Anatomy of scalenovertebral triangle: A vade mecum for clinicians.

OBJECTIVE OF THE STUDY: The thorough anatomical knowledge of scalenovertebral triangle or Triangle of the vertebral artery and its contents is crucial in various neurosurgical procedures such as scalenotomy, stellate ganglion block, direct isolation of proximal vertebral artery and proximal brachial plexus repair. MATERIAL AND METHOD: Thirty scalenovertebral triangles of known age and sex were dissected. The morphometry of the triangle and stellate ganglion was done. Various relevant distances were measured for topographical location of neurovascular structures especially stellate ganglion and vertebral artery within the triangle. RESULTS: The mean height and width of the scalenovertebral triangle was 21.7+5.1mm and 19.4+4.4mm respectively. Vertebral artery originated from subclavian artery within the triangle except in one case (left side) where it originated from aortic arch. The mean minimum distance of stellate ganglion from phrenic nerve, scalenus anterior and vertebral origin was 12.6+4.5mm, 12.26+4mm and 2.3+1.3mm respectively. CONCLUSIONS: The origin and proximal part of vertebral artery may not be present within the scalenovertebral triangle, thus topographic anatomy of the stellate ganglion is also affected and may cause complications during stellate ganglion block. Stellate ganglion is never located in the lateral or upper third of triangle. Occasionally, the phrenic nerve may cross the triangle, making it unsafe during stellate ganglion block.

Histological and immunohistochemical study of estrogen and progesterone receptors in normal human breast tissue in adult age groups vulnerable to malignancy.

Analysis of receptor status has become standard procedure for assessing breast cancer patients. Estrogen causes epithelial proliferation in breast tissue via the estrogen receptor (ER). The progesterone receptor (PR) is also regulated by the estrogen gene. Analyzing ER and PR together gives information regarding the likely response of carcinoma patients to hormonal therapy. The aim of the present study was to record the expression patterns of ER and PR in normal mammary tissue in different age groups to provide reference data to facilitate histological diagnosis. Breast tissues from the upper outer quadrant of each side of 27 adult female cadavers were examined after H & E staining. ER and PR were identified and examined by immunohistochemistry. The percentage area occupied by parenchyma relative to stromal tissue was calculated in different age groups and was about 4:6, 3.5:6.5, 3:7, 2:8, and 1.5:8.5 in the 3rd, 4th and 5th, 6th, 7th, 8th and 9th, and 10th decades of life, respectively. Both ER and PR were present in all age groups and the numbers of both receptors were maximal during the 4th decade. The distribution and staining patterns for both ER and PR were recorded in different age groups. The contiguous pattern of ER, which is considered pathognomonic of breast carcinoma, was not seen except in one case in the 6th decade. Moderately stained ER and PR receptor sites predominated throughout. The study of normal breast tissue of similar age might provide comparisons that will help histopathologists to make clinical diagnoses from breast biopsies. Clin. Anat. 29:729-737, 2016. © 2016 Wiley Periodicals, Inc.

Surgical anatomy of round window and its implications for cochlear implantation.

The objective of this work was to study the morphometry and morphology of the round window (RW) and its relationships with the internal carotid artery, jugular bulb (JB), facial nerve and oval window (OW). Fifty cadaveric temporal bones were microdissected to expose the medial wall of the middle ear. The areas around the RW were cleared and its shape, height and width were noted. Its distances from the carotid canal (CC), jugular fossa (JF), facial canal (FC), and OW were measured. Oval, round, triangular, comma, quadrangular, and pear shapes of RW were observed. The average height and width of the RW were 1.62 ± 0.77 mm and 1.15 ± 0.39 mm, respectively. There was a statistically significant correlation (r = 0.4, P < 0.01) between the height and width. The distances between the RW and the CC, JF, FC, and OW were in the ranges 4.39-11.05 mm, 0.38-8.65 mm, 2.99-6.3 mm, and 1.39-3.57 mm, respectively. In 8% of cases, the distance between the RW and the JF was <1 mm. There were no statistically significant differences with regard to age group, gender, or side. Electrode insertion can be challenging in cases where the height and width of the RW are <1 mm. The thin bone separating the roof of the JF from the RW (<1 mm in 8%) highlights a potential risk of injury to the JB during cochleostomy placement. This information could be useful for selecting cochlear implant electrodes in order to avoid potential risks to vital neurovascular structures during implant surgery.

Exophytic intramedullary meningioma of the cervical spinal cord.

Intramedullary spinal cord neoplasms are relatively uncommon. The most common intramedullary tumors are astrocytomas and ependymomas. Meningiomas can occur as an intradural tumor; however, they are typically in the extramedullary compartment. A 42-year-old male presented with progressive sensory loss in the upper extremities and lower extremity weakness. Pre-operative imaging suggested an intramedullary cervical lesion. To treat the progressive neurological abnormality, surgical resection was planned. At surgery, it was noted that the tumor originated in the cervical spinal cord and extended into the extramedullary region. Histology confirmed the lesion to be a meningioma. This meningioma variant has not previously been described. Spinal meningiomas may occur in locations other than intradural, extramedullary locations, and should be included in the differential diagnosis of intramedullary lesions. Intramedullary meningiomas can be successfully treated with surgery.

The use of LYVE-1 antibody for detecting lymphatic involvement in patients with malignant melanoma of known sentinel node status.

BACKGROUND: Sentinel node (SN) status is the most important prognostic indicator in patients with cutaneous melanoma without clinically evident metastatic spread, but the procedure is associated with considerable morbidity. The LYVE-1 lymphatic marker offers the possibility of studying lymphangiogenesis and tumour metastasis within the primary excision. AIMS: To establish whether lymphatic vessel numbers/distribution within the primary tumour correlated with SN status. To assess whether tumour cells were easily demonstrable within lymphatics and could be used as a surrogate for SN status. METHODS: Double immunostaining for LYVE-1 and S100 in cutaneous biopsies from 18 SN+ patients with no lymphatic/vascular involvement on routine histology and 18 SN- patients matched for tumour thickness and ulceration. RESULTS: Lymphatic vessels were detected in all cases. Vessels within the tumour mass were suggestive of active lymphangiogenesis; those outside were mainly mature vessels with well defined walls. Tumour cells within lymphatics were detected in one of 18 SN- and five of 18 SN+ patients. Lymphatics containing tumour cells were all outside the tumour mass in well formed vessels, suggesting melanoma cell invasion into preformed lymphatics. There was no significant difference in lymphatic counts between SN+ and SN- patients. Although peritumorous lymphatic counts were higher in ulcerated than non-ulcerated melanomas, they did not vary with Breslow thickness. CONCLUSION: LYVE-1 staining can reliably demonstrate lymphatic vessel distribution, but lymphatic counts cannot predict melanoma metastatic potential and cannot substitute for SN biopsy. LYVE-1 immunostaining can detect melanoma cells within lymphatics, but is unreliable in predicting melanoma metastasis, failing to detect metastatic spread in more than two thirds of patients with regional node metastasis.

Glaucoma induced by periorbital topical steroid use--a rare complication.

Eye complications arising during systemic and ophthalmic steroid use are well known. In contrast, there is little highlighting the similar risks associated with topical steroid use around the eyelids. We now describe a 29-year-old lady who used topical steroids in prolonged fashion throughout most of her life for severe eczema, with the recent application of large quantities of potent steroid continuously for one month, including to the periorbital region. Soon after, she presented to her ophthalmologist with severe bilateral glaucoma and irreversible visual loss attributed to the steroid use. Here we emphasise the possible risks of periorbital topical steroid use, as well as the importance of patient education and ophthalmological follow-up.

Diffusion coefficient for photon transport in turbid media.

Light propagation in a turbid medium is considered using the linear transport equation. The existence of a diffusion length is proved for the Henyey-Greenstein scattering kernel for all absorption ratios. Numerical methods are given that allow accurate computation of the diffusion coefficient quite easily.

Variations in collateral contributions to the blood supply to the sternum.

The blood supply of the sternum plays a major role in healing of the sternum after sternotomy. The sternal blood supply is derived mainly from the medial horizontal branches of the internal thoracic artery (ITA). The ITA is usually described as giving off sternal, anterior intercostal and perforating branches supplying their respective areas. The aim of the present study was to describe variations in the arterial branching pattern of collateral contributions to the sternum. The study was conducted on 30 fresh specimens of anterior thoracic wall in which cellulose acetate butyrate was injected into the ITA. The branches of the ITA in the first to sixth intercostal spaces were dissected and any additional artery supplying the sternum in each intercostal space was observed. In the present study, the ITA gave off non-collateral branches - sternal, anterior intercostal and perforating. The ITA was also found to have branches which divided into two to supply two destinations which could establish collateral flow to the sternum: (1). A sterno-intercostal branch (1-12 mm in length) divided and diverged in a Y or T shape. The medial limb supplied the sternum and the lateral limb supplied the adjoining thoracic wall, anastomosing with the terminal part of the posterior intercostal artery. (2). A sterno-perforating branch supplied the sternum either anteriorly or posteriorly before perforating and supplying the pectoral region and anastomosing with the thoracoacromial artery. This study reinforces the practice of ligating branches of the ITA close to its trunk as they have the potential to develop collateral blood supply. In the present study the posterior intercostal artery was at times found to supply the sternum directly or via its collateral branch and was named the persistent posterior intercostal artery.

Hepatic veins in northwest Indian subjects.

Formation, position, course and areas of drainage by hepatic veins were studied in 153 adult autopsy specimens. There were three major hepatic veins; left, middle and right. The middle hepatic vein (MHV) joined the left hepatic vein (LHV) in 88.2% specimens before the latter opened into inferior vena cava (IVC). Each major hepatic vein was joined by a superior vein. An intersegmental vein was present in the septum between the medial and lateral segments; it either joined the LHV or MHV. Formation and course of posterior hepatic veins (small veins) have been described and a nomenclature has been suggested. The right suprarenal vein either opened directly into IVC or joined the superior or inferior posterior hepatic veins.

Weight and measurements of kidneys in northwest Indian adults.

Weights and measurements of paired kidneys obtained from medicolegal autopsies of northwest Indian adults, 155 males and 84 females, were compared. The right and left kidneys weighed 108.7 +/- 22.6 g and 111.8 +/- 23.3 g (P > 0.05), respectively, in males. Corresponding weights in females were 96.6 +/- 19.3 g and 99.4 +/- 25.3 g (P > 0.05) for the right and left kidneys, respectively. Sex differences in the weights of both right and left kidneys were statistically significant (P < 0.001). Other measurements of the right kidney in males were as follows: length, 99.5 +/- 9.4 mm; width at the middle of the hilum, 45.8 +/- 6.2 mm; and the thickness 33.3 +/- 5.2 mm, which did not differ from corresponding measurements of the left kidney (99.7 +/- 10.9 mm, 46.4 +/- 7.1 mm, and 34.0 +/- 6.4 mm, respectively). Other measurements of the right kidney in females were as follows: length, 91.3 +/- 8.7 mm; width at the middle of the hilum, 44.6 +/- 4.6 mm; and thickness 31.2 +/- 4.7 mm, which did not differ from those of the left kidney (92.1 +/- 11.0 mm, 43.5 +/- 6.5 mm, and 31.1 +/- 6.1 mm, respectively). Sex differences in measurements of both right and left kidneys were significant except for the width of the kidney at the middle and below the hilum.

An Indian mummy: a case report.

A case of mummification occurring in northwest India (Chandigarh) is described. A middle-aged man developed an abscess on his back and was treated by a mystical man who did not allow him any food or water. After a few days the patient died. On the advice of the mystical man the body was kept in a room which was made hot and dry. The police discovered the body after 2 years. A postmortem examination was conducted and findings are reported.

Gross anatomy of the pancreatic ducts in north Indians.

Gross anatomy of the pancreatic ducts was studied in dissections and by preparing corrosion casts of pancreases, obtained from 218 male and 57 female adult cadavers. In addition 72 normal pancreatograms were also examined. The main pancreatic duct (MPD) started as two or more tributaries in the tail of the pancreas and crossed the body of the 12th dorsal or the first lumbar vertebra or in between in 72.5% males and 62.5% females. In 96% specimens MPD followed the usual course and opened at the major duodenal papilla. Twenty to thirty five lobular ducts opened on either side of the MPD while a few opened on the anterior or posterior walls. There was no 'herringbone' arrangement. The distance between the two ductules varied from 1 to 10 mm. Mode of formation of the accessory pancreatic duct (APD), its course and termination were also studied. In dissected specimens the embryonic type of pancreatic duct (pancreas divisum) was seen in 9 (4.5%) male and 3 (6%) female specimens. In 15.1% male and 26.3% female (p < 0.05) subjects APD will not act as a safety valve if an obstruction occurs in the distal part of MPD.

Time of fusion of the basisphenoid with the basilar part of the occipital bone in northwest Indian subjects.

To find out the time of fusion of the basisphenoid with the basilar part of the occipital bone in Northwest Indian subjects, a quadrilateral piece of bone extending from the posterior clinoid processes to the jugular tubercles was removed from 50 male and 34 female autopsy subjects between the ages of 10 and 20 years. The piece of bone was X-rayed and then macerated. In addition CT scan cuts of the basisphenoid were obtained in 46 male and 27 female living subjects between the age of 10 and 19 years. In the males, partial fusion was seen at 13 years while a complete fusion was noticed at 15 years in 25% of the subjects. The age of a boy showing complete fusion should be 15 years or above. If there is no fusion or partial fusion he should be below 19 years as complete fusion is seen in all male subjects at 19 years. In females, the earliest partial fusion was noted at 12 years and complete fusion was present at 13 years in 16.6%. All female subjects showed complete fusion at 17 years. The minimum age of a girl showing complete fusion should be 13 years; if no fusion or partial fusion is seen, her age should be below 17 years.

Incidence and structure of the appendices of the testis and epididymis.

In paired tests obtained from 425 adults, 50 children and 10 neonates, the incidence of testicular appendices was 76% in adults (93.3% sessile) and 83.3% in neonates/children (88% sessile). An epididymal appendix was present in 21.9% of adults and 20% of neonates/children, out of which 79% were stalked in both types of specimen. Three sessile testicular appendices and 11 epididymal appendices were double. The microscopic structure of the appendices and the ultrastructure of their epithelia are described. Testicular or epididymal appendices were not present in any domestic or laboratory animal examined except the horse.

Time of fusion of epiphyses at the elbow and wrist joints in girls of northwest India.

A radiological examination of both elbows and wrists of 149 Northwest Indian schoolgirls between the ages of 11 and 19 years, of middle socio-economic status, was undertaken to determine the time of fusion of the epiphyses with the metaphyses of the medial epicondyle of the humerus, the proximal end of the radius and the distal ends of both radius and ulna. The data were subjected to discriminant function tests as well as sensitivity and specificity tests. If the epiphysis of the medial epicondyle of the humerus or that of the head of the radius has not fused with metaphysis completely, the age of the girl would be < 16 years. However, the age of the girl should be > 16 years if the distal epiphyses of the radius and the ulna show complete fusion with their respective metaphyses. Discriminant function tests show that 91.95% of girls can be correctly classified as being above or below the age of 16 years.