Thyroidectomy for benign and malignant diseases has progressed dramatically over the last two decades. Moving from large collar incision to no scar is a very good news to the patient with neck swellings. The morbidity of the surgery remains low regardless of the technique and approaches used but scarless surgery is still limited to benign diseases and small cancers. Further study and future refinement of the technique might make these techniques also applicable to large tumours.
Antibiotic prophylaxis for inguinal hernioplasty is still practiced in many hospitals to prevent consequences of infected mesh, mesh removal and hernia recurrence. The common route of administration is intravenous. However this method can be associated with systemic side effects. Alternatively, locally applied antibiotics have been used and proven to significantly reduce the infection rate after inguinal hernioplasty.
Appendicitis within an Amyand's hernia is rare; when it occurs it is often misdiagnosed as a strangulated inguinal hernia. Management of these cases needs to be individualized according to the presentation. In uncomplicated cases, we recommend concurrent appendectomy and darning repair of the hernia. We present such a case and review the related literature.
Schwannomas are rare tumours arising from peripheral nerve linings. A case of a schwannoma arising from cervical sympathetic chain is presented. The clinical presentation was that of a right solitary thyroid nodule. Intra-operatively, a 3 x 3 cm encapsulated lesion was seen arising posterior to the vagas nerve and attached to the cervical sympathetic trunk. The lesion was excised together with part of the nerve. Post-operatively, the patient developed Horner's syndrome that persisted. Unitil 2000, less that 50 cased of cervical sympathetic schwannoma have been described in the Englidh literature. A brief description of the pathology, presentation, diagnosis and treatment of this condition is presented.
The decision for median sternotomy for retrosternal goiter is complex and proper consensus are lacking. Generally, it is based on clinical, radiological and intraoperative assessment. Among the few known features include primary mediastinal goiter, posterior mediastinal goiter and recurrent retrosternal goiter. We present a patient with posterior mediastinal, secondary goiter that extended until the tracheal bifurcation. The goiter was removed successfully via a low cervical incision and this was achieved by dissecting along the anatomical plane close to the thyroid capsule using blunt dissection with fingers. It is possible for these kinds of high risk retrosternal goitres to be safely removed without the need for thoracotomy when the surgery was performed along the proper plane.
Primary thyroid lymphoma is a rare tumour of the thyroid gland, accounting for 1-2 % of all thyroid malignancies. Diagnosis by fine needle aspiration cytology occasionally inconclusive, needing bigger biopsy or even thyroidectomy. This study reviews our experience with primary thyroid lymphoma.
The tumour suppressor gene p53 and the proto-oncogene Bcl-2 encode respectively, for a nuclear phosphoprotein and for a mitochondrial membrane protein involved in multiple cellular functions. Both proteins are linked to programmed cell death pathways and provide prognostic information on breast carcinoma. Our aim is to study the expression of p53 and Bcl-2 oncoproteins in breast carcinoma and correlate with patients’ age, tumour size, disease stage and histological grade. Fifty nine cases of breast carcinomas from Universiti Kebangsaan Malaysia Medical Centre (UKMMC) were studied with the immunohistochemical method. Our results showed 45.8% (27 of 59) and 40.7% (24 of 59) of the breast carcinomas were immunopositive for p53 and Bcl-2 respectively. There was significant correlation between Bcl-2 expression with early tumour stage (p=0.01). No significant relationship was seen with other variables. Results also showed an inverse relationship between p53 and Bcl-2 expression (p=0.001). These findings indicate a down regulation of Bcl-2 by p53 in breast carcinogenesis.
Type 1 Neurofibromatosis (von Reckinghausen’s disease) has been associated with several gastrointestinal tumor complications, either benign or malignant. We report a case of a middle age man who had Type 1 Neurofibromatosis and presented with acute intestinal obstruction. Laparotomy revealed multiple nodular lesions along the small intestine with two larger nodules which were resected. Histopathological examination of the nodules confirmed it as gastrointestinal stromal tumors (GIST) with malignant potential. The association between neurofibromatosis and GIST is discussed.
Parathyroid carcinoma is an uncommon cause of parathyroid hormone (PTH)-dependent hypercalcaemia, accounting for less than 1% of all cases of hyperparathyroidism. Parathyroid carcinoma is an indolent tumour with rather low malignant potential. Consideration of parathyroid carcinoma in the differential diagnosis of hypercalcaemic disorders is important because the morbidity and mortality are substantial and the best prognosis is associated with early recognition and surgical resection. Clinical indicators favouring parathyroid carcinoma over benign disease include markedly raised serum calcium levels, PTH and alkaline phosphatase. A palpable neck mass with both kidney and skeletal manifestations also give a high index of suspicion of parathyroid carcinoma. Histopathology alone is not sufficient to diagnose parathyroid cancer; it has to be correlated with the clinical findings. The initial and most effective treatment for parathyroid carcinoma is complete resection of the primary lesion, and repeated operations for recurrence are useful. The prognosis of parathyroid carcinomas is quite variable; 5-year survival rates vary from 40% to 86%, while the 10-year survival rate is approximately 49%. We report a case of parathyroid carcinoma occurring in a 55-year-old woman who presented with bone pain and hypercalcaemia.
Intraoperative identification of parathyroid tissue is crucial during parathyroid surgery. Frozen section is the most common tool, but is time-consuming and expensive. Scrape cytology is a modification of imprint cytology that provides rapid and cheap intraoperative identification of parathyroid tissue, but its reliability remains controversial. We assessed the sensitivity and specificity of scrape cytology in the intraoperative identification of parathyroid tissue.
Most breast cancer recurrences occur in the surgical scars or within other quadrants of the same breast. Isolated tumour recurrence occurring in the nipple after breast-conserving surgery and radiotherapy is extremely unusual. The reason for this is unknown, but is speculated to be due to involved surgical margins or an occult involvement of the nipple-areolar complex in a breast cancer of the same breast. We present a case of a 44-year-old Indian woman who had recurrent tumour over her right nipple after an ipsilateral breast-conserving surgery that was followed by adjuvant chemotherapy and radiotherapy. There was no typical malignancy features from the mammogram. However, histopathological study confirmed a malignant growth that infiltrated into the dermis and the underneath breast tissue. Completion mastectomy was then performed and the patient was later treated with Taxane-based chemotherapy. Nipple recurrence after breast-conserving surgery and adjuvant radiotherapy may be confused with other nipple conditions such as Paget's disease of the breast. Comprehensive assessments, which include mammogram and biopsy, have proved that such recurrence do occur, as presented in this case. This warrants a specific management strategy.
The anatomical orientation of structures in the axilla has not been well studied, although it is essential for a neat and safe dissection. The objective of this study was to determine the relations between neurovascular structures in the axilla as they were encountered during axillary lymph node dissection (ALND) for breast cancer.
OBJECTIVE: The aim of this study was to investigate if preemptive local infiltration (PLA) with ropivacaine could improve postoperative pain and determine its effect on drain output postmastectomy with axillary dissection.
METHODS: This was a prospective, randomized trial comprising 30 women allocated to two groups: one to receive postoperative wound infiltration (POW) of 20 mL of 0.2% (40 mg) ropivacaine (Naropin) versus PLA with 20 mL of 0.2% ropivacaine (Naropin) diluted with 80 mL of 0.9% saline, total volume 100 mL. A visual analogue scale (0-100 mm) and angle of shoulder abduction were used for evaluation of pain. Postoperatively, all patients received oral ibuprofen 400 mg tds.
RESULTS: There was no significant difference in postoperative pain for the first 3 days between the two groups. There were wider shoulder abduction angles in the 1st and 3rd postoperative days in the PLA group, but this was not significant. Operative time was significantly shorter in the PLA group than in the POW group (69.34+/-59.37 minutes vs. 109.67+/-26.96 minutes; p=0.02). The axillary drain was removed earlier in the preemptive group, 5.4+/-1.55 days versus 6.8+/-2.04 days in the postoperative group (p=0.04).
CONCLUSION: We found no difference in postoperative pain between preemptive tumescent ropivacaine infiltration and postoperative ropivacaine wound infiltration.
Ductal carcinoma in situ (DCIS) in females is a recognized premalignant disease. However, its occurrence in males is rare. Articles describing this disease are scarce with documented occurrence is less than 7% worldwide. We report a case of 52 year-old gentleman presented with 6 months history of left breast lump. It was painless with no nipple discharge. Despite an inconclusive biopsy, lumpectomy was performed in view of the suspicion of malignant disease. Histopathology confirms DCIS. He underwent mastectomy and sentinel lymph nodes. Most treatment strategies are based on evidence on female breast malignancy and modifications are needed due to the different pathological pathway in male.
A 40-year-old woman, a grand multipara with uncertain gestation, presented with severe, prolonged diarrhoea. She was previously diagnosed to have melanoma. Examination revealed gross ascites with hepatosplenomegaly and uterus corresponding to 29 weeks gestation. An emergency caesarean section confirmed widespread metastases to the ovaries, mesentery and placenta. A viable male foetus was delivered with features of intrauterine growth restriction. The baby survived, but the mother died a week later. This case highlights the importance of thoroughly assessing placentas and babies of patients with melanoma for metastases.
Presence of a hypofunctioning pigmented adenoma are commonly asymptomatic and is usually only found during an autopsy. In contrast, hyperfunctioning pigmented adenoma is a rare clinical entity and in the majority of cases results in Cushing's syndrome. In this case study, we report a 66-year-old male who presented instead with the clinical and biochemical features of Conn's syndrome. On laparoscopic adrenalectomy, it was found that the tumour had a functioning black adenoma which does not usually present with Conn's syndrome but rather to that of a Cushing's. The intraoperative changes and histopathological findings are discussed.
Radiotherapy has been widely use as an adjuvant therapy in the breast cancer management. The usage has increased the incidence of radiation induce sarcoma. We here present a case of radiation induce sarcoma of the axilla following mastectomy and axillary lymph node dissection for infiltrating ductal carcinoma.
Metaplastic breast cancer is a rare form of primary breast cancer. It contains a mixture of adenocarcinoma with metaplastic elements. It is important to differentiate with primary sarcoma of the breast which carries different treatment strategies and prognosis. A 55-year-old lady previously diagnosed to have a left breast cancer in the year 2000 and carcinoma of the endometrium in 2009, presented with a right breast lump. A trucut biopsy reported as an infiltrating ductal carcinoma with background of chondromyxoid and cartilagenous matrix,
most probably metaplastic carcinoma. A wide local excision with sentinel lymph node biopsy was performed, and the final histology was consistent with metaplastic chondroid carcinoma of the breast with no evidence of metastsis. The surgery was followed by adjuvant radiotherapy and currently free from any recurrence. The diagnostic dilemma on this very rare condition is reviewed.
Primary thyroid lymphoma is a rare disorder accounting for about 2% of all malignant lymphomas and less than 5% of thyroid malignancies. It is an aggressive disease with poor outcome. The majority of thyroid lymphomas are non-Hodgkin lymphomas of Bcell origin. Majority of cases occur in women in the sixth decade. We report two cases of primary thyroid lymphoma and highlight the clinical issues and challenges posed by this rare disease. Both cases presented with respiratory obstructive symptoms that required surgical intervention. The optimal management for a primary thyroid lymphoma be it chemotherapy, radiotherapy, surgery or monoclonal antibodies is still debatable. The role for surgery has evolved through the years but its importance in emergency situations should not be overlooked. Both our patients had to undergo surgery but only one patient received additional chemotherapy and radiotherapy. These two case reports illustrated the difficulties in managing this rare disorder.