Endometrial adenocarcinoma arising in a secretory endometrium

Endometrial adenocarcinoma in young women below the age of 45 years and in a functioning endometrium is rare. We present the case of a 41-year-old woman, who without clinical risk factors, was found to have a focal well-differentiated endometrial adenocarcinoma in the background of a histologically secretory endometrium. Endometrial evaluation for abnormal vaginal bleeding in a young ovulating female and thorough examination of the endometrium in its entirety in the hysterectomized uterus are reemphasized.

Orthotopic liver transplantation in two adults with Niemann-Pick and Gaucher's diseases: implications for the treatment of inherited metabolic disease

Two adults were seen with cirrhosis caused by different lipid storage diseases. A 42-yr-old woman with Niemann-Pick disease type B had marked hepatomegaly, ascites and recent variceal bleeding. Her evaluation showed chronic bilateral pulmonary infiltrates, multiple stigmata of chronic liver disease including the recent cessation of menses, diuretic-resistant sterile ascites, hepatic encephalopathy and variceal bleeding. Five percent of normal sphingomyelinase activity was measured in peripheral leukocytes. A 42-yr-old man with Gaucher's disease and a history of bilateral hip replacements presented with hepatomegaly, jaundice, refractory ascites and renal insufficiency. His evaluation showed 20% to 23% of normal glucocerebrosidase activity in peripheral leukocytes. Both patients underwent orthotopic liver transplantation with resolution of all aspects of decompensated liver function. Assessment of the underlying metabolic defect before and 6 to 14 mo after transplantation showed that after transplantation the patient with Niemann-Pick disease had above normal hepatic sphingomyelinase activity, a less-marked increase in peripheral leukocyte enzyme activity and lower than normal hepatic sphingomyelin and cholesterol content. In contrast, the patient with Gaucher's disease had only a 61% increase in hepatic glucocerebrosidase activity but had an elevated hepatic glucocerebroside content that was only 15% of the pretransplant level and decreased peripheral leukocyte enzyme levels. These findings suggest that variable relationships may exist between posttransplant hepatic and peripheral leukocyte enzyme activities in the different lipidoses, which may have implications for recurrence of glycolipid-induced liver damage.

Benign fibrous tumor of the tunica vaginalis testis. Report of a case with light, electron microscopic, and immunocytochemical study, and review of the literature

Benign fibrous tumor of the tunica vaginalis testis is an uncommon lesion of unknown pathogenesis and histogenesis, frequently described as fibrous pseudotumor. We describe a case of a fibrous tumor of the tunica vaginalis testis studied with light, immunocytochemical, and electron microscopy in a 64-year-old man who also developed a metachronous renal cell carcinoma. To our knowledge, this is the first such case to be presented. We describe the cell of origin of this rare entity and its similarity to fibrous tumors of pleura and extrapleural sites, with a review of the English-language literature and emphasize that not all intrascrotal tumors are malignant.

Mineral-associated hepatic injury: a report of seven cases with X-ray microanalysis

The patterns of hepatic injury associated with various minerals were studied in seven patients. The subjects included one patient who was a sandblaster (silica by inhalation), one patient who was a dental laboratory technician (silica and chromium-cobalt alloy by inhalation), one patient with inhalational talcum powder abuse, and four chronic intravenous (IV) drug abusers (talc by IV injection). In all cases, the liver was examined by light and polarizing microscopy, and by scanning electron microscopy with energy-dispersive x-ray microanalysis. In the two patients with silica exposure, silica-containing sclerohyaline nodules were diffusely present in portal tracts and lobules. Both chromium-cobalt alloy and silica were present in the dental technician. In contrast, in all cases of talc exposure, aggregates of talc-laden macrophages were present in portal and centrilobular areas. Three IV drug abusers and the talcum powder abuser had histologic evidence of chronic hepatitis, most probably of viral etiology. We conclude that mineral type plays an important role in the pathogenesis and fibrogenesis of hepatic lesions. Compared with silica, talc primarily elicits a macrophage response without granuloma formation or fibrosis. Hepatic silicosis is a rare complication in dental laboratory technicians, and chromium-cobalt alloy may contribute to hepatic injury and fibrosis in this setting.

Unusual computed tomography findings in hepatic amyloidosis

An unusual pattern of delayed enhancement in a patient with a focal hepatic defect due to amyloidosis is presented. Without the aid of region-of-interest density measurements, the lesion was not appreciated on unenhanced computed tomography scans.

Localized fibrous tumors of the pleura: correlation of histopathological, immunohistochemical and ultrastructural features

The histogenesis of localized fibrous tumor of the pleura (LFTP) is controversial. We studied 12 LFTP's by light microscopy; by immunohistochemical staining for cytokeratin (CK), vimentin, muscle-specific actin, desmin, S-100 protein, epithelial membrane antigen (EMA) and factor VIII; by electron microscopy in 6 tumors; and by lung digestion for asbestos bodies in 4 cases. Three histologic patterns occurred in combination: 1) collagenous, 2) cellular and 3) hypocellular/myxoid. Hemangiopericytoma-like foci were prominent in the cellular areas of 9 tumors. Unusual features included diffuse small cells in 3 tumors, microcystic foci in 2, macrocystic areas in 5 and tumor giant cells in 4 tumors. Neoplastic cells in all patterns stained positively for vimentin and actin in 9 and 4 tumors, respectively, and were negative for all other markers. CK and EMA were identified in mesothelial and epithelial invaginations only. Ultrastructurally, neoplastic cells demonstrated intercellular junctions, intermediate or thin filaments, dense bodies and rough endoplasmic reticulum. Basal lamina was focally present in 5 tumors, while tonofilaments, desmosomes and short microvilli were observed in one case. Our results support the conclusion that LFTP is a neoplasm of the multipotential subserosal cell, and usually expresses mesenchymal (fibroblastic/myofibroblastic) differentiation. Coexpression of mesothelial features is rare. Lung asbestos body quantitation in 4 patients suggests that there is no association between LFTP and asbestos exposure.

Histopathologic findings in the liver of rheumatoid arthritis patients treated with long-term bolus methotrexate

Twenty-three patients with severe rheumatoid arthritis were treated with oral methotrexate (MTX) for more than 10 years. MTX was given as a bolus of 5-15 mg/week; the total cumulative dose ranged from 4,690 mg to 10,230 mg. Liver biopsies were performed on 21 of the patients to assess possible fibrosis and cirrhosis. Grade I histopathologic changes were found in 13 of the 21 biopsy samples, grade II changes were found in 3, and grade IIIA changes (mild fibrosis) were found in 5 specimens. None of the biopsy samples showed cirrhosis. Repeat biopsies were performed on the 5 patients with grade IIIA changes while they were still taking MTX. No progression of the fibrosis was noted. Two of the 5 samples, however, were graded IIIB because of portal and perilobular inflammation. Our findings support the premise that prolonged administration of oral MTX, when given as a weekly bolus at a low dose, does not cause cirrhosis or severe fibrosis in the rheumatoid arthritis patient who does not abuse alcohol.

Hindsight bias: an impediment to accurate probability estimation in clinicopathologic conferences

Although clinicopathologic conferences (CPCs) have been valued for teaching differential diagnosis, their instructional value may be compromised by hindsight bias. This bias occurs when those who know the actual diagnosis overestimate the likelihood that they would have been able to predict the correct diagnosis had they been asked to do so beforehand. Evidence for the presence of the hindsight bias was sought among 160 physicians and trainees attending four CPCs. Before the correct diagnosis was announced, half of the conference audience estimated the probability that each of five possible diagnoses was correct (foresight subjects). After the correct diagnosis was announced the remaining (hindsight) subjects estimated the probability they would have assigned to each of the five possible diagnoses had they been making the initial differential diagnosis. Only 30% of the foresight subjects ranked the correct diagnosis as first, versus 50% of the hindsight subjects (p less than 0.02). Although less experienced physicians consistently demonstrated the hindsight bias, more experienced physicians succumbed only on easier cases.

Fecal protoporphyrin excretion in erythropoietic protoporphyria: effect of cholestyramine and bile acid feeding

The effect of cholestyramine and bile acid feeding upon fecal, red blood cell, and plasma protoporphyrin levels was evaluated in a patient with erythropoietic protoporphyria and evidence of hepatic damage. After a basal period on a controlled diet, bile acids alone were administered (300-900 mg) daily for 9 days, followed by cholestyramine (12 g) plus bile acids (900 mg) daily for 7 days, and cholestyramine alone (12 g) daily for 6 days. There was no substantial change in either the red blood cell or plasma protoporphyrin concentrations during any treatment period. However, cholestyramine and cholestyramine combined with bile acids caused a threefold increase in fecal protoporphyrin excretion, whereas bile acids alone had no effect in this regard. After 1 yr of cholestyramine therapy, fecal excretion of protoporphyrin remained elevated with concurrent improvement in liver function tests and photosensitivity. This study indicates that cholestyramine but not bile acids can substantially increase protoporphyrin excretion and therefore may be capable of ameliorating the hepatotoxicity that may occur in selected patients with erythropoietic protoporphyria.

Hepatic veno-occlusive disease associated with renal transplantation and azathioprine therapy

Four patients with renal transplants developed hepatic veno-occlusive disease after immunosuppressive therapy with azathioprine. Severe progressive portal hypertension developed in all patients, with the clinical presentation varying from a mild viral-like syndrome to rapidly fulminant liver failure and death. The disease was associated with cytomegalovirus infection but not with the dose of azathioprine, the type or duration of transplant, or the type of underlying kidney disease. In view of the high mortality rate associated with veno-occlusive disease (a combined 55% in our four patients and in five reported in the literature) and wide spectrum of clinical presentation in patients with renal transplants, a high index of suspicion is required and aggressive intervention indicated.

Tissue and plasma carcinoembryonic antigen in early breast cancer. A prognostic factor

A prospective study of plasma and tissue carcinoembryonic antigen (P-CEA and T-CEA) levels in 63 patients with early (Stage I and II) breast cancer was undertaken to determine if the presence of CEA in tissue and/or plasma at the time of primary surgery can be used as a prognostic factor. Thirty-two Stage I and 31 Stage II patients were evaluable with a median follow-up time of 26 months: 29/63 were T-CEA and/or P-CEA positive while 34/63 were T-CEA and P-CEA negative; 9/63 were both T-CEA and P-CEA positive; 13/63 were P-CEA positive alone, while 25/63 were T-CEA positive alone; 5/29 T-CEA and/or P-CEA positive showed disease progression with a mean DFI of 11.8 months, compared with 0/34 T-CEA and P-CEA negative patients (P less than 0.02); 2/9 T-CEA and P-CEA positive compared with 0/34 negative patients progressed (P less than 0.01). There was a significant difference (P less than 0.05) between P-CEA positive (3/13) patients with recurrence and P-CEA negative (2/50). When T-CEA positive patients (4/25) were compared with T-CEA negative (1/38), the difference approaches significance. When the recurrences were analyzed with respect to CEA, estrogen receptor (ER) and nodal status, only in the CEA + versus CEA - group was there a significant difference. The early data show that patients with positive T-CEA and/or P-CEA have a higher recurrence rate with probable poor prognosis. Prognosis correlates better with CEA status than with ER or nodal status.

Renal lipidosis associated with arteriohepatic dysplasia (Alagille's syndrome)

We report a 20-year-old patient with arteriohepatic dysplasia (Alagille's syndrome) who developed progressive renal failure associated with extensive renal lipidosis. A renal biopsy showed diffuse thickening of glomerular basement membrane mimicking idiopathic membranous glomerulonephritis on light microscopy. Electron microscopy, however, demonstrated numerous intramembranous and mesangial lipid deposits, quite similar to those described in familial lecithin cholesterol acyltransferase deficiency. We believe the renal lipidosis developed secondary to hyperlipidemia associated with longstanding intrahepatic cholestasis. This case illustrates that extensive lipid deposition in the glomerular basement membrane may occur in patients with arteriohepatic dysplasia, and it may lead to progressive renal failure.

Ductuloinsular tumors of the pancreas: a light, electron microscopic and immunohistochemical study

Most pancreatic tumors are of a single cell type and are identified delta as duct, acinar, or islet cell neoplasms. The authors report on three examples with both duct and endocrine characteristics as seen by light microscopy; two with further confirmation of endocrine differentiation by electron microscopy; and one by immunocytochemistry. Mixed differentiation of this sort can be understood by reference to the embryonic pancreas, which develops from the small intestine and forms ducts, intercalated ducts, acini, and islets, with their different cell types. The merging and intermingling of different cell prevents the identification of one specific cell of origin. It also suggests that the neoplastic process here may not be a clonal proliferation from a single cell mutation as this is generally understood. Alternative explanations are briefly mentioned.

The Brenner tumor: a report of multiple tumors

A case of multiple Brenner tumors was studied with light and electron microscopy. Among the epithelial elements, argyrophil cells were found in addition to the typical "transitional" and mucus-secreting cells. In some areas, it was not possible to distinguish epithelial from tumor stromal cells. By electron microscopy, dense-core secretory granules were identified, as well as previously undescribed cytoplasmic tubular bodies. Some epithelial cells were intimately associated with reticulin and collagen. Some stromal cells had desmosomes, dense bodies, incomplete basal lamina, and, occasionally, multivesicular bodies, which suggests epithelial differentiation. Previous authors have documented morphologic similarities and continuity between Brenner-tumor epithelium and ovarian cells of almost every type. The inference is that there are multiple possible sources for the Brenner tumor. Classification must therefore be based on realize differentiation rather than presumed cell of origin.

Carcinoma of the colon with undifferentiated, carcinoid, and squamous cell features

An undifferentiated small cell tumor of the colon that was found by light- and electron-microscopic study to possess features of a malignant carcinoid merged into keratinizing squamous cell carcinoma. Single cells contained both dense-core secretory granules and tonofilaments. The implications of this combination in relation to theories of tumor origin and differentiation are briefly discussed.

Stromal sarcoma of breast: a light and electron microscopic study

A case of stromal sarcoma of the breast was studied by light and electron microscopy. The tumor comprised of uniform, plump spindle cells with neither epithelial nor "metaplastic" mesenchymal elements. Ultrastructurally most of the tumor cells appeared immature containing abundant free ribosomes, variable amounts of microfilaments and profiles of rough endoplasmic reticulum, with scant intercellular collagen and elastic fibers. The cells often showed prominent nesting as well as a variety of cell junctions, including desmosomes. We believe this tumor is a poorly differentiated, precursor mesenchymal sarcoma which belongs in the category of "stromal sarcoma of breast," a term coined by Berg et al. in 1962. To our knowledge, this represents the first published electron microscopic study on this tumor. Despite a high mitotic figure count in the tumor, the patient has survived a simple mastectomy with no evidence of metastasis 30 months later.

Multiangle light scattering flow photometry of cultured human fibroblasts: comparison of normal cells with a mutant line containing cytoplasmic inclusions

Multi-angle light scattering flow photometry was used to study the light scattering properties of normal cultured fibroblasts and a mutant fibroblast line containing cytoplasmic lysosomal inclusions. The effect of glutaraldehyde fixation on the light scattering properties of the cells was also examined and correlated with their ultrastructure. Normal fibroblasts showed uniform organelle distribution with few vacuoles or dense bodies in the cytoplasm while the mutant line showed abnormal cytoplasmic inclusions of varying morphology, density and lucency. As predicted by light scattering theory, the mutant cells containing the cytoplasmic inclusions scattered more light at large angles (greater than theta = 1.85 degrees) than did the normal cells. Glutaraldehyde fixation decreased light scattering at small angles (less than theta = 1.85 degrees), increased light scattering at larger angles (greater than theta = 1.85 degrees) in both normal and mutant cells and enhanced resolution of the light scattering signatures. The mutant line scattered 2-3 times more light at a wide angle (greater than theta = 12.74 degrees) than did the normal cells. These data suggest that abnormal lysosomal storage inclusion bodies in the cytoplasm of the cells can be detected by differential light scattering methods.

Gingival biopsy in thrombotic thrombocytopenic purpura

Gingival biopsy has been advocated as a readily available, safe, rapid histologic confirmation of the clinical diagnosis of thrombotic thrombocytopenic purpura. Eighteen gingival biopsies from 16 patients with proven thrombotic thrombocytopenic purpura were reviewed. Seven (39%) showed characteristic histologic changes: [1] subendothelial hyalinelike deposits; [2] intraluminal deposits; [3] lack of inflammatory change in vessels and stroma. To assess specificity, gingival sections from 154 patients with oral pathology only and from 50 unselected autopsies were reviewed: 10% to 20% of biopsies from patients with oral pathology only (primarily inflammation) and three of 50 autopsy specimens showed occasional intraluminal deposits but no subendothelial deposits. In addition, other histologic features permitted them to be distinguished from thrombotic thrombocytopenic purpura. We conclude that gingival biopsy in thrombotic thrombocytopenic purpura, although helful in confirming the diagnosis, is less often positive than has been suggested. Biopsy of grossly inflamed gingiva should be avoided.

Pleomorphic adenoma ("mixed" tumor) of human female breast mimicking carcinoma clinico-radiologically

A case of pleomorphic adenoma ("mixed" tumor) of the breast is described Although rare, this is a distinctive primary neoplasm which can be mistaken for a malignant tumor both clinically and radiologically. Brief reviews of the pertinent literature and of the possible origin of the tumor are presented.

Pleomorphic adenoma ("mixed" tumor) of human female breast mimicking carcinoma clinico-radiologically

A case of pleomorphic adenoma ("mixed" tumor) of the breast is described Although rare, this is a distinctive primary neoplasm which can be mistaken for a malignant tumor both clinically and radiologically. Brief reviews of the pertinent literature and of the possible origin of the tumor are presented.