Biopsia por punción con aguja fina sin aspiración en el diagnóstico prequirúrgico del nódulo del tiroides / Fine needle biopsy without aspiration in the presurgical diagnosis of thyroid nodule

Se estudió un grupo de 100 pacientes operados de nódulo único del tiroides en el Servicio de Cirugía General del Hospital "Cmdte. Manuel Fajardo", para validar el método de la biopsia por punción con aguja fina sin aspiración (citopunción) en el diagnóstico prequirúrgico de esa afección. A cada paciente se le realizó una citopunción con aguja No. 25 antes de la intervención quirúrgica; los resultados se clasificaron en negativos (benignos) y positivos (malignos y sospechosos) y la histología posoperatoria, en benigna y maligna, según los intereses de nuestro trabajo y de criterios preestablecidos en el Departamento de Anatomía Patológica del hospital. El 100 (por ciento) de las muestras fue útil para diagnóstico con una correspondencia entre citopunción e histología del 83 (por ciento). Los valores de los indicadores de validación fueron: sensibilidad: 76 (por ciento), especificidad: 85 (por ciento), valor predictivo positivo: 57 (por ciento), valor predictivo negativo: 93 (por ciento) y eficacia general del método: 85 (por ciento). Concluimos que la citopunción es un método diagnóstico útil en el nódulo único del tiroides y que logra iguales resultados que la BAF, pero la primera es más recomendable por ser de más fácil aplicación, menos traumático y más económico(AU)

Efficacy of selective unilateral exploration in hyperparathyroidism based on localization tests.

OBJECTIVES: To determine the success of unilateral exploration vs bilateral exploration for primary hyperparathyroidism and to analyze the validity of preoperative localization tests. DESIGN: Case-control study of patients who underwent surgical exploration (unilateral, n = 43; bilateral, n = 57) by 1 surgeon from January 1991 through May 1996 and who had ultrasound examination of the neck and thallium-technetium scintigraphy performed before parathyroid surgery. Initially, unilateral exploration was used sparingly, but it became the standard approach in 1994 if localization was correct. SETTING: Urban multispecialty clinic, teaching hospital. PATIENTS: One hundred consecutive patients who underwent surgical exploration for primary hyperparathyroidism. INTERVENTIONS: Ultrasonography of the neck, thallium-technetium scintigraphy, and parathyroidectomy. MAIN OUTCOME MEASURES: Imaging success, operative success, and operative time. RESULTS: In 94 patients with solitary adenomas, the adenoma was demonstrated by ultrasound scans in 66%, by thallium-technetium scintigraphy in 83%, and by either test in 87%. Correct identification by ultrasonography was 59%; by thallium-technetium scintigraphy, 75%; and together, 73%. Of 6 patients with multiple-gland disease, 2 were correctly identified by localization tests and 9 of 15 abnormal glands were demonstrated. Of the 43 unilateral explorations, 43 single adenomas and no cases of multiple-gland disease were identified; of the 57 bilateral explorations, 51 single adenomas and 6 cases of multiple-gland disease were identified. No complications occurred in either group. Hypercalcemia persisted in 3 patients who underwent bilateral exploration and recurrent hypercalcemia developed in 1 patient in each group. The average operative time for the unilateral procedure was 105 minutes, and for the bilateral procedure, 184 minutes (P < .001). Since 1994, 31 (66%) of 47 patients have had unilateral exploration based on correct localization tests. CONCLUSIONS: Unilateral exploration that is based on the results of localization tests requires less operative time and produces results similar to bilateral exploration.

Assessment of a surgical pattern recognition examination.

BACKGROUND: Recent cognitive research in medicine has demonstrated that expert diagnosticians solve many clinical problems through "pattern recognition" rather than deductive reasoning strategies. Development of the ability to recognize and diagnose common surgical problems is a critical objective of undergraduate surgical education. A surgical pattern recognition examination (PAT) was developed to assess surgical diagnosis recognition in clerkship students. METHODS: Surgical faculty selected 18 diagnoses for 20 possible presenting complaints (eg, leg pain, soft tissue mass). A distinctive patient description was written for each diagnosis. An examination of 200 items was compiled covering 20 presenting complaints. RESULTS: The PAT was administered to clerkship students during the 1992-1993 academic year (n = 77). PAT scores ranged from 33% to 90% with a mean of 65% (SD = 12.7). PAT scores correlated highly with the National Board of Medical Examiners (NBME) Surgery Subject Examination (SSE) scores. The validity of the examination was assessed by a speeded administration of the exam to surgical house staff. Senior residents scored significantly higher than junior residents (mean 82% versus 63%, P = 0.004). Performance on the PAT was significantly affected by the order of the student rotation in the academic year (P = 0.02) while performance on the NBME SSE was not (P = 0.40), which is consistent with diagnostic ability improving with clinical experience. CONCLUSIONS: The surgical PAT examination is a new, reliable, and valid method for assessing diagnostic ability in third-year students.

Intraoperative diagnostic techniques for stereotactic brain biopsy: cytology versus frozen-section histopathology.

Stereotactic brain biopsy has gained widespread acceptance as a primary diagnostic tool for the evaluation of intracranial lesions. Intraoperative evaluation of such specimens has included the use of both cytological and frozen section histologic techniques. The current study seeks to compare the diagnostic utility of frozen section histopathology and cytology in the intraoperative evaluation of stereotactic brain biopsies in HIV-seropositive patients. Seventy-five HIV-seropositive patients undergoing stereotactic brain biopsy for the evaluation of intracranial lesions were evaluated; intracranial diseases were predominantly infectious or hematologic malignancies. Comparison of frozen section and cytology as a means of intraoperative evaluation showed cytology to have a greater sensitivity (86 vs. 78%), positive (95 vs. 90%) and negative (50 vs. 39%) predictive values and a greater overall diagnostic efficiency (84 vs. 75%) than frozen section. Thus, cytology is a highly effective tool equaling and in some cases surpassing frozen section in terms of sensitivity, predictive value, and overall accuracy. Cytologic examination may often be used as the sole means of intraoperative diagnosis, obviating the need for the freezing and sectioning of fresh tissue and potentially reducing specimen turn around time as well. In other cases, cytology can be used in conjunction with other methodologies for arriving at both intraoperative and final diagnoses in these often difficult cases.

Role of B72.3 iodine 125-labeled monoclonal antibody in colorectal cancer detection by radioimmunoguided surgery.

BACKGROUND: Radioimmunoguided surgery (RIGS) by means of radiolabeled monoclonal antibodies and a probe has been reported to be useful in recognizing subclinical tumor deposits during operation. Aim of this study was to understand the limits of this technique and to assess the potential diagnostic use of RIGS in colorectal cancer surgery. METHODS: Monoclonal antibody B72.3 reacting with TAG 72 antigen, labeled with iodine 125, was injected in 32 patients with primary tumors and in 22 patients with recurrent colorectal cancer. One hundred thirty-three suspected tumor sites were evaluated during operation by means of probe and resected with immunohistochemistry as control. RESULTS: Primary tumor sites were localized by RIGS in 60% of cases, and recurrent sites were localized in 82% of cases. There was a significant correlation both for primary (p < 0.001) and recurrent (p < 0.001) tumor sites between intraoperative RIGS findings and TAG 72 tumor antigen expression. Results obtained with the probe were instrumental in modifying the surgical approach in six (27%) of 22 patients with recurrences, allowing the removal of tumor masses that would otherwise have been overlooked. CONCLUSIONS: The results of RIGS seems to be encouraging in terms of clinical use. The potential high diagnostic resolution appears to improve surgical ablation of colorectal cancer, especially in patients with recurrent cancer or suspected recurrent tumors who have negative results for intraabdominal disease by all other roentgenographic criteria with rising carcinoembryonic antigen or TAG 72 antigen levels.

[A method of calculating the parameters of multifiber optic catheters]. / Metodika raschetov parametrov mnogovolokonnykh opticheskikh kateterov.

The paper underlines the necessity of taking into account the relationship of the basic characteristics of multifiber optical catheters, such as the number, position, and diameters of some fibers, to the informational potentials of diagnostic and imaging systems of the basis of the catheters. The relationship is established by applying discretization theorems. The main points are illustrated by an example of practical angioplastic calculation.

[The application of the sample recognition theory for a system of surgical diagnosis in microsurgery]. / Primenenie teorii raspoznavaniia obrazov dlia sistem operativnoi diagnostiki v mikrokhirurgii.

The paper outlines the applicability of the sample recognition theory to process the data obtained with the use of multifiber optical catheters as part of information systems for diagnostics and visualization for microsurgery. A specific example of synthesizing the image assessment algorithm by employing the sample recognition theory is considered for the visualization system for a laser angioplastic unit.

Impact of Radioimmunoguided Surgery.

Radioimmunoguided surgery (RIGS) is a technique employed to locate tumor deposits with the aid of intravenously injected, tumor-specific, radiolabeled monoclonal antibodies and a small gamma detecting device. The gamma detecting probe (GDP) is a small, portable unit which has the capacity to be used intraoperatively to survey the entire peritoneal surface for increased radioactivity indicative of targeted tumor tissue during abdominal exploration for colorectal cancer. Trials in humans have demonstrated the ability of this system to locate clinically nonpalpable tumor deposits in patients undergoing carcinoembryonic antigen second-look laparotomies. This feature may be of value in improving the definition of tumor location and extent as well as allowing a more thorough resection of tumor-bearing tissue to be performed and hopefully improving overall patient survival.

Can duplex scanning replace arteriography for lower extremity arterial disease?

This preliminary study was undertaken to determine if surgeons would choose different intervention for lower extremity occlusive disease when given basic clinical information and data from either a duplex scan or arteriogram. Information on degree of stenosis from duplex scans and arteriograms of 29 patients was indicated on an anatomical line drawing along with the ankle blood pressures and a brief clinical description. Based on these data sheets, six vascular surgeons chose a clinical plan in a blinded fashion for each patient. Each plan was placed into one of eight possible categories for comparison using the kappa statistic. Intraobserver agreement between surgeons' decisions based on duplex scanning versus those based on arteriography was very good (mean kappa .70 with exact agreement in 76%). Interobserver agreement between different surgeons' decisions based on the same studies was significantly less (mean kappa 0.56, p less than .05). Significant disparity in clinical approach occurred in 43% of the patients with nearly identical duplex scan and arteriogram reports, suggesting that much of the discrepancy lies in the clinical decision-making process. Clinical decisions made using duplex scans are very similar to those made using arteriograms. This technique can limit the need for arteriography in assessing patients with lower extremity arterial occlusion disease.

Tissue imprints in surgical pathology: a rapid intraoperative diagnostic aid.

We studied the intraoperative diagnostic value of imprint cytology in 230 samples obtained from surgical specimens submitted for frozen section diagnosis. A rapid hematoxylin-eosin stain was used. Intraoperative imprint cytology achieved an accuracy rate of 94.3%; for benign lesions the accuracy was 97.5%, and for malignant lesions it was 91%. Overall, the false-negative and suspicious-for-malignancy rates were 1.3% and 4.3%, respectively. No false-positive results were found. The diagnostic yield when intraoperative imprint cytology and frozen section were used together was 99%. It is apparent that imprint cytology is a quick and simple method with wide applicability in the histopathologic diagnosis of lesions from all organs. The value of the method is enhanced when it is used with frozen section diagnosis.

Surgical exploration before computed tomography scanning in children with traumatic tentorial herniation.

Seventeen consecutive children with early clinical signs of tentorial herniation after head injury underwent immediate burr-hole exploration before computed tomography scanning. In nine children (53%), a subdural hematoma was discovered and immediately evacuated. In one, a small intracerebral hemorrhage was diagnosed by intraoperative ultrasonography. Postoperative studies showed that no intraaxial or extraaxial hematoma was missed by surgical exploration. Nine children (53%) survived; eight (47%) died. The survival rate was higher among patients with a mass lesion than among those without. Seven children had a good recovery, and two were moderately disabled (mean follow-up, 15.2 months). We conclude that a significant proportion of head-injured children with clinical signs of tentorial herniation have extraaxial hematomas that can be readily identified and evacuated by immediate surgical exploration. The survival rate and extent of recovery in children appear to be better than in similarly injured adults.

Thoracoscopy: a review of 121 consecutive surgical procedures.

The records of 121 patients who underwent surgical thoracoscopy between 1976 and 1987 were reviewed. The indications for thoracoscopy were pleural effusion (88%), pleural thickening (7.4%), and a mass on the chest roentgenogram (15%). All procedures were performed under general anesthesia with a rigid thoracoscope and 91 patients (75%) were diagnosed as having a malignant process. Although thoracotomy was undertaken in 20 patients (16.5%), no patient with benign disease underwent diagnostic thoracotomy. Thoracoscopy had a 98.9% sensitivity and a 93.3% specificity in this series. One patient died of a myocardial infarction after the procedure, and 11 patients (9.1%) had other, predominantly respiratory, complications. We confirm that surgical thoracoscopy is a useful procedure in the diagnosis of pleural processes.

The value of microbiologic culture of tissue samples in surgical pathology.

The diagnosis of infectious disease is best achieved, and appropriate therapy best effectuated, by isolation and identification of the causative agent. With appropriate exercise of foresight, the necessary procedures can be carried out readily on tissue samples obtained at surgery for morphologic study. Close cooperation among involved specialists permits microbiologic investigation of surgical specimens to be carried out routinely with results highly beneficial to patient care. Four cases illustrating the value of such studies in facilitating diagnosis and treatment are described.

Office diagnostic procedures.

Tympanocentesis, punch biopsy of the skin, bone marrow aspiration and biopsy, and temporal artery biopsy are procedures discussed in this article. They are principally diagnostic procedures used in the evaluation of skin and serious systemic disease.

Purported absence of the testis following surgical exploration: the need for further investigation.

Two cases of purported absence of the testes following extensive surgical exploration are reported. On subsequent investigation both boys were found to have testes. It is recommended that when confronted with a patient with a similar history the operative record should be studied and the original surgeon should be contacted to ascertain that either a testis was removed or bind-ending internal spermatic vessels were found. If proper documentation is not available, further evaluation should be done.

Selective management of penetrating neck injuries. A prospective study.

We assessed the feasibility of a selective policy for operative exploration of penetrating neck wounds. Patients with bleeding, hematomas, crepitations, dysphagia, dysphonia, or impaired mental status rendering their conditions nonevaluative had prompt explorations. All other patients were observed in the hospital. Of the 77 patients in this study, 48 (62%) underwent neck exploration based on the preceding criteria; (85%) had major injuries. Of the 29 patients observed according to protocol, none required subsequent exploration for a missed lesion. Ancillary diagnostic procedures in the observed patients consisted of arteriography in four, esophageal contrast studies in five, esophagoscopy in two, and laryngoscopy in one. The average hospital stay for observation was 1.8 days. Our experience confirms the safety and cost-effectiveness of selective exploration for penetrating neck injuries. Moreover, observation does not mandate extensive ancillary testing for level II and III injuries.

Plastic embedding as a tool in surgical pathology diagnosis.

Plastic (polymer) embedding is recommended as the method of choice for studying small biopsies such as those obtained from liver, bone marrow, lung and by endoscopy from the gastro-intestinal tract. The method offers the opportunity to examine one to four micron thick sections and, therefore, to evaluate cytologic detail. Multiple levels can be obtained from such fragments, and the reasonably large blocks provide adequate section size for diagnostic purposes.

Open renal biopsy. Surgical technique and results.

This report describes our experience with a new modified approach for open renal biopsy. The biopsy is performed under general anesthesia through a small anterior incision and extraperitoneal approach. A generous incisional biopsy of the lower pole is obtained, and bleeding is controlled with mattress sutures. Thirty biopsies were obtained in 30 patients. The pathologic diagnoses included glomerulonephropathy (16), necrotizing vasculitis (5), degenerative phase of acute tubular necrosis (4), congenital nephrotic syndrome (2), interstitial nephritis (1), renal invasion by reticulum cell sarcoma (1), and juxtaglomerular cell hyperplasia (1). Ages ranged from 12 months to 75 years. There were no intra- or postoperative complications. There was one late postoperative death secondary to a ventricular arrhythmia. This approach is rapid, safe, and provides more adequate tissue for histologic and electron microscopic examination than does percutaneous needle biopsy.