[Cutaneous leiomyosarcoma]

Primary cutaneous leiomyosarcomas are rare mesenchymal skin tumors with relatively good prognosis and low risk of metastasis if there is no subcutaneous involvement. A 48-year-old patient with a primary cutaneous leiomyosarcoma of ten years duration is described. Therapy and differential diagnosis are discussed.

Distribution of lysozyme (muramidase) and alpha 1-antichymotrypsin in normal and neoplastic epithelial tissues: a survey

Lysozyme and alpha 1-antichymotrypsin are useful in differentiation of histiocytic tumours. Both enzymes, however, also can be expressed in epithelial tissues. In contrast to lysozyme, alpha 1-antichymotrypsin is more often found to be positive in non-histiocytic neoplasias. In general, the activity of parent tissue is retained in tumour cells. In malignant melanoma and in single cases of other epithelial tumours an activity of alpha 1-antichymotrypsin was found which could not be demonstrated in normal parent tissue and which may find its explanation in a dedifferentiation of tumour cells.

Extracardiac rhabdomyoma: report of different types with light microscopic and ultrastructural studies

Five extracardiac rhabdomyomas were studied by light and electron microscopy: two of the adult type, two of the fetal type, and one of the female genital tract type. The three types can be distinguished histologically and ultrastructurally. Adult type rhabdomyomas are encapsulated and reveal histologically closely packed, large tumor cells with granular or vacuolated cytoplasm and only scant stroma. Electron microscopically, myofibrils are haphazardly arranged with rodlike Z-band material. Sometimes a sarcomeric arrangement of myofibrils is seen. The tumor cells are packed with mitochondria bearing lamellar inclusions. Fetal type rhabdomyomas contain a mixture of muscle cells in different stages of differentiations; the amount of stroma is increased. The myofilaments are usually disorganized and in only a few cells is rodlike Z-band material found. The cytoplasm reveals few mitochondria. In the rhabdomyoma of the female genital tract, the tumor cells are large and resemble more mature muscle fibers; the stroma is abundant and the myofilaments are usually arranged in an orderly fashion. Generally, the prognosis for rhabdomyomas is good. Metastases are not known. Two of the five rhabdomyomas studied recurred. One rhabdomyoma was found at autopsy. Embryonal rhabdomyosarcoma must be considered in differential diagnosis particularly for fetal type rhabdomyoma.

[So-called histiocytosis X and malignant histiocytosis]

A retrospective study of 12 cases of so called histiocytosis-X and 3 cases of malignant histiocytosis was done. It was possible to establish the differences in clinical, morphologic and cytochemical findings of both diseases. The diagnosis of histiocytosis-X can be confirmed by multinucleated histiocytes interrupted by eosinophils and plasmacells. The histopathology of malignant histiocytosis is different and is characterized by atypical histiocytes. Erythrophagocytosis throughout the tissues is seen. Typical histochemistry (acid phosphatase and naphtol-AS-acetat-esterase) findings are also helpful for diagnosis. The treatment of both diseases should be continued at least six months after disappearance of clinical apparent lesions. Combination chemotherapy with vinblastine and prednisone is suggested. In cases of histiocytosis-X in isolated lesions curettage or irradiation may be adequate. Long term remissions and presumed cures of histiocytosis-X are possible in over 70% of the cases. A strict correlation between the prognosis and the degree of involvement is confirmed. Even in cases of malignant histiocytosis, previously reported as rapidly fatal disease, combination chemotherapy may produce complete long term remissions.

Lysozyme (muramidase) and alpha 1-anti-chymotrypsin as immunohistochemical tumour markers

Since lysozyme and alpha 1-anti-chymotrypsin are constituents of normal histiocytes, their value as tumor cell markers in histiocytes neoplasias has been investigated using the indirect immunoperoxidase method and commercially available specific antisera on formaldehyde-fixed, paraffin-embedded 5 micrometers sections after pretreatment with pronase. The distribution of both markers was determined in 35 cases of malignant fibrous histiocytoma (MFH) and in 13 cases of malignant histiocytosis (MH). In 12 cases of MH both markers were found whereas in MFH alpha 1-antichymotrypsin was demonstrated in 26 and lysozyme in 16 cases only. In general, the staining for alpha 1-anti-chymotrypsin was more intense than the staining for lysozyme. A negative reaction does not exclude the possibility of MH or MFH. The presence of both constituents in tumours, however, can be considered as indicative of histiocytogenic origin and both can be useful markers for distinguishing histiocytic neoplasias from other tumours.

Incidence and histological structure of the storiform pattern in benign and malignant fibrous histiocytomas

A starlike arrangement of cells and fibers, the "storiform pattern", was found to be a typical, but not obligatory, histological feature of benign and malignant fibrous histiocytomas. In 155 benign fibrous histiocytomas storiform structures were missing in 29 cases, chiefly of the fibroblastic type comparable with classical "dermatofibroma". 12 of 70 malignant fibrous histiocytomas did not reveal storiform structures, especially the cellular pleomorphic variant, i.e. the classical pleomorphic sarcoma. Storiform structures were either small and highly cellular with few fibers (collagen type III), or larger, less cellular, but with abundant fibers (collagen type I). There was no sharp demarcation between these two extremes, but many transitional structures or patterns were seen. The histiocytic nature of the cells was demonstrated in both variants of storiform structures by immunhistochemical methods on paraffin embedded material. Alpha 1-antichymotrypsin was especially valuable in this respect.

Chordoma with a predominant retrosacral tumor mass

Chordomas are malignant tumors with lobulated structure which usually consists of vacuolated physaliferous cells in a mucoid stroma (Enzinger et al. 1969). These cells originate from remnants of the chorda dorsalis. Most chordomas are located either at the end of the vertebral column, i.e., in the sacrococcygeal region or at the base of the skull near the sphenooccipital synchondrosis. More than half of all tumors are located in the sacrococcygeal region. In contrast to most cases of sacrococcygeal chordomas which show a predominant presacral tumor infiltration we report on a patient suffering from a sacrococcygeal chordoma with a retrosacral tumor mass. Here, the presacral tumor infiltration became apparent only much latter. It was nevertheless of great prognostic relevance as tumor infiltration of the urinary bladder lead to lethal septicaemia.

Extraskeletal Osteosarcoma. Case report and differential diagnosis

In this case of an extraskeletal osteosarcoma initially there were typical difficulties in diagnosing a) a malignant mesenchymal tumor and b) a bone-producing tumor. Only focally the test-booking findings of an osteosarcoma were present. The differential diagnosis concerned mainly pseudosarcomatous lesions with bone formations, which histologically may appear suspicious, however, follow a benign course clinically.

Sinus histiocytosis with massive lymphadenopathy and epidural involvement

Sinus histiocytosis with massive lymphadenopathy (SHML) was recognized as a new clinical-pathological entity in 1969. Up to the present 134 cases have been described. The disease is characterized by prominent cervical lymph node enlargment. Microscopic features include marked dilatation of sinuses with intrasinusal histiocytes and lymphophagocytosis. About 70% of the patients reported were affected during the first 2 decades of life. The disease is held to be benign on account of spontaneous resolution in some patients. A follow-up survey of 72 patients showed disappearance of the symptoms 10 years after the original diagnosis in 24 patients. In 42 patients the disease still persisted 6 months to 21 years later. Six patients died, but only one of them as a result of the disease. Extranodal involvement was seen in the orbit, eyelid, respiratory tract, skin, bone, salivary glands, and testis. In two cases, one of which will be reported here, paraparesis resulted from infiltration of the epidural space. Treatment with prednisolone was tried in some cases with excellent results. In our case treatment with prednisolone and vinblastine resulted in the disappearance of the neurological symptoms.

Immunohistochemical characterization of histiocytic tumours

Immunohistochemical labelling of histiocytic tumour cells in formalin-fixed paraffin-embedded material was usefully applied to malignant fibrous histiocytoma (MFH) and to malignant histiocytosis (MH). Not all cases of MFH showed a positive reaction, in contrast with the obligatory positive staining in MH. In general, histiocytic tumour cells stained more intensively with alpha 1-antichymotrypsin than with lysozyme. False positive results can be due to intermingled non-neoplastic histiocytes or degenerating neoplastic cells in any mesenchymal tumour.

Familial lymphohistiocytosis

Familial lymphohistiocytosis is a genetically transmitted disease affecting infants and very young children with usually a fatal outcome. Cardinal symptoms are fever, hepatosplenomegaly, and pancytopenia. Histologic examination shows infiltration of all organs with phagocytosing histiocytes and lymphocytes as well as atrophy of the normal lymphoid tissue. The distinction from other histiocytic disorders, i.e., Letterer-Siwe disease or malignant histiocytosis, may be difficult. However, the familial occurrence and characteristic findings in the coagulation system and lipid pattern make familial lymphohistiocytosis a sufficiently distinct clinical entity. This report review 79 cases fron the literature and adds four of own observations.

[Value of the "region of interest" technique in the scintigraphic diagnosis of primary bone tumors (author's transl)]

Employing ROI-technique, a ratio Q was obtained from relating accumulation of 99mTc-MDP at the site of the bone lesion (n = 150) with that of contralateral non-involved osseous areas. Values of Q were correlated with histologic tumor diagnosis, its dignity and frequency. Values of Q of greater than 3.0 were found in 95% of all sarcomas, in 100% of the osteosarcomas but in only 3.8% of all benign bone tumors. Values ranging from 1.0 to 1.2 were exclusively measured in benign tumors (e.g., in 52% of juvenile bone cysts and in 67% of non-ossifying fibromas). Since the threshold--separating benign from malignant lesions--at Q = 3.0 was blurred by tumorlike lesions, metastases and especially by Paget's disease, this method does not precisely predict dignity. However, this method may complement radiographic evaluation with low values supporting the diagnosis of a benign lesion. The combined findings of radiography and these rations gained by nuclear imaging may help determine the pathway of a patient through further diagnosis and treatment.

Wolman's disease: clinical, biochemical and ultrastructural studies in an unusual case without striking adrenal calcification

A case of Wolman's disease is described in a German infant who died at the age of 4 months. Hepatosplenomegaly, abdominal distention, gastrointestinal symptoms, dyserythropoietic changes in the bone marrow, but not adrenal calcification on X-ray were present. Stored lipid material could be demonstrated in liver, spleen, intestine, adrenals, thymus, kidneys, blood cells, but not in the central nervous system. Cholesterylesters and triglycerides were markedly increased in liver and spleen. Lysosomal acid lipase was found to be decreased in leucocytes and liver to less than 10% of normal, when measured with synthetic and natural substrates.

[Histological grading and typing in osteosarcoma. Comparison with the survival time of 22 patients]

Histological grading from I--III was carried out for 22 osteosarcomas. There was a positive correlation between higher histological grade of differentiation and higher rate of 2-years-survival. The death rate was 3,7 times higher for osteosarcomas of grade III than for grade I and II tumors. However, no significant differences as to prognosis and age of the patients, localization of tumor metastases, various stages and kind of therapy became evident. In spite of distinct regional differences, as subclassification according to 6 subtypes proposed by Scranton et al. (1975) was possible in all our cases. Statistically significant correlations between these subtypes of osteosarcoma and differences in survival time could not be found, neither for our own limited material, nor for the combined material, including the cases of Scranton et al.

[Solitary carcinoma metastasis in Paget's disease. Distinction from sarcomatous changes (author's transl)]

This report concerns a 77 years old woman with a solitary metastasis of a bronchiogenic carcinoma to the humerus, which had been involved by previously diagnosed polyostotic M. Paget (ostitis deformans). The distinction from sarcomatous changes in Paget's disease is discussed.

[Metastasized osteosarcoma with undifferentiated carcinoma-like parts]

This was the case of a 64-year-old man with osteosarcoma. The biopsy yielded undifferentiated tumor without bone or cartilage formation. Because of high age of the patient and radiological changes present, a metastatic carcinoma was suspected. However, no primary could be found. Autopsy revealed an osteosarcoma in the region of the hip joint with alternating formation of tumor cartilage and tumor bone. There were also undifferentiated portions of "endocrine osteosarcoma," simulating carcinoma. In spite of extensive skeletal involvement and pulmonary metastases--and high age--no evidence of morbus Paget of bone as possible preneoplastic disease was found.

Malignant histiocytosis. Clinical findings and therapy

Diagnosis of malignant histiocytosis (MH) was confirmed in 16 patients. Stage at diagnosis was I-II in nine, and III-IV in seven patients. Porr prognosis and "B",-symptoms were correlated to advanced stages. Bone marrow biopsy proved most useful to verify organ involvement. Scintigraphy and computerized tomography, too, detected organ involvement in some patients and were helpful for judging response to therapy. Relapses after radiotherapy were frequent. Polychemotherapy using "CHOP"-combination is recommended for most patients and may in stages I-II be supplemented by primary or secondary involved or extended field irradiation and in more advanced stages by mainbulk-irradiation. The value of prophylactic CNS-therapy remains controversial. Pathophysiological aspects and differential diagnosis are discussed.

Malignant histiocytosis. Immunohistochemical characterization on paraffin embedded tissue

Clinically, malignant histiocytosis is a malignant neoplasia with poor prognosis. Diseased are lymphnodes (especially cervical nodes), liver, spleen and bones. Few cases become leukemic. The cells show characteristic pale roundish, often indented nuclei, without large nucleoli and with abundant ill-defined cytoplasm. Phagocytosis of erythrocytes and leukocytes, as well as, hemosiderin deposits may serve as indicators for histiocytic, respectively macrophagic qualities. On touch preparation, tumor cells previously had been marked by acid phosphatase and non-spevific esterase, as being histiocytic. - A comparable marking could be carried out on paraffin embedded material with lysozyme (muramidase) and alpha1-antichymotrypsin, by the indirect immuno-peroxidase technique. No correlation could be proven between any special shape of tumor cells or between different grades of cellular atypism and presence or absence of the immunohistochemical reaction. The reaction with lysozyme and alpha1-antichymotrypsin was also tested in other tumors and was found to be positive in a variety of different tumor cells showing degenerative changes, respectively necrobiosis. - But lysozyme and alpha1-antichymotrypsin are markers characteristically found in histiocytes, respectively histiocytic tumor cells. They are apparently less distinct in MH with a larger number of immature histiocytic tumor cells.

Malignant tumor of humerus with features of "adamantinoma" and Ewing's sarcoma

This female patient was born in 1935 and died in 1976 with a malignant bone tumor involving the proximal humerus following multiple local recurrences, axillary lymph node metastases, and pulmonary metastases. Histologically, over the course of time, there was an increase in features of an atypical Ewing's sarcoma, at the expense of findings of a typical, extra-cranial so-called adamantinoma. In contrast to another report, our case showed neither epithelial nor endothelial features on fine structural examination, but rather primitive mesenchymal cells, as is described for Ewing's sarcomas.

Nodular fasciitis and proliferative myositis as variants of one disease entity

The concept of nodular fasciitis and proliferative myositis as variants of the same fibroblastic disorder is supported by intermediary cases, showing simultaneous features thought to be typical of either nodular fasciitis or proliferative myositis. Various other anatomical, pathological and clinical similarities found in this study of 100 cases support such conclusions. 'Ganglion-like' cells were a distinct, but not exclusive, feature of all cases with sole, or only partial, muscle involvement.

Analysis of proliferative compartments in human tumors. I. Renal adenocarcinoma

Vascular perfusion of 16 renal adenocarcinomas with radioactive DNA precursors provides a possibility of characterize proliferative compartments of this tumor type. Immediately after resection of the tumor-bearing kidney, the organ is perfused via renal artery with dextran-diluted, heparinized oxygenated blood at physiological temperature, pH, flow, and pressure in a recirculation system. DNA synthetizing cells are labeled by addition of 3H- or 14C-thymidine or both isotopes at different intervals. Beta camera scans and whole-tumor autoradiograms disclose a striking proliferative heterogeneity of the tumor. Cell proliferation depends on intratumoral localization, cellular differentiation, histological structure and vascular supply. Subpopulations of high proliferative activity are found at the invasive borderline near normal kidney, focally in subcapsular areas and in intrarenal metastases, but also immediately adjacent to necrotic areas in the tumor center. Quantitative evaluation of autoradiograms yields, at the cellular level, a significantly higher labeling index in granular cells (3.21%) than in clear cells (0.65%), with a large variability dependent on the histological structure. The highest number of DNA synthetizing cells is seen in papillary and mixed solid-tubular zones and at peripheral parts of solid areas, whereas in central parts of solid tumor cords and in highly differentiated tubular areas lower labeling indices are observed. The labeling index decreases exponentially as a function of the distance from the supporting blood vessel. In solid cords, no labeled cells are seen at a distance of more than 200 micron from the capillary. The ts determined by 3H/14C-thymidine double labeling is between 9.9 and 16.8 hr for granular cells and about 9.2 hr for clear cells. Potential population doubling time calculated for various subpopulations yields values between 4 and 50 days. It is concluded that cell loss is high, for granular cells in particular. Besides cell loss, a large nonproliferating compartment contributes to a delay of the tumor volume doubling time. Proliferative heterogeneity of advanced human tumors, as exemplified by the renal adenocarcinoma, bears important implications for therapy and prognosis.

Palmar fibromatosis-"Dupuytren's contracture". A comparison of light electron and immunofluorescence microscopic findings

A comparison of light, immunofluorescence and electron microscopic findings in palmar fibromatosis (Dupuytren's disease) revealed that the three morphologic phase of Luck; I. proliferative, 2. involutional, and 3. residual, corresponded for the most part to I. fibroblastic, 2. myofibroblastic or 3. fibrocytic lesions, respectively. The spectrum between proliferative phase and residual phase appeared immunohistochemically as a decrease in collagen type III, and an increase of collagen type I. Myosin was found in substantial quantities only during the involutional phase, distinguished by myofibroblasts, presumably with contractile capabilities. Thus, the clinical presence of contractures with palmar fibromatosis might also be explained in the absence of distinct fiber formation.

Osteosarcoma: histological evaluation and grading

With 60 cases of osteosarcomas a histological evaluation from + to +++ carried out for mitoses, osteoid formation, presence of multinucleated giant cells, and tumor necrosis. A subclassification in osteoblastic, chondroblastic, and fibroblastic type of osteosarcoma (according to Dahlin) and a histological grading from + to +++ based on degree of cellular atypism was also done. In our material no relations between these three types of osteosarcoma and chance for survival became evident. There was, however, a significant correlation between grade of atypism and rate of mitoses. Grading of oestosarcomas from + to +++ showed that cases with grade III osteosarcoma remained only seldomly without metastases during the course of the disease. Grade I osteosarcomas and also grade II tumors showed a higher number of patients with 2-year survival. However, neither correlation between tumor grade and incidence of metastases, nor with chances for survival were statistically significant. Nevertheless, characterization of osteosarcomas, by a histological grading from + to +++ based on cellular atypism and mitotic count is advisable, in addition to the TNM stages. This histological grading appeared to be more practicable than subclassifications of osteosarcoma by type which had been tested by us in a previous study (Konrad et al., in press).

Fibrous histiocytoma: an analysis of the storiform pattern

A storiform pattern is an important structural feature of fibrous histiocytoma (FH). In this analysis reconstructions of histological patterns were carried out from drawings. Highly FH with only a suggestion of storiform pattern and small star-formations were seen, there were other lesions with more pronounced fiber formation which showed more distinct and larger storiform stars. These structures can frequently be followed for only 3 sections of 5 micron thickness. In contrast to leiomyomas or meningioma, no regular or consistent orientation of these structures with respect to vessels is evident. Storiform structures apparently develop at the periphery of adjacent proliferating cells groups. They show a typical and diagnostically significant histological pattern, which was found to some degree in all FH examined.

Fatal eosinophilic gastroenterocolitis in a two-year-old child

We report a case of eosinophilic gastroenterocolitis in a 2-year-old child with extensive fibrosis, atrophy of the muscularis propria and involvement of stomach, small bowel and colon. Following an attack of acute gastroenteritis at the age of 15 months the symptoms of ileus persisted. A biopsy of small bowel at the age of 18 months showed numerous eosinophilic granulocytes in the mucosa. At the age of 28 months the child died with paralytic ileus. This is the first case known to us of an eosinophilic gastroenteritis in early childhood with a fatal outcome.

[Non-Hodgkin's lymphoma in children: improved prognosis through aggressive multiple drug combination and irradiation (author's transl)]

From 1964-1975 43 children with non-Hodgkin's lymphoma (NHL) were treated. 60% of the patients had far advanced disease at diagnosis. Therapy before 1970 consisted of low dose irradiation to the primary and single agent chemotherapy; no C.N.S. irradiation to prevent meningeal recurrence was given. Median survival in this group was 5 months; all patients died. Since 1970 all children with NHL were entered into a modified leukaemia protocol regardless of stage or primary site. Therapy comprised an aggressive multiple drug combination, high dose local irradiation and prophylactic C.N.S. irradiation with intrathecal methotrexate. 41% of the patients treated since 1970 survive in continuous complete remission with a median observation time of 31+ (1-93+) months. All relapses occurred within 30 months after diagnosis. Stage of disease was the most important prognostic factor in our patients. Risk of a primary C.N.S. relapse in the total group was 30% for patients without prophylactic C.N.S. therapy compared to only 6% for patients with treatment.

Nephroblastoma and neuroblastoma--histology and prognosis

Statistically evaluating the influence of a histological grading, respectively of morphological differences on prognosis of nephroblastomas and neuroblastomas, better chances for survival become evident not only for earlier clinical stages, but also for nephroblastomas with high differentiation, or neuroblastomas with signs for differentiation. Only for neuroblastomas a relevant predeliction of tumors with signs of differentiation for the early clinical stage I is present. Combined subclassification according to clinical stages and histological grades results in 3 risk groups with different chances for survival. These 3 groups may play a role for specific therapeutic considerations.