with special reference to transverse axial tomography.

Spinal stenosis due to malalignment and/or hypertrophy of the bony margins of the spinal canal is a recognized cause of cauda equina compression and nerve root entrapment. The plain lumbosacral spine roentgenograms reveal the number of lumbar vertebrae, their alignment, their interpedicular distances, the height of the intervertebral disk spaces and the presence of osteophyte formation. It correlates poorly with encroachment on the spinal canal. The transverse axial tomogram directly demonstrates a cross-section of the spinal canal and will show abnormal areas of bone encroachment usually arising from hypertrophied lamina and articular processes. These narrow the posterior portion of the spinal canal and encroach on the lateral recesses. This examination does not demonstrate soft tissue hypertrophy and the stenosis may be even greater than what is apparent due to the bony encroachment. The myelogram expresses how the narrowed spinal canal affects the dural sac and its contained cauda equina. Not infrequently there is an associated herniated disk.

Valve dynamics.

Flow between two contiguous elastic sheets (valve leaflets) generates one of two types of behavior. At low pressure differences, e.g. 1 cm H2O, the sheets part slightly and the fluid passes silently between them. The aperture under these silent conditions varies with the square of the length of the orifice, the transvalvular pressure difference and the kinetic energy, divided by the thickness of the leaflets. At higher transvalvular pressure differences the downstream end of the bicuspid valve alternately closes and reopens (flitter), and functions as an acoustic oscillator. The recurrence rate of flitter varies with the tension on the leaflets and inversely with the thickness. The threshold of the onset of flitter varies with the product of the pressure and the square of the length of the valve aperture, divided by the wall tension and thickness. The significance of these data in the onset of the flitter and of the recurrence rate is discussed in terms of the production of sounds and murmurs at the heart valves, vocal cords and other sites.