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PubMed2006

Application of alpha-methylacyl coenzyme A racemase immunohistochemistry in the diagnosis of prostate cancer: a review.

Alpha-methylacyl coenzyme A racemase (AMACR) is a recently discovered enzyme protein that has been shown to be increased at both the mRNA and protein levels in prostatic adenocarcinoma as compared with normal prostatic tissues. Since its discovery, AMACR has gained wide acceptance for use in the diagnosis of prostatic adenocarcinoma in conjunction with morphology and immunohistochemical staining for basal cell markers. Numerous studies have consistently shown high sensitivity and specificity of AMACR for prostate cancer. This review focuses on AMACR expression in prostate cancer and its morphologic variants, high grade prostatic intraepithelial neoplasia, adenosis and benign conditions of the prostate. In addition, we discuss AMACR expression in other tumors. We also focus on the utility and technical aspects of the now-popular "triple stain" immunohistochemical antibody cocktail, consisting of antibodies to high-molecular-weight keratin, p63 and AMACR. Finally, we emphasize diagnostic pitfalls in the application of AMACR to small, atypical foci of glands seen on prostate needle core biopsy and project future diagnostic as well as clinical applications for the protein.

Adenocarcinoma↗
PubMed1984

The intrahepatic and extrahepatic bile ducts in surgical jaundice: radiological evaluation and therapeutic implications.

Many invasive and noninvasive imaging modalities are available to image the biliary tract in suspected surgical jaundice. Technical advances in existing techniques and development of new techniques allow biliary obstruction to be detected in its earliest stages. Criteria for the presence of biliary obstruction include anatomic visualization and measurement of both the intrahepatic and extrahepatic portions of the biliary tree. These criteria will be reviewed and potential diagnostic pitfalls discussed. Anicteric dilatation, disparate dilatation, and segmental obstruction of the biliary tract will be discussed as these entities pose a diagnostic as well as therapeutic challenge. The newer endoscopic and percutaneous interventional techniques will be considered and placed in perspective.

Carcinoma↗
PubMed2004

Florid reactive periostitis of the hands.

Reactive periostitis of the hand can be a confounding lesion on both radiological and histological grounds. An erroneous diagnosis of a malignant tumor, particularly an osteosarcoma, is a possibility. Two cases of florid reactive periostitis of the hand mistaken for osteosarcoma are reported here to illustrate this entity and caution against a diagnostic pitfall.

Adolescent↗
PubMed1986

Diagnostic workup and treatment of multilocular cystic kidney. Difficulties in differential diagnosis.

The diagnostic pitfalls of multilocular renal cystic disease are illustrated by the medical histories of 4 patients. Although ultrasonography and CAT scans are considered reliable diagnostic methods in cystic renal disease, in the 4 cases reported these methods could not give the correct diagnosis. In multilocular cystic disease, segmental excision is the preferred treatment, if frozen section does not show malignancy. However, frozen section done intraoperatively can give misleading results, as illustrated in these cases.

Adult↗
PubMed1996

Proliferating tricholemmal cyst: a possible pitfall in cytological diagnosis.

We report a case of proliferating tricholemmal cyst, which made difficulties in the cytological analysis of the fine-needle biopsy aspirates. This rare dermatopathologic entity is a possible diagnostic pitfall due to its close cytological resemblance to squamous cell carcinoma-the abundance of material, with predominance of squamoid cells, which form concentric structures (so-called squamous eddies), that simulate keratin pearls of well-differentiated squamous cell carcinoma. However, careful and strict application of the cytological criteria prevents overdiagnosis; the small squamoid cells that predominate in the smears occur mainly in clusters and sheets, they do not show prominent atypia, and the squamous eddies may not undergo complete keratinization.

Adenoma↗
PubMed1987

Disseminated adenovirus infection in an immunocompromised host. Pitfalls in diagnosis.

In this report, a bone marrow transplant recipient with rapidly fatal gastroenteritis is presented. The presence of intranuclear inclusions on postmortem light microscopic examination of liver, lung, and small bowel tissue was considered diagnostic of cytomegalovirus infection. However, electron microscopic examination of liver tissue demonstrated adenovirus infection. This was confirmed by isolation of an adenovirus type 2 with unusual laboratory features from liver, lung, colon contents, serum, esophageal swab, and oral ulcerations. Results of a complement fixation test for antibodies to adenovirus performed on postmortem serum samples were negative, and a titer of 1:4 was noted for antibody against cytomegalovirus. This case illustrates the diagnostic pitfalls that may be encountered in establishing a specific viral diagnosis in severely ill patients.

Adenoviridae Infections↗
PubMed1994

[Artifacts in magnetic resonance angiography].

UNLABELLED: This study was aimed at assessing and classifying the incidence of Magnetic Resonance Angiography (MRA) artifacts using the 2D and 3D time-of-flight (TOF) technique. MATERIALS AND METHODS: from 300 MRA examinations performed January 1991 through April 1993, we selected the first 10 examinations for each vascular region which exhibited an artifact. Many kinds of artifacts were considered, i.e., hardware, sequence, magnetic susceptibility, patient and maximum intensity projection (MIP) artifacts. A superconductive 1.5-T magnet (Magnetom, Siemens) was used, with 2D and 3D TOF acquisitions. RESULTS: the quantitative analysis of artifact frequency showed that in the intracranial vessels (2D and 3D TOF sequences) the most common artifacts are saturation (30%) and magnetic susceptibility (30%) artifacts. As for neck vessels (3D TOF sequences), turbulence (40%) and lack of inclusion (30%) artifacts are the most common ones. In thoracic vessels (2D TOF sequences), MIP (50%) and ghost (30%) artifacts are the most common ones, while in the abdominal aorta (2D TOF sequences) magnetic susceptibility (20%), voluntary movement (20%), peristalsis (20%) and MIP (20%) artifacts occurred most frequently. Saturation (30%) and respiratory movement (30%) artifacts were the most common ones in the study of the renal arteries (3D TOF sequences), while MIP artifacts prevailed (40%) in the inferior vena cava (2D TOF sequences). Finally, MIP (40%) and patient movement (30%) artifacts were the most frequent ones in the study of the lower limbs (2 TOF sequences). CONCLUSIONS: in 2D and 3D TOF studies, being familiar with artifacts and their physical principles helps avoid image misinterpretation so that, if no technical means can prevent an artifact from occurring, at least it will not become a diagnostic pitfall.

Artifacts↗
PubMedDate not supplied

Fatty liver: imaging patterns and pitfalls.

Fat accumulation is one of the most common abnormalities of the liver depicted on cross-sectional images. Common patterns include diffuse fat accumulation, diffuse fat accumulation with focal sparing, and focal fat accumulation in an otherwise normal liver. Unusual patterns that may cause diagnostic confusion by mimicking neoplastic, inflammatory, or vascular conditions include multinodular and perivascular accumulation. All of these patterns involve the heterogeneous or nonuniform distribution of fat. To help prevent diagnostic errors and guide appropriate work-up and management, radiologists should be aware of the different patterns of fat accumulation in the liver, especially as they are depicted at ultrasonography, computed tomography, and magnetic resonance imaging. In addition, knowledge of the risk factors and the pathophysiologic, histologic, and epidemiologic features of fat accumulation may be useful for avoiding diagnostic pitfalls and planning an appropriate work-up in difficult cases.

Diagnosis, Differential↗
PubMed2006

MR arthrography in calcific tendinitis of the shoulder: diagnostic performance and pitfalls.

The purpose was to assess the diagnostic performance of MR arthrography to diagnose calcific tendinitis of the shoulder and to assess the reasons for diagnostic errors. Standard MR arthrograms of 22 patients with calcific tendinitis and 61 controls were retrospectively analyzed by two independent and blinded radiologists. All cases were consecutively collected from a database. Conventional radiographs were available in all cases serving as gold standard. The supraspinatus was involved in 16, the infraspinatus in four and the subscapularis in two patients. All diagnostic errors were analyzed by two additional readers. Reader 1 correctly detected 12 of the 22 shoulders with and 42 of the 61 shoulders without calcific tendinitis (sensitivity 0.55, specificity 0.66). The corresponding values for reader 2 were 13 of 22 and 40 of 61 cases (sensitivity 0.59, specificity 0.69). Inter-rater agreement (kappa-value) was 0.42. Small size of the calcific deposits and isointensity compared to the surrounding tissue were the most important reasons for false negative results. Normal hypointense areas within the supraspinatus tendon substance and attachment were the main reason for false positive results. In conclusion, MR arthrography is insufficient in the diagnosis of calcific tendinitis. Normal hypointense parts of the rotator cuff may mimic calcific deposits and calcifications may not be detected when they are isointense compared to the rotator cuff. Therefore, MR imaging should not be interpreted without corresponding radiographs.

Adult↗
PubMed2005

Pitfalls in salivary gland fine-needle aspiration cytology: lessons from the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology.

CONTEXT: We use data from the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology to identify common diagnostic errors in salivary gland fine-needle aspiration (FNA). OBJECTIVE: To identify salivary gland FNA cases with poor performance characteristics in the Nongynecologic Cytology Program surveys, so that the most common diagnostic pitfalls can be avoided. DESIGN: A retrospective review of the College of American Pathologists Nongynecologic Cytology Program's cumulative data from 1999 to 2003 revealed the most common false-positive and false-negative interpretations on FNA for common salivary gland lesions. Slides that performed poorly were then reviewed to identify the cytologic characteristics that may have contributed to their poor performance. RESULTS: A total of 6249 participant responses with general interpretations of benign (n = 4642) or malignant (n= 1607) were reviewed. The sensitivity and specificity of the participant responses for correctly interpreting the cases as benign or malignant were 73% and 91%, respectively. Benign cases with the highest false-positive rates were monomorphic adenoma (53% false-positive), intraparotid lymph node (36%), oncocytoma (18%), and granulomatous sialadenitis (10%). Malignant cases with the highest false-negative rates were lymphoma (57%), acinic cell carcinoma (49%), low-grade mucoepidermoid carcinoma (43%), and adenoid cystic carcinoma (33%). Selected review of the most discordant individual cases revealed possible explanations for some of the interpretative errors. CONCLUSIONS: These data confirm the difficulty associated with interpretation of salivary gland FNA specimens. Cytologists should be aware of the potential false-positive and false-negative interpretations that can occur in FNAs from this organ site in order to minimize the possibility of diagnostic errors.

Biopsy, Fine-Needle↗
PubMed2005

Clinical diagnoses and autopsy findings: a retrospective analysis of 252 cases in Greece.

CONTEXT: Despite medical and technologic advances, clinicians may misdiagnose a patient's situation and the cause of death. Autopsy may be valuable in uncovering the most frequent diagnostic pitfalls and helping clinicians to learn and to develop the medical art and science. OBJECTIVE: To compare the clinical diagnoses with postmortem findings and evaluate the frequency of diagnostic errors assessed by autopsies. DESIGN: Retrospective analysis of the protocols of 252 consecutive cases of adult patients autopsied in the Department of Forensic Medicine and Toxicology of Athens Medical School during the period 1999-2003. The outcome measures included concordance between diagnosis before death and at autopsy, sex, age, and length of hospitalization of the patient. RESULTS: In 73 cases (29%), the autopsy findings confirmed the clinical diagnosis and the cause of death suggested by the clinicians. In 45 cases (19%), the clinical diagnosis and the cause of death suggested by the clinicians were discordant with the autopsy findings. In 105 cases (42%), the autopsy requests did not include any suggestion about the cause of the patient's death. In 7 cases (3%), several diagnoses were suggested by the clinicians, and in 16 cases (6%), the comparison between clinical and postmortem diagnosis was not possible. The most frequently misdiagnosed diseases were coronary disease and pulmonary embolism. CONCLUSIONS: It is concluded from this study that autopsies may reveal unexpected findings that are of critical importance and that a continued emphasis on autopsy evaluation is necessary to improve the quality of patient care.

Aged↗
PubMed2004

Empirical antifungal therapy in treating febrile neutropenic patients.

Persistent or recurrent unexplained fever in neutropenic patients receiving antibiotics can be caused by invasive fungal infections, which are often difficult to diagnose. Early trials of empirical antifungal therapy with amphotericin B deoxycholate (AmB) documented reductions in the frequency of and the morbidity and mortality associated with invasive fungal infections. Because of AmB's infusional and renal toxicities, subsequent trials used newer, less toxic agents, such as the lipid formulations of AmB, the extended-spectrum azoles, and, more recently, the echinocandins. To date, alternatives to AmB have shown less toxicity, but improved efficacy has been less clear. Overall, empirical antifungal therapy can help prevent the morbidity associated with many fungal infections, eliminate concerns about diagnostic pitfalls, and prevent breakthrough undetected infections. However, its potential shortcomings are overtreatment, toxicity, and increased treatment-related costs when treatment is given to persons not needing it. Newer diagnostic tools are needed to target those most in need of antifungal therapy.

Amphotericin B↗
PubMedDate not supplied

Cytodiagnosis of 112 salivary gland lesions. Correlation with histologic and frozen section diagnosis.

Aspirates of 112 cases of salivary gland lesions with histologic correlation were reviewed. Fifty-five cases (49%) had frozen sections made. The 112 cases included 76 cases of benign lesions (31 cases of pleomorphic adenoma, 19 of Warthin's tumor and 26 of nonneoplastic lesions), 22 of primary salivary gland malignancy and 14 of metastatic malignant lesions. The overall accuracy in diagnosing benign and malignant lesions was 95%. The accuracy in diagnosing the exact category of neoplastic lesions was 70%. The diagnostic sensitivity for malignant lesions was 86% and the specificity, 99%. There was one false positive, in which a pleomorphic adenoma was diagnosed as small cell carcinoma. Five false-negative cases were encountered that were due to underdiagnosis of mucoepidermoid carcinoma and adenoid cystic carcinoma. The smears were reviewed, and the diagnostic pitfalls are discussed. A comparison of the cytodiagnosis and frozen section diagnosis was made. In frozen sections there were two false negatives, and two diagnoses were deferred. The overall diagnostic accuracy was 91%. The accuracy in diagnosing the exact category of neoplastic disease was 77%. The diagnostic sensitivity for malignant disease was 70% and specificity, 100%. Frozen section, however, did supplement the fine needle aspiration diagnosis in 13 cases.

Adolescent↗
PubMed1989

[Hereditary hyperoxaluria or oxalosis. Apropos of a case].

We report a case of primary oxalosis in a 12-year old girl. This unusual observation exemplifies two diagnostic pitfalls, i.e. false urinary tract infections and technical difficulties in accurately measuring oxalate urinary excretion. On the basis of this case and a review of the literature, we discuss diagnostic and therapeutic methods. Early diagnosis of the disease is important in order to monitor the patient and provide genetic counseling.

Child↗
PubMed1994

Postmenopausal squamous-cell atypias: a diagnostic challenge.

Exfoliative cytologic studies directed toward atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (LSIL) have been neglected in the rising postmenopausal population. This retrospective study from 60 cases, initially interpreted as ASCUS or LSIL, concentrates on these lesions and their associated diagnostic pitfalls. Cytologic reevaluation of the 60 patients revealed squamous-cell abnormalities in 45 (18 ASCUS and 27 LSIL) and cervicitis alone in 15 cases. Follow-up studies of the 18 ASCUS cases showed cervicitis in seven, persistent ASCUS in five, CIN I in five, and VAIN I-II in one. Follow-up of the 27 cases categorized as LSIL, showed ASCUS in two, CIN in 20 and VAIN in one, while four had cervicitis alone. Interestingly, two of these 45 patients had only vaginal dysplasia. By application of uniform diagnostic criteria, 15 of the 60 cases were reviewed as benign. Pitfalls included inflammatory and drying alterations, reactive metaplasia, and sampling problems. Thus, squamous-cell abnormalities in postmenopausal women can be significant when artifactual alterations are eliminated.

Carcinoma, Squamous Cell↗
PubMed1995

[Role of imaging in the management of abdominal trauma in children].

Blunt abdominal trauma is common in children and induces significant morbidity and mortality. Trends in management of solid viscera lesions have changed over the past 15 years and a conservative approach is now preferred whenever possible. Such management has become possible in selected cases due to advances in pediatric intensive care and medical imaging. The authors provide a review-based on international literature data-of the respective roles of medical imaging studies in the initial management of blunt abdominal trauma in children. The place of these investigations is discussed for each organ, with emphasis on the diagnostic value of sonography and computed tomography. Diagnostic pitfalls and limitations in prognostic accuracy are discussed.

Abdominal Injuries↗
PubMed2003

Natural history and treatment of fibrous dysplasia of bone: a multicenter clinicopathologic study promoted by the European Pediatric Orthopaedic Society.

A multicenter study on fibrous dysplasia of bone (FD) was promoted by the European Pediatric Orthopaedic Society in 1999 in order to gain insight into the natural history of the disease and to evaluate current diagnostic and therapeutic approaches. We collected and reviewed clinical, radiographic, pathological, and molecular genetic data when possible, from a total of 64 cases diagnosed as either monostotic FD (MFD), polyostotic FD (PFD), or McCune-Albright syndrome (MAS), evaluated or treated in 11 participating centers. Results from the initial analysis of the series indicate five main points: (1) Significant diagnostic pitfalls affect the diagnosis of MFD and, to a lesser extent, PFD in orthopedic centers and allied radiology and pathology facilities, which may be circumvented by the adoption of stringent diagnostic criteria, and in some cases by the analysis of FD-associated GNAS1 mutations. (2) MFD carries a significant risk for fracture in the face of limited disease in the proximal femur, whereas its tendency to progress is restricted to a minority of cases, and long-term outcome is usually satisfactory, regardless of treatment, in non-progressive cases. (3) The profile of tibial disease, both in MFD and in PFD, is markedly different from that of femoral disease. (4) As expected, MAS patients have the most extensive disease and the most complicated course, regularly experience multiple fractures, and require adequate surgical treatment. It appears that conservative treatment of femoral fracture, or curettage and cancellous bone grafting, or fixation with screws and plates are not indicated for the treatment of femoral fractures in these patients and should all be discouraged. Internal fixation with intramedullary nails provides stabilization of extensively affected bones, and prevents further fractures and major deformities, and thus providing a better option both for acute and elective surgery in patients with extensive involvement of the femur or of other limb long bones. (5) Evaluation of patients with FD at orthopedic centers should include, but rarely does, a thorough evaluation of endocrine profile and phosphate metabolism, and proper pathological and radiographic assessment.

Adolescent↗