Axillary lymph node dissection for intraductal breast carcinoma--is it indicated?

One hundred patients with intraductal breast carcinoma (DCIS) were treated with either mastectomy (49 patients) or radiation therapy (51 patients). All patients underwent axillary lymph node dissection (average number of nodes removed, 16) as part of their treatment. No patient had any positive axillary lymph nodes. There has been one recurrence in each treatment group (median follow-up, 27 months) and no deaths. Intraductal breast carcinoma has little potential for metastasis to axillary lymph nodes.

Hooked-wire-directed breast biopsy and overpenetrated mammography

Six hundred fifty-three biopsies were performed for clinically occult, mammographically detected breast abnormalities. One hundred forty-seven cancers (22.5%) were found. Eighty-nine of those cancers (60.5%) were noninvasive. None of the in situ lesions had involved axillary lymph nodes. Of the 58 invasive cancers, only six (10.3%) had metastases to axillary nodes. Fifty-four patients (36.7%) were treated by mastectomy while 93 patients (63.3%) were treated conservatively, 20 by biopsy only, and 73 by lumpectomy, axillary node dissection, and radiation therapy. Only four patients (0.7%) had significant complications.

Cervical paraganglioma with intranuclear vacuoles in a fine needle aspirate

In a 56-year-old man who presented with a cervical mass, a fine needle aspiration specimen was suggestive of a papillary thyroid adenocarcinoma because of the presence of prominent intranuclear vacuoles in rare cells. Operation and subsequent examination of the mass removed from the bifurcation of the carotid artery clearly identified a paraganglioma. This case emphasizes the following points: aspirates of cervical paragangliomas are difficult to interpret, especially when scanty; intranuclear vacuoles are found in cells of a variety of cervical lesions, including paragangliomas, and should not in themselves define the diagnosis of papillary thyroid adenocarcinoma; and aspiration of cervical paragangliomas is probably contraindicated (but may be done unwittingly from time to time).

Primary carcinoid tumor of testis with metastasis

A primary carcinoid tumor of the testis metastatic to one preaortic lymph node in a forty-three-year-old man is reported. The case was of great clinical interest not only because of the extreme rarity of testicular carcinoid with metastasis but also because of a coincidental bacterial endocarditis.

Subepithelial hematoma of the renal pelvis (Antopol-Goldman lesion): a case report and review of the literature

A 45-year-old woman presented with gross hematuria and pain in the right flank. Blood was found in the right renal pelvis with bleeding from the lower pole of the kidney. Partial nephrectomy revealed hematomas in and about the pelvis and calices, confirming the diagnosis of Antopol-Goldman lesion. The cause of the lesion remains uncertain, although renal trauma superimposed on a hyperplastic pelvic capillary network, secondary to analgesic abuse, is suspected.

Multilocular cyst of renal hilum

A case of a multilocular cyst in a sixty-three-year-old woman is reported. The cyst was located in the hilum of a kidney and was distorted but did not involve the renal pelvis or parenchyma. Although unique in location, it fulfilled all the criteria for a multilocular renal cyst.

The significance of lymph nodal involvement in renal angiomyolipoma

Renal angiomyolipoma, a benign tumor, can involve regional lymph nodes. Although this phenomenon has been reported previously followup information has been scant. We have treated 3 patients who had renal angiomyolipoma with nodal involvement and all had further evidence of tuberous sclerosis. Each patient had hematuria with flank pain and required nephrectomy. In the ensuing 3 to 11 years none of these patients has had evidence of further disease progression. Nodal involvement may reflect the multicentricity of angiomyolipoma or may represent a form of "benign metastasis" but it does not appear to be a harbinger of disease progression.

Nephrotoxicity of epinephrine-assisted venography

A retrospective study was performed to determined the nephrotoxicity of epinephrine-assisted venography (EAV). The results showed an increase in the serum level of creatinine (sCr) up to five days after EAV in 67% of patients, in comparison with 16% in patients who had other types of renal angiography. Microscopic examination of renal specimens from patients who had undergone EAV showed vacuolization of the epithelial cells of the proximal tubules. Risk factors for acute renal failure that have been described in the literature were not statistically significant in this study. These findings suggest that EAV is a more nephrotoxic procedure than renal angiography without EAV.

Liver scintigraphy in colon carcinoma: correlation with modified Duke pathological classification

Hepatic scintigraphy was performed prior to surgical exploration in 89 patients with primary carcinoma of the large bowel. Of these patients, 26% had positive liver scans at the time the diagnosis was established. The presence or absence of liver metastasis by scintigraphic criteria was correlated with surgical findings, a modified Duke pathologic classification, and the presence of tumor markers. The sensitivity of hepatic scintigraphy was 96% and the specificity was 98%. A total of 63% of patients with abdominal lymph node involvement had positive liver scans while 4.6% of patients without lymph node involvement had positive scans. A total of 91% of patients with positive liver scans had positive abdominal nodes. Of 60 patients with normal liver scans, one (1.7%) had hepatic metastasis and 27% had tumor in regional lymph nodes. Hepatic scintigraphy is highly sensitive in detecting liver metastasis from large bowel carcinoma. However, a negative liver scan did not exclude abdominal lymph node spread.

Aspiration biopsy of prostate

Needle biopsy of the prostate has been widely practiced for more than twenty-five years, whereas transrectal aspiration biopsy, first described fifty years ago, has not. We describe our experience using the transrectal aspiration biopsy and correlate the results with histologic studies of the prostate obtained by conventional needle biopsy and surgical specimens. Aspiration needle biopsy of the prostate has a high degree of diagnostic accuracy, it causes minimal inconvenience and discomfort, the results are rapidly available, the ease of entering the suspected area in the prostate is more precise than with conventional needle biopsy, and sampling of prostate can be greater. The disadvantages of aspiration biopsy are that the technique, being unfamiliar to most urologists, must be learned and requires an experienced cytologist for interpretation. Cytologic evaluation by aspiration biopsy and the histologic diagnosis by conventional needle biopsy are complementary.

Cutaneous and subcutaneous metastases from carcinoma of prostate

Secondary cutaneous and subcutaneous metastases originating from a visceral carcinoma are relatively uncommon and are associated most frequently with mammary, pulmonary, renal, and colonic cancers. Cutaneous and subcutaneous deposits from cancer of the prostate must be classified as extremely rare, e.g., only one solitary cutaneous metastatic carcinoma of prostatic origin was seen among 136,017 surgical and postmortem specimens submitted to the department of pathology at UCLA Hospital from male patient thirty-five years of age and older during the years between 1955 and 1980. Recently we observed a second case. A discussion of these 2 cases and a review of the English literature are reported.

Papillary adenocarcinoma of ureter

A well-differentiated papillary adenocarcinoma developed in a ureteral stump thirty-six years after nephrectomy and was associated with a combined transitional-epidermoid carcinoma in the urinary bladder. Carcinoma in a ureteral stump is not uncommon and should be suspected in patients with a ureteral stump and hematuria. The very rare adenocarcinoma of the ureter is typically papillary and is associated with urinary tract infection and stones. At present successful treatment requires the early identification and extirpation of the ureteral tumor and consideration of associated cancer elsewhere in the urinary tract.

Long-standing virilism in a woman with hyperplasia and neoplasia of ovarian lipidic cells

A woman with bilateral hyperplasia of ovarian hilar cells, stromal lipidic cells (hyperthecosis), and unilateral adenoma of Leydig cells is described. Her clinical course was characterized by long-standing virilism with a recent exacerbation suggesting growth of a tumor from the hyperplastic stromal lipidic cells. Evidence for this hypothesis included similar light and electron microscopic features of the hyperplastic and neoplastic cells and identical patterns of secretion of steroid hormones. Comparison of the in vivo steroid biosynthesis of the hyperplastic lipidic cells with that of testicular Leydig cells showed several similarities. These included 1) secretion of 5 and delta 4 steroids; 2) greater secretion of the delta 4 hormones, progesterone and 17-hydroxyprogesterone, than of the delta 5 steroids, pregnenolone and 17-hydroxypregnenolone; 3) prominent secretion of testosterone but not androstenedione; and 4) limited secretion of estrogens, with estradiol as the principal estrogen. These findings support prior microscopic evidence that ovarian lipidic cells and testicular Leydig cells represent cells of common function and, likely, common origin.

The reliability of the "hypernephroma halo"

The excretory urograms and renal arteriograms of 68 patients with renal adenocarcinoma and 84 patients with renal masses other than renal adenocarcinoma were reviewed. The radiographs were examined for the presence or absence of the "hypernephroma halo." The sensitivity of this sign was observed to be only 6% and 35% on excretory urography and arteriography, respectively. The specificity was 92% and 77%. However, the overall accuracy of this sign was only 54% and 59%. The relation between the halo and its postulated structural correlate, the tumor capsule, was also examined. There was no significant association demonstrable. It was concluded that the hypernephroma halo is not a reliable sign for diagnosing renal adenocarcinoma and that it probably does not represent the tumor capsule.

Radiographic and microscopic findings in multiple ureteral diverticula

Ten cases of multiple ureteral diverticula are presented. Microscopic correlation was available in 5. Associated findings included urinary stones, obstruction, infection, and transitional-cell carcinoma. Such diverticula are one manifestation of epithelial hyperplasia, more commonly seen as ureteritis cystica.

Acute lymphoblastic leukemia with giant intracytoplasmic inclusions

Leukemic cells of bone marrow and peripheral blood showing clusters of distinctive, large, uniform, rounded intracytoplasmic inclusions were found in a patient who had acute lymphoblastic leukemia. These membrane-bound inclusions ranged from 0.8 to 1.4 microgram in diameter and were clearly demonstrated on routinely stained preparations. Electron microscopy disclosed transitions between well-developed mitochondria and the electron-dense structures. The functional significance of these presumably altered mitochondria is uncertain. Whorled lamellar internal structures, in occasional fingerprintlike arrangements, may represent duplication of mitochondrial cristae and, functionally, may reflect increased metabolic rate or otherwise abnormal metabolism. Cytochemical studies demonstrated the presence of both periodic acid-Schiff positivity and nonspecific esterase activity in these inclusions, but no peroxidase or acid phosphatase was found. These findings support the lymphoid nature of the disorder. Immunologic surface membrane markers are consistent with this case being, as with the majority of acute lymphoblastic leukemias, of non-B, non-T cell type. Cytogenetic studies on cultured leukemic cells from bone marrow and peripheral blood showed a consistently abnormal karyotype associated with the presence of an XXY chromosomal constitution. Since no other tissues (e.g., dermal fibroblasts) were examined, the diagnosis of Klinefelter's syndrome cannot be confirmed. A causal relationship between the coexistence of the abnormal karyotype and the acute leukemia was not proven but was suspected.

Wilms' tumor in the adult patient: diagnosis, management, and review of the world medical literature

Adult Wilms' tumor, unlike that of childhood, is a rare disease. A total of 167 cases have been reported in the world medical literature. However, there is controversy as to whether all of these are indeed truly nephroblastomas or in actuality represent sarcomatoid renal carcinomas. The pathologic hallmarks of this neoplasms are distinctive and it is histologically similar to the childhood tumor. The therapeutic guidelines and surgical principles that govern childhood Wilms' tumor should be applied to adult Wilms' tumor. Agressive and multimodal therapy should be the hallmark of management of this rare neoplasm. Three well documented cases of Wilms' tumor in the adult patient are presented. Of these three patients, two who presented with Stage IV disease and were treated with multimodal therapy were rendered free of disease, one living at 24 months and the other dead at five months.

Mucinous adenocarcinoma probably arising in the renal pelvis and ureter: a case report

A patient with widely disseminated mucinous adenocarcinoma had polypoid tumors in the left renal pelvis and ureter. While no certain primary site was determined, either clinically or at postmortem examination, microscopic examination of the left renal pelvis and ureter revealed atypical glandular metaplasia adjacent to the tumors and made the upper urinary tract a likely site of origin for the adenocarcinoma.

Immunologic indicators of prognosis in bladder cancer: the importance of cell surface antigens

The loss of isoantigens on the surface of cells has been correlated with invasion in 89 patients with bladder cancer: 73 underwent cystectomy and 16 had stage A tumor and were followed. Tumors from these 89 patients were re-examined for the presence or absence of A, B and O (erythrocytic) isoantigens on the surface of neoplastic cells by the red cell adherence test. In 97% of the cystectomy patients with transitional carcinoma lacking superficial cellular antigens (red cell negative tumors) there was documented evidence of invasion and 71% of the patients with stage A, red cell negative tumors eventually had invasion. This high degree of correlation between the loss of cellular antigens and the presence of invasion lends credence to the usefulness of the specific red cell adherence test as an important adjunct in the decision for appropriate therapy of cancer of the bladder.

RBC exchange pheresis for priapism in sickle cell disease

An intermittent-flow blood cell separator was used to perform a sub-total RBC exchange pheresis with prompt relief or priapism secondary to sickle cell disease. The blood cell separator offers an efficient, practical, safe method of performing exchange transfusion in the adult. Surgical procedures in the treatment of priapism have met with limited success and carry a 50% rate of subsequent impotence. We believe that RBC exchange pheresis offers a superior approach in the treatment of complications of sickle cell crisis, including priapism, and should be instituted in the symptomatic patient before more drastic procedures are undertaken.

Renal carcinoma: computer analysis of 96 patients treated by nephrectomy

We submitted to computer analysis 109 items of pathologic, clinical and survival data from 96 patients with renal carcinoma treated by nephrectomy with or without adjuvant therapy between 1956 and 1976. The combined 1, 5 and 10-year calculated survival rates for potentially curable non-metastatic renal carcinoma (stages I, II and III, provided the regional lymph nodes were not involved) were 95, 61 and 47 per cent, respectively, compared to 1, 5 and 10-year survival rates of 61, 5 and 0 per cent, respectively, for stage IV tumors. The cytoplasmic appearance (clear or granular) was not a significant microscopic feature relevant to survival of the patient but the grade of the tumor was predictive of the outcome of disease. Other features of renal carcinoma, particularly invasion of the renal vein and, to a lesser degree, perinephric fat, were not as prognostically significant in this series. In this retrospective study we further analyze the clinical, radiologic, pathologic and survival data of this group of patients.