Sentinel lymph node evaluation for tumor metastasis

The sentinel lymph node biopsy procedure for evaluation of metastatic tumor has become a common procedure for breast carcinoma and malignant melanoma. There is little standardization in the histopathologic management of these specimens. The history, technical details, and histopathologic work-up for sentinel lymph node biopsy are reviewed. Particular attention is paid to the intraoperative consultation and a protocol for optimal histopathologic management is presented.

Histologic features of surgically removed fallopian tubes

CONTEXT

The fallopian tube is a common specimen in a pathology laboratory. It may be examined either alone as a salpingectomy or tubal ligation specimen, or as part of a more complex specimen from a hysterectomy and/or oophorectomy operation. Although the common histologic findings in the fallopian tube have been described previously, to our knowledge no study has documented the frequency of histologic changes in fallopian tubes removed for all reasons or associations with clinical history.

DESIGN

Hematoxylin-eosin-stained slides from 287 fallopian tube specimens were reviewed without knowledge of the clinical history. Three categories and associated subcategories of histologic findings were identified (listed in descending order of frequency): stromal and architectural alterations (fibrosis, intramuscular edema, cellular luminal contents, inclusion cysts, Walthard nests, pigmentosis tubae, Wolffian duct remnants, decidualized stroma, endosalpingiosis, and metastatic carcinoma), epithelial characteristics (cytologic atypia, vacuolization, metaplasia, and tufting), and inflammatory changes (intramuscular mast cells, plasma cells, neutrophils, and lymphoid follicles). Histologic findings were correlated with clinical history, surgery type, and age.

RESULTS

Intramuscular edema was identified in 12.5% of specimens, most frequently in postpartum women. Plical fibrosis (35.5% of specimens), epithelial atypia (7.3%), epithelial vacuolization (6.6%), and epithelial tufting/stratification (3.5%) correlated with increased patient age. Inflammatory cells were relatively common; 69% of specimens contained intramuscular mast cells, 19.9% had stromal plasma cells, 10.5% had neutrophils, and 2.1% had lymphoid follicles.

CONCLUSIONS

This study provides data that may be valuable for surgical pathologists involved in identifying and characterizing common histologic changes in surgically removed fallopian tubes.

Bone formation in carotid plaques: a clinicopathological study

BACKGROUND AND PURPOSE

Bone formation and dystrophic calcification are present in carotid endarterectomy plaques. The clinical significance of these findings is unknown. The purpose of this study was to determine whether bone formation and extensive dystrophic calcification are associated with stable plaques and protective against ischemic vascular events.

METHODS

Carotid endarterectomy plaques were collected from 142 patients (94 men) with carotid stenosis. The specimens were evaluated for lamellar bone formation, dystrophic calcifications, inflammatory infiltrates, neovascularization, and histological type or grade of plaque according to a standard AHA grading system. Immunohistochemical staining was performed to identify vascular endothelial cells in neovascularization (factor VIII) and lymphocytes. Clinical data, including history of cerebrovascular and cardiovascular events, were recorded at the time of surgery.

RESULTS

Patients with calcification of carotid plaques had fewer symptoms of stroke and transient ischemic attack (P=0.042) than those without calcification. Stroke and transient ischemic attack occurred less frequently in patients with plaques with large calcific granules (P=0.021). Of the patients, 13% had lamellar bone formation, which directly correlated with the presence of sheetlike calcifications (P=0.0001) and inversely correlated with ulcerated lesions (P=0.048). The presence of bone also correlated with diabetes (P<0.01) and coronary artery disease (P<0.01). Of the 20 patients with bone, 6 had a history of stoke and transient ischemic attack (P=0.5).

CONCLUSIONS

The results indicate that bone formation tends to occur in heavily calcified carotid lesions devoid of ulceration and hemorrhage. Patients with extensive calcification of the carotid plaques are less likely to have symptomatic disease.

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

Loss of heterozygosity mutations of tumor suppressor genes in cytologically atypical areas in chronic lymphocytic thyroiditis

The relationship between chronic lymphocytic thyroiditis (CLT) and papillary thyroid carcinoma (PTC) is a subject of controversy. Some investigators suggest a causal relationship, whereas others regard the two as only a coincidental occurrence. An additional complicating factor is the presence of atypical nuclei frequently found within lymphoid infiltrates in CLT, which resemble those in PTC. The finding of the RET-PTC translocations in CLT has been reported by two independent groups of investigators, suggesting that the areas of nuclear atypia in CLT are neoplastic rather than reactive. In the present study, we report additional molecular findings that support the hypothesis that the atypical nuclear changes in CLT may be preneoplastic or neoplastic. We microdissected small areas with atypical nuclei in glands with CLT and observed loss-of-heterozygosity mutations of tumor suppressor genes. These genetic mutations are evidence of clonal preneoplastic or neoplastic changes in the follicular cells of CLT. The clinical malignant potential of these minute foci is likely to be very small but remains to be determined.

Repeated injury to the lumbar nerve roots produces enhanced mechanical allodynia and persistent spinal neuroinflammation

STUDY DESIGN

A lumbar radiculopathy model investigated pain behavioral responses after nerve root reinjury.

OBJECTIVES

To gain a further understanding of central sensitization and neuroinflammation associated with chronic lumbar radiculopathy after repeated nerve root injury.

SUMMARY OF BACKGROUND DATA

The pathophysiologic mechanisms associated with chronic radicular pain remain obscure. It has been hypothesized that lumbar root injury produces neuroimmunologic and neurochemical changes, sensitizing the spinal cord and causing pain responses to manifest with greater intensity and longer duration after reinjury. However, this remains untested experimentally.

METHODS

Male Holtzman rats were divided into two groups: a sham group having only nerve root exposure, and a chromic group in which the nerve root was ligated loosely with chromic gut suture. Animals underwent a second procedure at 42 days. The chromic group was further divided into a reinjury group and a chromic-sham group, in which the lumbar roots were only re-exposed. Bilateral mechanical allodynia was continuously assessed throughout the study. Qualitative assessment of spinal cord glial activation and IL-beta expression was performed.

RESULTS

Mechanical allodynia was significantly greater on both the ipsilateral and contralateral sides after reinjury (P < 0.001), and the response did not return to baseline after reinjury, as it did with the initial injury. There were also persistent spinal astrocytic and microglial activation and interleukin-1beta expression.

CONCLUSIONS

The bilateral responses support central modulation of radicular pain after nerve root injury. An exaggerated and more prolonged response bilaterally after reinjury suggests central sensitization after initial injury. Neuroinflammatory activation in the spinal cord further supports the hypothesis that central neuroinflammation plays an important role in chronic radicular pain.

Differential activation of coronary and pulmonary endothelial cells by thermal injury

Remote organ dysfunction during resuscitation of severe thermal injury is characterized by early, transient pulmonary insufficiency and cardiac contractile dysfunction. Thermal injury is typified by profound systemic alterations of endothelial immunological, vasoactive, and barrier functions. The unique location of this ubiquitous, fragile monolayer makes it vulnerable to circulating serum factors created at remote cutaneous wounds. We examined endothelial "activation" in 2 distinct cell types, human coronary and pulmonary endothelial cells (EC), after severe thermal injury. By using human serum isolated at specific times after thermal injury ("early" [2 h post-burn] or "late" [26 h post-burn]), the endothelial release of vasoactive mediators, ICAM-1 expression, and monolayer permeability were assessed in vitro. Early burn serum enhanced coronary EC vasoconstrictor (ET-1) release and ICAM expression, inhibited vasodilator (PGI2) release, but had no effect on permeability. Conversely, under similar conditions, pulmonary EC PGI2 release and permeability were enhanced, ET-1 release was diminished, but ICAM was unaffected. Late burn serum enhanced vasodilator (NO) release and permeability to albumin in both coronary and pulmonary EC, whereas ET-1 release was inhibited. Under these conditions, only pulmonary ICAM expression was significantly enhanced. These data suggest that human endothelium isolated from divergent vascular beds are activated by burn injury in a unique manner for time post-burn and vascular site of cell origin.

Magnetic resonance imaging of the ovary

Magnetic resonance imaging (MRI) of the pelvis can characterize a wide variety of ovarian lesions. We discuss MRI strategies for identification and characterization of ovarian neoplasms and correlate MRI findings with lesion gross pathological and histopathological structure.

Objective estimates of the incidence and consequences of multiple organ dysfunction and sepsis after burn trauma

BACKGROUND

Organ dysfunction and sepsis are frequent after major burn trauma, represent quantifiable consequences of the systemic response to injury, and may be important end points by which to measure treatment effectiveness. However, standard and widely applied methods for their measurement have not been applied to burn trauma victims. Therefore, the purpose of this study was to quantify these complications after burn trauma.

METHODS

Patients with > or = 20% total body surface area burns admitted to a single center were prospectively enrolled. Standard sepsis criteria and multiple organ dysfunction (MOD) scores for the pulmonary, renal, cardiovascular, hepatic, and hematologic systems were determined. The incidence and risk factors for severe MOD (cumulative MOD score > or = 6) and severe sepsis were determined. The relationships between these complications and mortality and resource utilization were examined by univariate and multivariate analyses.

RESULTS

A total of 85 patients were enrolled over 1 year. Severe MOD developed in 24 (28%) and severe sepsis or septic shock developed in 12 (14%). Both were associated with increasing age and burn size and were more likely to occur in men. Most patients who developed severe MOD or severe sepsis survived (71% and 67%, respectively), and both were associated with longer intensive care unit stays and duration of mechanical ventilation.

CONCLUSION

According to simple and objective scoring systems, severe MOD and severe sepsis/septic shock are both related to burn size, age, and male sex. Both are related to intensive care unit length of stay and duration of mechanical ventilation.

Ovarian teratomas: tumor types and imaging characteristics

Ovarian teratomas include mature cystic teratomas (dermoid cysts), immature teratomas, and monodermal teratomas (eg, struma ovarii, carcinoid tumors, neural tumors). Most mature cystic teratomas can be diagnosed at ultrasonography (US) but may have a variety of appearances, characterized by echogenic sebaceous material and calcification. At computed tomography (CT), fat attenuation within a cyst is diagnostic. At magnetic resonance (MR) imaging, the sebaceous component is specifically identified with fat-saturation techniques. The US appearances of immature teratoma are nonspecific, although the tumors are typically heterogeneous, partially solid lesions, usually with scattered calcifications. At CT and MR imaging, immature teratomas characteristically have a large, irregular solid component containing coarse calcifications. Small foci of fat help identify these tumors. The US features of struma ovarii are also nonspecific, but a heterogeneous, predominantly solid mass may be seen. On T1- and T2-weighted images, the cystic spaces demonstrate both high and low signal intensity. Familiarity with the US, CT, and MR imaging features of ovarian teratomas can aid in differentiation and diagnosis.

An evaluation of risk factors for mortality after burn trauma and the identification of gender-dependent differences in outcomes

BACKGROUND

The primary objective of this study was to determine an objective method for estimating the risk of mortality after burn trauma, and secondarily, to evaluate the relationship between gender and mortality, in the setting of a quantifiable inflammatory stimulus. Previously reported estimates of mortality risk after burn trauma may no longer be applicable, given the overall reduction in case-fatality rates after burn trauma. We expect that future advances in burn trauma research will require careful and ongoing quantification of mortality risk factors to measure the importance of newly identified factors and to determine the impact of new therapies. Conflicting clinical reports regarding the impact of gender on survival after sepsis and critical illness may in part, be from different study designs, patient samples, or failure to adequately control for additional factors contributing to the development ofsepsis and mortality.

STUDY DESIGN

Data from the prospectively maintained burn registry for patients admitted to the Parkland Memorial Hospital burn unit between January 1, 1989 and December 31, 1998 were analyzed. Logistic regression was used to generate estimates of the probability of death in half of the study sample, and this model was validated on the second half of the sample. Risk factors evaluated for their relationship with mortality were: age, inhalation injury, burn size, body mass (weight), preexisting medical conditions, nonburn injuries, and gender.

RESULTS

Of 4,927 patients, 5.3% died. The best model for estimating mortality included the percent of total body surface area burned; the percent of full-thickness burn size; the presence of an inhalation injury; age categories of: < 30 years, 30 to 59 years, > or = 60 years; and gender. The risk of death was approximately two-fold higher in women aged 30 to 59 years compared with men of the same age.

CONCLUSIONS

We have provided a detailed method for estimating the risk of mortality after burn trauma, based on a large, contemporary cohort of patients. These estimates were validated on a second sample and proved to predict mortality accurately. We have identified an increased mortality risk in women of 30 to 59 years of age.

The fate of the coracoacromial ligament in arthroscopic acromioplasty: an anatomical study

This study defines the normal anatomical relationships among the coracoacromial ligament, the deltoid, and the acromion in cadavers. The effect of arthroscopic acromioplasty on the acromial attachments of the coracoacromial ligament and the anterior fibers of the deltoid was also studied. After arthroscopic acromioplasty, the fibers of coracoacromial ligament and overlying deltoid inserting into the anterior part of the acromion remained attached to the acromion by a bridge of tissue composed of periosteum and collagen fibers of the coracoacromial ligament and deltoid tendon. We have called this the coracoacromial-deltoid-periosteal complex; it has not previously been described. This study demonstrates that arthroscopic acromioplasty preserves the acromial attachment of the coracoacromial ligament and the anterior fibers of the deltoid.

Cardiovascular effect of 7.5% sodium chloride-dextran infusion after thermal injury

HYPOTHESIS

Clinical study can help determine the safety and cardiovascular and systemic effects of an early infusion of 7.5% sodium chloride in 6% dextran-70 (hypertonic saline-dextran-70 [HSD]) given as an adjuvant to a standard resuscitation with lactated Ringer (RL) solution following severe thermal injury.

DESIGN

Prospective clinical study.

SETTING

Intensive care unit of tertiary referral burn care center.

PATIENTS

Eighteen patients with thermal injury over more than 35% of the total body surface area (TBSA) (range, 36%-71%) were studied.

INTERVENTIONS

Eight patients (mean +/- SEM, 48.2% +/- 2% TBSA) received a 4-mL/kg HSD infusion approximately 3.5 hours (range, 1.5-5.0 hours) after thermal injury in addition to routine RL resuscitation. Ten patients (46.0% +/- 6% TBSA) received RL resuscitation alone.

MAIN OUTCOME MEASURES

Pulmonary artery catheters were employed to monitor cardiac function, while hemodynamic, metabolic, and biochemical measurements were taken for 24 hours.

RESULTS

Serum troponin I levels, while detectable in all patients, were significantly lower after HSD compared with RL alone (mean +/- SEM, 0.45 +/- 0.32 vs 1.35 +/- 0.35 microg/L at 8 hours, 0.88 +/- 0.55 vs 2.21 +/- 0.35 microg/L at 12 hours). While cardiac output increased proportionately between 4 and 24 hours in both groups (from 5.79 +/- 0.8 to 9.45 +/- 1.1 L/min [mean +/- SEM] for HSD vs from 5.4 +/- 0.4 to 9.46 +/- 1.22 L/min for RL), filling pressure (central venous pressure and pulmonary capillary wedge pressure) remained low for 12 hours after HSD infusion (P = .048). Total fluid requirements at 8 hours (2.76 +/- 0.7 mL/kg per each 1% TBSA burned [mean +/- SEM] for HSD vs 2.67 +/- 0.24 mL/kg per each 1% TBSA burned for RL) and 24 hours (6.11 +/- 4.4 vs 6.76 +/- 0.75 mL/kg per each 1% TBSA burned) were similar. Blood pressure remained unchanged, and serum sodium levels did not exceed 150 +/- 2 mmol/L (mean +/- SD) in either group.

CONCLUSIONS

The absence of deleterious hemodynamic or metabolic side effects following HSD infusion in patients with major thermal injury confirms the safety of this resuscitation strategy. Postburn cardiac dysfunction was demonstrated in all burn patients through the use of cardiospecific serum markers and pulmonary artery catheter monitoring. Early administration of HSD after a severe thermal injury may reduce burn-related cardiac dysfunction, but it had no effect on the volume of resuscitation or serum biochemistry values.

Thermal injury alters endothelial vasoconstrictor and vasodilator response to endotoxin

BACKGROUND

The unique location of the endothelium makes it vulnerable to injury from circulating factors created at remote wounds. In this study, we examined the effect of a sequential burn and lipopolysaccharide (LPS) challenge on endothelial function in vitro.

METHODS

Human umbilical vein endothelial cells treated with 20% human serum isolated from burn patients (>40% total burn surface area) at 2 and 24 hours postinjury. Cultures were subsequently treated with Escherichia coli LPS:0111:B4 (0.10-100ng/mL). Endothelin-1 (ET-1), 6-ketoPGF1a, and NO2/NO3 were detected by using specific enzyme immunoassays.

RESULTS

Burn serum did not alter endothelial ET-1, PGI2, or NO secretion compared with Control serum. LPS significantly enhanced 6-ketoPGF1a (54,242+/-14,466 pg/10(6) cells) and NO2/ NO3 (723+/-210 microM) secretion, but not ET-1 compared with Control serum alone (3,878+/-963 and 219+/-110). Burn serum pretreatment significantly enhanced the ET-1 response to LPS (303+/-36 pg/10(6) cells vs. 193+/-47). The 6-ketoPGF1a (16,509+/-3,785) and NO2/NO3 (354+/-98) responses to Burn/LPS were significantly diminished compared with Control/LPS. Although this level of 6-ketoPGF1a was elevated compared with Control alone (7,518+/-2,299), NO2/NO3 was unchanged (significance at p < 0.05).

CONCLUSION

Thermal injury may prime remote endothelium and alter the response to a septic focus with an enhanced vasoconstrictor (ET-1) and diminished vasodilator (PGI2/NO) response, a situation that may contribute to postburn distal organ injury.

Traumatic wound care

The scope and importance of traumatic wound care, assessment, debridement, pre and postoperative management, and subsequent skin care during the course of treatment cannot be over-emphasized, and indeed, are the most important considerations for functional and cosmetic outcome. Care begins in the emergent phase and continues through acute and convalescent phases. Efforts are directed at methods and techniques which prevent infection, facilitate wound healing, promote comfort, and at the same time, maintain optimal function and minimize deformities.

Identification and structural characterization of a novel member of the vitamin D binding protein family

The apparent high degree of homology of a blood protein with a unique dual binding affinity for two distinct hormones, thyroxin (T4) and vitamin D, isolated from a turtle, Trachemys scripta (Family Emydidae) and mammalian vitamin D binding protein (DBP) prompted further interspecific comparison to better understand the structure of functional binding sites. Using polymerase-chain reaction (PCR) with primers derived from the putative nucleotide sequences encoding peptides from the degradation of the T. scripta protein, we cloned the cDNA. The mature turtle protein contains 466 amino acids, about eight residues more than in mammalian DBP. The nucleotide sequence of the coding region showed 63% nucleotide and 73% amino acid homology (approximately 53% identity) to mammalian DBP (human, rat, mouse, and rabbit). However, there was no significant homology to mammalian T4-binding globulin (TBG) or transthyretin (TTR). Comparisons with mammals help define further the requirements for the vitamin D and actin binding sites. Northern blots of RNA isolated from turtle tissue probed with the 5' portion of cDNA established expression of the transcript in liver, kidney, and brain (in order of abundance), in contrast to mammal sequences in which expression of DBP is largely confined to the liver.

Evaluation of troponin-I as an indicator of cardiac dysfunction after thermal injury

BACKGROUND

Biochemical serum markers commonly used to assess human cardiac injury (creatinine phosphokinase, creatine phosphokinase-MB) have been shown to have diminished specificity for detection of cardiac injury in the setting of burn-related soft-tissue and skeletal muscle injury. Laboratory studies have demonstrated that severe cutaneous thermal injury is associated with cardiac contractile dysfunction and a corresponding elevation in serum cardiac troponin-I (cTn-I) in several species.

METHODS

Twenty-three patients admitted to a tertiary care burn referral center were evaluated. Patients were monitored with pulmonary artery catheters, and creatinine phosphokinase, creatine phosphokinase-MB, and cTn-I levels were determined for 24 hours. Using a database, 6,722 burn patients were reviewed to determine the incidence of preexisting cardiac disease and postburn cardiac complications.

RESULTS

All patients had persistent sinus tachycardia (>115 beats per minute) without obvious electrical anomalies. All patients centrally monitored with a pulmonary artery catheter (n=20) maintained a cardiac index of greater than 3.0 L x min(-1) x m(-2) x cTn-I was present (>0.3 ng/mL) within 3.0 hours and elevated (>0.55 ng/mL) at 24 hours for all burns of more than 18% total body surface area. Historically, although only 5% of all admissions manifest acute postburn cardiac complications, 94% of these patients presented with preexisting heart disease.

CONCLUSION

Severe thermal injury was associated with a mild elevation in serum troponin-I; however, this did not correlate with overt cardiac morbidity or mortality. Postburn elevation of cTn-I suggested that a subtle degree of cardiac injury was present after a severe thermal injury despite hyperdynamic cardiac function during resuscitation.

Tracheostomy in the young pediatric burn patient

OBJECTIVE

To evaluate the incidence of complications in comparison with the benefits of tracheostomy in young pediatric burn patients (newborn to 3 years old).

DESIGN

Retrospective survey.

SETTING

Tertiary care burn center.

PATIENTS

A total of 1549 consecutive pediatric burn patients, of whom 180 were intubated.

INTERVENTIONS

Tracheostomy was performed in 76 children.

MAIN OUTCOME MEASURES

Duration of mechanical ventilation, mortality, respiratory complications, airway complications, and condition of the airway at discharge from the hospital.

RESULTS

Seventy-six patients required tracheostomy. Their mean burn size was 34% total body surface area and mean length of stay in the hospital was 56 days. There were no perioperative complications. Eight patients (10%) could not be decannulated because of airway obstruction. Five of these outgrew their obstruction, 2 required surgery, and 1 continues to be evaluated for laryngeal reconstruction.

CONCLUSION

Pediatric tracheostomy can be performed safely with no perioperative complications and acceptable chronic morbidity.

Immunohistochemical analysis of gel-transferred cells in cytologic preparations following smear division

Fine-needle aspirations on solid tumors are used increasingly as a means of obtaining a primary diagnosis. In many cases, a panel of immunostains performed on these aspirates is necessary to further characterize the cytologic interpretation. The amount of material obtained through aspiration, however, is often quite limited and is present on few glass slides. Previous studies have demonstrated the success of dividing cytologic smear preparations into smaller parts that could then be used for a panel of immunohistochemical stains. These results, however, did not compare the immunoreactivities of various antibodies before and after tissue transfer on cytologic preparations. In the present study, 41 immunohistochemical stains that employed 16 antibodies on 15 tumor preparations were performed following smear partition using the tissue-transfer technique. The percentage of cells that stained positive after transfer was determined and was correlated quantitatively to the untransferred controls. Specific immunoreactivity was demonstrated in 30 of 38 cases (79%) but was significantly decreased or lost in 8 of 38 cases (21%), which included antibodies for S-100, estrogen and progesterone receptors, chromogranin, neuron-specific enolase, and cytokeratin. Morphology was well preserved following tissue transfer, although limited cytoplasmic damage was seen in up to 25% of tumor cells. Immunopositive samples were found to be easily interpretable. Because sporadic cases fail to show immunohistochemical staining reactions following cytologic smear division and transfer, negative immunohistochemical stains in such preparations should be approached with caution.