Atypical clinical picture of waldenström’s macroglobulinemia: a difficult path to diagnosis

Objective. To describe the difficulties of diagnosis of Waldenström macroglobulinemia in a patient with atypical clinical picture.Materials and methods. Patient K., 57 years old, came in outpatient department with complaints of unilateral increase in submandibular lymph nodes on the right, discomfort in the nasopharynx, cough without sputum, increased fatigue. During the examination she was consulted by: an infectious disease specialist, otolaryngologist, surgeon, dentist, phthisiologist, hematologist and oncologist consulted her. To confirm the diagnosis conducted diagnostic activities: dynamic assessment of laboratory parameters, examination program cancer search (including multislice computed tomography and magnetic resonance imaging of various areas), with the exception of tuberculosis, monogenically study proteins in the blood and urine tests, biopsy of the ileum, immunohistochemistry trepanobiopsy.Results. During the 4‑year examination in the patient’s blood, an M-gradient in the gamma zone was detected, monoclonal immunoglobulin М-κ 19.3 g / l, Bens-Jones-κ protein in urine (daily proteinuria 0.45 g) was detected during immunofixation. In the myelogram at the light-optical level, the number of cell elements was significantly reduced with a pronounced lymphoid proliferation of 40 %, the granulocytic series and erythropoiesis were relatively narrowed, and plasma cells 6 %. Immunomorphological picture trepanobiopsy our patient based on the data of laboratory methods of research corresponds to the defeat of the bone marrow in Waldenström’s disease-κ, secretion of M-paraprotein. An important feature that allowed to go on the right path of diagnosis was almost pathognomonic for tumor lymphoproliferation, detection of Bens-Jones protein in the urine, which was absent in the onset of the disease.Conclusion. This clinical case is interesting not only by the complexity of the diagnosis of macroglobulinemia of Waldenström in General, but also by the atypical, erased clinical disease in our patient

The role of digital mammography, scintimammography with ^99mTc-methoxyisobutylisonitrile (MIBI) and ultrasound in the diagnosis of multicentric breast cancer

Background. The development of effective methods for diagnosing multicentric breast cancer patients (BC) is of great clinical importance, because it determines the tactics of surgical and radiation treatment.The aim of study: to compare diagnostic accuracy of scintimammography (SMG), digital mammography (MMG) and ultrasound (US) in the diagnosis of multicentric BC.Materials and methods. 410 women with histologically confirmed BC were included in this analysis. SMG was performed with dual detector SPECT unit Forte (Philips, Netherlands). Mammographic digital images were obtained on Senographe DS unit (GE Healthcare, USA). In 319 of 410 evaluated women we were able to determine results of preoperative US with high-frequency (7—18 MHz), high resolution linear array transducer. The pathological report was used as the gold standard. Multicentric BC was defined as 2 or more distinct invasive tumors occupying more than one quadrant. Detection of additional grouped calcifications of malignant type occupying a small portion of breast tissue (more than 15 pieces per 1 sq. cm) was considered as another mammographic sign of multicentric BC.Results. According to histopathological examinations multicentric BC was diagnosed in 51 of 410patients. SMG was more effective than MMG in detecting multicentric BC: sensitivity — 84.3 % vs 54.9 % (p <0.001), specificity — 98 % vs 95.8 % (p = 0.02), accuracy — 96.3 % vs 90.7 % (p = 0.04), positive and negative predictive values — 86 % vs 65.1 % (p = 0.004) and 97.8 % vs 93.7 % (p = 0.01), respectively. Histologically multicentric BC was revealed in 44 of 319 women that had US of the breasts. Sensitivity, specificity, accuracy, positive and negative predictive values for US were 52.3 %, 94.5 %, 88.7 %, 60.5 % and 92.5 %, respectively. SMG significantly (p <0.001) outperformed US for all diagnostic characteristics. Combination of MMG and SMG characterized by increased sensitivity (94.1 %), 94.2 % specificity, 94.1 % accuracy and positive predictive value of only 69,6 %.Conclusions. SMG is significantly more sensitive (84.3 %) than MMG (54.9 %) and US (52.3 %) in detection of multicentric BC. High (86 %) positive predictive value of SMG advocates it as a tool for surgery and radiotherapy planning