Acute lymphocytic leukaemia terminating in malignant histiocytosis. A case report and literature review

A 5-year-old Black girl with acute lymphatic leukaemia died after a short illness during which haematological remission was induced with standard chemotherapeutic agents. At autopsy an unexpected finding was involvement of the spleen, lymph nodes, bone marrow and liver by malignant histiocytosis (MH). There was also evidence of residual leukaemia. A review of the literature revealed 11 other cases with a similar association of leukaemia preceding MH; in 8 of these the leukaemia was of the acute lymphatic type, in 2 of the monocytic type and in 1 of an unusual atypical large lymphoid cell type. The clinico-pathological features of these cases are reviewed.

Nongranulomatous septic vasculitis due to miliary tuberculosis. A pitfall in diagnosis for the pathologist

A 38-year-old patient with chronic alcoholism was on chemotherapy for acute myelomonocytic leukemia and developed purpuric and erythematous papules. Skin biopsy showed a vasculitis. Subsequent autopsy revealed disseminated tuberculosis with a poor cellular response. This case calls attention to the lack of tuberculoid granulomatous reaction is anergic patients and to the need of pathologists to suspect tuberculosis when necrotizing vasculitis in the skin is encountered in a patient with decreased immunological competence.

Locally aggressive fibrous histiocytoma of bone. A case report

A fibrohistiocytic tumour involving the distal diaphysis of the left femur in a 44-year-old woman is described. The lesion had a completely benign appearance cytologically but behaved in a locally aggressive manner in that it eroded the adjacent cortical bone and even extended into the soft tissue. To the best of our knowledge, no other similar case has been documented. A lesion of the humerus has been described as an atypical fibrous histiocytoma on the basis of prominent nuclear pleomorphism; the patient involved was alive 5 years after a disarticulation. The differential diagnosis of such a locally aggressive fibrous histiocytoma of bone would include a metaphyseal fibrous defect, benign fibroxanthoma, and malignant fibrous histiocytoma. We believe that the differentiation of a locally aggressive fibrous histiocytoma from the malignant variety may be important in view of the probable differing therapeutic and prognostic implications.

Primary meningeal mesenchymal chondrosarcoma

A primary meningeal mesenchymal chondrosarcoma initially resembled an angioblastic meningioma because the typical chondroid islands were not demonstrable. Cartilage was seen only in an intracerebral recurrence and in subsequent extracranial metastases. Ultrastructural examination of noncartilaginous regions of the tumor demonstrated mesenchymal cells with features suggestive of cartilaginous differentiation, viz, scalloped cell membranes, sac-like distension of abundant rough endoplasmic reticulum, and a matrix containing fibrillary and finely granular material. Features of meningeal or pericytic cells were not seen.

Benign lymphoepithelial lesion (Mikulicz's disease) of the salivary gland: an ultrastructural study

An ultrastructural study of a benign lymphoepithelial lesion of the parotid gland demonstrated that the so-called epimyoepithelial cell islands were sharply demarcated from the surrounding parenchyma by a thick basement membrane containing collagen fibers. The hyaline material seen by light microscopy within the islands was ultrastructurally similar in appearance to this delimiting basement membrane. The epithelial cells within the islands were united by well formed desmosomes and many had prominent tonofilament bundles, but myogenic differentiation was not observed. Hydropic degeneration was not seen in these epithelial cells; cells with a perinuclear clear space seen by light microscopy corresponded to large lymphoid cells ultrastructurally.

Malignant fibrous histiocytoma (malignant fibrous xanthoma: xanthosarcoma) of bone

Seven cases of malignant fibrous histiocytoma of bone are documented. In addition to typical histologic features such as the presence of a storiform pattern, histiocytic and fibrocytic cell types and severe cellular atypism, in five cases there were areas in which osteoclast-type giant cells were prominent and the lesion resembled a giant cell tumor. Three of the seven patients developed pulmonary metastases within two years of amputation, one developed extensive local recurrence including soft tissue and vascular invasion, and the other three are without evidence of disease but have been followed for only short periods.

Amyloid tumor. A clinicopathologic study of four cases

Four examples of amyloid tumors were studied to determine whether there was an association with myelomatosis. Three patients had follow-up examinations of 12 years, 9 years, and 2 1/2 years, respectively. A local recurrence developed in one patient and a second lesion developed in this patient and in one other who also had a transient monoclonal 7S globulin peak. In spite of these findings, none of our patients developed myelomatosis. A study of the scanty literature on amyloid tumors reveals that only patients with lesions of the lung and urinary bladder have had long-term follow-up. They have invariably remained free of disease. Several reports of bone lesions have inferred that amyloid tumors occurring here signify solitary myeloma despite a lack of follow-up confirmation. Our longest surviving patient developed two bone lesions over a 12-year period without developing myelomatosis. Our findings lead us to conclude that there is little evidence to regard the presence of an amyloid tumor at any site as a manifestation of solitary myeloma or myelomatosis.

Myogenic cells in Kaposi's sarcoma: an ultrastructural study

An ultrastructural study of a metastatic Kaposi's sarcoma in a cervical lymph node demonstrated the presence of endothelial cells, smooth muscle cells, fibroblasts and myofibroblasts. Some of these cells exhibited phagocytic activity in relation to extravasated red blood cells. The ultrastructural features favour the suggestion of an origin of Kaposi's sarcoma from pluripotential mesenchymal cells which may differentiate into more specialised cell types including endothelial, smooth muscle, fibroblastic and myofibroblastic cells.

Carcinoma of the breast with metaplasia to chondrosarcoma: a light and electron microscopic study

Two carcinomas of the breast containing large areas of sarcomatous tissue were studied by light and electron microscopy. In one of these, the sarcomatous element was frankly cartilaginous and in the other, predominantly myxoid but with small cartilaginous-looking foci. By light microscopy, a highly suggestive metaplastic transition could be traced from cells within the epithelial nests to those within the sarcomatous lobules. Ultrastructurally, cells in the former region showed epithelial characteristics and those in the latter region, mesenchymal and/or cartilaginous features. The carcinomatous cells contained desmosomes and formed intercellular spaces lined by microvilli; a few cells showed prominent profiles of rough endoplasmic reticulum. In the first case, the cells in the immediate vicinity of the epithelial nests and those in the fully developed cartilaginous regions showed a progressive dilatation of their endoplasmic reticulum to form large sac-like structures filled with a finely granular and floccular material. The intercellular matrix was electron lucent and contained scattered dense particles, fibrillo-granular material and collagen fibres. Condensation of this material at some distance from the cell resulted in the formation of lacunae. In the second case, the cells in the myxoid areas also showed prominent dilatation of endoplasmic reticulum.

So-called pseudosarcoma of the esophagus: nodal metastases of the spindle cell element

A polypoid lesion of the esophagus with all the morphological features of a so-called pseudosarcoma produced nodal metastases of the spindle cell element. Ultrastructurally, these spindle cells showed only fibroblastic features. The findings in this case and a review of cases reported as pseudosarcoma of the esophagus lend little support for the contention that they differ from cases categorized as carcinosarcoma of the esophagus.

Primary malignant tumors of the thyroid gland: a clinicopathologic study of 254 cases

Of 254 primary malignant tumors of the thyroid gland diagnosed in the pathology department of the University of Cape Town, 212 (83.5%) were differentiated carcinomas. In this differentiated group, tumors composed exclusively of papillary structures exhibited the most favorable prognosis; local recurrences and/or spread were noted in tumors with a mixed papillary and follicular pattern and, more commonly association with 21 tumors (8.3%) but an associated multinodular goitre was found in only nine patients (3.5%). In addition to the well-known preponderance of thyroid carcinoma in women, a majority of lesions occurred in white patients in this series despite a higher hospital admission rate for coloreds (mulattos).

Angiolymphoid hyperplasia with eosinophilia: report of 3 cases

Angiolymphoid hyperplasia with eosinophilia is reported in 3 patients. This lesion is an uncommon reactive vasoproliferative disorder which presents with swellings in the dermis and subcutis. The aetiological agent which produces this tissue response is unknown. Clinically the disease follows a benign prolonged course without evidence of systemic involvement. The histological features consist of a prominent fibroblastic and proliferative vascular reaction associated with an inflammatory infiltrate in which lymphoid aggregates with germinal centres and eosinophils are conspicuous.

Lymphoma of the skin. A comparative clinico-pathologic study of 50 cases including mycosis fungoides and primary and secondary cutaneous lymphoma

A clinico-pathologic study of lymphomas of the skin included 14 cases of mycosis fungoides, 14 of primary lymphoma and 22 of secondary lymphoma. Mycosis fungoides has clinical and histopathologic features which allow for separation from the other groups. In this study, patients with mycosis fungoides had a longer duration of history and presented with papules, plaques, erythroderma or generalized dermatitis but not with tumor nodules ab initio. A confident histologic diagnosis required the presence of the mycosis cell, which was usually present in association with a mixed inflammatory cell infiltrate. Another important histologic feature was the presence of invasion of the epidermis by the mycosis cells singly and/or in nests (Pautrier microabscesses). Primary and secondary lymphomas of the skin presented clinically as multiple tumor nodules and histologically as a monomorphic infiltrate of neoplastic cells confined to the dermis and subcutis. A feature which has not been adequately documented in a large series was the presence of an associated prominent epithelioid cell reaction in several cases from all three groups.

Superficial cystic gastritis with alopecia. A forme fruste of the Cronkhite-Canada syndrome

The Cronkhite-Canada syndrome is a rare and often fatal condition. A case of superficial cystic gastritis was suspected on peroral gastric biopsy and was later confirmed at autopsy. The selective involvement of the stomach together with the presence of alopecia leads us to conclude that this case is unique and represents a forme fruste of the Cronkhite-Canada syndrome. A complicating feature was the presence of an opportunistic cytomegalovirus infection of the gastrointestinal tract and lungs.

Control of auto-immune thrombocytopenia by removal of an atrophic spleen: a case report

We report a patient with systemic lupus erythematosus in whom resection of a completely atrophic spleen (weight 5 g) reversed steroid-refractory thrombocytopenia. The spleen plays a central role in the pathogenesis of autoimmune thrombocytopenia by synthesizing antibodies directed against autologous platelets and by sequestering these immunoglobulin-coated cells. Both functional disturbances occur without splenic enlargement, and splenectomy wll, in selected cases, improve thrombocytopenia. A similar rise in platelet count may follow resection of much smaller masses of splenic tissue such as splenunculi. We have, however, been unable to find documentation of this phenomenon after removal of a completely atrophic spleen.

Alpha-chain disease. A case report with autopsy findings

A 19-year-old Coloured man with alpha-chain disease died after perforation of a lymphoma in the duodenojejunal region. At autopsy he was found to have a dense plasma cell infiltration of the lamina propria of the entire small bowel, causing thickening of that organ, and a malignant lymphoma in the duodenojejunal region which had spread to regional mesenteric nodes and to the liver only.

Florid epithelioid cell and sarcoid-type reaction associated with non-Hodgkin's lymphoma

Five patients suffering from non-Hodgkin's lymphoma associated with an intense infiltration of epithelioid histiocytes and even sarcoid-type granulomas in the involved tissue are described. A similar tissue reaction, at both involved and uninvolved sites, has been described in patients with Hodgkin's disease. The cause of this reaction may be immunological; its prognostic significance still awaits elucidation. In the case of non-Hodgkin's lymphomas, it may cause difficulty in diagnosis of lymphoma and hence may result in unnecessary delay in the initiation of therapy.

Myofibroblasts and related cells in malignant fibrous and fibrohistiocytic tumors

Myofibroblasts were detected by electron microscopy in five of five cases of fibrosarcoma and in five of six cases of malignant fibrous histiocytoma. In some areas myofibroblasts constituted up to 75 per cent of the tumor cells. Most myofibroblasts contained only sheaves of myofilaments along the margins of the cells, but some cells contained larger bundles of myofilaments and very closely resembled smooth muscle cells. An additional related type of cell was seen in several cases; it was large and possessed abundant eosinophilic cytoplasm, resembling a rhabdomyoblast at the light microscopic level. By electron microscopy this type of cell was seen to contain plentiful rough endoplasmic reticulum and large aggregates of fine filaments with rare dense bodies. These findings suggest that fibrosarcomas and malignant fibrous histiocytomas contain cells showing a spectrum of differentiation from fibrocytic to myogenic and that at the ultrastructural level the distinction between fibroblast and smooth muscle tumors may be blurred.

Vagal body tumor (nonchromaffin paraganglioma, chemodectoma, and carotid body-like tumor) with cervical node metastasis and familial association: ultrastructural study and review

A case of a vagal body tumor with a solitary cervical node metastasis is described. There was a remarkable familial association: a biopsy-proven paraganglioma occurred in two members of the patient's family and there was a strong clinical suspicion of a paraganglioma in two others. In a review of the literature, eight patients with metastasizing vagal body tumors and eight patients in whom the vagal body tumor was a component of multicentric presentation of paragangliomas were found. Only one other patient in whom there was a familial occurrence involving a vagal body tumor has been reported. Ultrastructural study of the cervical node metastasis revealed the presence of light and dark chief cells containing scanty, membrane-bound, densecore, neurosecretory-type granules. Atypical granules were noted in a few of the dark cells. Nerve fibers, synaptic vesicles, and sustentacular cells, such as occur in normal paraganglionic tissue, were not observed in this tumor.

Primary intestinal lymphoma of "Western" and "Mediterranean" type, alpha chain disease and massive plasma cell infiltration: a comparative study of 37 cases

The clinical and pathological features of 17 "Western" type primary abdominal lymphomas (WTL) are compared with 14 of "Mediterranean" type (MTL). The MTL involved only young adult Mulatto and African patients in whom malabsorption and abdominal pain were the major clinical features. The WTL also predominantly affected Mulatto patients but four cases occurred in Caucasians, and the mean age at presentation was two decades later. An obstructive presentation was the most common; only one patient in this group had evidence of malabsorption. The WTLs were located mainly in the distal small bowel and were nearly all of monomorphic lymphocytic or histiocytic type. The MTLs were sited mainly in the duodenum and jejunum and were of an unusual pleomorphic histologic type. A spectrum of cells from those resembling atypical lymphocytes to large histiocytic types were seen, some of the latter resembling Reed-Sternberg cells. The pattern of mesenteric node infiltration in the MTLs was also unusual in that preservation of the medullary sinuses was a common finding. A notable feature of the MTLs was the presence of a heavy infiltration of mature-looking plasma cells associated with a fairly severe villous atrophy in the lamina propria of the small bowel. In the WTLs the adjacent small bowel did not show this feature. In addition to the above cases three patients with a similar heavy plasma cell infiltrate and villous atrophy but without evidence of a lymphoma are described. These cases may represent examples of MTL in a pre-malignant phase. Also included in this study are three patients with alpha-chain disease (alpha-CD), all with a heavy plasma cell infiltration and villous atrophy of the lamina propria and a pleomorphic type lymphoma involving the mesenteric nodes in all, and the small bowel in two. The lymphomas in alpha-CD have been interpreted as immunoblastic sarcoma by Lukes and Collins. Both genetic and environmental factors may be operative in the MTLs including the cases of alpha-CD.

Subepidermal bullous disease. A correlated clinico-pathologic study of 51 cases

The histologic features of 51 cases of subepidermal bullous disease were evaluated and correlated with the clinical features including the course of the disease and the response to therapy. There was a good clinico-pathologic correlation, 46 out of 51 cases showing concordant clinical and histologic diagnoses. We conclude that although immunofluorescence is a confirmatory procedure histologic diagnosis is still of great value, particularly in the early stages of the disease when the clinical features may not yet have evolved sufficiently to allow for a confident diagnosis.