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“Endoscopically unresectable” benign polyps identified during screening colonoscopy are often referred for segmental colectomy. Application of advanced endoscopic techniques can increase endoscopic polyp resection, sparing patients the morbidity of colectomy. This retrospective case-control study aimed to evaluate the success of colon preserving resection of “endoscopically unresectable” benign polyps using advanced endoscopic techniques including endoscopic mucosal resection, endoscopic submucosal dissection, endoluminal surgical intervention, full-thickness laparo-endoscopic excision, and combined endo-laparoscopic resection. A prospectively maintained institutional database identified 95 patients referred for “endoscopically unresectable” benign polyps from 2015 to 2018. Cases were compared to 190 propensity score matched controls from the same database undergoing elective laparoscopic colectomy for other reasons. Primary outcome was rate of complete endoscopic polyp removal. Secondary outcomes included length of stay, unplanned 30-day readmission and reoperation, 30-day mortality, and post-procedural complications. Advanced endoscopic techniques achieved complete polyp removal without colectomy in 66 patients (70%). Failure was most commonly associated with previously attempted endoscopic resection and occult malignancy. Compared with matched colectomy controls, endoscopic polyp resection resulted in significantly shorter hospital length of stay (1.13 ± 2.41 vs 3.89 ± 4.57 days; p

Sellar metastases account for 0.87% of all intracranial metastases. They are usually asymptomatic and can be the first manifestations of some occult malignancy. The diagnosis is made mainly during the screening of patients with known primary lesions or can present with neurologic or hormonal changes related to compression or invasion of surrounding structures. Differentiating these lesions from other more common lesions such as pituitary adenoma maybe difficult. Management is mainly aimed at the primary lesion and is palliative to improve quality of life or for pathologic confirmation.

Summary Background Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. Owing to the rarity of PASH, the pathogenesis, clinical manifestation, and optimal treatment of this condition remain unclear. We aimed to clarify the appropriate management of PASH. Methods We performed a retrospective analysis of the clinicopathological data of 66 cases with a diagnosis of PASH, confirmed by core needle biopsy (CNB) or surgical excision at Severance Hospital between 2000 and 2016. The primary endpoint was pathologic results after surgical excision of the lesion that confirmed PASH by CNB. The secondary endpoint was progression after the first treatment. Result The median age of patients was 41 years (range, 14–61 years). Findings on medical imaging were nonspecific. CNB was performed in 61 cases, with a diagnosis of PASH confirmed in 39 cases (63.9%). No malignant or premalignant cells directly arising from PASH were identified after surgical excision that confirmed PASH via CNB. The progression rate after the first treatment was 16.6%, with lesion size, enlargement of palpable mass size, and a diagnosis other than PASH on CNB being factors associated with progression. Conclusion CNB is sufficient to confirm PASH what is necessary for an abnormal imaging or suspicious physical examination finding. Surgical excision is not necessarily indicated to rule out occult malignancy after a diagnosis of PASH. Close monitoring or surgical excision are required to manage large lesions (>3 cm) or progressive growth of a PASH lesion.

Highlights • DVT presentation may be an atypical manifestation of an occult malignancy. • Thorough search and work up for idiopathic DVT is mandatory. • The aim of this article is to report a case of lymphoma presented as DVT with brief literature review., Introduction Idiopathic deep venous thrombosis is a relatively common clinical finding. The aim of this article is to report and discuss a case of lymphoma presented as DVT in line with SCARE guidelines with brief literature review. Case report A 19-year-old male presented with right lower limb swelling for two week duration. Examination showed pitting leg edema with warm tense calf. Hematological investigations showed lymphopaenia. Duplex ultrasound showed DVT of right common femoral vein with inguinal lymphadenopathy. Computed tomography showed inguinal lymphadenopahthy. Histopathological examination of lymph node specimen confirmed the diagnosis of Non-Hodgkin’s Lymphoma (Burkett's type). Discussion Several series have documented a significantly higher risk of malignancy in patients with presumed idiopathic DVT. Among such patients, 7.6% have been noted to have a malignancy during follow-up; the incidence of occult malignancy diagnosed within 6–12 months of an idiopathic DVT is 2.2–5.3 times higher than that expected from general population estimates. Conclusion Idiopathic DVT regardless of age should be approached seriously with a special consideration to malignancy, lymphoma could present only with DVT.

A 56-year-old man presented with a periorbital subcutaneous mass and ipsilateral visually significant orbital inflammation that was refractory to broad-spectrum antibiotics. Orbitotomy with biopsy revealed the diagnosis of metastatic lung cancer, and the patient was initiated on systemic chemotherapy and adjuvant radiation. This is the first report of pulmonary adenocarcinoma metastatic simultaneously to the periocular cutaneous and intraorbital soft tissues. Atypical periorbital and orbital inflammation may be the initial presentation of occult malignancy and require a high index of suspicion and tissue biopsy for diagnosis and life-saving management.

CASE Acrometastasis is extremely rare, accounting for 0.1% of all skeletal metastases. Metastases to the carpus are rarer still. This condition can be the first manifestation of an occult malignancy and generally indicates advanced disease. We present the case of a 53-year-old woman with acrometastasis of squamous cell lung cancer to the trapezium as the initial presentation of her malignancy. CONCLUSION The presentation of acrometastasis can mimic infectious or inflammatory processes, leading to an erroneous diagnosis. Although exceptionally uncommon, it is important to consider as a differential diagnosis for a destructive hand lesion.

Contralateral prophylactic mastectomy (CPM) is not recommended for average-risk women with breast cancer due to lack of evidence for survival benefit, yet recent studies demonstrate increasing CPM rates.We identified patients with breast cancer treated with unilateral mastectomy (UM) with or without CPM. Rates of malignancy in CPM specimens and factors in CPM rates were assessed.From 2013 to 2017, 1353 patients had UM and 355 had CPM. Our institution's occult malignancy detection rate was 5.04%. CPM rates decreased from 31.6% to 17.3% (p 0.001) over 5 years. Compared to patients receiving UM only, patients receiving CPMs had significantly higher reconstruction rates (p 0.001), which did not significantly change over time (p = 0.551) and tended to be younger (p 0.001).Patients having UM have low risk of contralateral malignancy. CPM is associated with younger age and breast reconstruction, suggesting factors to identify for patient and provider education.

Objective This study introduces and evaluates the feasibility, safety, and surgical outcomes of the in-bag power morcellation technique during single-port assisted (SPA) laparoscopic myomectomy in comparison with manual scalpel morcellation. Methods This is a retrospective review of a total of 58 patients who underwent SPA laparoscopic myomectomy employing in-bag power morcellation (n=27) or manual scalpel morcellation (n=31), performed between December 2014 and December 2016. Surgical outcomes, including total operation time, estimated blood loss, postoperative hemoglobin changes, postoperative hospital stay, postoperative pain (visual analog scale), perioperative and postoperative complications were evaluated. Results The demographics and patient characteristics were similar between both groups. The median patient age was 34 years and median body mass index was 20.84 kg/m2. The median specimen weight was 110 g. The median operating time was 138 minutes. The median estimated blood loss was 50 mL and the median postoperative hemoglobin change was 2.2 g/dL. The median postoperative hospital stay was 2 days and the median postoperative pain scores were 5 after 6 hours, 3 after 24 hours, and 2 after 48 hours. Occult malignancy was not identified in any patients. There were no intraoperative complications such as LapBag ruptures or gross spillage. Conclusion In-bag power morcellation for SPA laparoscopic myomectomy is feasible and safe, minimizing the risks of open power morcellation. There were also no statistically significant differences in surgical outcomes.

Background The present meta-analysis aimed to evaluate the efficacy and sensitivity of an extensive screening strategy for occult malignant diseases in patients with unprovoked venous thromboembolism (VTE). Methods We conducted a systematic search of PubMed, Cochrane, EMBASE, and relevant article references. Meta-analysis was used to pool weighted relative risks (RR) for the rate of missed diagnosis, all-cause mortality, and cancer-related mortality. Heterogeneity test was performed using the inconsistency index. Furthermore, pooled analysis of the sensitivity and the proportion of false-positive findings of PET/CT were conducted. Results A total of 5 controlled studies were included with 1,115 and 1,159 unprovoked VTE patients receiving limited or extensive screening strategy, respectively. The risk of missed diagnosis (RR, 0.51; 95% CI, 0.20–1.28; P = 0.15) was not significantly different between the limited and extensive screening group. Moreover, there was no statistically significant difference in all-cause mortality (RR, 0.86; 95% CI, 0.58–1.27; P = 0.44) and cancer-related mortality (RR, 0.86; 95% CI, 0.46–1.62; P = 0.65) between the two groups. The pooled sensitivity and proportion of false-positive findings of PET/CT as a screening tool for occult malignancy in patients with unprovoked VTE was 95% (95% CI, 38%–100%) and 33% (95% CI, 20%–47%), respectively. Conclusions Extensive screening strategy did not show a clinically significant benefit over limited screening strategy. Considering the high cost and the additional physical and emotional harm, current evidence did not support extensive screening for each patient in the setting.

Uterovaginal prolapse may be treated with or without concomitant hysterectomy. Many patients express interest in uterine-sparing prolapse procedures, for which there are increasing evidence available regarding techniques and outcomes. Uterine-sparing procedures to treat uterovaginal prolapse require a unique set of surgical considerations including uterine abnormalities, possibility of occult malignancy, and future pregnancy. Data, including randomized controlled trials, support the use of sacrospinous hysteropexy. Other prospective trials detailing outcomes following uterosacral hysteropexy, mesh augmented sacrospinous hysteropexy, and sacrohysteropexy are also encouraging.

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are premalignant mucin-producing epithelial tumors that arise from the pancreatic ductal system. These cystic tumors represent 15-30% of cystic lesions of the pancreas [Basturk et al. in Am J Surg Pathol 39(12):1730-1741, 1; Ferrone et al. in Arch Surg (Chicago, Ill: 1960) 144(5):448-454, 2, Kosmahl et al. in Virchows Arch Int J Pathol 445(2):168-178, 3; Spinelli et al. in Ann Surg. 239(5):651-657, 4]. It is believed that IPMN can progress from low-grade dysplasia to high-grade dysplasia to invasive cancer, and this pathway of progression accounts for 20-30% of pancreatic cancer [Adsay et al. in Am J Surg Pathol 28(7):839-848, 5; Tanaka et al. in J Gastroenterol 40(7):669-675, 6; Wu et al. in Sci Transl Med 3(92):92ra66, 7]. Furthermore, it is also widely believed that IPMN represent a field defect of the pancreas in which the entire ductal system is at risk of developing invasive carcinoma, not only in the area of radiographically detectable IPMN, and thus the remaining gland should undergo surveillance after partial pancreatectomy [Salvia et al. in Ann Surg 239(5):678-685, 8; Izawa et al. in Cancer 92(7):1807-1817, 9; Yamaguchi and Tanaka in Jpn J Clin Oncol 41(7):836-840, 10]. Increasingly, surgeons are faced with the dilemma between recommending highly complex resections-that have significant morbidity and mortality-in patients who may have low-risk IPMN (low-grade dysplasia), or alternatively, recommending observation for those who could possibly be harboring a radiographically occult malignancy. Given the complexity of the management decisions for patients with IPMN, the purpose of this paper is to review the current literature and to provide a summary of how accurate we are currently with the identification of high-grade dysplasia or progression to carcinoma in patients who present with IPMN.

Potential causes of embolic stroke of undetermined source (ESUS) include occult malignancy, venous thrombosis (VTE) with paradoxical embolism, and hypercoagulable disorders. Given the association of markers of coagulation and hemostatic activation (MOCHA) with these causes, the objective of this study was to validate the utility of the MOCHA profile in identifying the underlying cause of stroke.We prospectively identified ESUS patients from January 1, 2017 to December 1, 2019 who underwent MOCHA profile (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) testing. Abnormal MOCHA profile was defined as ≥ 2 abnormal markers. New diagnoses of malignancy, VTE, hypercoagulable disorders and recurrent stroke were identified during routine clinical follow-up.Of 236 ESUS patients, 104 (44%) patients had an abnormal MOCHA profile. In multivariable analyses the number of MOCHA abnormalities was significantly associated with malignancy, VTE, and hypercoagulable disorders (OR 2.59, CI 95% 1.78-3.76, p0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of an abnormal MOCHA profile for the combined outcome of malignancy, VTE, and hypercoagulability was 96%, 62%, 23%, and 99% respectively.The MOCHA profile was able to identify ESUS patients more likely to have malignancy, VTE, and hypercoagulable disorders during follow-up. Our results show that a normal MOCHA profile in ESUS patients can effectively rule out these potential causes of ESUS.

Background The optimal role of breast magnetic resonance imaging (MRI) in the management of ductal carcinoma in situ (DCIS) remains controversial. We sought to better define the impact of breast MRIs when utilized during the workup of DCIS. Methods Patients with biopsy-proven DCIS without any additional invasive disease were prospectively enrolled in the multidisciplinary breast cancer pathway and comprised the study group. Patients who met any additional criteria for MRI screening were excluded. Results From 2008 to 2014, 93 women met the inclusion criteria. 81 patients underwent MRI as part of their workup. One patient benefited from MRI via identification of occult malignancy not previously identified. 35 MRIs identified no additional information whereas 46 had additional findings. These findings led to 23 procedures and 16 negative biopsies; recommendations for 16 radiographic studies that were normal; and influenced nodal sampling in 7 women with 1 positive metastatic focus. Conclusions The routine use of breast MRI for women diagnosed with DCIS has limited benefit. Often, it leads to multiple procedures and studies that are clinically insignificant and delays surgical treatment.

The Department of Health estimates the annual incidence of deep vein thrombosis (DVT) in the UK to be 1 in 1000, rising with age. Various studies have suggested that approximately 10–20% of patients with DVT are diagnosed with a malignancy before, or at the time of a thrombotic event. This prospective study investigates the prevalence of various factors affecting the occurrence of DVT in patients. All patients diagnosed with DVT at the acute medical unit at Hillingdon Hospital between September 2014 and February 2015 were studied with the use of proforma data collection. The information collection was analysed with SPSS software. The majority of patients with DVT were white males with restricted mobility and an underlying malignancy. It was found that the distribution of DVT for age, sex, ethnicity and risk factors (such as malignancy) was quite similar to previous studies. The physician in primary and secondary care should be aware of the possibility of occult malignancy in DVT patients with similar circumstances.

Background The management of intraductal papillomas (IDPs) diagnosed on core needle biopsy (CNB) remains controversial regarding whether excision is required. We evaluated whether excision of IDPs might be overtreatment based on a consecutive patient population where all IDPs were routinely excised. Materials and methods We retrospectively reviewed the records of consecutive patients treated with excision of IDPs at our institution from 2009 to 2016. We evaluated the rate of upgrade of IDPs on CNB and factors predicting for malignant upgrade. Results Of 153 CNB specimens, 136 (88.9%) were IDPs without atypia and 14 (9.2%) showed atypia. The overall upgrade rate on final pathology was 7.3% with 1.3% for invasive cancer, 2.7% for ductal carcinoma in situ, and 3.3% for atypical ductal hyperplasia. Of the 14 patients with atypia on CNB, two of these patients (14.2%) were found to have ductal carcinoma in situ. In the absence of atypia on CNB, upgrade rates were 1.5% for invasive and 1.5% for in situ carcinoma. Personal history of breast cancer and magnetic resonance imaging–guided biopsy predicted for malignant upgrade. Conclusions IDPs on CNB have a low chance of harboring an occult malignancy. Given the low probability of upgrade to invasive breast cancer, it is reasonable to consider watchful surveillance in the absence of a prior personal history of breast cancer or atypia on CNB.

Venous thromboembolism (VTE) can occur as the first manifestation of an underlying occult malignancy. It remains unclear whether or not a better selection of high risk patients might lead to more efficient occult cancer screening strategies. Our aim was to assess the predictors of occult malignancy diagnosis in patients with unprovoked VTE. Univariate analyses were performed to assess the effect of candidate predictors on occult cancer detection in patients enrolled in a prospective, multicenter, randomized, controlled study (MVTEP study) whose primary aim was to compare a limited screening strategy with a strategy combining limited screening and FDG PET/CT in patients with unprovoked VTE. This trial is completed and registered with ClinicalTrials.gov, number NCT00964275. Between March 3, 2009, and August 18, 2012, 399 patients were included. Five patients withdrew consent and refused the use of their data, and no VTE was confirmed in 2 patients who were excluded from this analysis. A total of 25 (6.4%) out of the 392 analysed patients received a new diagnosis of malignancyduring the 2-years follow-up. Age≥50years (p=0.01), male gender (p=0.04), leukocytes count (p=0.01), and platelets count (p=0.03) were associated with occult cancer detection. Patients with leukocytosis or thrombocytosis had a risk of cancer way above 10%. Previous VTE and smoker status (combining previous and current smokers) were not associated with occult cancer diagnosis (p>0.05). Demographic characteristics (age and sex), and laboratory tests (high platelets and leukocytes counts) may be associated with cancer detection in patients withunprovoked VTE.

The number of reduction mammoplasties performed in the United States continues to increase annually. Given the high incidence of breast cancer in women, it is routine practice for breast tissue excised during routine breast reductions procedures to be sent for pathology review. During pathology assessment, occult malignancy and on-occasion proliferative breast lesions of unknown and/or variable malignancy may also be present. We provide a review of commonly diagnosed atypical proliferative breast lesions in breast reduction specimens and a guide to plastic surgeons for further management.

Study Objective To conduct a systematic review to estimate the prevalence of occult uterine malignancy, of any subtype, among women undergoing surgery for pelvic organ prolapse. Design Systematic review Setting N/A Patients or Participants Women undergoing surgery for pelvic organ prolapse. Interventions Hysterectomy Measurements and Main Results The PRISMA guidelines were followed in this systematic review. The search terms used were “occult malignancy” or “occult uterine pathology” paired with “morcellation” or “hysterectomy.” March 25, 2019 was the last date that articles were searched. We did not restrict articles based on language or publication date. Inclusion criteria included any peer-reviewed journal articles reporting occult uterine malignancy rates at the time of surgery for benign conditions, regardless of whether morcellation was used or not. We excluded articles that were reported exclusively on women with pre-operatively diagnosed or suspected uterine malignancies. Our search yielded a total of 233 journal articles, of which 53 met the criteria for a full-text review and 27 were included in the final systematic review. Of these 27 studies, 9 studies provided specific data on occult uterine malignancy among women undergoing surgery for pelvic organ prolapse. Among the 9 studies examined, the total number of patients combined was 35,880 and there were 144 total occult uterine malignancies. The overall crude prevalence of occult uterine malignancy was 0.40% (95% CI 0.30 – 0.47%). Among the 9 studies, the occult uterine malignancy rate ranged from a low 0% to a high of 3.17%. The largest of these 9 studies incorporated 31,567 patients and the occult uterine malignancy rate was 0.40% in that study. Conclusion This is the first attempt to synthesize data on occult uterine malignancies among women specifically undergoing surgery for pelvic organ prolapse. Based on this systematic review incorporating over 35,000 patients, the crude prevalence of occult uterine malignancy among this population is approximately 0.40%.

Study Objective To conduct an updated systematic review to estimate the prevalence of occult uterine malignancy, of any subtype, among women undergoing surgery for benign gynecologic conditions. Design Systematic review. Setting N/A Patients or Participants Women undergoing surgery for presumed benign gynecologic conditions. Interventions Hysterectomy or Myomectomy. Measurements and Main Results The PRISMA guidelines were followed in this systematic review. The search terms used were “occult malignancy” or “occult uterine pathology” paired with “morcellation” or “hysterectomy.” March 25, 2019 was the last date that articles were searched. We did not restrict articles based on language or publication date. Inclusion criteria included any peer-reviewed journal articles reporting occult uterine malignancy rates at the time of surgery for benign conditions, regardless of whether morcellation was used or not. We excluded articles that were reported exclusively on women with pre-operatively diagnosed or suspected uterine malignancies. Our search yielded a total of 233 journal articles, of which 53 met the criteria for a full-text review and 27 were included in the final systematic review. There were 339,420 patients across 9 countries that were included in these 27 studies. As a comparison, the previous systematic review done by the Agency for Healthcare Research and Quality (AHRQ) only included a total of 136,195 patients. There were a total 2,479 occult uterine malignancies (all subtypes combined) among these 339,420 patients. The crude unadjusted occult uterine malignancy rate was 0.73% (95% CI 0.70 – 0.76%). When we examined a subset of the included studies that reported specific data on women undergoing morcellation, there were 82 occult malignancies among a total of 25,422 patients (Crude proportion = 0.32% [95% CI 0.25 – 0.39%]). Conclusion Based on this systematic review, incorporating over 300,000 patients, the overall prevalence of occult uterine malignancy at the time of surgery for benign gynecologic indications is approximately 0.73%.

Purpose We investigated rates of occult malignancy in the breast and sentinel lymph nodes (SLNs) in patients undergoing prophylactic mastectomy (PM) and whether routine sentinel lymph node biopsy (SLNB) is justified. Methods A retrospective review of our database identified patients undergoing PMs with SLNB. Descriptive statistics were utilized for data summary. A P value of

The authors report a case of Trousseau's syndrome presenting in a previously asymptomatic 58-year-old man diagnosed with pancreatic adenocarcinoma and liver metastases during a workup prompted by migratory venous thrombosis and pulmonary embolism. It was followed by an ischaemic stroke that occurred while the patient was just one day off anticoagulant therapy with low-molecular-weight heparin to allow for liver and pancreatic biopsies. Trousseau's syndrome is defined by recurrent or migratory venous thrombosis, arterial embolism caused by non-bacterial thrombotic endocarditis, or both, in patients with underlying malignancy. Treatment relies on the lifelong administration of heparin, and its interruption – however brief – may promote new thrombotic events.

Background and objectives The inadvertent dissemination of uterine cancer cells with the power morcellator has received much attention in the press and a warning from the U.S. Food and Drug Administration. Many hospitals prohibit the use of the morcellator in gynecologic surgery. We conducted a survey in an attempt to assess gynecologic surgeons' beliefs regarding the intracorporeal power morcellation of fibroids in light of the risk of dissemination of malignancy in patients in whom the presence of cancer is unknown before surgery. Methods We conducted an Internet-based survey of 3505 members of the Society of Laparoendoscopic Surgeons (SLS) to assess demographics, current use of the intracorporeal power morcellator, and whether the recent negative press has affected gynecologic surgeons' use of the morcellator. Results Of the 3505 SLS members surveyed, 518 responded (response rate, 14.77%). Three hundred thirteen (61%) of the respondents were not using the intracorporeal power morcellator. Of those, 48% reported the reason was a hospital-wide ban, and an additional 17% reported lack of availability (not in stock). Senior attendings with >20 years of experience used the morcellator more often than junior attendings and fellows (P = .007). Furthermore, the morcellator was used significantly less among those with the belief that morcellation of occult malignancy affects survival (P = .013). Three hundred sixty-one (76%) of the participants currently perform laparotomy in fewer than a quarter of their cases; most those cases are still performed using laparoscopic and robot-assisted techniques. Conclusion The recent negative press suggesting that intracorporeal power morcellation can disseminate occult malignancy and affect survival has decreased the use of the morcellator. Despite the declining use of power morcellation, most practicing gynecologic surgeons have not converted their procedures to laparotomy.

A spontaneous subcapsular hematoma in an allograft kidney is a rare condition with only a few cases reported in the literature. Common causes of subcapsular hematoma of an allograft include trauma, post-biopsy status, occult malignancy, vascular diseases, and infection. Chronic allograft dysfunction related to spontaneous subcapsular hematoma is extremely rare. We report a case of spontaneous subcapsular hematoma in a patient who underwent a renal transplant 14 years ago in which we could not find an associated condition.

The routine pathological analysis of therapeutically resected traumatic or postoperative neuroma specimens to confirm diagnosis and rule out occult malignancy remains a controversial issue. Some experts advocate histological analysis of all specimens, and others rely on institutional policy. A retrospective chart review of all patients who underwent excision of clinically diagnosed neuroma over a 6-year period at one institution by a single surgeon was initiated. The correlation of preoperative diagnoses with histological analysis and cost of analyzing specimens individually and over the 6-year period was calculated. Of 515 neuromas resected, 100 were sent for pathological review. Every submitted specimen was histologically confirmed to be a traumatic neuroma, and none of the specimens harbored occult malignancy. Ultimately, no treatment plan was altered after final histology was confirmed. The cost to analyze each specimen (Current Procedural Terminology code 88305) was $495, expressed in U.S. dollars. If every specimen was analyzed, a total cost of $254,925 would have be incurred over the 6-year period. Routine pathological analysis of clinically and intraoperatively confirmed neuromas must be questioned in terms of standard of care requirements given its failure to aid in treatment plans as well as its significant cost to health care systems.

The EU Tissues and Cells Directive (2004/23/EC, 2006/17/EC, 2006/86/EC) (EUTCD) provides standards for quality and safety for all aspects of banking of tissues and cells for clinical applications. Commission Directive 2006/17/EC stipulates that the complete donor record with all the medical information is assessed for suitability before releasing tissues for clinical use. The aim of this study was to investigate the medical reasons for post-procurement donor exclusion, to identify the various potential sources for gathering information about donors' medical and behavioural history and to evaluate their contribution to maximising the safety of donations. Information was collected from the Tissue Services (TS) records of 1000 consecutive deceased donors submitted to National Health Service Blood and Transplant (NHSBT) medical officers for authorisation for release for subsequent tissue processing and then for transplantation. Of the 1000 donors 60 (6%) were excluded because they did not fulfil the donor selection requirements of the EUTCD and NHSBT donor selection guidelines. The main reasons for medical exclusion were the presence of significant local or systemic infection in 32 donors (53% of those excluded for medical reasons) and a history of past or occult malignancy in 9 donors (15% of those excluded for medical reasons) which was not identified prior to procurement. The information leading to post-procurement exclusion was obtained from autopsy reports in 35 of the 60 excluded donors for medical reasons (58%) and from the general practitioner for 10 donors (17% of those excluded for medical reasons). In summary, careful evaluation of complete donor records reduces the potential risk of disease transmission by tissue allografts and ensures compliance with regulations and guidelines. The findings may lead to changes in donor selection policies with the aim of improving efficiency without compromising safety.

En bloc removal of the prostate has traditionally been an integral component of radical cystectomy for men with bladder cancer owing to a high incidence of occult prostatic malignancy. However, the risk of functional morbidity following this procedure is considerable and can delay patient acceptance of cystectomy, which can adversely affect the long-term prognosis. Recently, some investigators have advocated prostate-sparing cystectomy (PSCx) to improve postoperative continence and potency rates, and this may also improve timely patient acceptance of cystectomy. Several of these PSCx series describe excellent functional results postoperatively and PSCx may also facilitate a laparoscopic approach, offering further dividends. However, valid concerns regarding the oncologic efficacy of this procedure still predominate and protocols for patient selection, technique and postoperative surveillance are not well defined. The concept of PSCx is arguably one of the most controversial topics in the field of bladder cancer today.

Objectives To evaluate the clinical presentation and disease course of symptomatic plantar vein thrombosis. Patients and methods Patients with a first diagnosis of symptomatic plantar vein thrombosis at our institution were retrospectively identified from a prospectively maintained database. All patients underwent complete venous compression sonography extended to the plantar veins because of local symptoms at the sole of the foot. Clinical characteristics were obtained from the medical records. Results Between 2005 and 2013, 22 patients were diagnosed with a first episode of plantar vein thrombosis (64% women, mean age at diagnosis 58.2 years, range 32–79 years). All patients reported moderate to heavy pain of the sole of the foot. The lateral plantar veins (96%) were more frequently affected than the medial plantar veins (41%) and extension into the deep calf veins was common (27%). Half of the episodes were idiopathic, with subsequent diagnosis of occult malignancy in two of these patients. In seven patients (32%), plantar vein thrombosis occurred in association to physical strain to the foot. All patients were treated with anticoagulation. Symptomatic pulmonary embolism was not observed and during a mean follow up of 21 months, the post-thrombotic syndrome did not occur. However, recurrences were common (27%) and frequently again affected the plantar veins. Conclusion Plantar vein thrombosis should be considered as an important differential diagnosis of acute foot pain.

The objective of this article is to present the first case reported in the literature of metachronous pleomorphic adenoma of bilateral parotid glands and submaxillary gland. The authors report the case of a 27-year-old female with metachronous mixed tumors in her right parotid and submandibular glands. The patient has no history of previous radiotherapy. All three lesions were diagnosed by fine-needle aspiration. The histopathologic evaluation of all three major salivary gland masses demonstrated pleomorphic adenomas, with no occult malignancy observed on serial sections. The presentation of pleomorphic adenomas in the parotids and submandibular glands probably represents three unrelated primary sites of tumor, yet the possibility of metastasis from one gland to the other cannot be excluded.

We report here a case of Marjolin's ulcer developing in a long-standing, inadequately treated, chronic ringworm infestation of the lower limb. A 35-year-old female patient with a ten-year history of a chronic ringworm infestation had developed a nonhealing ulcer in an area of infestation on the right leg. A biopsy revealed well-differentiated squamous cell carcinoma associated with the ringworm infection. A below-knee amputation by an inguinal block dissection was performed. We conclude that proper and timely treatment of fungal infections of the skin is needed to allow for healing of dermal infections and thus the prevention of the disastrous consequences that recurrent mechanical trauma from scratching of the affected area, leading to occult malignancy, which may occur in a small number of patients.

Background The rate of breast reconstruction following mastectomy is increasing, and currently sits at about 15%. Free flap reconstruction techniques using the thoracodorsal vessels as recipients provide an opportunity for a “second look” at the axillary nodal basin post-mastectomy. The purpose of this study was to determine the occult malignancy rate associated with free flap breast reconstruction. Methods A retrospective chart review was performed to ascertain the occult malignancy rate of women who received a delayed free flap reconstruction at our institution between 1990 and 2001. Any additional therapy as a result of a positive result was also recorded. Results Free flap breast reconstructions between 1990 and 2001 totalled 322, and of those 136 reconstructions were delayed and met our inclusion criteria. An occult malignancy rate of 3.6% (five patients) was identified for these patients. Four patients received additional therapy as a result of this finding. Conclusion This study serves to alert reconstructive surgeons to the potential for finding occult tumour during free flap breast reconstruction. J. Surg. Oncol. 2008;98:94–96. © 2008 Wiley-Liss, Inc.

Ultrasound is the principal method used for diagnosing deep venous thrombosis in the United States, and its accuracy and limitations are well known. As venous ultrasound examination has matured, several controversial issues, primarily clinical, have arisen concerning the application of this diagnostic method. This article addresses some of the more noteworthy and vexing issues, including, but not limited to (a) the need to examine both legs in patients with unilateral symptoms; (b) the role of venous ultrasound in patients with bilateral leg swelling; (c) the necessary extent of the venous ultrasound examination; (d) the importance of calf vein thrombosis; (e) the significance of negative leg veins in a patient with possible pulmonary embolus; and (f) deep venous thrombosis in patients with occult malignancy. Technical aspects of the venous ultrasound examination, and diagnostic accuracy are not described.

Objective Asymmetry of tonsils that arouses suspicion for malignancy is one of the indications for tonsillectomy. The purpose of this study was to evaluate the incidence of occult malignancy in patients with asymptomatic unilateral tonsillar enlargement. Study design and setting A prospective controlled trial was carried out in two institutions, Beyoglu Research and Training Hospital and Karaelmas University Hospital, during a 6-year period. Of patients selected for tonsillectomy, patients with unilateral tonsillar enlargement were identified and were included in this study. Patients who had risk factors that were significant for malignancy were excluded. After excision , two tonsil specimens were measured before sending for histology. Matched controls with symmetric tonsils underwent the same procedures. Preoperative diagnosis of tonsil asymmetry with the postoperative histologic diagnosis were correlated for the incidence of malignancy. Results Of the 792 patients undergoing tonsillectomy, 53 patients (6.69%) with asymmetry of tonsils and who had no other risk factors for malignancy underwent tonsillectomy. The size difference of the tonsils ranged from 0 to 19 mm. In the control group of 51 patients with symmetric tonsils, the size difference ranged from 0 to 8 mm. The analysis showed statistically significant difference in the degree of asymmetry between the two groups (P < .001). Most of the specimens contained reactive lymphoid hyperplasia in both groups (58.49% and 54.9%, respectively). No malignancies or unusual pathological findings were encountered on histologic examination in either group. Conclusion and significance Tonsil asymmetry may only be apparent in patients with an otherwise normal physical examination, secondary to benign hyperplasia or anatomical factors. Therefore, the presence of tonsil asymmetry without factors such as suspicious appearance, significant systemic signs and symptoms, progressive enlargement of the tonsil, concomitant neck adenopathies, and history of malignancy or immunocompromise, may not indicate malignancy, as a sole clinical feature.

Unilateral axillary adenopathy may be caused by a wide range of both benign and malignant aetiologies. While the most common cause is inflammation, infection or trauma of the breast, thoracic wall or arm, a significant proportion of cases are due to occult malignancy. In female patients particularly, breast malignancy must be excluded with mammography and ultrasound. Local inflammation, infection or trauma of the thoracic wall or arm should also be sought when deciding the most appropriate recommendation for management. This case report outlines the most significant pathologies and discusses the need to rule out sinister pathology, even when a benign local cause is evident.

Oral metastases from internal carcinomas are extraordinarily rare. From hepatocellular carcinoma (HCC), there is a 1% rate of metastasis to the oral and maxillofacial region, which is most commonly localized to the mandible. However, such metastases can be the initial and only presentation of an occult malignancy. Given the rapidly increasing incidence of HCC in North America and Europe, high clinical suspicion and prompt diagnosis are crucial given its poor prognosis. The authors present a case of a single metastatic HCC tumor to the mandible that clinically manifested as focal periodontitis. To the authors’ knowledge, this is the first case of such an initial presentation.

The association between malignancy and thrombosis has long been appreciated but remains incompletely understood. This is the second of a two-part review of the complex, integral relationship between these two entities, and addresses the specifics of cancer outcomes, occult malignancy in the presence of thrombosis, and the possibilities of cancer suppression by modulating thrombogenesis.

Tissue recovery personnel often find themselves in a situation in which, upon donor physical assessment, they discover an unusual or suspicious skin or tissue lesion. Because of the concern about the possibility of recovering tissues from a donor who may have an occult malignancy or infection, the Recovery Team may elect not to recover. Otherwise they may continue with the recovery, documenting their concern on the physical assessment form. At the time of evaluation of donor suitability the Medical Director must determine what the lesion is. This is inherently difficult and sometimes has led to the discard of recovered tissues. In order to optimize the gift of donation and avoid unnecessary deferral or discard of tissues we instituted a recovery biopsy procedure several years ago. Between January, 2005 and March, 2010, 561 biopsies were performed. In 552 donors (98.4%) there was no negative effect on medical suitability. Nine donors (1.6%) were found unsuitable based on the biopsy results. The recovery biopsy has allowed Recovery Teams to better manage their time by quickly identifying and biopsying suspicious lesions without trying to make a determination of donor eligibility and possibly ruling ineligible a qualified donor. The recovery biopsy has allowed the Medical Directors to make suitability decisions to accept or reject based on diagnostic certainty.

Metastatic tumour progression to the pericardium is generally characterised by an effusional pericarditis. It is extremely rare for tumour to metastasise to the pericardium and cause constrictive pericarditis in the absence of a pericardial effusion. We report the recent case of a patient who was referred to our centre with constrictive pericarditis. Following pericardectomy and histopathological analysis this was found to be secondary to an occult metastatic adenocarcinoma.

Lymphangitis carcinomatosa describes a condition of diffuse infiltration of the lymphatics of both the lungs by malignant cells. It may be the only manifestation of an occult malignancy and should be included in the differential diagnosis of dyspnoea, especially in young patients in whom this diagnosis is usually not suspected. The diagnosis rests on a high index of suspicion in the setting of progressive respiratory failure. In this article we review the clinical presentation and the diagnostic methods. We also review the relevant literature pertaining to this rare entity.

BACKGROUND & AIMS: Current guidelines recommend empirical, noninvasive approaches to manage dyspeptic patients without alarm symptoms, but concerns about missed lesions persist; the cost savings afforded by noninvasive approaches must be weighed against treatment delays. We investigated the prevalence of malignancies and other serious abnormalities in patients with dyspepsia and the cost of detecting these by endoscopy. METHODS: We studied 2741 primary-care outpatients, 18-70 years in age, who met Rome II criteria for dyspepsia. Patients with alarm features (dysphagia, bleeding, weight loss, etc) were excluded. All patients underwent endoscopy. The cost and diagnostic yield of an early endoscopy strategy in all patients were compared with those of endoscopy limited to age-defined cohorts. Costs were calculated for a low, intermediate, and high cost environment. RESULTS: Endoscopies detected abnormalities in 635 patients (23%). The most common findings were reflux esophagitis with erosions (15%), gastric ulcers (2.7%), and duodenal ulcers (2.3%). The prevalence of upper gastrointestinal malignancy was 0.22%. If all dyspeptic patients 50 years or older underwent endoscopy, 1 esophageal cancer and no gastric cancers would have been missed. If the age threshold for endoscopy were set at 50 years, at a cost of $500/endoscopy, it would cost $82,900 (95% CI, $35,714-$250,000) to detect each case of cancer. CONCLUSIONS: Primary care dyspeptic patients without alarm symptoms rarely have serious underlying conditions at endoscopy. The costs associated with diagnosing an occult malignancy are large, but an age cut-off of 50 years for early endoscopy provides the best assurance that an occult malignancy will not be missed.

The hand is the site of a great variety of benign lesions and, rarely, of malignant lesions. Acrometastasis can be the first manifestation of occult malignancy. Frequently, these lesions present in a similar way to benign conditions leading to erroneous diagnosis and inappropriate treatment. When located in the finger, the most frequent cause is lung cancer, while in the toes it is due to genito-urinary tumours. Awareness of the possibility of metastatic disease during orthopaedic assessment is essential to decrease patient morbidity. A case that was referred to our institution with a single metastasis in a digit from occult gastric adenocarcinoma is used to illustrate the way these lesions are managed. The diagnostic difficulties are summarised and an overview of literature was performed to determine management pathways to aid others in the treatment of these case.