The role of FNA in the initial management of thyroid lesions: 7-year experience in a district general hospital.

Fine needle aspiration (FNA) cytology plays a major role in the diagnosis of the thyroid lesions in university hospitals and tertiary referral institutions. Our aim was to find out if this was possible in small district hospitals with limited resources. Over a 7-year period, from October 1994 to April 2002, 303 patients with thyroid swellings underwent FNA with an overall adequacy rate of 97.7%. FNAs were performed specifically by the pathologists, so that our inadequacy rate, 2.3% was far lower than 11-29% reported elsewhere. The FNA findings were compared with subsequent histology results in 67 cases. The diagnosis of benign and neoplastic lesions was predicted accurately by FNA in 93% and 94.7% of cases, respectively. The latter reached 100% if results of FNA in follicular neoplasms were excluded. Sensitivity and specificity were 85.6% and 97.6%, respectively, which is comparable with results from tertiary institutions. The commonest thyroid lesions in our hospital were nodular goitre (52.4%), followed by thyroiditis (17.6%) and neoplasia (13.9%). We conclude that, with the availability of appropriate personnel, FNA is feasible as the major modality in district general hospitals. FNA in follicular lesions remains challenging but could be overcome in part by recognizing the criteria to differentiate follicular variant of papillary carcinoma and other follicular proliferations. Aspiration, smearing, staining and interpretation should be left to pathologists or other well-trained personnel to ensure good quality and consistency.

Management of symptomatic cholelithiasis in pregnancy.

BACKGROUND: Symptomatic cholelithiasis occurs in pregnancy in our patient population, some of whom are diabetic. But its management remains controversial. How common is the problem? Is our current policy of management appropriate for our patients? PATIENTS AND METHODS: The management of 162 pregnant patients admitted over a ten-year period with symptomatic cholelithiasis was evaluated in a retrospective study. The patients were divided into two groups: Group A, 58 patients with diabetes mellitus, and Group B, 104 nondiabetic patients. RESULTS: Symptomatic cholelithiasis occurred in only 0.3% of our pregnant patients. Of 162 patients, 148 (91.4%) had successful conservative (nonsurgical) management. There was no fetal loss, premature birth, maternal morbidity or mortality. Fourteen patients who had failure of conservative treatment had surgical management. When the postpartum cholecystectomy hospitalization days were added to the total days of admission for the nonoperative cases, there was a significant difference in the mean total number of days of hospitalizations between the surgical cases, 12.4 days, and the nonsurgical cases, 20.5 days (P<0.001), but not in the mean number of hospitalizations, 2.3 versus 3.3. CONCLUSION: Our current policy of conservative management seems optimal. It has, however, been achieved at the price per patient of 8 extra days of hospitalization. In keeping with recent improvements in surgery and the advent of laparoscopic surgery, a more cost-efficient approach would suggest a more aggressive policy.

Small intestinal obstruction in pregnancy and puerperium.

The problem of intestinal obstruction in pregnancy and puerperium is worsened by the risk it poses not just to the mother, but also to the fetus. In this review of 10 pregnant/puerperium patients the maternal mortality was 10% and fetal wastage 20%. In pregnancy and puerperium, intestinal obstruction carries a higher mortality, 10-33%, than in non-pregnant patients, 6-10%. The rarity of the problem, delay in diagnosis, anxiety over radiological examination in pregnant women, worry over laparotomy in pregnant women, all result in delay in instituting definite treatment and contribute to the morbidity. Application of established principles in the management of intestinal obstruction even when it occurs in pregnancy and puerperium might help to improve the results of management and reduce the current level of morbidity and mortality.

Cholelithiasis in young Saudi women.

We studied some of the factors associated with gallstones in a sub population of Saudi women who presented with cholelithiasis at a rather young age, 17-30 years. We determined the weight, height, ideal weight, overweight, Quetelet index, ideal Quetelet index, and parity in 152 such women designated the study group and in another aged matched group of 152 women without biliary disease designated the control group. Although the mean weights of both groups were greater than ideal, the mean weight, level of overweight, and mean Quetelet index in the study group were greater than those of the controls at virtually all age groups (p > 0.001). In the study group, comparison of the 17-25 year olds with the 26-30 year olds showed close similarity in weight, Q index, and level of overweight (p = 0.50). There was no significant difference in parity between the study group and the controls. We conclude that obesity is a significant factor in the development of cholelithiasis in Saudi women who develop symptomatic gallstones in the age group 17-30 years.

Comparison of laparoscopic and open cholecystectomy at Prince Abdulrahman Al Sudairy Hospital, Saudi Arabia.

The initial 300 patients whose symptomatic cholelithiasis was managed by laparoscopic cholecystectomy (LC) were matched to and compared with 300 patients managed by open cholecystectomy (OC) during the 30 months prior to the introduction of LC. Of the 300 LC attempted 292 (97.3%) were successful with conversion to OC rate of 2.7%. Besides the obviously better cosmetic results, LC patients had less post operative pain, mean doses of opiates needed 0.01 versus 5 for OC (p < 0.0001), were discharged earlier from the hospital, mean 3.1 days versus 8 days for OC (p < 0.001) and had less postoperative complications 4% versus 11% for OC. We conclude that not only is LC a better operation than OC, but also that in the regional referral centres such as ours, LC can safely supplant OC as the preferred modality for the management of symptomatic cholelithiasis.

Morbidity, mortality and survival in the management of cT4 breast cancer in Nigeria.

The absence of other modalities mandates surgical management of T4 breast cancer in Nigeria. The management, course and survival of 120 Nigerian females who presented with breast cancer in stage UICC T4N1-2MO were studied prospectively. All patients underwent total mastectomy and partial axillary dissection. Eighty patients (group 2) who received postoperative chemotherapy were matched to 40 patients (group 1) who did not receive chemotherapy. Group 1 patients had significantly earlier tumor recurrence, more rapid progression to M1 disease, required hospitalization more often and for longer periods, had earlier deterioration of Karnofsky index and a shorter survival than group 2 patients. Although the overall survival even for group 2 patients was low, the achievement of local tumor control, the avoidance of uncontrolled tumor growth, delay in recurrent disease and the achievement of a measure of social acceptability and prolongation of life justifies surgical management plus chemotherapy in circumstances like ours, where no better modality is available, for the management of cT4 breast cancer.

Antimicrobial prophylaxis for cholecystectomy in diabetes.

Two schedules of antimicrobial agents were compared in this prospective study of antimicrobial prophylaxis in diabetes mellitus patients undergoing cholecystectomy for symptomatic cholelithiasis. One hundred women grouped into two matched groups of 50 women each were studied. The results suggest that apart from a population of patients with identifiable risks of complications, a 24 hour, four dose antimicrobial prophylaxis is adequate and more cost effective than the five day schedule for most patients.

Testicular infarction complicating strangulated inguinal herniae in Nigerian children.

Between 1985 and 1990 30 children were operated on for strangulated inguinal herniae in the University of Benin Teaching Hospital, Benin City, Nigeria. Six of the children (20%) had testicular infarction secondary to the strangulated hernia. Half of the children with infarcted testes had viable bowel at operation. The surgeon dealing with African children with strangulated herniae needs to be sensitised to this condition and the possibility that the testis may well be infarcted before the intestines.

Progesterone receptors in advanced breast cancer.

Progesterone receptor (PR) assay was performed on tumor specimen obtained from 145 women consisting of 82 women with advanced breast cancer and 73 women with early breast cancer (EBC). Advanced breast cancer patients consisted of 50 (61%) of 82 women with advanced primary breast cancer (APBC) and 32 (39%) women with recurrent or secondary breast cancer (SBC). Of 82 advanced breast cancer, 35 (42.7%) were PR+. These consisted of 21 APBC and 14 SBC patients. 43 (59%) of 73 EBC patients had PR+ tumors. Quantitative value of PR correlated with age in overall and in all groups. There was also a significant difference in PR quantitative value between PR+ tumors and PR- tumors. Finally premenopausal APBC patients with PR+ tumors had a 2:1 survival advantage over those with PR- tumors. PR assay is as an invaluable a tool as ER assay in the management of breast cancer.

Mondor's disease. Relationship to use of body girdle.

Ten Mondor's disease patients and twenty matched controls provided data for this prospective study of the relationship of Quetelet Index, breast size and the use of body girdle on the development of Mondor's disease. Comparison of the study group patients with the controls in terms of percentage excess over their ideal Quetelet Index, extent of overweight, breast cup size and habitual use of body girdle showed only statistically significant difference in the use of the body girdle. It is concluded that among our patients, extensive use of a body girdle by a mesomorphic, overweight and large breasted female increases the risk of Mondor's disease.

Prognostic significance of exclusive skeletal metastases in stage IV primary carcinoma of the breast.

The clinical presentation and survival rate for 30 patients with Stage IV carcinoma of the breast in whom the M1 disease was limited exclusively to the bones were compared with those of 30 women with stage, age and menopausally matched carcinoma of the breast with M1 disease limited exclusively to nonosseous tissue. The clinical findings at presentation and the histologic grades of the cancers (70.0 per cent grade II for osseous versus only 36.7 per cent for nonosseous), relative to the mean duration of tumor presence, identify the cancer with exclusive skeletal metastases as less aggressive. Also, the median survival time of the patients with bone-only metastases was 12 months as compared with six months for the nonosseous metastatic group. It is concluded that exclusive skeletal metastases identify more slowly growing carcinoma of the breast and is, therefore, prognostically significant.

Mondor's disease associated with breast cancer.

An unusual case of Mondor's disease associated with carcinoma of the breast is reported. "Forked string" and "triple beads" have been reported previously in this disease. In this patient, however, one of the "beads" of her triple beads was malignant. It is suggested that biopsy and histologic examination are the best course of action for Mondor's disease associated with beads.

Breast cancer in pregnancy and lactation.

Thirty-six Nigerian women admitted with breast cancer during pregnancy and/or lactation (SGP) are the basis of this study of breast cancer in pregnancy and lactation. Thirty-six non pregnant but age and c TNM stage matched breast cancer patients and another thirty-six non pregnant, age matched women with benign breast neoplasms served as control group A (CGA) and control group B (CGB) respectively. Even though of similar c TNM state, the mean duration of tumor presence in the SGP (6 months) was shorter than in CGA (12 months). Also the SGP presented with tumor of higher histological grade (grade III, 55.6%) than those of CGA (grade III, 19.4%). These lead to the conclusion that breast cancer in the study group patients was more rapidly progressing and was therefore of worse prognosis. This conclusion is confirmed by a finding of survival in CGA patients that was 1.4 times that of the study group patients. We therefore conclude that breast cancer associated with pregnancy or lactation in Nigerian women progresses more rapidly and has a worse prognosis than cancer in their non pregnant counterparts.

Rapidly progressing breast cancer in Nigeria.

To test the hypothesis that the bleak prognosis of breast cancer in Nigeria may be due, in part, to a subset of patients with rapidly progressing type of breast cancer, a prospective study of 120 breast cancer patients was undertaken. Patients were staged by the UICC-TNM system and the PEV system. Eighty-one (67.5%) of the patients had non PEV while 39 (32.5%) had PEV breast cancer. Of the 24 patients in TNM stage IV, 21 had PEV. Also 17.5% of all breast cancer patient or 53.8% of PEV patients were in the PEV stage with the worst prognosis. Following similar treatment, the median survival of non PEV patients (14 months) was significantly greater than that of PEV patients (6 months). Overall median survival of the cancer patients was 9.5 months. It is concluded that the finding that fully one third of our breast cancer patients have rapidly progressing breast cancer contributes significantly to the poor prognosis of breast cancer in Nigeria.

Nonpuerperal nipple discharge in Nigerian women.

100 Nigerian women were entered into a prospective study of spontaneous occurring nipple discharge over a seven year period. The patients consisted of 25 study group patients and three groups of 25 patients comprising the controls. In the study group, seven types of nipple discharge were identified, namely: bloody (40%), watery (4%), and milky (4%). Intraductal papilloma and other benign breast disease were the cause of nipple discharge in 23 of 25 (88%) study group patients. Only 28% of breast cancer patients in control group A, 16% of bloody or serosanguineous and 16% of benign breast tumor patients of control group B presented with nipple discharge. Nipple discharge was an incidental finding in 16% of normal control group C patients. Thus Nigerian women are more likely to seek medical intervention for bloody and serosanguineous discharge. Surgical management remains the optimal management for nipple discharge.

Breast cancer in Nigeria.

Breast cancer as seen in 116 Nigerian women over a 5-year period, 1974 to 1979, at the University of Benin Teaching Hospital, Benin, Nigeria, is presented. The disease occurs one decade earlier in Nigerians and is mainly a disease of premenopausal and perimenopausal women. Reflecting their relative youthfulness, more than 10% of them are pregnant or lactating on presentation. The most common histologic finding is anaplasia with very unfavorable histological grade. Breast cancer does not seem to have a different biologic behaviour in Nigerians, but it carries a truly bleak prognosis because many of the patients present with incurable disease that is close to its end stages.

Management of advanced breast cancer in Africa: strategies in the absence of hormone receptor assay data.

The oncologist in Africa and many other Third World countries is hampered in the management of breast cancer by the absence of hormone receptor assays in most teaching hospitals. The little information that is available in the literature on hormone receptors in black, breast cancer patients as well as other available hormone receptor information can serve as a data base for the development of a rational approach to this management dilemma. Using the available information, an approach, in the form of a flow chart, has been developed for the management of breast cancer in Africa. It is further suggested that breast cancer should be managed using protocols designed to answer various questions about breast cancer in Africa.

Breast carcinoma in young Nigerian women.

Breast cancer presenting in 32 Nigerian women 30 years of age or younger was studied; 32 other premenopausal women matched in TNM stage of disease served as controls. More than 80% of both groups presented with advanced breast carcinoma; 18.7% of the study group patients were pregnant or lactating. Management consisted of some form of surgery and chemotherapy (methotrexate, cyclophosphamide, 5-fluorouracil and prednisolone for both groups). Two year survival for the study group (25%) was lower than that of the control group (37.5%). Breast cancer in this age group is a problem which needs further documentation in Africa. Earlier diagnosis, and a more aggressive combined modality therapy are needed to improve the prognosis.

Gangrenous bowel. Benin experience.

A retrospective study of 115 patients who presented to the University of Benin Teaching Hospital with intestinal gangrene over a 5 year period is presented. Although hernia is the most common cause of bowel gangrene, more patients with volvulus end up with gangrenous bowel. Because Nigerian patients present with late intestinal obstruction, more dead bowel would have been expected than is currently noted. Is it possible that the African is resistant to intestinal strangulation?