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Table of Contents Original Article A Study of Transmission Transmitted Infections (TTI) prevalence in a large sample A134-A139 of 25,000 blood donors at a tertiary care center Sheetal Arora, Deepshikha Rana, Varsha Chauhan, Shraddha Mishra, Dushyant S Rawat
Case Reports
Role of bone marrow biopsy in myeloproliferative neoplasm: study of 49 cases Manjit Kaur, Arun Puri
A140-A142
Role of Fine-Needle Aspiration Cytology in Evaluation of Breast Lumps Ashish Kosthi, Maneesh Sulya, Reeni Malik
A143-A149
Innovative approach to lingual base lesions Manish Munjal, Archana Arora, Amanjeet Singh, Dinesh Sood, Tushar Singla
C21-C23
A case of Synchronous Multifocus Gastric Adenocarcinoma. Shikha Sharma, Bawana Raina, Misbah Rashid, K C Goswami
C24-C27
Confronting the unexpected: saddle defect during septal surgery Manish Munjal, Japneet Kaur, Amanjot Kaur, Amanjeet Singh, Nidhi Mathur, Shubham Munjal
C28-C30
Submandibular haemangioma involving parotid tail - Case report Manish Munjal, Sanjeev Puri, Japneet Kaur, Amanjot Kaur, Porshia Rishi, Shubham Munjal, Anmol Singh
C31-C33
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Original Article DOI: 10.21276/AABS.1593
A Study of Transmission Transmitted Infections (TTI) Prevalence in a Large Sample of 25,000 Blood Donors at a Tertiary Care Center Sheetal Arora1*, Deepshikha Rana1, Varsha Chauhan1, Shraddha Mishra2, Dushyant Singh Rawat3 Department of Pathology, ESIC Medical College, NH-3, NIT Faridabad, India Department of Pathology, Safdarjung Hospital and VMMC, New Delhi, India 3 Department Of Blood Bank, Safdarjung Hospital and VMMC, New Delhi, India 1
2
ABSTRACT Introduction: Blood transfusion increases the risk of acquiringtransfusion transmitted infections (TTI ).We report the seroprevalence of hepatitis B (HBV), hepatitis C(HCV), Human Immunodeficiency Virus (HIV), syphilis and malaria along with combined infections in 2 years Material and methods: A two-year retrospective study of 25,000 healthy blood donors. Results: Prevalence of HIV, HBsAg, HCV and syphilis were 3.24%, 0.82%, 0.42%, 0.82% respectively. Twenty five (%) of these had co infection (>2TTIs).Of the 25 blood donors with co infections, fifteen were HIV seroreactive ,out of these nine were seroreactive with HBsAg , two were seroreactive with HCV and four with syphilis (VDRL).One donor was positive for HBsAg , HCV and HIV. Among ten HIV seronegative blood donors HBsAg and HCV seroreactivity was present in seven donors followed by HBsAg and STS in three. Conclusion: Seroprevalence of HCV is steady after 2006 as no effective vaccine is available against HCV infection. High prevalence of HBsAg may be attributed to vaccine mutants or concealing of information by replacement donors. High prevalence of co-infection (0.1%) emphasizes the need for highly sensitive donor screening techniques, NAT, educational programs to enable detection of TTIs and decreasing transmission. Keywords: Co Infections, Seroprevalence, Transfusion Transmitted Infections
Introduction
Blood transfusion service (BTS) are an integral and indispensable part of the healthcare system. The priority objective of BTS is to ensure safety , adequacy , accessibility and efficiency of blood supply at all levels [1].Transfusion of blood and blood components, as a specialized modality of patient management saves millions of lives worldwide each year and reduces morbidity . It is well known that blood transfusion is associated with a large number of complications, some are only trivial and others are potentially life threatening, demanding for meticulous pretransfusion testing and screening. Use of unscreened blood transfusion keeps the patient at risk of acquiring many transfusion transmitted infections (TTI ) like hepatitis viruses (HBV, HCV), human immune deficiency viruses (HI V), syphilis, malaria etc. Transfusion departments have always been a major portal to screen, monitor and control infections transmitted by blood transfusion. Blood transfusion departments not only screen TTI but also give clue about the prevalence of these infections in healthy populations [2]. The past several decades have witnessed great advantage in techniques of detecting these TTIs. Developed countries
have decreased the risk of TTIs to a major extent with the advent of nucleic acid amplification technique (NAT). Despite this dramatic progress, India is far from achieving a “zero risk� blood supply. Amongst the infections, HIV and hepatitis are the commonest to occur in the window period which is often negative. With the advent of component single donor bag for two to three recipients, there is possibility of one positive infecting two-three persons. [3, 4]In the present study we attempted to assess the prevalence of markers of HCV, HIV and HBV. We report the seroprevalence of hepatitis B(HBV), hepatitis C(HCV), Human Immunodeficiency Virus (HI V), syphilis and malaria along with combined infections over a period of 2 years from 2010 to 2012 in a tertiary care hospital . Such studies give insight for the safety of blood transfusion and an accurate assessment of known risks versus benefits of blood transfusion [5].
Materials and Methods
In this retrospective study, we reviewed records of 25,000 healthy blood donors over a period of two years (2010-2012) from the records of blood bank. In our study majority of donors were replacement donors who were
This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)
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either relatives or friends of the patient concerned .Donors were selected and screened thoroughly, as per the guidelines of WHO manual of transfusion medicine [6]. Professional blood donors and those with previous history of jaundice were excluded. All the 25,000 donor serum samples were screened for HBV, HCV and HIV. Hepatitis surface antigen (HBS Ag) was screened using third generation ELISA kits (Monalisa; BioRad), with reported sensitivity and specificity of 100% each (as per manufacturer’s manual). HCV was screened using third generation ELISA kits (HCV microlisa) with reported sensitivity and specificity of 100 and 97.4% respectively.HIV was screened by third generation ELISA kits(HIV monalisa; Biorad) with reported sensitivity and specificity of 100% each. Tests were performed according to manufacturer`s instructions.
HIV seroreactive, of which nine were seroreactive with HBsAg, two were seroreactive with HCV and four with syphilis (VDRL). There was one donor who was positive for HBsAg, HCV and HIV. Among the ten HIV seronegative blood donors HBsAg and HCV seroreactivity was present in seven donors followed by HBsAg and STS in three (Table 1,2)
Discussion
Blood transfusion is a significant route of transmission of infectious diseases. Among all viral infections, HIV and Hepatitis are lethal. In the present study, an analysis of donor profile and estimations of prevalence of HIV, HCV and HBV along with syphilis, malaria and co infections are attempted. Replacement donors constitute the largest group of blood donors in India [7] and the same was found in our study. In a study by Singh et al. [8]82.4% of their donors were replacement donors while Kakkar et al. [9] had 94.7%.
Results
A total of 25,000 apparently healthy donors were screened during the study period. (Figure1)
The seroprevalence of HCV in our study was 0.82%. Garg et al [10] reported an HCV prevalence of 0.28% in blood donors in western India. In India compulsory HCV testing was started in 2001-2002.It was found that in the studies done in Delhi before 2006,the seroprevalence of HCV showed a wide range of 0.5 to 2.2% [8,11-15], lowest prevalence found in 2004-2005. While the studies after 2006 showed seroprevalence of 0.22 to 0.26% [1618]. The wide variation of HCV seroprevalence in different
Among them 97.84% were males and 2.16% were females. 64.78% were replacement donors while 35.22% were voluntary donors. The overall prevalence of HIV, HBsAg, HCV and syphilis were 3.24%, 0.82%, 0.42%, 0.82% respectively (Figure 2) No blood donor tested showed positivity for malarial parasite. Twenty-five (%) of these had confection (>2TTIs). Of the 25 blood donors with co-infections, fifteen were Table 1: Shows Pure and Mixed Infections in Various Categories. Category
Pure infection
%age
Mixed infection
%age
HBsAg
791
97.53%
20
2.47%
HCV
197
95.63%
9
4.37%
STS
99
93.40%
7
6.60%
HIV
189
92.65%
15
7.35%
Table 2: Shows Various Coinfections Found in Donors. Category
Count
HBsAg+HCV
7
HbsAg+STS
3
HbsAg+HIV
9
HCV+STS
0
HCV+HIV
2
STS+HIV
4
HbsAg+HCV+STS
0
HbsAg+HCV+HIV
1
HbsAg+STS+HIV
0
HCV+STS+HIV
0
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Fig. 1: Shows out of 25000 healthy donors, 23673(94.6%) were not infected and 1327 (5.3%) were infected.
Fig. 2:Shows various infections in donors.
studies in India[19-21]might be due to use of different generations of ELISA test kits, having different sensitivities and specificities. The above data infers that after 2006 prevalence has decreased although it is almost steady. The decrease in prevalence till 2006 was due to effective screening, literacy rate and level of awareness in donors but as it is steady after 2006 it shows that it is a potential threat to the safety of blood. The cause of which can be attributed to it is that no effective vaccine is available for immunization against HCV infection.
that replacement donors conceal information about their health during donor selection to get the blood for their patient thus compromising blood safety.
Prevalence of HBsAg in our blood donor population was found to be relatively higher (3.24%). India has been placed in the intermediate zone of prevalence of hepatitis B by World Health Organization (2-7%) [22]. Prevalence rate of 1-2% was reported in 2001[23], 1.8% in 2004[21], 2.7% in 2003[24] and 1.66% in 2008[15]. HBsAg prevalencein Punjab blood donors was 1 .7% [14], while Rajasthan had 3.44% [10] and Delhi had 2.23% [13]. In Karnataka, coastal area [25] had 0.62%, Jammu had 0.66%[27]and Bangalore [26] had 1.86% HBV seropositivity . On the other hand, the prevalence of HBV infection is lower in the United States and Western Europe (0.1–0.5%) and is reported to be higher, 5–15% in South East Asia and China [10]. The data regarding HBsAg infection among blood donors infers that there was no particular trend and except for few studies, remaining had high prevalence, i.e.,>1.6 %. India is still in the intermediate prevalence zone for HBsAg and has been estimated to be home to over 40 million HBsAg carriers [16]. Despite the fact that a safe and effective vaccine has been available since 1982[28], the HBsAg prevalence in India remains high. This is mainly because despite giving hepatitis B vaccination, there are various mutants which might be responsible for increasing trends. Other cause of increasing prevalence of HBV infection may be due to fact
As this prevalence was obtained from ELISA and not the HBcAg or NAT and could not detect mutants, exact prevalence might be much higher, so assays to detect these mutants should be used for detection. For HIV, India is next to South Africa and Nigeria in terms of overall number of people living with HIV. The Indian National AIDS Control Organization suggested an overall prevalence of 0.91% (2005) and 0.25% in Delhi [29]. West India has reported a prevalence of HIV of 0.47% [30] while that in Punjab is 0.26% [14]. Sonawane et al [31] reported a prevalence of 1.83% in rural population. The present study showed an HIV seroprevalence of 0.82%. A WHO report states thatthe viral dose in HIV transmission through blood is so large that one HIV positive transfusion leads to death, on an average, after 2 years in children and after three to 5 years in adults [32]. Hence, safe transfusion practices like avoidance of single donorsand practices of autologous blood transfusion should be encouraged [8]. Sexually transmitted infections arewidespread in developing countries and constitute amajor public health problem. The VDRL reactivityin our study was 0.42%, a comparatively low value when compared to 1.6% noted by SriKrishna et al. [26] and 2.6% by Singh et al. [8] in Delhi. Arora [32] have reported a 0.9% ofVDRL reactivity while Bhattacharya [33] found0.72% reactivity. Syphilis has also acquired a newpotential for morbidity and mortality through associationwith increased risk ofHIV infection, thus making safe blood more difficult to get. Although in our study no correlation was found in co infection with HIV.
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Data on the prevalence of >2 TTIs is limited. In HIVpositive donors, HBsAg was positive in 12.2%while VDRL was reactive in 11.8% [34]. The seroprevalence of hepatitis virus in patients infected with HIV showed that 9.9% of patients were HBsAg-positive, 6.3% were HCV-positive and about 1% had dual infection with HBV and HCV [35]. However, this study enrolled patients who received antiretroviral therapy and not blood donors. Mathai et al. [36] found that of 31,942 donors screened over a 6-year period, mixed infections were seen in only 10 donors (0.03%). We found that 25 of 25000 donors had co-infection (0.1%). As is evident, the prevalence of more than one TTI is very low. Studies on the prevalence of hepatitis viruses in patients with HIV have shown the HIV and HBV/HCV co-infection rate to be 12%–15% [37– 39]. However, studies from India show that this varies with the geographical region with rates of 9%–30% for HBV and 2%–8% for HCV [40–43].We encountered HIV and HBV in 9 of 25 (36%) and HCV in 2 of 25 (8%) coinfections. Many factors favor mixed infections including a high degree of epidemiological similarity between the HIV and hepatitis viruses. They have similar routes of transmission, risk factors such as high risk sexual behavior and a higher prevalence with other sexually transmitted diseases such as syphilis. It is important to detect these as >2 TTIs would pose a greater threat to the recipient of the infected blood. We found a higher rate of VDRL seroreactivity than that in other studies [44].This may be because we did not use any other test to confirm the presence of syphilis. Syphilis infection can increase the susceptibility to HIV infection. For its part, HIV can alter the clinical course of syphilis, increase the likelihood of relapse, and confound the diagnosis of neurosyphilis. In a study done to analyze the association of HIV infection with hepatitis B and syphilis in blood donors, of the 60 Western blot confirmed HIV-positive blood samples, none were positive for HBsAg and 4 were positive for syphilis [45]. In contrast, we found an association of both syphilis and hepatitis B with HIV in blood donors. This reflects the trend in the general population [37-39]. This emphasizes the need for highly sensitive donor screening techniques to enable the detection of TTIs. These pose a definite risk to the recipient of the blood. Due to a similarity in risk factors and routes of transmission, public awareness and education would go a long way in curbing the prevalence of these infections and increasing blood safety. In the West, the practice of donor self-exclusion helps in the deferral of high risk donors. However, due to low socioeconomic status and lack of awareness, the implementation of donor
self-exclusion is difficult in India. Voluntary donations are safer as compared to replacement ones and should be encouraged. Efforts should be made to increase the number of voluntary donors and reduce replacement donations to a minimum.
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
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Conclusion
With the advent of nucleic acid amplification techniques (NAT), western countries have decreased the risk of TTI to a major extent [10]. This will decrease the window period and hence decrease the incidence of TTI. But the cost-effectiveness of NAT is poor [3]. The NAT has added benefits but its high financial cost is of concern, especially in economically restricted countries like India. Along with advanced technology such as NAT for donor screening, other factors suchas public awareness, vigilance of errors, educational and motivational programs, help in decreasing the infection [10].
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*Corresponding author: Dr. Sheetal Arora, Department of Pathology, ESIC Medical College, NH-3, NIT Faridabad, INDIA Email: sheetalaroragupta@gmail.com
Financial or other Competing Interests: None.
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
Date of Submission : 06.07.2017 Date of Acceptance : 19.07.2017 Date of Publication : 18.08.2017
e-ISSN: 2349-6991; p-ISSN: 2455-0396
Original Article DOI: 10.21276/AABS.1603
Role of Bone Marrow Biopsy in Myeloproliferative Neoplasm: Study of 49 Cases Manjit Kaur* and Arun Puri Baba Farid University of Health Sciences, Faridkot, India
ABSTRACT The aim of the current study was to analyze the value of bone marrow biopsy and imprint smears in myeloproliferative neoplasm. Chronic myeloid leukemia is the most common leukemia amongst MPN as well as all acute and chronic adult leukemia. Diagnosis can be made on peripheral blood, bone marrow examination and molecular pathology findings. But in some cases bone marrow plays a very valuable role in the diagnosis. In the present study, bone marrow biopsies were re-examined in 49 patients with MPN. And it was found that BMB helped in 10 cases of MPN for making final diagnosis. Keywords: Chronic Myeloid Leukemia, Bloody Tap, Bone Marrow Biopsy, Smear Imprint
Introduction
In India as mentioned in various cancer registries, chronic myeloid leukemia (CML) amongst myeloproliferative neoplasm (MPN) is one of the most common adult leukemias in Indian population. It constitutes 30% to 60% of all adult leukemias [1, 2]. Median age at presentation is 38-40 years in India and it is a decade younger compared with the age presented in European as well as in American literature. MPN is predominantly diseases of adults with a minority of patients are children and young adults [3]. Clinical presentation, peripheral blood film (PBF) examination, bone marrow examination (BME) along with molecular studies is essential for the diagnosis [4]. Bone marrow biopsy (BMB) with smears imprints (SI) is still a vital tool as it can further help in the diagnosis and categorization especially when bone marrow aspiration comes out to be dry tap or bloody tap [5].
Material and Method
The present study, 49 bone marrow biopsy cases of MPN were taken into consideration. Age at presentation, sex,
absence/presence of splenomegaly along with duration of symptoms and total leukocytic count was re-analysed. Total leucocyte count, bone marrow aspiration and imprint smears were re-examined and findings obtained were correlated with bone marrow biopsy sections. Diagnosis of MPN was reassessed and histopathological findings were analyzed.
Results
A total of 49 bone marrow biopsies of MPN patients were analyzed. The mean age of presentation was 41.2 Âą 15.4 years (range 16 - 70 years). There were 23 males and 26 females (M:F ratio, 1.1:1). The males had a higher mean age than the females (42.7 vs. 40.0 years). Total leucocytes count ranges from 3000 cells/ cmm to 5,00,000 cells/ cmm in all the cases. Amongst 49 biopsies done, 39 cases showed complementary results of BMA, SI and BMB. The final diagnosis was made on BMB imprint smears and histopathological examination in 10 cases (Table 1&2). Out of 10, 8 cases underwent biopsy after the complete treatment of CML.
Table 1: haematological findings of ten undiagnosed cases with correlation with gender distribution. PBF
Total cases
M
F
Pancytopenia
4
Nil
4
Thromcythemia
1
1
Nil
Pancytopenia
2
Nil
2
Accelerated phase
1
Nil
1
Pancytopenia
1
1
Nil
Pancytopenia
1
1
Nil
Total
10
3
7
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Table 2: Bone marrow examination findings of ten undiagnosed cases Total cases
BMA
BMB
SI
4
Bloody tap
MF
No findings
1
Dry tap
ET
Increased dysplastic megakaryocytes
2
Dry tap
Blast crises
Myeloblasts
1
Bloody tap
Accelerated phase
Accelerated phase
1
Dry tap
Lymphoma
Atypical lymphoid cells
1
Bloody tap
Marrow repair
No findings
10
Fig 1: Showing fibrosis of marrow (Haematoxylin &Eosin stained section 20X).
Fig. 2: Showing abnormal topographic arrangement of megakaryocytes (H&E stained sections 40x).
Discussion
In the present study 39 out of total 49 cases showed comparable results of CML between BMA and BMB [5]. An important limitation of bone marrow obtained by aspirate in 6 cases was dilution of the sample. The admixing of marrow and sinusoidal blood results in false low cellularity hence BMB is In rest of the four out of ten cases, dry tap was obtained and ultimately diagnosis was made on BMB [9].
As mentioned in the literature BMA does not have much role in diagnosis of primary myelofibrosis, as it can be confirmed on BMB only [10]. In one known case of CML, bone marrow aspiration yielded diluted blood only. BMB and imprint smears provided the clue for diagnosis of accelerated phase [11,12]. One young male who was undergoing treatment of CML, presented with pancytopenia showed bloody tap on BMA. Bone marrow biopsy showed changes of marrow repair histopathologically [7]. In addition role of trephine biopsy in association with imprint smear examination is critical to measure the marrow cellularity, topographic arrangement and blasts. In two cases of dry tap, BMB revealed blast crises in known case of CML [11]. The histopathological examonation in another case of dry tap showed increased number of megakaryocytes with abnormal topographic arrangement (Fig2) [13].
Four out of six cases of bloody tap presented with pancytopenia, was found to be cases of myelofibrosis (Fig 1).
One another case of treated CML presented with pancytopenia and biopsy revealed second malignancy of lymphoid origin [14].
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
e-ISSN: 2349-6991; p-ISSN: 2455-0396
Diagnosis of MPN included complete blood count (CBC), comprising differential and platelet count, marrow aspiration, and marrow biopsy with recent development in diagnosis including sensitive tests such as standard cytogenetics [6]. The bone marrow examination is valuable investigation in hematology. These procedures are also useful for follow up of the patients undergoing chemotherapy [7, 8].
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Conclusion
5.
These days diagnosis of myeloproliferative neoplasm depends upon the molecular genes studies along with basic investigations and clinical presentation. Bone marrow biopsy with the help of imprint smears still plays a crucial role in making the diagnosis.
Kaur M, Singh APS, Kapoor SH, Puri A. Diagnostic Value of Bone Marrow Aspiration and Biopsy in Routine Hematology Practice Journal of Clinical and Diagnostic Research. 2014 Aug, Vol-8(8): FC13-FC16
6.
Lee SJ. Chronic myelogenous leukemia. Br J Haematol. 2000;111:993–1009.
Acknowledgements
7.
Riley RS, Hogan TF, Pavot DR, Forysthe R, Massey D, Smith E, et al. A pathologist’s perspective on bone marrow aspiration and biopsy; Performing a bone marrow examination. J Clin Lab Anal. 2004;18(2):70–9.
Abbreviations and Symbols
8.
Islam A. Bone marrow aspiration prior to bone marrow core biopsy using the same bone marrow biopsy needle. A good or bad practice. J Clin Pathol. 2007;60:212–15.
9.
Humphries JE. Dry tap bone marrow aspiration: clinical significance. Am J Hematol. 1990;35(4):247-50.
We are thankful to Mr. Kuldeep Singh for his help in collecting the data. MPN – Myeloproliferative Neoplasm BMA- Bone marrow aspiration BMB- Bone marrow biopsy
10. Yookarin KH, Basu D, Dutta DK. Bone marrow trephine biopsy findings in chronic myeloid leukemia. Malaysian Journal of pathology. 2002;24:37-43.
SI- Smear imprint MF- Myelofibrosis ET- Essential thrombocythemia
Reference: 1.
Aziz Z, Iqbal J, Akram M, Saeed S. Treatment of chronic myeloid leukemia in the imatinib era: Perspective from a developing country. Cancer 2007;109:1138-45. 2. Bhutani M, Vora A, Kumar L, Kochupillai V. Lymphohemopoietic malignancies in India. Med Oncol 2002;19:141-50. 3. Nowell PC, Hungerford DA. Chromosome studies on normal and leukemic human leukocytes. J Natl Cancer Inst 1960;25:85-109. 4. Sokal JE, Baccarani M, Tura S, et al. Prognostic discrimination among younger patients with chronic granulocytic leukemia: relevance to bone marrow transplantation. Blood 1985;66:1352–7.
11. Younus U, Saba K, Aijaz J, Bukhari MH, Naeem S. Significance of Bone Marrow Histology in the Diagnosis of Acute Myeloid Leukemia. ANNALS. 2011;17(1):5-8. 12. Tilak V, Das S, Bundhun S. Value of Bone Marrow Imprint Smears in Early Diagnosis Of Bone Marrow Pathologies. J Clin Diagn Res. 2014 Nov; 8(11): FC01–FC03. 13. Steven J, Jubelirer. The role of the bone marrow examination in the diagnosis of immune thrombocytopenic purpura: case Series and Literature Review. Clinical and Applied Thrombosis/Hemostasis. 2002;8:173-76. 14. Miranda MB, Lauseker M, Kraus MP, Proetel U, Hanfstein, Fabarius A et al. Secondary malignancies in chronic myeloid leukemia patients after imatinib-based treatment: long-term observation in CML Study IV. Leukemia 2016 Jun; 30(6): 1255–1262.
*Corresponding author: Dr. Manjit Kaur, Baba Farid University of Health Sciences, Faridkot, India Phone: +91 8427950069 Email: drmrsmanjitkaur@gmail.com Date of Submission : 13.07.2017 Date of Acceptance : 23.07.2017 Date of Publication : 18.08.2017
Financial or other Competing Interests: None.
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Original Article DOI: 10.21276/AABS.1602
Role of Fine-Needle Aspiration Cytology in Evaluation of Breast Lumps Ashish Kosthi, Maneesh Sulya* and Reeni Malik Department of Pathology, Gandhi Medical College, Bhopal, India
ABSTRACT Background: Breast lump is most common presentation in most of the breast diseases. Fine-Needle Aspiration Cytology (FNAC) is the immediate tool of the physician when first time patient is examined. The method is rapid, accurate, minimally invasive and serve as a therapeutic procedure when a cyst is encountered. Method: This is a retrospective hospital based study conducted at department of Pathology,Gandhi Medical College, Bhopal over a period of two and a half years. It included 531 patients with breast lump attending the outpatient department (OPD). Result: FNAC was done on 531 cases of breast lump, 31 (5.84%) cases were not satisfactory and remaining 500 (94.16%) were satisfactory enough for a cytological diagnosis. Out of 500 cases, benign lesions were 358 (71.60%), malignant lesions were 87 (17.40%), inflammatory lesions were 41 (8.20%) and suspicious category include 14 (2.80%). Fibroadenoma was the most common benign lesion and ductal carcinoma was the common malignant lesion. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of FNAC was 98.13%, 100%, 100%, 98.98% and 99.34% respectively. Conclusion: FNAC of the breast lump is a simple, safe, economical, and rapid diagnostic procedure which can be used routinely on OPD basis, because the cytopathological examination of these lesions before operation or treatment serves as an important diagnostic modality. Keywords: FNAC, Breast Lesions, Fibroadenoma, Ductal Carcinoma.
Introduction:
All breast lesions are not malignant, and all the benign lesions do not progress to cancer; however the accuracy of diagnosis can be increased by a combination of preoperative tests (like physical examination,mammography, fineneedle aspiration cytology, and core needle biopsy). These modalities are more accurate, reliable, and acceptable when compared with a single adopted diagnostic procedure despite of having their own technical limitations .[1, 2] Most common symptoms associated with breast lesions reported by women are pain, palpable mass, lumpiness without a palpable mass or nipple discharge.[3] A breast mass is generally palpable when it exceeds 2cm in size. The likelihood of a palpable mass being malignant increases with age. Only 10% of breast masses under the age of 40 are malignant compared to 60% of masses over the age of 50 years.[3] Fine-needle aspiration (FNA) is an established and highly accurate method for diagnosing breast lesions. The use of core biopsy (CB) is being increasingly advertised but its procedure is more cumbersome, expensive and time consuming as compared to FNA procedure.[4–6] Core Biopsy or tru cut needle biopsy is not widely used because of its complications, interpretation, and time-consuming
results; therefore palpable breast lesions can be accurately diagnosed by triple test only (FNAC, physical examination and Mammography).[7] It has been shown that, FNAC can reduce the number of open breast biopsies.[8] FNAC has been found to have sensitivity ranging from 82% to 97.5% and specificity of more than 99% .[9,10,11] The adequacy of FNAC is dependent on multiple factors. The rate of inadequate aspiration ranges from 0.7% to 25.3% , and this is influenced by the nature of the lesion, the available technology, and the experience and preference of the operator. [12] It was reported that the nature of the lesion was the most common cause of inadequacy of FNAC, accounting for 68% of the inadequate aspirates, followed by the experience of the aspirator that accounted for 32% of the inadequacy rate. [13] Some studies advocated that both aspirator and interpreter should ideally be the same, as the number of inadequate aspirates was far lower and the accuracy of diagnosis was higher when the same person aspirated and reported on the specimens. [12, 14, 15] The National Cancer Institute (NCI) definition of adequacy was one that led to resolution of a problem presented by a lesion in a particular patient’s breast. [16] Nevertheless,
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many authors considered epithelial cell clusters as the most important adequacy criteria. Studies demonstrated that an appropriate number of epithelial cell clusters could be an important factor in lowering the false-negative diagnosis rate in palpable and nonpalpable breast masses. [17,18] It was further suggested that a cut-off of six epithelial cell clusters may provide a reasonable balance between reduction of false-negative FNAC smears and an increase in the rate of inadequate smears. [18] Since diagnosing malignancy involves evaluation of the cytologic features of the epithelial cells, quantification of epithelial cells in the smears is most likely helpful. [17]
Result
FNAC of palpable breast lesions was done in different age group ranging from 11 yrs 80 yrs and the mean age was 34.33 yrs. It is find decade (21-30) showed maximum number of breast lesion (35.97%) while no case was found in the first decade. In the present study, 45 patients (8.47%) presented with bilateral lesions, where as 486 patients presented with unilateral involvement of the breast. Majority of the lumps 269 (50.66%) were located in left breast and 217 (40.87%) were located in the left breast.
Standard reporting system for breast FNAC, In the UK National Health Service Breast Screening Programme (NHSBSP) guidelines use a C1–C5 system: C1, inadequate; C2, benign; C3, atypical, probably benign; C4, suspicious; and C5, malignant. So that we find that the C3 and C4 categories always go to biopsy, be it core biopsy (CB) or otherwise. [19,20]
Among the quadrants majority of the lumps 302 (56.88%) were located in upper outer quadrant, followed by upper inner quadrant which constituted 87 cases (16.38%) and rest as shown in the (Table No.3). Out of 500 cases, inflammatory lesion were 41 (8.20%) benign lesions 358 (71.60%) and malignant lesion 87 (17.40%) with suspicious category 14 (2.80%) .
Most of the institutions in the USA follow the National Cancer Insistute (NCI) consensus conference recommendations belonging to the following categories: unsatisfactory, benign, atypical, suspicious and malignant. [21
Amongst inflammatory lesion, mastitis was commonest with 36 cases (9.02%) followed by Abscess 3 (0.75%) A single case of granulomatous lesion and epthelial hyperplasia was encountered in this category of inflammatory lesions.
The present study was undertaken to evaluate frequency, cytomorphological variations, and clinical presentation of different breast lesions.
Material and Methods
A retrospective hospital based study was conducted at the pathology department, Gandhi Medical College, Bhopal, India. Data was collected from the records of FNAC of breast lesions done in last two and half year duration. All the fine needle aspiration (FNA) was carried out with a 22 or 23 gauge needle attached to a 20 cc airtight disposable syringe fitted in a syringe holding FNA gun which provided a better grip and a negative pressure to aspirate adequate sample. The sample was obtained by to and fro motion. Samples were smeared onto glass slides just previously smeared with albumin for cellular adhesion; a thin smear was made and the slide was fixed immediately in 95% methanol. In cystic lesions, after aspiration of fluids, the lesion was again aspirated. The fluid was centrifuged and smears are made from sediment. Wet-fixed smears were stained with Haematoxylin and Eosin (H&E), and Papanicolaou stain. FNAC results were studied in detail for findings of inflammatory, benign breast lesions, suspicious and malignant lesions.
Amongst Benign lesions, Fibradenoma (39.94%) was the most common lesion, followed by fibroadenosis and fibrocystic disease. This benign category also includes two false negative cases which proved to be malignant on histopathology. Fibrocystic Disease: Smear showed cyst macrophages, bare nuclei and small groups of benign ductal epithelial cells and RBCs in all cases. Fibroadenoma: The aspirate was whitish granular in these cases. Cellular smears showed benign duct epithelial cells in tight cohesive clusters. Background was formed by bare nuclei and stromal fragments. A few cases showed apocrine changes and antler horn pattern. Out of 101 malignant lesions, 94 were infiltrating duct carcinoma (93.07), 4 were Lobular carcinoma (3.96%) and 1(0.99%) each of Apocrine carcinoma, Metaplastic carcinoma and Non-Hodgkin’s lymphoma. Infiltrating Ductal Carcinoma: Smear showed malignant cells with hyperchromatic nuclei and prominent cytoplasm. A few cases showed mitotic figures, multinucleate. Invasive Labular carcinoma: Smear showed Indian file arrangement of malignant cells with poorly cohesive cluster s. Also there was intra cytoplasmic neolumina.
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Metaplastic Carcinome: Smear showed high celluarity of fragments of fibromyxoid stroma containing spindle cells with nuclear pleomorphism and hyperchromasia. Also showed tumor giant cell.
hyperchromatic nucliei with scanty cytoplasm.
Non- Hodgkin’s Lymphoma: Cellular smear showed proliferation of lymphocytes with mixture of centrocytes and centroblasts having round, irregular and cleaved
Microphotograph of infiltrating lobular carcinoma showing typical Indian File of malignant cells with poorly cohesive clusters ( PAP: 40X).
Apocrine carcinoma: Smear showed malignant cells both individually scattered and arranged in syncytial fragments having apocrine features.
Table 1: Age incidence Age Group 0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 Total
Number of Cases 00 74 191 139 63 15 32 17 531
Percentage (%) 00 13.94 35.97 26.18 11.86 2.82 6.03 3.20 100.00
Sr. No.
Side
Number of Cases
Percentage (%)
1
Right
217
40.87
2
Left
269
50.66
3
Bilateral
45
8.47
Total
531
100
1 2 3 4 5 6 7 8 Table 2 : Side Of Involvement
Table 3: Involvement of different quadrants Sr.No.
Quadrant
Number of Cases
Percentage (%)
1
Upper outer
302
56.88
2
Upper inner
87
16.38
3
Lower outer
85
16.01
4
Central
40
7.53
5
Lower inner
17
3.20
Total
531
100
Table 4: Categorization Of Various Lesions Of Breast Lesions
Number of Cases
Percentage (%)
Inflammatory
41
8.20
Benign
358
71.60
Malignant
87
17.40
Suspicious
14
2.80
Benign Lesions
Number of Cases
Percentage (%)
Mastitis
36
87.80
Abscess
3
7.32
Granulomatous
1
2.44
S/o Epithelial Hyperplasia
1(False Negative )
2.44
Table 5: Categorization of inflammatory lesions of breast
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Table 6: Categorization of benign lesions of breast Benign Lesions Fibroadenoma Fibroadenosis Fibrocystic disease Gynecomastia Benign cyst Galactocele Benign phylloides tumor Lipoma Fibroadenoma with Apocrine cell change
Number of Cases 143 111 41 35 13 7 4 3 1 (False Negative )
Percentage 39.94 31.01 11.45 9.78 3.63 1.96 1.12 0.84 0.27
Number of Cases 94 4 1 1 1
Percentage 93.07 3.96 0.99 0.99 0.99
Table 7: Categorization of malignant lesions of breast. Malignant Lesion Infiltrating carcinoma Lobular carcinoma Non Hodgkin’s lymphoma Apocrine carcinoma Metaplastic carcinoma
Fig. 1 : Microphotograph of Fibroadenoma showing Antier horn pattern.
Fig. 2: Microphotograph of Invasive duct carcinoma showing dispersed malignant cells.
Fig. 3: Microphotograph of Invasive duct carcinoma showing dispersed malignant cells with multinucleation.
Fig.4: Microphotograph of infiltrating lobular carcinoma showing typical Indian File of malignant cells with poorly cohesive clusters ( PAP: 40X).
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Discussion
In the present study, left breast was more commonly involved than the right breast. Similar finding were found in studies of Ahmed et al [23] and Sandhu 49 et al [24]. Upper outer quadrant was more commonly involved followed by upper inner quadrant which correlated well with the study condructed by Zuk et al [25] and Sandhu et al [24]. In the present study inflammatory lesion were well in comparison with those of Singh et al [26] G. Jayaram [27] and Pradhan M [28] . Benign breast lesions accounted for 71.60% of the cases (358 cases), and this finding is comparable with finding of G. Jayaram [27] , Choi et al [29] and Pandit et al [30]. Malignant lesions accounted for 17.40% (101 cases) of total cases and there were (14) 2.64% lesions diagnosed as suspicious for malignancy on cytology, these finding are comparable with the finding of the breast of the breast FNAC study reported by Pradhan M [28] and Singh et al [26] .
In the present study, fibroadenoma was the most common benign lesion diagnosed in 39.94% which is in comparison with the study of breast lesion FNAC by Singh et al [26]. It is followed by Fibroadenosis as second most common benign lesion which is similar finding to that of Singh et al [26] and Pradhan et al [28]. Out of 500 cases in the present study, malignancy was noted in 101 cases (including 14 cases reported as ‘suspicious for malignancy’) accounting for 20.20% incidence. Among these 101 cases, 94 were reported as infiltrating duct carcinoma, 4 as lobular carcinoma and 1 each as Apocrine carcinoma, Metaplastic carcinoma and Non-Hodgkin’s lymphoma. the incidence of infiltrating ductal carcinoma is similar to studies of Goel et al [31] and Pradhan et al [28] . In the present study Sensitivity is 98.13% Specificity 100.00% Positive predictive value 100.00% Negative predictive value 98.98% and Overall accuracy 99.34%. Sensitivity and Specificity are similar to Kapila and Verma et al [32] and Q. He et al [33]. Whereas Positive and Negative Predictive value is similar to Kapila and Verma et al [32].
Table 8: Side of involvement (in Percentage) Sr. No.
Author
Right
Left
Bilateral
Total
1
Ahmed et al (2010)
43.0
51.0
6.0
200
2
Sandhu et al (2010)
47.4
51.6
1.0
267
3
Present study
40.87
50.66
8.47
531
Table 9: Presenting quadrants of breast lesions: (In Percentage) Presenting Quadrants
Zuk et al (1989)
Sandhu et al (2010)
Present study
Upper outer
42.2
47.7
56.88
Upper inner
6.4
9.5
16.38
Lower outer
5.3
3.6
16.01
Lower inner
4.3
1.6
3.20
Central
31.6
4.9
7.53
Table 10: Comparative analysis of Breast Lesions: (In percentage) Sr.No.
Author
Inflammatory
Benign
Malignant
Suspicious
1
Pandit et al (1988)
16.97
67.42
28.02
4.55
2
G. Jayaram (1996)
7.4
69.7
12.2
3.3
3
Singh et al (2001)
8.5
83.33
14.58
2.08
4
Choi et al (2004)
0.77
75.6
14.0
2.9
5
Pradhan M (2008)
8.24
81.92
15.49
2.32
6
Ahmed et al (2010)
11.00
66.00
34.00
00
7
Present study
8.20
7160
17.40
2.80
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Table 11: Comparative analysis of benign lesions: (In percentage) Cytological diagnosis Fibroadenoma Fibroadenosis Fibrocystic disease Gynecomastia Galactocele Benign phylloides tumor Benign cyst Lipoma
Singh et al (2001) 48.5 40.5 00 00 1.0 00 3.0 00
Pradhan et al (2008) 8.01 43.41 4.27 2.18 0.71 0.18 0.09 0.31
Ahmed et al (2010) 28.0 00 11.5 1.5 4.0 1.0 6.0 3.0
Present Study 39.94 31.01 11.45 9.78 1.96 1.12 3.63 0.84
Table 12 : Comparative analysis of malignant lesions : (In Percentage) Cytological diagnosis Infiltrating ductal carcinoma Lobular carcinoma Medullary carcinoma Mucinous carcinoma Non-Hodgkin’s lymphoma Apocrine carcinoma Metaplastic carcinoma Metastatic
Goel et al (2003) 90.0 2.0 2.0 00 00 00 00 3.0
Pradhan et al (2008) 97.13 0.29 0.86 0.86 0.29 00 00 00
Present study 94.07 04.96 00 00 01.99 01.99 01.99 00
Table 13: Statistical Result- Comparative Analysis Sr.No. 1 2 3 4 5
Study Kapila & Verma (1989) Collaco et al (1999) Choi et al (2004) Q. He et al (2007) Present study
Sensitivity 97.6 92.1 77.7 97.72 98.13
Conclusion
The fine needle aspiration cytology of the breast lumps is a simple, safe and rapid diagnostic procedure which can be used routinely on OPD basis. The main purpose of FNAC of breast lumps is to confirm cancer preoperatively and to avoid unnecessary surgery in specific benign conditions. A diagnosis of malignancy allows pre-operative discussion on available therapeutic option. The benign breast lesions were far more common than the malignant breast lesions.
Specificity 99.4 98.6 99.2 99.4 100
Accuracy 98.4 91.1 97.94 99.34
M. H. Bukhari and Z. M. Akhtar, “Comparison of accuracy of diagnostic modalities for evaluation of breast cancer with review of literature,” Diagnostic Cytopathology, vol. 37, no. 6, pp. 416–424, 2009.
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Susan C. Lister. The Breast. In, Kumar, Abbas, Fausto, Aster(Ed). Robbins and Cotran Pathologic basis of disease.8th edition. Philadelphia, Pensylvania, Saunders,2010;1066-8.
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M. Rubin, K. Horiuchi, N. Joy et al., “Use of fine needle aspiration for solid breast lesions is accurate and costeffective,” American Journal of Surgery, vol. 174, no. 6, pp. 694– 698, 1997.
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A. Berner, E. Sigstad, W. Reed, and B. Risberg, “Fine-needle aspiration cytology or core biopsy when diagnosing tumours of the breast,” Tidsskrift for den Norske Laegeforening, vol. 123, no. 12, pp. 1677–1679, 2003.
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D. Lieu, “Value of cytopathologist-performed ultrasoundguided fine-needle aspiration as a screening test for ultrasound- guided core-needle biopsy in nonpalpable breast masses,” Diagnostic Cytopathology, vol. 37, no. 4, pp. 262–269, 2009.
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T. Ishikawa, Y. Hamaguchi, M. Tanabe et al., “False-positive and false-negative cases of fine-needle aspiration cytology
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NPV 97.2 82.1 88.0 98.98
2.
Ethical Approval
The study was approved by the Institutional Ethics Committee.
PPV 99.5 99.4 98.4 100
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Yong WS, Chia KH, Poh WT, Wong OY. A comparison of trucut biopsy with fine needle aspiration cytology in the diagnosis of breast cancer. Singapore Med J 1999; 40(09): 123-123.
10. Francis IM, Das DK. Role of fine needle aspiration, intraoperative imprint cytology and frozen section in the diagnosis of breast lumps and thyroid lesions. Medical principles and practice 1999; 8: 173-182. 11. Dutta SK, Chattopadhyaya A, Roy S. Fine needle aspiration and imprint cytology in the diagnosis of breast lesions. Journal of the Indian Medical Association. 2001 August; 99(8): 421- 23. 12. H. Zakhour and C. Wells, Diagnostic Cytopathology of the Breast, Churchill Livingstone, London, UK, 1999. 13. C. D. Scopa, D. Koukouras, J. Androulakis, and D. Bonikos, “Sources of diagnostic discrepancies in fine-needle aspiration of the breast,” Diagnostic Cytopathology, vol. 7, no. 5, pp. 546–548, 1991. 14. K. R. Lee, R. S. Foster, and J. L. Papillo, “Fine needle aspiration of the breast. Importance of the aspirator,” Acta Cytologica, vol. 31, no. 3, pp. 281–284, 1987. 15. L.A. Brown and S. B. Coghill, “Fine needle aspiration cytology of the breast: factors affecting sensitivity,” Cytopathology, vol. 2, no. 2, pp. 67–74, 1991. 16. “The uniform approach to breast fine needle aspiration biopsy. A synopsis,” Acta Cytol, vol. 40, pp. 1120– 1126, 1996. 17. S. Boerner and N. Sneige, “Specimen adequacy and falsenegative diagnosis rate in fine-needle aspirates of palpable breast masses,” Cancer, vol. 84, no. 6, pp. 344–348, 1998. 18. L. J. Layfield, E. E. Mooney, B. Glasgow, S. Hirschowitz, and A. Coogan, “What constitutes an adequate smear in fineneedle aspiration cytology of the breast?” Cancer, vol. 81, no. 1, pp. 16–21, 1997. 19. NHSBSP. Non-operative Diagnosis Subgroup of the National Coordinating Group for Breast Screening Pathology. 2001, Publication No 50. 20. NHSB. Guidelines for cytology procedures and reporting on fine needle aspirates of the breast. Cytology Subgroup
22. Perry N, Broeders M, de Wolf C, To¨ rnberg S, Holland R, von Karsa L. European guidelines for quality assurance in breast cancer screening and diagnosis. Fourth edition– summary document. Ann Oncol 2008;19:614–22. 23. Ahmed H.G. Ali AS, Almobarak AO. Frequency of breast cancer among Sudanese patients with breast palpable lumps. Indian Journal of Cancer 2010:47(1):23-26. 24. Sandhu DS, Sandhu S, karwasra RK, Marwah S. Profile of breast cancer patients at a tertiary care hospital in north India. Indian Journal of Cancer 2010; 47(1):16-22. 25. J.A. Zuk, G Maudsley, H D Zakhour, Rapid reporting on fine needle aspiration of breast lumps in outpatients. J Clin Pathol 1989; 42:906-11. 26. Kuldeep Singh, Satish Sharma, V.K. Dubey, P.R. Sharma. Role of FNAC in diagnosis of breast lumps. JK Science 2001:3(3):126-28. 27. G Jayaram, SF Alhady, CH Yip, Cytological anaysis of breast lesions: a review of 780 cases. Malaysia J Pathol 1996; 18(2):81-87. 28. Pradhan M. Dhakal HP. Study of breast lump of 2246 cases by fine needle aspiration, J Nepal Med Assoc 2008; 47 (172): 205-9. 29. Hyun Joo Choi, In Ae Park. Fine needle aspiration cytology of metastatic choriocarcinoma presenting as a breast lump- a case report. Act cytol 2004; 48:91-94. 30. A.A. Pandit, K.S. Mayekar. Fine needle aspieration cytology of the breast tumour. Indian Journal of Cancer 1988:25:136-43. 31. A Goel, CM Bhan, K N Srivastava. Five year Clinicopathological study of Breast cancer cancer. Ind J Med Sci 2003; 57(8):347-49. 32. Kusum Verma & Kusum Kapila. The role of fine needle aspiration cytology of breast lumps in the management of patients. Indian J Med. Res. 1989:90:135-39. 33. Qungqing He, Xihong Fan Tinggui Yuan, Lixin Kong, Xiumin Du, Dayong Zhuang, Ziyi Fan. Evelven years of experience reveals that fine needle aspiration cytology is still a useful method for preoperative diagnosis of breast carcinoma. The Breast 2007; 16:303-06.
*Corresponding author: Dr.Maneesh Sulya, F-83/48 Tulsi Nagar,Near 2nd Bus Stop,Bhopal,Madhya Pradesh,India Email: drmanish1619@gmail.com
Financial or other Competing Interests: None.
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
Date of Submission : 11.07.2017 Date of Acceptance : 10.08.2017 Date of Publication : 18.08.2017
e-ISSN: 2349-6991; p-ISSN: 2455-0396
Case Report DOI: 10.21276/AABS.1643
Innovative Approach to Lingual Base Lesions Manish Munjal1, Archana Arora1*, Amanjeet Singh1, Dinesh Sood2 and Tushar Singla3 Deptt of ENTHNS, Dayanand Medical college and Hospital, Ludhiana, Punjab, India Deptt of Anesthesia, Dayanand Medical college and Hospital, Ludhiana, Punjab, India 3 Dayanand Medical college and Hospital, Ludhiana, Punjab, India
1 2
ABSTRACT Visualization and resection, in toto or sampling of base tongue lesions involves either a “ceiling” or a “floor” intervention. The concerned area is not in a straight line of view, necessitating thereby either 45 or 70 degree angled telescopes with 45 or 90 degree angled punch trucut instrumentation. In addition a curved tongue retractor is needed to lift out the anterior part of the tongue. To obviate the need of one instrument, a curved blade intubation video laryngoscope can be utilized with ease. A massive base tongue hemispherical mass was excised using this innovative technique. Keywords: Base Tongue, Video Laryngoscope
Introduction
Visualization of the tongue base can be difficult because of the angled trajectory and salivary secretions obscuring the view during assessment. Also, the biopsy specimens taken from this site can be non-diagnostic, mostly because of the tissue being too small or too superficial. The video laryngoscope gives a wide view of the base tongue and the ability to use sinus biopsy forceps, which can take larger and deeper specimens. [1,2]
Case Report
A 68 yr elderly male was admitted under head neck services with uneasiness at the back of the tongue for the last 6 months. There was no bleed per os nor any referred otalgia. A flexible fibroptic evaluation revealed a dome shaped pale mass extending to either pharyngoepiglottic folds. The vallecula and the median glossoepiglottic folds were free though the laryngeal inlet could not be discerned [Fig 1]. Contrast enhanced computed tomography axial, coronal and saggital views [Fig 2] delineated an oval mass at the base tongue area, in proximity to the lingual surface of the suprahyoid epiglottis. The naso -pharyngo-laryngotracheal airway could be well demarcated. The naso-laryngeal intubation was deferred considering the site, size, shape and friability of the lesion. In lieu of an upper airway bypass, a tracheostomy was performed for inhalational general anaesthesia. Under video laryngoscopic guidance, illumination and blade tip camera, a 270 degree resection of the friable mass could be carried out [Fig 3]. The surgery could be seen under magnified vision on the table side video monitor with meticulous
circumscribed dissection with the bipolar curved tip cutting coagulation blended mode. Tissue and blood spillage in the laryngeal inlet could be easily checked with this interventional modality. After the resection, laryngeal inlet could be seen to be free of the disease [Fig 4]. Tissue was sent for histopathological examination which was consistent with a lymphomatous malignancy. It revealed a cellular tumor with tumor cells arranged in sheets. The cells had pleomorphic vesicular nuclei, prominent nucleoli and scant to moderate amount of cytoplasm. Brisk mitosis was noted. Overlying stratified squamous epithelium showed orderly cell maturation. Foci of haemmorage and necrosis were also noted. The patient was thus referred for Radio-chemotherapy for further management.
Fig. 1: Pale dome shaped mass at base of tongue completely obscuring the laryngeal inlet.
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Fig. 2: Saggital, Axial and Coronal cuts showing oval mass at base of tongue.
Fig. 3: Mass found to be fragile on resection.
Fig. 4: Normal laryngeal inlet seen after resection.
Discussion
infectious, or congenital. Differential diagnosis includes benign neoplastic lesions like leiomyoma, neurofibroma, and schwannoma; congenital lesions like lingual thyroid, thyroglossal duct cyst, dermoid and epidermoid cysts. [5]
The base of the tongue is a subsite within the oropharynx. The circumvallate papilla and the posterior oral cavity are the anterosuperior boundary, inferoposteriorly are the vallecula and lingual surface of epiglottis, and laterally it is bounded by the glossoepiglottic folds. [3] Lesions of this area usually present as difficult or painful swallowing or a vague sensation of a lump in the throat. Some patients may complain of referred ear ache or hemoptysis. Diagnosis usually gets delayed because of the non specific nature of symptoms and the relative inaccessibility of the area to routine examination. Indirect or flexible fiberoptic laryngoscopy in the outdoor is a useful adjunct to the physical examination. [4] A systematic approach is therefore recommended for diagnosing a posterior tongue mass, which can be neoplastic,
Video laryngoscopes are an innovative option for examining the base of tongue as their curvature allows easy gliding along the tongue base. Also, a wider area can be visualized and the images can be seen on the monitor. They can be easily employed in morbidly obese patients or those who pose a difficulty in intubation. With the use of this laryngoscope, image guided biopsies can be taken from the lesion in appropriate depth and the blood and salivary secretions can be suctioned out thus preventing spill into the laryngeal inlet. [1,2]
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Conclusion
Base tongue lesions of the magnitude as above have a differential of being the benign lingual tonsils, ectopic lingual thyroids, schwannomas or the malignant primary or metastatic carcinomas. Circumscribed and friable lesions that bleed on touch, like these are a rarity. They necessitate an “encirclement view” prior to any intervention; else they spill into the lower airway. The role of the video laryngoscope, from the armamentarium of the anesthetist colleague cannot be better appreciated than in the above surgical situation.
AABS; 4(3): 2017
References 1. 2.
3. 4. 5.
P K Shenoy, M Aldea. The use of GlideScope for biopsies of the tongue base. The Journal of Laryngology & Otology (2013), 127, 215–216. Hughes J, Paul R. Use of the Venner™ A.P. Advance™ video laryngoscope for biopsy examination of the base of the tongue. British Journal of Oral and Maxillofacial Surgery, Vol 51, Issue 2, Pages e22-e23 http://emedicine.medscape.com/article/847955-overview#a9 http://emedicine.medscape.com/article/847955-overview#a8 Badar Z, Farooq Z. Tongue base schwannoma: differential diagnosis and imaging features with a case presentation. Radiol Case Rep. 2016 Dec; 11(4): 336–340.
*Corresponding author: Dr Archana Arora, 159-C rishi nagar, Ludhiana-141001. Punjab, India Phone: +91 9888780218 Email: drarchana.ent@gmail.com
Financial or other Competing Interests: None.
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
Date of Submission : 11.08.2017 Date of Acceptance : 26.08.2017 Date of Publication : 05.09.2017
e-ISSN: 2349-6991; p-ISSN: 2455-0396
Case Report DOI: 10.21276/AABS.1663
A case of Synchronous Multifocus Gastric Adenocarcinoma Shikha Sharma*, Bawana Raina, Misbah Rashid, K.C. Goswami Department of Pathology. ASCOMS & Hospitals, Sidhra, Jammu, J&K, India
ABSTRACT Synchronous neoplasms are defined as two or more primary tumors identified in the same patient, at the same time, in the same organ or in different organs. Here we present an interesting case of Synchronous Multifocus Gastric Adenocarcinoma with a concern that the diagnosis of synchronous multifocal gastric neoplasms can sometimes be missed during initial endoscopic investigations and during grossing sessions in histopathology units, making it obligatory for the surgeon and the histopathologist to be aware of such lesions. Keywords: Synchronous Multifocus Gastric Carcinoma, Endoscopic Mucosal Resection, Endoscopic Sub-mucosal Dissection.
Introduction
Synchronous neoplasms are defined as two or more primary tumors identified in the same patient, at the same time, in the same organ or in different organs (1). Synchronous tumors are characterized by the presence of different histological features with no physical connection between the two tumors and no metastasis between the two tumors (2). The North American Association of Central Cancer Registries (NAACCR) classifies multiple primary tumors into 2 categories: Synchronous, in which cancers occur at the same time and Metachronous in which cancer follows in sequence that is more than two months apart (3). Synchronous multifocal gastric carcinomas have a rare occurrence and the present case is one of the very few cases reported in Jammu region.
Case Report
A 65 year old man presented to the Surgical OPD of ASCOMS hospital, Jammu, with complains of nausea, recurrent episodes of vomiting and weakness. CBC was done, reports revealed anemia with a hemoglobin of 7g/ dl, urine examination was unremarkable, LFT, KFT were within limits, stool test for occult blood was positive. This gave an initial suspicion of malignancy. Endoscopy revealed a small growth measuring about 0.5×0.9cm just below the GE junction and a circumferential growth measuring 3×4 cm at the antrum, causing luminal narrowing. A biopsy was taken from both the growths, which later proved to be adenocarcinomas. A CECT was also performed. CECT revealed no thickening in the region of GE junction and a circumferential, irregular, mildly enhancing, wall thickening, involving approximately 4.5 cm long segment, having maximum thickness of 11.5mm, narrowing the lumen was seen in the antrum of the stomach. Along with this, 4 subcentric, perigastric lymph nodes were also seen. After
taking patients’ consent a total gastrectomy with feeding jejunostomy under GA was performed and the specimen was taken to the histopathology unit for further evaluation. On gross examination, a small ulcero-proliferative growth measuring 1.5×1cm was seen near the GE junction (fig.1) and a circumferential growth was identified at the antrum measuring 4.5×3(fig.1). 8 lymph nodes were identified from the lesser and the greater curvature varying from 0.5 cm to 1.5 cm in diameter. On complete microscopic examination, the growth near the GE junction showed moderately differentiated adenocarcinoma with papillary and glandular differentiation, infiltrating the superficial smooth muscle (fig.2) and the growth at the antrum showed poorly differentiated adenocarcinoma, with extensive smooth muscle infiltration, reaching upto serosa (fig.2). Perineural infiltration was seen. There was no lymphovascular invasion. 3 out of 8 lymph nodes identified, showed metastatic deposits. Surrounding mucosa showed no tumor or any, metaplastic change. Resection margins were free from tumor. The post operative course was uneventful and the patient was discharged on 14th day after surgery. He is under regular follow-up on outpatient basis.
Discussion
Synchronous multifocus gastric carcinoma accounts for 6-14% of all early gastric cancer(4-7). The high incidence has been attributed to the recent advances in endoscopic techniques and therapeutic modalities like Endoscopic Mucosal Resection (EMR) and Endoscopic Sub-mucosal Dissection (ESD). These therapies conserve the function but after resection a large quantity of gastric mucosa remain, which can give rise to further cancers (8). According to Nasu
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Fig.1: showing an Ulcero-proliferative growth at GE junction(arrow head) and a Circumferential growth narrowing the lumen at antrum of stomach (arrow).
Fig. 2: showing uninvolved Squamous epithelium (arrow) from GE junction and underlying Moderately differentiated adenocacinoma.
Fig. 2b: 100X Showing Normal gastric glands and Poorly differentiated adenocarcinoma(arrow) at the antrum of stomach.
et al (8) 11% patients developed synchronous multifocal gastric carcinoma within 1 year of initial EMR. Similarly in a study by Taro Isobe et al (9) the incidence of SMGC was 10.9%. So, it is important to identify patients who are at high risk of developing multiple gastric lesions because of the complexities that are involved in fully diagnosing and treating the patients using these advanced techniques. In present case the patient was diagnosed simultaneously after endoscopic biopsy .
the pathogenetic importance of intestinal metaplasia (10) in development of gastric carcinoma in elderly patients, as gastric glands generally show atrophic changes with a concomitant increase in intestinal metaplasia in stomach of elderly people. Although in present case, no metaplastic change could be seen.
SMGC occurs more commonly in elderly patients as is seen in the present case also. Taro Isobe et al explained
Patient with family histoy of gastric carcinoma have been reported to have high incidence of gastric carcinoma. (11,12) Similar history was reported by our patient. This may be attributed to genetic or environmental factors.
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
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Smoking and alcohol consumption have been reported to be risk factors for gastric cancers. (13,14,15) Morita et al (16) found no significant association between the occurrence of multiple gastric cancers and either of these factors.(16) However, Taro Isobe et al (9) found significant differences in smoking and drinking habits between patients with SMGC and those with single gastric cancer based on univariate analysis, but none of these risk factors were found to be independent risk factors in multivariate study. Hence the effect remains controversial. In the present case the patient was neither a smoker nor an alcoholic. Thus the effects of these factors cannot be attributed to the development of cancer in the present case. In studies by Otsuji E et al, Morita et al and Nasu et al(17,18,19), most SMGC’s were shown to have differentiated type and mostly both primary and secondary lesions were of same histologic type(17). In present case, both lesions were of same histological type but different histological grades. A total gastrectomy has been recommended for the treatment of multiple gastric cancers as the remnant stomach of patients who have undergone a partial gastrectomy is at increased risk for ongoing carcinogenesis (20). In present case the patient underwent a total gastrectomy and since 1 year is on follow up and is doing well.
Conclusion
We conclude by saying that the incidence of Synchronous multifocus gastric carcinomas is increasing and owing to their small size or the observers’ neglect, these lesions are likely to be missed in preoperative or intra-operative diagnostic assessment. Thus we must put efforts for the diagnosis of gastric cancers in early stages and must be aware of multifocal gastric carcinomas during endoscopic examinations and also during grossing sessions in the histopathology units.
3.
“A Review of the Definition for Multiple Primary Cancers in the United States,” in Worshop Proceedings From December 4-6, 2002 in Princeton, New Jersey, H. L. Howe, Ed., North American Association of Central Cancer Registries, Springfield, Ill, USA, 2003.
4.
Ribeiro U, Jorge UM, Safatle-Ribeiro AV, Yagi OK, Scapulatempo C, Perez RO, Corbett CE, Alves VA, Zilberstein B, Gama-Rodrigues J. Clinicopathologic and immunohistochemistry characterization of synchronous multiple primary gastric adenocarcinoma. J Gastrointest Surg. 2007;11:233–239.
5.
Otsuji E, Kuriu Y, Ichikawa D, Okamoto K, Hagiwara A, Yamagishi H. Clinicopathologic characteristics and prognosis of synchronous multifocal gastric carcinomas. Am J Surg. 2005;189:116–119.
6. Morita M, Kuwano H, Baba H, Taketomi A, Kohnoe S, Tomoda H, Araki K, Saeki H, Kitamura K, Sugimachi K. Multifocal occurrence of gastric carcinoma in patients with a family history of gastric carcinoma. Cancer. 1998;83:1307–1311. 7.
Borie F, Plaisant N, Millat B, Hay JM, Fagniez PL, De Saxce B. Treatment and prognosis of early multiple gastric cancer. Eur J Surg Oncol. 2003;29:511–514.
8.
Nasu J, Doi T, Endo H, Nishina T, Hirasaki S, Hyodo I. Characteristics of metachronous multiple early gastric cancers after endoscopic mucosal resection. Endoscopy. 2005;37:990–993.
9.
Characteristics and prognosis of synchronous multiple early gastric cancer Taro Isobe, Kousuke Hashimoto, Junya Kizaki, Naotaka Murakami, Keishiro Aoyagi, Kikuo Koufuji, Yoshito Akagi, andKazuo Shirouzu
10. Nitta T, Egashira Y, Akutagawa H, Edagawa G, Kurisu Y, Nomura E, Tanigawa N, Shibayama Y. Study of clinicopathological factors associated with the occurrence of synchronous multiple gastric carcinomas. Gastric Cancer. 2009;12:23–30.
Acknowledgements
11. Chen JD, Kearns S, Porter T, Richards FM, Maher ER, Teh BT. MET mutation and familial gastric cancer. J Med Genet. 2001;38:E26. [PMC free article]
Competing Interests
12. Kato I, Tominaga S, Matsumoto K. A prospective study of stomach cancer among a rural Japanese population: a 6-year survey. Jpn J Cancer Res. 1992;83:568–575.
Dr. Bawana Raina, Dr Arvind Khajuria. This case report bears no competing interests.
Reference 1.
2.
Nosho, K., Kure, S., Irahara, N. et al, Aprospective cohort study shows unique epigenetic, genetic, and prognostic features of synchronous colorectal cancers. Gastroenterology. 2009; 137:1609–1620. A. Dąbrowski, A. Ciechański, G. WallnerAssociation of non-Hodgkin’s lymphoma of stomach with other neoplasms of gastro-intestinal tract.GastroenterologiaPolska, 4 (4) (1997), pp. 427-429
13. Nomura A, Grove JS, Stemmermann GN, Severson RK. A prospective study of stomach cancer and its relation to diet, cigarettes, and alcohol consumption. Cancer Res. 1990;50:627–631. 14. Ji BT, Chow WH, Yang G, McLaughlin JK, Gao RN, Zheng W, Shu XO, Jin F, Fraumeni JF, Gao YT. The influence of cigarette smoking, alcohol, and green tea consumption on the risk of carcinoma of the cardia and distal stomach in Shanghai, China. Cancer. 1996;77:2449–2457.
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C-27 15. La Vecchia C, Negri E, Franceschi S, Gentile A. Family history and the risk of stomach and colorectal cancer. Cancer. 1992;70:50–55. 16. Morita M, Kuwano H, Baba H, Taketomi A, Kohnoe S, Tomoda H, Araki K, Saeki H, Kitamura K, Sugimachi K. Multifocal occurrence of gastric carcinoma in patients with a family history of gastric carcinoma. Cancer. 1998;83:1307–1311. 17. Otsuji E, Kuriu Y, Ichikawa D, Okamoto K, Hagiwara A, Yamagishi H. Clinicopathologic characteristics and prognosis of synchronous multifocal gastric carcinomas. Am J Surg. 2005;189:116–119.
AABS; 4(3): 2017 18. Morita M, Kuwano H, Baba H, Taketomi A, Kohnoe S, Tomoda H, Araki K, Saeki H, Kitamura K, Sugimachi K. Multifocal occurrence of gastric carcinoma in patients with a family history of gastric carcinoma. Cancer. 1998;83:1307–1311. 19. Nasu J, Doi T, Endo H, Nishina T, Hirasaki S, Hyodo I. Characteristics of metachronous multiple early gastric cancers after endoscopic mucosal resection. Endoscopy. 2005;37:990–993. 20. Moertel CG, Bargen JA, Soule EH. Multiple gastric cancers; review of the literature and study of 42 cases. Gastroenterology. 1957;32:1095–1103.
*Corresponding author: Dr. Shikha Sharma, H.NO. 130, Sector -3, near new shiv mandir,nanak nagar ,jammu,J&k. Phone: +91 7298030012 Email: mywish2330@gmail.com
Financial or other Competing Interests: None.
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
Date of Submission : 27.08.2017 Date of Acceptance : 30.08.2017 Date of Publication : 05.09.2017
e-ISSN: 2349-6991; p-ISSN: 2455-0396
Case Report DOI: 10.21276/AABS.1676
Confronting The Unexpected:- Saddle During Septal Surgery Manish Munjal, Japneet Kaur*, Amanjot Kaur, Amanjeet Singh, Nidhi Mathur and Shubham Munjal Department of ENT, DMCH, Ludhiana, India
ABSTRACT Septal surgery is aptly captioned the “ bread and butter surgery “ , of the ent surgeon .Sometimes in this basic surgery the unexpected happens . A septal perforation or a saddle of the cartilaginous dorsum . The former lies hidden deep inside while the latter effects the facial profile and one becomes an object of ridicule. Utilising the resected tissue or tissues from nasal vicinity one can augment the depression . In certain septal deformities ,the inferior border of the quadrangular cartilage overrides the premaxillary and the maxillary crest ,thereby producing a sharp or a blunt spur. Resection of the same with a “ antero -posterior chondrotomy” attains a good nasal patency . A jutting premaxillary or maxillary crest is amenable to a similarly oriented “ osteotomy “. Keywords: Saddle Nose, Rhinoplasty, Septoplasty
Introduction
Septal surgery is aptly captioned the “ bread and butter surgery “ , of the ent surgeon .Sometimes in this basic surgery the unexpected happens . A septal perforation or a saddle of the cartilaginous dorsum . The former lies hidden deep inside while the latter effects the facial profile and one becomes an object of ridicule. Utilising the resected tissue or tissues from nasal vicinity one can augment the depression . In certain septal deformities ,the inferior border of the quadrangular cartilage overrides the premaxillary and the maxillary crest ,thereby producing a sharp or a blunt spur. Resection of the same with a “ antero -posterior chondrotomy” attains a good nasal patency . A jutting premaxillary or maxillary crest is amenable to a similarly oriented “ osteotomy “ .
Case Report
An 18 year old male underwent a septal surgery for a deviated septum where the inferior septal border and the anterior part of the ethmoidal plate , was resected . Though the nasal patency was attained but accentuation of the saddle on the cartilaginous dorsum was noticed . The cartilage resected from the quadrangular cartilage was refashioned and two segments, in a palisade arrangement , were positioned in a pocket created on the cartiginous dorsum . A transcolumellar incision was given to gain access to the nasal dorsum . Dissection was limited to the midline to avoid a lateral displacement of the grafts. The larger graft was oriented with the convexity facing upwards and the small sized one in the arch of the former.
Discussion
Saddle nose deformity corresponds to loss of projection of the cartilaginous and/or bony structure of the dorsum of the nose, which has aesthetic as well as functional repercussions Although not so common, septoplasty carries the risk of inducing nasal deformity such as saddle nose and deviated nose. Surgical correction for these deformities is a formidable task to deal with, because the septal cartilage framework is already weakened due to the procedure. The classification of saddle nose given by Durbec et al1 Stage 1: minimal saddle nose Minimal saddle nose corresponds to a depression above the supratip of the nose due to loss of septal support associated with slight retraction of the base of the columella, while tip projection and rotation are not affected Stage 2: moderate saddle nose Moderate saddle nose corresponds to more marked recession of the dorsum, but not exceeding 5 mm. It induces loss of septal support that can affect its anatomical relations with the triangular cartilages, the tip or even the columella. The nose has a flattened appearance on all views. Decreased projection and/or cephalic rotation of the tip may be observed at this stage and will need to be taken into account Stage 3: major saddle nose Major saddle nose corresponds to a marked lack of bony and cartilaginous support. The bony arch of the middle third of the nose is amputated inducing major retraction of the
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Fig. : 1
Fig. : 2
Fig. : 3
Fig. : 4
nasal mucosa, while loss of the height of the cartilaginous septum is responsible for columellar retrusion. Tip projection is decreased and the nostrils are broader, giving a short nose appearance. Functionally, this deformity alters the internal (due to collapse of septal support) and external nasal valves (due to lack of central support, the nostrils become flatter and wider)
rhinoplasty help to restore a harmonious appearance of the middle third of the nose and correct the defect of the internal nasal valve. The base of the nose is tightened by means of the sagittal support of the cartilaginous framework. Other graft materials that can be used are autologous conchal cartilage and costal cartilage.
In our case it was minimal saddle nose which was corrected by restoring satisfactory septal height. We performed an extracorporeal rhinoplasty with excision of the nasal septum and constitution of a cartilaginous framework. This technique has been described for the management of a crooked nose 2which remains its main indication, but it can be adapted to minimal stages of saddle nose.
Due to the ease of harvestation and anatomical similarity in our case we preferred using the autologous septal cartilage. CONCLUSION
In this the defect can be corrected with sagittal projection and restoration of a harmonious and regular dorsum. Autologous graft from the septum associated with this
Septoplasty is a routine otorhinological procedure with few complications like septal perforation, saddle nose due to excessive resection of the nasal septum. If recognised early during intraoperative interval, this can be corrected in the same sitting by using the autologous septal cartilage through a transcolumellar incision. This technique produces minimal scarring and adequately counters the saddle defect following the septal surgery.
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
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Case Report
References 1.
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M. Durbec, F. Disant :Les ensellures nasales : classification et prise en charge thérapeutique Annales françaises d’Otorhino-laryngologie et de Pathologie Cervico-faciale, Volume 131, Issue 2, April 2014, Pages 83-91
C. Terra Brito, F. Disant The nasal framework in rhinoplasty and its dimensions: the importance of a third element Rev Laryngol Otol Rhinol, 131 (2) (2010)119-12
*Corresponding author: Dr. Japneet Kaur, Senior Resident, Department of ENT, Dmch, Civil Lines, Ludhiana-141001 India Email: drjapneetkaur@gmail.com Date of Submission : 10.09.2017 Date of Acceptance : 20.09.2017 Date of Publication : 01.10.2017
Financial or other Competing Interests: None.
http://www.pacificejournals.com/aabs
Case Report DOI: 10.21276/AABS.1678
Submandibular Haemangioma Involving Parotid Tail: Case Report Manish Munjal, Sanjeev Puri, Japneet Kaur*, Amanjot Kaur, Porshia Rishi, Shubham Munjal and Anmol Singh Department of ENT, DMCH, Ludhiana, India
ABSTRACT Fasciocervical haemangiomas present as a doughy swelling in the submandibular or the parotid region. Imaging studies preferably the MRI clinch the diagnosis with areas of vascular voids. A rare case of haemangioma interposed between the tail of parotid and submandibular gland was delivered from the upper presternomastoid gutter. Keywords: Haemangioma, Parotid, Submandibular
Introduction
Hemangiomas are the most common lesions of the major salivary glands during infancy and early childhood1,2. They occur predominantly in the parotid gland and adjacent structures, but they are very rarely reported in submandibular area The parotid and the submandibular glands, the major salivary glands come in contact with each other at the upper third of the sternocleidomastoid muscle. A rare case of haemangioma interposed between the tail of parotid and submandibular gland was delivered from the upper presternomastoid gutter.
Case Report
A 30 year make presented with a soft kneadable swelling on the left upper neck. The swelling was soft and could be localised between the mastoid tip and the angle of the mandible , The swelling was extending beneath the tail of the parotid and upper limited could be discerned . The posterior edge could be rolled over the upper third of the sternocleidomastoid muscle . Anteriorly and on bimanual palpation a blunt edge could be palpated . No bruit was detected on auscultation, thereby reconfirming a low vascular flow lesion . Fine needle aspiration cytology revealed haemangioma of the submandibular gland. On CT imaging homogenous mass seen arising from the submandibular gland and abutting the tail of parotid . He was taken up for cervical exploration under general anaesthesia . A transverse skin crease incision was given at the level of the hyoid and superficial fascia with fat and platysma was dissected to develop superior and inferior flaps , The plane of dissection was just superficial to the mid third of the submandibular gland anteriorly and the
sternomastoid posteriorly . The external jugular vein and the greater auricular nerve were liberated from the overlying fat and this marked the posterior limit of exposure . Superiorly the tail of the parotid was exposed between the angle of the mandible and the sternocleidomastoid fibres(Picture 1A) . The haemangioma was lifted off ,by creating a plane of anterior cleavage over the fascia of the submandibular gland and proceeding posteriorly till the sternomastoid(Picture1b) . Upward dissection freed the lesion from the angle of the mandible . Resection was completed with transfixation and ligating a cm of the tail parotid ,from which the lesion was inseparable(Picture 1C) . Haemostasis was maintained throughout . An indwelling drain was placed to be retained for 48 hrs and absorbable vicryl followed by nonabsorbsle sutures were applied . There was slight deviation of the angle of the mouth which was expected to recover in three weeks . Histo pathology reported haemangioma from the tail of parotid.
Fig. : 1A
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Case Report
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Fig. : 1B
Fig. : 1C
DISCUSSION
Hemangiomas are the most common lesions of the major salivary glands during infancy and early childhood1,2. They occur predominantly in the parotid gland and adjacent structures, but they are very rarely reported in submandibular area The parotid and the submandibular glands, the major salivary glands come in contact with each other at the upper third of the sternocleidomastoid muscle. The region marks the posterior border of the submandibular and the inferior limit of the parotid . Discrete fascial envelopes exist over either glands and a cleavage of dissection can be created so as to gain access to the floor mouth or the
sublingual space superomedially or the massetric and the parapharyngeal space supero-laterally . Anterior retraction of the tail of the submandibular gland and superior retraction of the tail parotid , gives a wider access to deliver capsulated bulky tumors of the parapharyngeal compartment . Haemangiomas, of low vascular flow and single or limited feeding vessels are amenable to surgical intervention while those with a high vascular flow necessitate an angiographic evaluation to plan the ideal therapeutic modality . In the latter sclerosing agents and embolisation is to be considered . Haemangioma s in proximity to the salivary glands are usually juxtaposed to their lateral surface with small pseudopods indenting or invaginating the acinar framework . A fiery red cobblestone
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appearance and a doughy feel characterise these pathologies . Mostly they can be peeled off the underlying bed . The parotid ones are notable in the paediatric age group while the submandibular in the middle aged .
is infiltrative in nature.3It is interesting to note that these benign mesenchymal tumours are common in parotid, probably due to lack of well defined capsule and presence of neurovascular structures in it4
Salivary Gland Hemangiomas constitute about 1.5% of all tumors affecting the salivary glands. The tumor can be present in adults and children of a wide age range; a congenital presentation is also observed. Approximately 65% of the cases are seen before age 20 years. A predilection for children is noted; a hemangioma is the most commonly noted tumor of the salivary glands affecting children. Both males and females are affected; some studies report a male-female ratio of 1:2.All races and ethnic groups may be affected.
Conclusion
Cervicofacial haemangioma s are notorious for giving a facial asymmetry ,the primary pretext for intervention ,sclerotherapy , embolisation or surgical . The lesion in low pressure situations can be taken for surgery.
1.
Kauffman St, Stout AP. Tumour of major salivary glands in children. Cancer 1963; 16: 1317-31.
2.
In the salivary glands two main types of haemangiomas occur : cavernous and capillary. Capillary type is lobulated, lacks a capsule, is purplish in colour and infiltrates the gland involved. Microscopically solid masses of cells and multiple anastomosing capillaries replacing the acinar structure of the gland are seen. The cavernous type is formed by dilated blood vessels or sinusoids lined by endothelium. It is also devoid of a capsule and
Coldman RL, Perzik SL. Infantile hemangloma of parotid gland: a clinicopathological study of 15 cases, Arch otolaryngol1969; 90: 605-8.
3.
McDanial PK. Benign measenchymal neoplasma. In : Ellis GL, Auclair PL, Gnepp DR Editors. Major problems in pathology, Vol 25, Surgical Pathology of salivary glands Philadelphia, WB Saunders;1991: 489-513.
4.
Mcmenamin M, Quinn A, Barry H, et al: Cavernous haemangioma in the submandibular gland masquerading as sialadenitis. Oral Surg Oral Med Pathol Oral Radiol End 1997; 146-8.
A meticulous dissection undertaken in the sternomastoid -glandular region can deliver vascular lesions with minimal morbidity. Submandibular gland haemangiomas may have extension into the tail of parotid gland. Therefore, careful dissection is imperative for diseases clearance and prevention of recurrence. A sound anatomical knowledge is a must for exploration of submandibular region.
References
*Corresponding author: Dr. Japneet Kaur, Senior Resident, Department of ENT, Dmch, Civil Lines, Ludhiana-141001, India Email: drjapneetkaur@gmail.com
Financial or other Competing Interests: None.
Annals of Applied Bio-Sciences, Vol. 4; Issue 3: 2017
Date of Submission : 11.09.2017 Date of Acceptance : 20.09.2017 Date of Publication : 01.10.2017
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