Müllerian adenosarcoma with ovarian sex cord-like differentiation. A light- and electron-microscopic study

A Müllerian adenosarcoma in which the sarcomatous element showed ovarian sex-cord like differentiation, occurred as a polypoid growth in the uterine cervix of a 53-year-old woman. The tumor was composed of an admixture of benign neoplastic glands and a sarcomatous stroma, the latter containing in addition to endometrial stromal sarcoma, nests of lipid-rich cells resembling ovarian sex-cord elements. This is the first report of such differentiation in Müllerian adenosarcoma. Origin from a focus of cervical endometriosis is postulated.

Primary thymic carcinoma. An unusual case originating in a lymphocytic rich thymoma

A case of thymic carcinoma arising within a lymphocyte rich thymoma is reported. The undifferentiated carcinoma contained cellular elements resembling choriocarcinoma but could be differentiated therefrom by positive staining for prekeratin antigen and an absence of staining for B-HCG antigen utilizing immunohistochemical techniques.

Vocal cord polyps: biochemical and histologic evaluation

The stratified squamous epithelium covering vocal cord polyps can vary from normal to hyperplastic and keratinized. We have analyzed the histology and cytokeratins of 11 of these polyps. Cytokeratins were separated on one-dimensional SDS-acrylamide gels to determine molecular weights. There was significant heterogeneity in the cytokeratins present in the different polyps. Comparison of histologic findings and cytokeratin content showed a correlation between extent of keratinization and presence of high molecular weight cytokeratins. We conclude that the epithelium of vocal cord polyps exhibit patterns of cytokeratins characteristic of both hyperproliferation and abnormal states of differentiation, which are mirrored by histologic variations, and that vocal cord polyps are a heterogeneous group of benign lesions.

Adenocarcinoid of the appendix presenting as bilateral Krukenberg's tumor of the ovaries. Immunohistochemical and ultrastructural studies and literature review

A patient with an adenocarcinoid of the appendix presented with bilateral Krukenberg's tumors of the ovaries. Immunohistochemical and ultrastructural studies revealed a selective ability of the mucinous (goblet cell) component of the appendiceal neoplasm to metastasize. A review of the literature has revealed nine previously published cases of appendiceal adenocarcinoid metastatic to the ovaries. All showed involvement of both ovaries, but none provided unequivocal evidence of a metastatic proliferating carcinoid element. As the appendiceal lesion is often grossly inconspicuous, it may be overlooked in cases presenting initially with ovarian tumors. Routine appendectomy is therefore recommended in such patients where no grossly obvious primary tumor is evident.

Sinus histiocytosis with massive lymphadenopathy and unusual extranodal manifestations

We describe a predominant extranodal involvement of unusual sites by sinus histiocytosis with massive lymphadenopathy (SHML). The patient first presented at 13 years of age with bilateral parotid gland enlargement and was discovered to have a large asymptomatic left renal mass and adjacent hilar adenopathy, histologically diagnostic of SHML. Following a left nephrectomy, he remained well with persistent parotid and lacrimal gland disease and, 20 years later, plaquelike meningeal involvement mimicking meningioma en plaque developed that was associated with reactive meningeal nests within the body of the lesion. At no time during the last 20 years has there been a recurrence of significant external nodal enlargement, and biopsy specimens of neck and intrathoracic lymph nodes have been nondiagnostic of SHML.

Gastrointestinal lymphoid neoplasms

Primary gastrointestinal lymphomas (PGLs) are the most frequent extranodal non-Hodgkin's lymphomas and involve stomach more commonly than small bowel in Western countries. PGLs need to be differentiated from a variety of tumor-like hyperplastic lymphoid lesions; this may be facilitated by immunotyping of lymphoid cells. In PGLs, large-cell types predominate. Our study of 76 PGLs utilizing the ABC immunoperoxidase technique has led us to conclude that the majority are of B cell origin and that, while true histiocytic PGLs do indeed exist, their incidence is not greater than in nodal lymphomas. An important observation was that 26% of the cases showed an intense admixture of muramidase-positive reactive histiocytes, a feature that could result in an erroneous impression of a histiocytic derivation of the neoplasm. The prognostic significance of immunologic subtypes is currently not known. However, survival in PGL is determined by the clinical stage of the disease and to a lesser extent by the histologic type. Current optimal therapy includes resection of tumor-bearing bowel followed by radiotherapy and/or chemotherapy.

Benign isolated histiocytosis mimicking chicken pox in a neonate: report of two cases with ultrastructural study

Two cases of benign isolated cutaneous histiocytosis X in newborn infants are reported. Clinically, the lesions mimicked chicken pox, and the histologic findings in skin biopsies were indistinguishable from those described in infantile Letterer-Siwe disease. Electron microscopy showed Langerhans' cells with the classical trilaminar, racket-shaped granules. Our cases a well as 10 of the 21 previously reported cases showed spontaneous resolution of the skin lesions. Since this is a benign spontaneous resolving histiocytosis, we recommend that no therapy be given provided that no other signs of systemic involvement are found.

Granulocytic sarcoma of breast: aleukemic bilateral metachronous presentation and literature review

This report describes an unusual case of bilateral metachronous granulocytic sarcoma of the breast. The patient initially did not have evidence of leukemia and her marrow cell culture in soft agar (CFU-C array) showed normal in vitro growth pattern. The patient was treated with systemic chemotherapy at a time when there was no evidence for systemic disease but she nevertheless developed meningeal leukemia and bone marrow disease 11 and 18 months, respectively, following the initial chemotherapy.

Osteogenic sarcoma producing human chorionic gonadotrophin. Case report with immunohistochemical studies

An osteogenic sarcoma occurring in a 22-year-old woman was found to be associated with production of a large amount of beta human chorionic gonadotrophin (B-hCG). Pregnancy was excluded on the basis of a normal ultrasonogram and a proliferative type endometrium obtained by curettage. A homogenate of the tumor was strongly positive for B-hCG while immunohistochemical staining of the tumor cells was strongly positive for B-hCG and negative for pregnancy associated glycoprotein. These results indicate ectopic production of hCG by the osteosarcoma.

Calcospherites in pituitary prolactinomas. A hypothesis for their formation

Calcospherites are being reported with increasing frequency in pituitary prolactinomas. Ultrastructural study of such a case, along with the recent characterization of the molecular composition of prolactin granules, has led us to hypothesize that a unique intracellular milieu exists in which calcification can be initiated and can proceed to calcospherite formation.

Immunohistochemistry of Hodgkin's disease. A study of 20 cases

An immunoperoxidase study of 20 cases of Hodgkin's disease demonstrated universal staining of Reed Sternberg cells and their mononuclear variants for both kappa and lambda light chains and, in all but one case, for IgG. Staining for IgA and albumin was variable and for IgD and IgM uniformly negative. A double staining procedure using two different chromogens produced the paradoxical finding of both light chain types within the same cell, but these could only be demonstrated sequentially and not simultaneously, suggesting a blocking phenomenon. The above findings coupled with the demonstration of muramidase and/or alpha-1-antitrypsin in Reed-Sternberg cells and their mononuclear variants in all but two cases studied favor a histiocytic origin for these cells. This characteristic profile of results is also very helpful in distinguishing Hodgkin's disease from other neoplasms which mimic Hodgkin's disease because of the presence of Reed-Sternberg-like cells.

The significance of microscopic invasive cancer in endoscopically removed polyps of the large bowel. A clinicopathologic study of 51 cases

A clinicopathologic study of 51 patients with endoscopically removed large bowel polyps showing histologic evidence of malignancy, either focally, to a massive extent, or comprising the entire polyp, revealed only one absolute finding capable of predicting residual disease, namely, the presence of cancer at the resection line. Of 23 radical resections, only one was justified. This case showed evidence of residual disease in the colectomy specimen that could have been predicted on the basis of involvement of the diathermy margin by carcinoma. Of 28 patients having polypectomy alone, 1 patient developed a Dukes' B carcinoma. The polyp, removed 9 months previously from the same site, had shown involvement of the margin by carcinoma. A conservative approach is thus advocated in the absence of this finding.

Chondroid chordoma. Electron-microscopic study of two cases

Chondroid chordoma is an unusual tumor composed of an admixture of chondromatous and chordomatous tissue usually located in the spheno-occipital region. This tumor shares many of the clinical and histologic features of classic chordoma and chondrosarcoma and has been shown to have a better prognosis than either of these lesions. To the best of our knowledge, no ultrastructural studies have been performed in the 26 cases of chondroid chordoma published previously. We document the ultrastructural features of two examples of chondroid chordoma. Certain features such as prominent and dilated rough endoplasmic reticulum, intracytoplasmic glycogen aggregates, and abundant fibrillogranular matrix are common to chordoma, chondrosarcoma, and chondroid chordoma. The presence of well-formed tonofilament desmosome complexes as well as complexes composed of alternating profiles of rough endoplasmic reticulum and mitochondria were seen only in chordoma and chondroid chordoma, but not in cartilaginous tumors. Of particular interest was the finding of crystalline, tubular structures within the rough endoplasmic reticulum of both cases of chondroid chordoma, a finding not described previously. The distinction of chondroid chordoma from classical chordoma is said to be a difficult one at the light-microscopic level, and we suggest that these intraergastoplasmic tubular structures might constitute an extremely helpful differential marker.

Case report 235. Ewing-like adamantinoma of the left radial head and neck

Skeletal adamantinoma is a rare malignant bone tumor with a poorly understood histogenesis. The lesion is easily recognized by a distinctive microscopic pattern of anastomosing trabeculae of epithelial-like cells in a fibrous stroma. Ultrastructural evidence has been presented to support an origin from two widely-divergent cell types: an epithelial cell with squamous characteristics [12, 15] and a mesenchymal cell with endothelial features [5, 9]. An addition to the histogenetic controversy has been the recent description of a bone neoplasm with an adamantinoma-like growth pattern which proved both by subsequent histological evolution and ultrastructure, to have features of Ewing tumor [10]. The authors report a further example of this entity and suggest that it may be sufficiently distinctive within the adamantinoma group to merit the term Ewing-like adamantinoma. Consonant with increasing evidence supporting the concept of tumor "metaplasia" that transcends traditional concepts of epithelial-mesenchymal immutability, the authors propose that all adamantinomas arise from a common stem cell.

Extraskeletal osteosarcoma arising in an ectopic hamartomatous thymus. Report of a case and review of the literature

A unique case of an osteosarcoma arising within a hamartoma of the thymic gland located in the left pleural cavity of an 11-year-old girl is described. The presence of abundant mature lamellar bone within this thymic hamartoma provides an explanation for the osseous histogenesis of the sarcoma. The development of an osteosarcoma from extraskeletal osseous tissue is a rare occurrence and has been documented in association with myositis ossificans and most recently in a case of dermatomyositis with metaplastic ossification.

Chronic granulomatous disease of childhood presenting as gastric outlet obstruction

A case of chronic granulomatous disease of childhood was first diagnosed when a 20-month-old infant developed gastric outlet obstruction. Because of the unusual clinical presentation and negative gastric mucosal biopsies, the diagnosis was delayed. A subsequent full thickness biopsy of the stomach wall which led to a correct diagnosis showed a granulomatous infiltrate in the muscularis propria. Characteristic yellow pigment-laden macrophages were seen in the gastric mucosa and pyloric lymph node. Early recognition of this chronic disorder is important not only for proper management but genetic counseling as well.

Angio-immunoblastic lymphadenopathy

Two patients presented with a short history of constitutional symptoms including fatigue, weight loss, night sweats and pruritus. Both had hepatosplenomegaly and tender lymphadenopathy, and in each case lymph node biopsy revealed prominent vascularization of the interfollicular zones and the presence of an amorphous eosinophilic fibrillar material, together with many epithelioid histiocytes, immunoblasts and plasma cells. In other areas of the same lymph nodes unequivocal lymphocytic lymphoma was present. The first patient was treated with levamisole, to which there was dramatic response. She subsequently died of septicaemia, and at autopsy was shown to be free of lymphoma. The second patient responded completely to the epipodophyllotoxin VP16-213 and is back at work as a heavy labourer without any residual disease. These 2 cases illustrate that complete clinical remission can be obtained in patients with this disease even after lymphomatous transformation has occurred. Levamisole has the additional attraction of being less immunosuppressive in patients whose immune response is already impaired.

Ultrastructural comparison of Hodgkin's and non-Hodgkin's lymphomas

The ultrastructural features of Reed-Sternberg cells and reactive epithelioid histiocytes from patients with Hodgkin's disease were compared with those of large cell non-Hodgkin's lymphomas. The cytoplasmic organelles of Reed-Sternberg cells were dissimilar to those of neoplastic large lymphocytes from follicular centre cell lymphomas, immunoblastic lymphomas, lymphoblastic lymphomas, and mycosis fungoides both in type and distribution. Reed-Sternberg cells could be distinguished from reactive epithelioid histiocytes; however, the cytoplasmic organization of the Reed-Sternberg cells bore a closer resemblance to these histiocytes than to the cells of the various large cell non-Hodgkin's lymphomas.

Multiple juvenile polyposis. A study of the pathogenesis of juvenile polyps and their relationship to colonic adenomas

Solitary juvenile polyps are common lesions whose pathogenesis is poorly understood. Multiple juvenile polyposis is characterized by large numbers of these lesions either confined to the colon or throughout the gastrointestinal tract. A study of two cases of multiple juvenile polyposis provided fresh insight into the pathogenesis of juvenile polyps and their relationship to colonic adenomas. Mucosal ulceration in very early lesions, together with glandular epithelial calcification, suggested that impaired cell renewal resulting from disturbed regenerative kinetics may predispose to surface epithelial erosion, setting in motion a cycle of ulceration, inflammation, and granulation tissue formation. We postulate that a dyskinetic continuum may link juvenile, "metaplastic," and adenomatous polyps. The finding in our second case of multiple adenomatous lesions, including a villoglandular polyp, emphasizes the neoplastic potential of juvenile polyposis.

Hemangiopericytoma: a light microscopic and ultrastructural study

An ultrastructural study of three cases of hemangiopericytoma showed cells partially or completely enveloped by well-formed basement membrane and basement membrane-like material. The cells exhibited prominent cytoplasmic filaments, some showing dense body formation, interdigitating cytoplasmic processes, and pinocytotic vesicles. A review of the literature revealed only 19 other cases of hemangiopericytoma studied by electron microscopy, and these included seven cases of meningeal origin ("angioblastic meningioma"). The most consistent feature seen in all but two cases was the presence of a basal lamina or basal lamina-like material either partially or completely surrounding tumor cells and separating endothelial cells from pericytes. The light microscopic diagnosis of hemangiopericytoma is difficult, and there is a tendency to append the diagnosis to a variety of other tumors with a prominent vascular pattern in which other specific diagnoses are not immediately evident. The presence, ultrastructurally, of well-developed basement membrane, myogenic type filaments, and pinocytotic vesicles in a tumor with light microscopic features suggestive of hemangiopericytoma would consolidate the diagnosis and usually eliminate diagnostic uncertainty.