Argyrophilic breast carcinomas: evidence of lactational differentiation

Twenty unselected breast carcinomas were examined for argyrophilia by the Sevier-Munger stain and for dense-core secretory granules by electron microscopy. All cases were examined for lactalbumin and five cases were also studied for gastrin, insulin, calcitonin, somatostatin, glucagon, ACTH, prolactin, and pancreatic polypeptide by an immunoperoxidase technique; two cases were further analyzed for lactalbumin by ultrastructural immunoperoxidase stain. Focal or diffuse argyrophilia was present in ten cases. Intracytoplasmic lactalbumin was present in seven of these cases, but immunoperoxidase staining for the neuroendocrine hormones was negative. Fine structural examination demonstrated varying numbers of 95 to 450-nm-diameter, round, membrane-bound, dense-core secretory granules in 13 cases. Nine of the granule-containing cases were also argyrophilic, and seven of these contained intracytoplasmic lactalbumin. Both the argyrophilia and the dense-core secretory granules thus correlated with the presence of intracytoplasmic lactalbumin. None of the 20 patients had clinical evidence of carcinoid syndrome or showed evidence of other hormone secretion. Argyrophilia and granular lactalbumin staining in a somewhat similar pattern was found in pregnant and lactating breast controls. Argyrophilia and ultrastructural dense-core granules are common in breast carcinomas and might represent lactational differentiation. These findings do not indicate the presence of a carcinoid tumor because in most of these tumors the secretory granules appear to contain milk protein secretory product rather than neuroendocrine polypeptides, and most argyrophilic tumors do not morphologically or clinically resemble carcinoid tumors.

Diffuse intrapulmonary hemorrhage and glomerulonephritis unrelated to anti-glomerular basement membrane antibody

Nine patients with diffuse intrapulmonary hemorrhage and glomerulonephritis not due to anti-glomerular basement membrane (anti-GBM) antibody are described and similar previously reported cases are reviewed. Eight patients were seen during a four-year interval and represented 47 percent of the cases of pulmonary hemorrhage and glomerulonephritis seen during this period. Diagnoses included systemic vasculitis of unspecified type in two patients with seropositive rhematoid arthritis, idiopathic crescentic glomerulonephritis with negative immunofluorescence in two, Wegener's granulomatosis in two, and polyarteritis nodosa, Henoch-Schönlein purpura, and mixed connective tissue disease in one each. Differentiation from anti-GBM antibody-mediated pulmonary hemorrhage and glomerulonephritis by clinical evaluation alone was frequently difficult, emphasizing the importance of both immunopathologic studies and evaluation of serum for anti-GBM antibody in all patients with pulmonary hemorrhage and glomerulonephritis. In eight of nine patients, significant episodes of pulmonary hemorrhage improved markedly within 24 to 72 hours following initiation of high-dose corticosteroid therapy. In contrast, renal function did not improve in the majority of patients.

Incidence and significance of recurrent focal segmental glomerulosclerosis in renal allograft recipients

Renal transplantation was performed in 25 patients for renal failure secondary to nephrotic syndrome and histologically proven segmental glomerulosclerosis (FSGS). They received 33 allografts, 13 from cadaveric (CAD) and 20 from living related donors (LRD) including 6 HLA-identical siblings. All have been followed for at least 1 year with none lost to follow-up. Overall, functional graft survival of the 33 grafts was 68.7% at 12 months and 60.5% at 48 months, similar to controls matched for age, sex, time of transplant, and donor source. Recurrent FSGS was documented histologically in 9 (5 CAD and 4 LRD) of 33 grafts (27.3%) and resulted in loss of graft function in 3 (9.9%). The presence and extent of mesangial proliferation (MP) in conjunction with or preceding typical lesions of FSGS in native kidneys was predictive of recurrent disease. Age at onset, duration of disease, and donor source were not. Sixteen patients with only FSGS on multiple biopsies of native kidneys received 22 allografts and recurrent disease occurred in 4 (18%) but did not cause loss of graft function in any. Six patients with focal areas of MP as well as FSGS underwent eight transplants, in which recurrent FSGS developed in two (25%) and caused graft loss in one. All three grafts transplanted to the patients with diffuse MP and FSGS developed recurrent disease, this resulting in graft failure in two. This study demonstrates the importance of a thorough histological evaluation by multiple biopsies of all patients with steroid-nonresponsive nephrotic syndrome. Only in this manner does it appear possible to define that subgroup of patients with FSGS who are at greatest risk of clinically significant recurrent disease.

Polymorphic diffuse B-cell hyperplasias and lymphomas in renal transplant recipients

The lymphoproliferative processes that developed in five renal transplant recipients were studied in an attempt to characterize and classify them morphologically. Nine surgical specimens, hematological material on all patients, and autopsy specimens from three patients were available. Studies performed included: conventional histopathology; evaluation of cell markers (immunoglobulins and sheep erythrocyte, complement, and Fc receptors) and cytoplasmic immunoglobulins (peroxidase-antiperoxidase technique); ultrastructural examination; and karyotype analysis. The lymphoid lesions in our patients shared marked cytological polymorphism (small and large cells, of both follicular center and "medullary" type) and polyclonal B-cell features, which indicated a common reactive nonneoplastic origin. However, other features, such as morphological atypia of the immunoblasts, extensive necrosis, chromosomal aberrations, and an incipient monoclonal component suggested the development of lymphoma in some of these lesions. In contradistinction, the abundance of typical immunoblasts was a feature that seemed to correlate with the clinical activity of the disease rather than with the biological malignancy. The multiplicity of B-cell types and the presence of a follicular center cell component with diffuse distribution, as well as the extensive necrosis in the malignant forms, seem to differentiate morphologically the lymphoproliferative processes arising in transplant recipients from both the hyperplasias and the lymphomas developing in immunologically normal hosts. For the former, we propose the terms of "polymorphic diffuse B-cell hyperplasias" and "polymorphic B-cell lymphomas."

Mononuclear phagocytic system stimulation. Protective role from glomerular immune complex deposition

Experimentally, glomerular deposition of circulating IC is increased when the MPS is saturated. Clinically, an association between glomerulonephritis and dysfunction of MPS-Fc receptor-mediated clearance of IC has recently been described in patients with certain forms of autoimmune diseases. Thus we hypothesized that stimulation of the MPS may be beneficial, by decreasing circulating IC and hence, reduce glomerular deposition of IC. To test this experimentally, we studied glomerular uptake and disappearance of AHIgG . 125I (macromolecular proteins biologically akin to IC) in normal control rats and in rats with ZY-stimulated MPS. ZY-treated and control rats were given 30 mg/100 gm body weight AHIgG . 125I and sacrificed at 30 min and 1, 2, 4, 8, 16, and 24 hr after AHIgG . 125I injection. Glomerular AHIgG . 125I was measured in preparations of isolated glomeruli and compared to simultaneous liver, spleen, lung, and blood greater than 7S AHIgG . 125I. The blood t 1/2 of greater 7S AHIgG . 125I in ZY rats was 40% shorter than that in control rats. Blood greater than 7S AHIgG . 125I in ZY rats was 63% lower than in control rats at 4 hr and 73% lower at 8 hr after injection. At all time intervals, glomerular AHIgG . 125I was reduced in ZY rats proportionately to the decreased blood levels. By immunofluorescence microscopy, the intensity of staining for human IgG correlated with the quantitative determination of AHIgG . 125I in preparations of isolated glomeruli in control and ZY rats. The reduction in blood and glomerular AHIgG . 125I in ZY rats was a result of a marked increased in hepatic and splenic uptake of AHIgG . 125I. Serum complement depletion of ZY rats with CVF prior to AHIgG . 125I injection did not significantly alter the kinetics of AHIgG. 125I. This suggests that the increased MPS uptake of AHIgG . 125I in ZY rats was predominantly Fc-receptor-mediated. Thus ZY stimulation of the MPS increased the clearance of AHIgG . 125I and protected glomeruli from AHIgG . 125I deposition. Clinically, agents that would specifically stimulate the MPS may be useful in reducing IC-mediated glomerular injury.

Renal failure as a complication of acute antihypertensive therapy

Adult patients with long-standing hypertension have been reported to experience an impairment in renal function when treatment with potent vasodilating agents is initiated. To document that this sequence may occur in children as well, we report the case of a 4-year-old boy with renal disease in whom reduction of blood pressure to normal levels was accompanied on three occasions by oliguric renal failure. During each episode, the correlation between reduction in blood pressure and increase in serum creatinine level was significant (P less than .05); furthermore, the slope of the relationship was similar with each episode. This phenomenon suggests an impairment of renal autoregulation in this patient. Maintenance of normal blood pressure for several months was accompanied by a gradual return of renal function to pretreatment levels. This case suggests that particular attention should be paid to renal function during the initiation of antihypertensive therapy, particularly in patients with renal vascular damage. Present evidence does not appear to warrant modification of the current therapeutic philosophy of aggressive management in patients with severe hypertension.

The electron microscopic features of sinus histiocytosis with massive lymphadenopathy: a study of 11 cases

Eleven cases of sinus histiocytosis with massive lymphadenopathy (SHML) involving lymph nodes were studied electron microscopically. Histiocytes were the most conspicuous element of the infiltrate. They could be divided into small and large forms, although transitions were apparent among them. Most of the small histiocytes were located in the medullary cords. The large histiocytes were predominantly seen within sinuses and were subdivided into two types on the basis of their appearance. The most distinctive feature of these histiocytes was the presence of lymphocytes, plasma cells, and neutrophils within their cytoplasm. Other cells present in the infiltrate were lymphocytes, plasma cells, and occasional neutrophils and mast cells. Blood vessels were prominent throughout. Virus particles, bacteria, and Langerhans' granules were consistently absent. No morphologic clues were provided by this study as to the etiology of this disorder.

Ultrasound in acute renal transplant rejection

Gray-scale ultrasound and biopsy were compared in 63 patients with suspected acute kidney allograft rejection. Sonographic findings of increased size and decreased echogenicity of renal pyramide, focal zones of sonolucency in renal cortex, and patchy sonolucent areas involving both cortex and medulla with coalescence correlated well with biopsy in 46 out of 50 patients (92%) treated for acute rejection (sensitivity = 0.92). Abnormal perirenal fluid collection was encountered in three out of 60 patients (5%). Out of 63 sonographic studies, 10 (16%) gave either false positive (6) or false negative (4) results for an overall accuracy of 85%.

Malignant histiocytosis: A light- and electron-microscopic and histochemical study

The light- and electron-microscopic features and histochemical characterization of three consecutive cases of malignant histiocytosis (MH) are reported. Each case demonstrated involvement of lymph nodes and bone marrow. In the lymph node, the characteristic destructive sinusoidal pattern of involvement by cytologically malignant cells was present. Phagocytosis by malignant cells was rare and most readily appreciated in the imprint preparations. The major problem in differential diagnosis related to defining the histiocytic nature of the malignant cells. This question was resolved by the demonstration of diffuse cytoplasmic staining with the nonspecific esterase and acid phosphatase reactions as well as the ultrastructural demonstration of histiocytes. Although benign, reactive histiocytes were positive, malignant histiocytes did not stain for lysozyme by an immunoperoxidase technique. In contrast to the uniform appearance of these cases, many reports of MH in the past have consisted of heterogeneous cases with variable histologic appearances from a proliferation of predominantly mature histiocytes with marked phagocytosis to cytologically malignant cells with little apparent functional activity. This variation in histologic appearance is due in part to inclusion of cases of reactive histiocytic proliferations, including the recently described virus-associated hemophagocytic syndrome.

Renal artery aneurysms: an angiographic sign of transplant rejection

Intrarenal arterial aneurysm is an uncommon manifestation of allograft rejection. We present two cases of transplant rejection with aneurysm formations. One case simulated polyarteritis nodosa, while in the other, the aneurysm appeared similar to those seen in post-stenotic arterial dilatation.

Neuroendocrine (Merkel cell) carcinoma of the skin. A histologic and ultrastructural study of two cases

The clinical, histologic, and ultrastructural features of two cases of a primary cutaneous neuroendocrine neoplasm probably arising from Merkel cells are presented and compared with previously reported examples. This recently described tumor arises in the dermis of elderly individuals, is often locally aggressive, may metastasize to regional lymph nodes, and eventually may cause death. Microscopically, sheets of primitive cells fill and expand the dermis. Ultrastructural study of our cases revealed morphologic similarities to normal cutaneous Merkel cells, including peripherally situated dense-core neurosecretory-like granules, zonula adherens-type intercellular junctions, prominent Golgi apparatus, and varying numbers of mitochondria and rough endoplasmic reticulum. This unusual tumor is readily confused with cutaneous lymphoma and various undifferentiated primary or metastatic neoplasms by conventional light microscopy. The definitive diagnosis can be made only by electron-microscopic examination.

Pulmonary alveolar proteinosis: an uncommon cause of chronic neonatal respiratory distress

A full-term newborn infant had the onset of respiratory distress immediately after birth. She required supplemental oxygen from birth, and had pulmonary alveolar proteinosis (PAP) documented by open lung biopsies at 6 and at 12 weeks of age. Light and electron microscopy showed dense, PAS-positive granular, homogeneous material within the alveolar spaces, diagnostic of PAP. No Pneumocystic carinii organisms were demonstrated on silver staining, and bacterial and viral cultures were negative. The infant died of progressive respiratory insufficiency at 1 yr or age. Pulmonary alveolar proteinosis should considered a rare cause of chronic respiratory distress in the newborn infant.

Well-differentiated peripheral cholangiocarcinoma with an unusual clinical course

A patient with an unresectable well-differentiated bile duct tumor who survived for 15 yr after biopsy diagnosis is presented. Histologic examination of the tumor revealed bland features of bile duct adenoma despite extensive spread within the liver. Over its subsequent course, the tumor progressively replaced the liver, achieving huge size, although there was no evidence of metastases until shortly before the patient's death. This clinical course was very unusual for either bile duct adenoma or cholangiocarcinoma, but would be more characteristic of another tumor of intrahepatic bile duct origin, the biliary cystadenoma. However, this latter diagnosis was excluded with both gross and microscopic pathologic criteria. Evidence is presented to support classification of this tumor as an unusual varient of peripheral cholangiocarcinoma which requires correlation of the clinical and pathologic findings for correst diagnosis.

Crescentic glomerulonephritis and renal failure associated with malignant lymphoma

Two cases of crescentic glomerulonephritis and renal failure associated with malignant lymphoma are reported. The relationship of the lymphoma to the immune-complex glomerulonephritis is discussed.

Malignant small cell tumor of the thoracopulmonary region in childhood: a distinctive clinicopathologic entity of uncertain histogenesis

This report describes a unique clinicopathologic entity characterized as a malignant small cell tumor of the thoracopulmonary region in 20 children and adolescents (average age 14.5 years). There was a female predilection (75%) for this tumor which appeared to originate in the soft tissues of the chest wall or the peripheral lung. The neoplasm tended to recur locally and did not seem to disseminate as widely as some of the other small cell tumors of childhood (rhabdomyosarcoma, Ewing's sarcoma, neuroblastoma and malignant lymphoma). However, the median survival was only 8 months. Electron microscopy of 3 cases suggested a neuroepithelial derivation, but, at the present, the histogeneis remains a subject for further investigation.

Malignant melanotic neuroectodermal tumor of infancy: a clinical, pathologic, ultrastructural and tissue culture study

The melanotic neuroectodermal tumor of infancy is an uncommon neoplasm typically of early childhood which has a predilection for the head and neck region, particularly the maxilla. Except for one previous example in the literature, this tumor has consistently behaved in a benign fashion. This study documents the clinical course and pathologic findings of a tumor which began in the maxilla of a 4-month-old boy, followed by a local recurrence, metastasis to a cervical lymph node and finally, widespread dissemination and death at 18 months, 24 months and 38 months, respectively. The tumor was initially composed of nests consisting of melanin-containing cells and small dark cells. An elevated vanillylmandelic acid level was recorded during the course of the disease. At autopsy, the tumor in lymph nodes, liver, bone and soft tissues had a monotonous pattern of small dark cells similar to a conventional neuroblastoma. Previous ultrastructural studies indicate that the melanotic neuroectodermal tumor of infancy is composed of melanocytes and neuroblast-like cells. Our case provided the unique opportunity to examine in sequence the ultrastructural and in vitro characteristics of a recurring and eventually metastasizing melanotic neuroectodermal tumor. Although the neuroblast-like cells were initially difficult to identify by electron microscopy, a melanin-producing cell line and a separate nonpigmented cell line were successfully isolated from various tumor explants. Various stages of melanosome development were identified in the pigmented cells from the local recurrences and in vitro. Dibutyryl cAMP accentuated the formation of pigment and dendritic development in the melanocytes and dendrites only in the small nonpigmented cells. Electron dense granules were observed in the cultured smaller cells and also in the lymph node and soft tissue metastases. Tyrosine hydroxylase activity was demonstrated in the neuroblast-like cells. In the final biopsy and autopsy material, only the neuroblast-like cells remained and the tumor resembled a conventional neuroblastoma.

Multicentric colonic lymphoma complicating ulcerative colitis

A 72-year-old female with ulcerative colitis of 30 years duration underwent total proctocolectomy for a cecal mass thought to be an adenocarcinoma. Pathologic examination of the colon revealed 22 tumors, all of which proved to be malignant lymphoma, histiocytic type. Thirteen cases of non-Hodgkins malignant lymphoma and 2 cases of Hodgkins disease of the colon arising in ulcerative colitis are reviewed and discussed.