Impact of Preoperative MRI in Invasive Ductal Carcinoma With Lobular Features on Core Biopsy.

BACKGROUND: Invasive breast cancer is comprised of a wide spectrum of histological types with different clinical presentations, imaging characteristics, and behaviors. Almost 10% of breast cancers with predominantly invasive ductal features have lobular components on core biopsy at primary diagnosis. Although the role of magnetic resonance imaging (MRI) in patients with purely lobular cancers is well-established, it is not clear if preoperative MRI is indicated in ductal cancer with lobular features. The aim of this study was to assess the role of preoperative MRI in patients with invasive ductal cancers with lobular features on core biopsy. MATERIALS AND METHODS: Data regarding patients with lobular features on core biopsy who underwent a preoperative MRI from January 2015 to December 2017 were retrospectively identified and analyzed. Imaging findings, additional investigations, and changes in treatment plans following the MRI scan were reviewed. RESULTS: The study included 120 patients, of whom 42 (35%) patients required a second-look ultrasound. Following a repeat ultrasound scan, 25 breasts and 4 axillae were biopsied. Thirty-eight percent of the breast biopsies and 50% of the axillary biopsies were malignant. Based on MRI findings, treatment plans changed in 22.5% of patients. MRI size was concordant with the histological size in 58.3% of cases, and MRI was accurate in 90% of patients in detecting multifocal disease requiring mastectomy. The majority of patients with changes in the management plans had mixed ductal and lobular cancer on final histology. CONCLUSION: This study has demonstrated that MRI picks up additional malignancies and changes management plans in patients with lobular features on core biopsy and should be considered in the preoperative workup.

A stuck haemodialysis central venous catheter: not quite open and shut!

Removal of tunnelled central venous catheters can become complex if left in situ for a prolonged period. We report a challenging case of a stuck tunnelled haemodialysis catheter, which required sternotomy with cardio-pulmonary bypass for retrieval. A 47-year-old female had failed attempts to remove the venous limb of a Tessio line on the ward. A cut down on the internal jugular vein and division of the fibrin sheath failed to release it. Synchronous traction was applied via a snare inserted through a femoral approach. On table trans-oesophageal echocardiogram showed the tip of the catheter traversing the tricuspid valve. At sternotomy with cardio-pulmonary bypass, the tip of the catheter was found attached to the septal leaflet of the tricuspid valve requiring release and repair. The management of stuck line has potential serious complications. Prophylactic catheter exchange should be considered to avoid complications.

Abdominal compartment syndrome--a fatal complication from a rectus sheath haematoma.

Rectus sheath haematoma is increasingly being seen in patients with anticoagulation therapy. Abdominal compartment syndrome is a rare complication of rectus sheath haematoma with only two cases reported in literature. The authors report a case of a young male who developed abdominal compartment syndrome from a rectus sheath haematoma secondary to anticoagulation therapy. The case highlights the need for a surgical intervention in such exceptional cases.

Endoscopic management of migrated biliary stent causing sigmoid perforation.

Endoscopically deployed biliary stents are a well established method for dealing with biliary diseases. Perforation of the gut secondary to migrated biliary stent is reported in less than 1% cases. The authors present the first case of a colonic perforation from migrated biliary stent which was managed endoscopically. An 82-year-old female had a biliary stent for a postcholecystectomy bile leak and presented 6 months later with left iliac fossa pain. Barium enema showed a stent perforating the sigmoid colon. In view of the patient's frailty and absence of peritonitis, an endoscopic retrieval of stent was attempted. Flexible sigmoidoscopy showed a stent partially embedded within the sigmoid diverticulum which was successfully removed and the defect was closed endoscopically using three titanium clips. She had an uncomplicated recovery following the procedure and was discharged home on the second day following the procedure.