Diagnostic challenges from conflicting results of tests and imaging

Accurate diagnosis is the foundation of clinical care but accurate diagnosis is not easily reached in some cases.In rare instances,even a sophisticated multidisciplinary team at an academic medical center cannot reliably reach an accurate diagnosis after extensive testing and imaging,and has to wait until histological diagnosis or even autopsy results are available.The underlying reason of challenging diagnoses is mostly conflicting data from history,tests,and imaging that point to different diagnoses.In this issue of World Journal of Clinical Cases,Huffaker et al reported such a challenging case of a tricuspid mass in a patient with Li-Fraumeni syndrome.The case by Huffaker et al powerfully illustrates the occasional diagnostic challenges inherent in our current diagnostic approach and the current technology.Clinicians should realize that in rare situations,agnosticism in diagnosis is unavoidable but a treatment has to be initiated so long as the principle of primum non nocere is upheld.

Clinical and CT Histological Diagnosis of Orbital Tumors

Summary: The clinical manifestation and characteristics of CT image of 117 cases of orbital tumors in our hospital were investigated. The hemangioma had the highest incidence, and the less common tumors were, in sequence of incidence, pseudotumor, dermoid cysts, neurilemmoma, polymorphous adenoma and meningioma. The sensitivity in diagnosis of orbital tumor by CT was 93. 3 %. The coincidence of CT histological diagnosis with pathology were 83. 3 %, 82. 6% and 71. 4 % for dermoid cysts, hemangioma, and pseudotumor respectively, but the general coincidence of CT histological diagnosis with pathology was only 67. 8 %. When CT was combined with ultrasound, cytological examination and clinical manifestations, the accuracy of histological diagnosis could be improved to 83.3%.

Accuracy between clinical and radiological diagnoses compared to surgical orbital biopsies

AIM:To assess the concordance between diagnosing orbital lesions by clinical examination,orbital imaging,and histological evaluation,in order to help guide future research and clinical practice.METHODS:A retrospective analysis was undertaken at a large regional tertiary referral centre of all surgical orbital biopsies performed over a 5-year period,from 1st January 2015 until 31st December 2019.Accuracy and concordance between clinical,radiological and histological diagnoses are reported as percentage sensitivity and positive predictive value.RESULTS:A total of 128 operations involving 111 patients were identified.Overall,sensitivities of 47.7%for clinical and 37.3%for radiological diagnoses were found when compared to the histological gold standard.Vascular lesions that have characteristic clinical and radiological features had the highest sensitivity at 71.4%and 57.1%,respectively.Inflammatory conditions showed the lowest sensitivity in both clinical(30.3%)and radiological(18.2%)diagnoses.The PPV for inflammatory conditions were 47.6%for clinical and 30.0%for radiological diagnoses.CONCLUSION:Accurate diagnoses are difficult to reach by relying on clinical examination and imaging alone.Surgical orbital biopsy with histological diagnosis should remain the gold standard approach for definitively identifying orbital lesions.Although larger scale prospective studies would help further refine concordance and guide future research avenues.

Choice of serum tumor markers in patients with small cell lung cancer:progastrin-releasing peptide,neuron-specific enolase,and carcinoembryonic antigen

Lung cancer is a leading cause of cancer-related deaths worldwide.It mainly consists of 2 histological types:small cell lung cancer(SCLC)and non-small cell lung cancer(NSCLC,including squamous cell carcinoma and adenocarcinoma).The present study aimed to assess the role of serum progastrin-releasing peptide(ProGRP),neuron-specific enolase(NSE),and carcinoembryonic antigen(CEA)and their combinations in the histological diagnosis of lung cancer(specially SCLC),which is of great importance for the initiation of treatment and prognostic implications.Serum ProGRP,NSE,and CEA were determined by the electrochemiluminescence immunoassay(ECLIA)in 66 patients with SCLC,73 with adenocarcinoma,44 with squamous cell carcinoma,45 with non-malignant pulmonary diseases,and 50 healthy controls.Receiver operating characteristic curves were constructed to compare the predictive ability of each biochemical marker and their combined detection models to discriminate among the patients with lung cancers of different histological groups,benign pulmonary diseases and healthy individuals.In the ECLIA detection system,ProGRP showed the sensitivity and specificity for SCLC diagnosis were 71.2%and 91.1%to 93.2%,respectively.Among the markers,the largest area under the ROCs was for ProGRP in discriminating SCLC from benign pulmonary diseases,squamous cell carcinoma and adenocarcinoma(0.815,0.859,and 0.835,respectively),which indicated that ProGRP was the most efficient marker for identifying SCLC.Besides,ProGRP and NSE exhibited almost equivalent diagnostic performance in discriminating SCLC from benign diseases.As for squamous cell carcinoma,we recommended proGRP,while for adenocarcinoma,the combination of proGRP and CEA was preferred.Remarkably,when ProGRP≤66pg/mL,CEA was of great value in diagnosing SCLC and adenocarcinoma.If CEA≤5ng/mL,the patient was at higher risk for SCLC,whereas the patient was more likely to be diagnosed with adenocarcinoma.Our study provided promising information about the diagnostic values of serum ProGRP,NSE,CEA in distinguishing SCLC from benign pulmonary diseases and NSCLC,which was of crucial clinical significance in the early diagnosis and therapy of SCLC.