Percutaneous biopsy in diffuse liver disease: increasing diagnostic yield and decreasing complication rate by routine ultrasound assessment of puncture site

OBJECTIVE

To evaluate the usefulness of routine ultrasound assessment of puncture site before performing percutaneous biopsy in diffuse liver disease. Seven hundred fifty-three consecutive patients were studied retrospectively.

METHODS

Serial scanning of the last intercostal spaces allowed us to establish the most suitable access to the thicker liver parenchyma (assessing the most favorable angulation of the needle too), avoiding the puncture of adjacent organs; no more than 1 min was necessary for such a determination.

RESULTS

In 99.4% of patients, a definitive or indicative pathological diagnosis of chronic liver disease was obtained. Only one hemorrhagic complication (0.13%) occurred, requiring no surgical treatment or blood transfusion. Three cases of vasovagal reaction occurred (0.40%): two of these recovered spontaneously, while the other one needed i.v. administration of atropine. Mortality was 0 in our series.

CONCLUSIONS

Routine ultrasound of the puncture site is a quick method of assessment, allowing one to increase the diagnostic yield of percutaneous liver biopsy and to maintain low complication rates for such a procedure.

Preoperative embolization in surgical treatment of spinal thoracic dumbbell schwannoma. A case report

Schwannoma is the most common intraspinal tumor, which at times goes out of spinal canal and spreads into the paraspinal tissue to produce a dumbbell configuration. A 58-year-old woman is reported, in whom a plain thorax X-rays accidentally disclosed a mass located in the posterior mediastinum. Computerized tomography (CT) revealed a dumbbell lesion, 4.5 cm in diameter, in the right rib-vertebral groove at the T9 level. Spinal angiography showed localization of Adamkievicz artery at the T10 level on the left side. The lesion appeared hypervascular and was embolized by particulate agents (Contour Emboli 150-250 mu) with reduction of its blush. A combined two-team (thoracic and neurosurgeon) approach permitted an uneventful removal of a schwannoma.

Comparative effects of growth hormone on water and ion transport in rat jejunum, ileum, and colon

Specific growth hormone (GH) receptors are located along the entire rat intestine. We have recently shown that GH induces water and ion absorption in the rat ileum. This raises the possibility that GH regulates water and ion transport throughout the intestine. To test this, we have evaluated the effects of GH administration on jejunal, ileal, and colonic water and ion transport, by the in vivo rat perfused intestine, and in vitro, in corresponding segments of intestine mounted in Ussing chambers. In vivo, GH increased water absorption by 250%, 180%, and 80% over baseline in the jejunum, ileum, and colon, respectively. The effect had similar kinetics in the three intestinal regions. In vitro, serosal GH administration induced a decrease in short-circuit current, consistent with an absorptive effect. The effect showed a proximal to distal decreasing pattern. These findings suggest that GH plays a role in the body fluid homeostatic control, promoting water and ion absorption.

Linkage analysis identifies gene carriers among members of families with hereditary nonpolyposis colorectal cancer

BACKGROUND & AIMS

Uncertainty about genetic risk in hereditary nonpolyposis colorectal cancer (HNPCC) may lead to unnecessary screening. The aims of this study were to show how gene linkage findings can elucidate who is at risk and requires intensive screening and how cancer control can be enhanced by screening high-risk family members. This information can be useful given the public health magnitude of HNPCC.

METHODS

An extended family with HNPCC was studied using formal linkage analysis with DNA extraction from blood samples, followed by genotyping with polymerase chain reaction technique for microsatellite markers. Sixty-one blood relatives of a family with HNPCC, 5 of whom had colorectal cancer, and 12 unrelated family members underwent DNA sampling for genetic analysis.

RESULTS

Linkage analysis showed that all 5 affected individuals had a haplotype with the same alleles 10/7/9, which was also detected in 13 first-degree healthy gene carriers and absent in the remaining 43 non-gene carriers. In the asymptomatic subjects screened, one incidental colorectal cancer and four adenomas were detected in 3 of 6 gene carriers. An adenoma was found in 1 of 17 noncarriers; the remaining 16 noncarriers have undergone 67 unnecessary colonoscopies.

CONCLUSIONS

Linkage analysis can differentiate gene carriers from non carriers. Colorectal cancer screening should be restricted to gene carriers.

Ultrastructural study of Kaposi's sarcoma

An electron microscopic (EM) study of 25 Kaposi's sarcomas (KS) (24 cutaneous lesions, 1 lymphnodal) from 23 patients, mainly sporadic in type, has enabled us to study both the spindle and endothelial cells seen by light microscopy (LM) with the conclusion that they have both a fibroblastic-like EM aspect. Both cell types manifested a spindle shape with oval and occasionally notched nuclei and a reticular pattern of nucleoli. The cytoplasm was characterized by numerous rough endoplasmic reticulum cisternae with few other organelles. The plasma membranes consistently lacked an external or basal membrane and failed to show true cell junctions. In cells delimiting erythrocytes containing spaces it was never possible to document Weibel-Palade (W.-P.) bodies or plasmalemmal vesicles. Unusual findings such as ferritin loaded phagosomes, microtubular reticular structures (MTRS), intracisternal crystalline inclusions (ICCI), multivesicular bodies (MVB), acanthosomic vesicles (AV) and test-tube inclusions or ring-shaped forms (TTI/RSF) were occasionally seen in both sporadic and epidemic KS. The authors discuss the non specific nature of these latter findings.

Oncocytic nonsecretory multiple myeloma. A clinicopathologic study of a case and review of the literature

We report on a morphologic variant of multiple myeloma, identified in a 39-year-old man, with osteolytic lesions in two ribs and three lumbar vertebrae. Serum electrophoresis was normal and immunofixation of serum and urine was negative. Histologic examination of a resected rib revealed a homogeneous population of neoplastic plasma cells with granular and eosinophilic cytoplasm. Immunohistochemical stains showed monoclonality for lambda light chain and negativity for all heavy chains. At the ultrastructural level, the cytoplasm of the neoplastic plasma cells was almost totally occupied by round and elongated mitochondria, pushing the rough endoplasmic reticulum to the periphery. To the best of our knowledge, only two similar cases have been reported in the literature so far. The usefulness of obtaining a clinicopathologic correlation for the behaviour of this extremely rare variant of multiple myeloma is discussed.

[Techniques for the diagnosis of kidney diseases. Is there a role for the immunoperoxidase method in the evaluation of immunologic glomerulopathy on biopsy specimens, including those in paraffin? Our experience: preliminary results]

Firstly an extensive summary of the diagnostic power and limits in renal glomerular pathology of light microscopy even corroborated by all the special histochemical stains is made. Secondly a complete list of all those renal glomerular diseases in which electron microscopy is unanimously considered necessary for the diagnosis is given as well as the main and most updated references pertinent to those rare and recently recognized pathological entities in which EM proved as a fundamental diagnostic tool are provided. Thirdly the authors focus on the importance of immunohistochemistry (IIC) in the diagnosis of immune-mediated renal glomerular diseases. The advantages and disadvantages of immunofluorescence microscopy (IF) and immunoperoxidase method (I-perox) are respectively discussed. The value of I-perox staining method applied to sections from paraffin blocks is emphasized and some technical suggestions in order to optimize results are given. Among the latter the choice of the used fixative for the purpose of preserving antigenicity of immunoglobulins and complement fractions, the timing of tissue fixation as well as the quantitation of enzymatic pretreatment relative to the duration of fixation, and the repeated washings with phosphate-buffer saline to minimize background staining. Ultimately the authors report on their preliminary personal results with the use of I-perox staining on sections from paraffin embedded renal core biopsies. Although if is their favourite diagnostic microscopy for evaluating renal immunopathology the authors underline I-perox method as a helpful tool to rely on at least in those circumstances when frozen material for IF is not available due to the scarcity of core biopsy, when glomeruli are absent in frozen sections, or when due to a technical lab accident the frozen tissue devoted to IF has been ruined or lost, and the only available material is the one which lies embedded in paraffin. The LSAB ("labelled streptavidin biotin") complex and PAP ("peroxidase-antiperoxidase") working procedures are provided in detail.

Inflammatory myofibroblastic tumor of the larynx. A clinicopathologic study of eight cases simulating a malignant spindle cell neoplasm

BACKGROUND

Inflammatory myofibroblastic tumors of the larynx are uncommon lesions that easily may be misinterpreted as malignant epithelial or mesenchymal spindle cell neoplasms.

METHODS

Eight cases of laryngeal inflammatory myofibroblastic tumors were identified from the files of the Otolaryngic Tumor Registry--Armed Forces Institute of Pathology. Clinical records and follow-up were available in all cases. The light microscopic features (hematoxylin and eosin and special histochemical stains) were evaluated in all cases; immunohistochemical analysis was performed in the seven cases with available paraffin blocks; in four cases ultrastructural analysis was done.

RESULTS

The patients included five males and three females ranging in age from 19-69 years (median, 59 years). Presenting symptoms included hoarseness, dysphonia, or rapidly progressive stridor with the duration of symptoms ranging from 10 days to 4 months. The most common site of involvement was the true vocal cord. The lesions appeared as polypoid or pedunculated masses. Histologically, the cellularity of the lesions varied, consisting of spindle-shaped to stellate cells with no consistently discernible growth pattern, in a fibromyxoid stroma that included a mixed inflammatory cell infiltrate. Features suggesting a malignant cellular infiltrate were not present. The spindle-shaped cells had consistent immunoreactivity with vimentin, muscle specific actin, and smooth muscle actin. Ultrastructurally, intracytoplasmic microfilaments were identified. In seven of the patients, conservative but complete excision of the lesion was curative; these patients have been free of disease over periods ranging from 12 to 36 months. In one patient, the lesion recurred twice over a 2-year period and ultimately required a total laryngectomy. This patient died of unrelated causes.

CONCLUSIONS

Inflammatory myofibroblastic tumors of the larynx are unusual benign proliferative lesions. Conservative surgical management is advocated and is curative. Recurrence is rare, but metastases disease or death attributable to these lesions is not.

[Interhemispheric epidermoid cyst. A clinical case]

The authors report a rare case of epidermoid cyst with interhemispheric growth closely connected to the anterior portion of the corpus callosum. Although extremely sensitive in determining the site, dimensions and relations of the lesion, NMR does not allow the nature of this pathology to be diagnosed owing to the lack of signal specificity. CT, using the measurement of Hounsfield units, allows a differential diagnosis of epidermoid cysts and arachnoid cysts and lipomas to be made in almost all cases. Treatment is surgical and the complete excision of the capsule avoids recidivation.

Inflammatory pseudotumour of soft tissues: a clinicopathological and immunohistochemical analysis of 18 cases

Pseudosarcomatous proliferation of myofibroblasts, fibroblasts and inflammatory cells have been reported in a wide variety of sites and are most commonly termed inflammatory pseudotumours. Despite increasing recognition, the occurrence of inflammatory pseudotumour in somatic soft tissue is poorly documented, such that these lesions are commonly mistaken for a variety of benign and malignant neoplasms. This report documents our experience of 18 cases of soft tissue inflammatory pseudotumour. All arose in adults (median age 54.5 years; range 28-83 years) and showed no sex predilection. Anatomical location was varied but the head and neck region and abdominal cavity were most common. They displayed a spectrum of histological appearances but all were characterized, to a greater or lesser extent, by an admixture of myofibroblasts and fibroblasts, most commonly arranged in short interwoven fascicles, together with a polymorphic inflammatory cell component, consisting principally of lymphocytes and plasma cells. In some cases xanthoma cells were prominent. Simple surgical excision appeared to be curative. The importance of recognizing the presence of a wide clinicopathological spectrum is emphasized and the differential diagnosis, especially from fibrohistiocytic neoplasms or Hodgkin's disease, is discussed.

[The variation of the vestibular response vs. the variations of the auditory threshold after administration of glycerol in patients with Meniere's disease]

Vestibular and auditory functions after glycerol intake were assessed correlated in twenty-eight patients diagnosed as menieric according to AAOO criteria. All patients had unilateral Ménière's disease confirmed by monolateral hypoacusia and labyrinthine hypofunction. Hearing thresholds were tested by tone-audiometry, according to the standard glycerol test. Variation in vestibular response were assessed comparing the VOR during the rotatory sinusoidal test as well as the caloric test, before glycerol intake and 2 hours after drug administration. Slow phase angolar velocity, directional preponderance percentile and percentile variation between basic and control observation were calculated. The audiometric glycerol test was positive in 58% of the cases. The vestibular glycerol test was positive in 30% of the cases and no correlation between and individual results hearing threshold result was found. The findings reported by other Authors regarding auditory and vestibular responses to glycerol intake were verified. Possible reasons which may account for variation with regard to reaction patterns in the acoustic and non acoustic labyrinth after glycerin administration are discussed. In the Authors' view, incoherence between vestibular and cochlear response might be linked to differences in the physiology of the fluid in the two labyrinths. In the vestibular district, glycerol might induce an early depletive effect and a later paradoxal effects due to mechanical modification of the ampulla function.

Plasma cell granuloma of the thyroid associated with Hashimoto's thyroiditis

A patient was diagnosed with plasma cell granuloma (PCG) of the thyroid associated with a fibrous variant of Hashimoto's thyroiditis (HT), after total thyroidectomy. Immunoperoxidase staining of the mass in the left lobe revealed polyclonal lambda and kappa chains. A literature search was conducted to determine other cases of such an association. Five other cases of PCG of the thyroid were found in the literature. None of them was associated with HT. This case-report confirms the possible association of HT with either plasmacytoma or PCG, previously only hypothesised.

[Primary angiosarcoma of the thyroid. Presentation of a case (epithelioid type) and nosological problems]

There is a great deal of confusion in the literature as to whether or not true angiosarcomas of the thyroid exist or whether these are all anaplastic carcinomas of the thyroid which have an angiosarcomatoid appearance. Due to the fact that undifferentiated carcinomas of this organ can strikingly resemble various sarcomas it is recommended that great care should be taken prior to qualify as an angiosarcoma a malignant thyroid tumor. A lot of viewpoints have been expressed so far in literature concerning this theme, and they can be summarized as follows. On one side and not admitting the existence of angiosarcoma in this location there are opinions which think of it as a "variant" of undifferentiated carcinoma (a pure carcinoma with a pseudovascular pattern or a carcinoma with an intermingled non-neoplastic reactive vascular component), or as a neoplasm in transition from epithelial to endothelial differentiation ("mesenchymal neometaplasia"), or as a carcinoma with aberrant expression of endothelial markers, or as a carcinoma with a non-specific uptake of endothelial antigens(e.g. from serum in case of F-VIII R-Ag positivity). On the other side there are opinions in favor of the existence of such an entity, based upon light microscopy features coupled with immunocytochemical results (endothelial antigens expression without or with cytokeratins expression) and with the possible support of electron microscopy. Anyway ultrastructural findings of specific markers (Weibel-Palade bodies, pericellular basal lamina, tight junctions, subplasmalemmal pinocytotic vesicles) according to some authors are not a prerequisite: so poorly differentiated neoplasma can fail to show those histogenetic markers.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary amyloid tumor of the breast. Case report and review of the literature]

Along with an introductory summary concerning practically with all types of amyloidoses the authors report on a case of a primary amyloid tumor in a female patient, which resulted the eight after a computer-assisted literature search. Amyloid deposits in the breast represent an extremely rare event, which has been described in three clinical settings, in patients with reactive or secondary amyloidosis, in patients with immunocytic amyloidosis (this term including both the so-called primary form and the myeloma-associated form), and finally even in patients who are well and otherwise asymptomatic. Amyloid deposits in the breast can occur in the course of a systemic involvement as well as in form of a localized or organ-limited disease ("amyloid tumor"). Further the latter form is qualified as a "secondary amyloid tumor" (in those patients affected by certain neoplastic diseases, plasmacellular or non plasmacellular, or by a chronic infectious-inflammatory-dysreactive process) or as a " primary amyloid tumor" in those who are found free of any disease and of any other amyloid deposits. The case the authors report on deals with a lady who was admitted due to a breast lump which mammographically was thought suspicious for malignancy by virtue of a cluster of variously sized microcalcifications. At histology the lesion was diagnosed as an amyloid deposit on special stains and disclosed of the AL type with Congo red stain on sections previously treated with KMn04, according to standard methods.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary microcytoma of the larynx. Case report, ultrastructural study and review of the literature]

Oat cell carcinoma of the larynx is a rare tumor. A throughout search of the literature revealed only 80 cases; the first case in literature was reported by Olofsson in 1972. The tumor often presents in the sixth and seventh decades of life and appears to be highly aggressive and metastases develop early. We have had the opportunity to study ultrastructurally a small cell carcinoma of oat cell type arising in the larynx.

[Inflammatory pseudotumor of the breast. Report of a case and review of the literature]

Inflammatory pseudotumor (IPT) truly represents an enigmatic entity. A tumor-like lesion known with many synonyms according to the various patronymic authors who named it on the basis of the different observed morphological appearances. Among these names plasma cell granuloma, plasma cell/histiocytoma complex, xanthomatous pseudotumor, xanthoma, fibrous xanthoma, histiocytoma, xanthogranuloma, inflammatory myofibroblastic tumor, inflammatory myofibrohistiocytic proliferation are just the most renown. The enigma consists in the fact that it can easily be misunderstood as a sarcoma with a marked inflammatory component just as reciprocally an inflammatory sarcoma can be misinterpreted as an IPT. As it was not enough some authors believe that some so-called IPT actually represent or may evolve into a true neoplastic process. For this reason a big debate has been raised concerning the biologic behaviour of this entity and a sense of scepticism often surrounds pathological diagnoses termed under this rubric. The predominant pattern is that of a plasma cell infiltration with a definitely histiocytic component and mostly bland spindle shaped cells which occasionally can look somewhat atypical, and can form fascicles in some areas. Anyway putting apart diagnostic misinterpretations, IPT pathogenetically is intended as the result of an inflammatory process mediated locally by an inappropriate production of monokines. It has been described in many different anatomic visceral and somatic sites, from the classical ones such as soft tissues and retroperitoneum to the most unusual such as nervous system and its covering to the most recently observed such as skin or lymph nodes or salivary glands. Breast is definitely an exoteric site of location of such kind of lesion. Only one case has previously been described. This case regards a lady aged 38 years which was locally treated by surgical excision: this case aside the standard microscopic examination was also studied immunohistochemically including proliferation markers (Ki-67/MIB-1) and on flow cytometry which are helpful means to confidently diagnose such entity. The differential diagnoses and diagnostic difficulties concerning the correct interpretation of this lesion are dealt with.

[Cerebral amyloid angiopathy (congophilic angiopathy): a rare cause of massive cerebral hemorrhage. Report of an "age-related" sporadic case]

Cerebral amyloidosis is a form of organ-limited amyloidosis, which doesn't involve any organ other than brain and which comprises several subtypes, including "congophilic angiopathy" (CA), "senile plaques" (SP), "neurofibrillary degeneration" (ND), "stellate amyloid cores" of spongiform encephalopathies. It is found in 5 to around 20% of human population in people aged 60 to 90 years, the increasing being strictly related to ageing. Usually it is associated to SP and occasionally to ND, being distinguished into familial and non-familial (age-related) variants. It affects intracortical and leptomeningeal variously sized vessels of the brain and is a leading pathogenetic factor in determining a rare but possibly even recurrent form of a massive intraparenchymal cerebral hemorrhage, constituting a 0.2 per cent of brain vascular accidents of any origin and a 5-10 per cent if only primary non traumatic brain hemorrhages are considered. A case of non-familial CA in a previously non-demented nor hypertensive female patient aged 65 years is reported on, who was admitted due to an almost abrupt onset of neurologic symptoms mainly dominated by a sudden loss of consciousness together with a left sensory-motor deficiency syndrome. The patient who had been operated on of unilateral mastectomy eight years earlier due to an invasive ductal carcinoma of the breast was found affected by a devastating brain hemorrhage in the right temporo-occipital lobes with subsequent deflection of the brainstem axis toward the opposite side detected by means of CT/MRI and angiographic investigations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tumor and tumor-like benign mesenchymal lesions of the breast]

All the spectrum is encompassed of those miscellaneous pathologic entities occurring in the mammary stroma which are on record up to date other than "mixed fibroepithelial" tumors (fibroadenomas and phyllodes tumors) and tumors both "pure" and "mixed" originating from myoepithelium (adenomyoepitheliomas and pleomorphic adenomas). Also they were excluded those dysreactive-autoimmune diseases (sarcoidosis, sclerosing lymphocytic lobulitis, lobular granulomatous mastitis) and those inflammatory-infectious conditions (tuberculosis, actinomycosis, foreign body reactions, Mondor's disease) which can mimick breast tumors clinically or on image analysis, but on the contrary not evoking the idea of a tumor on histology. Specifically, inflammatory pseudotumor, myofibroblastoma, leiomyoma, neurinoma/neurofibroma, benign fibrous histiocytoma, hemangiopericytoma, fibromatosis, nodular fascitis, variants of lipoma, mesenchymoma, amartoma and its variants, hemangiomas, pseudoangiomatous hyperplasia of stroma, amyloid tumor, granular cell tumor, are consecutively described and discussed, with a large list of references enclosed to each rubric. Most of the pictures are taken from personally observed lesions of the breast. Only few pictures referred to are from their analogue lesions which occurred in soft parts of other locations, with specific mention of that when it was the case. Of note after reviewing the literature the fact that no glomus tumor, nor Kaposi's sarcoma either sporadic or in the context of any immunodeficiency, nor myelolipoma has been recorded yet.

NERDS syndrome: an additional case report

NERDS is an eosinophilic disorder recently described by Butterfield and characterized by an association of nodules, eosinophilia, rheumatism, dermatitis and swelling. We describe an additional case, the third, of this new eosinophilic syndrome. The cardinal features included joint and cutaneous manifestations with prominent para-articular nodules and rheumatism, xerosis, recurrent urticarial eruption with angioedema associated with tissue and peripheral blood eosinophilia. A drug-induced (diclofenac) allergic rash and lymphadenopathy appeared during the course of the illness. Persistent leukocytosis with a maximum of 65% of eosinophils, mostly exhibiting the hypodense phenotype (activation index), was always present. During the acute phase of the disease, flow-cytometric analysis of blood and bone marrow revealed proliferation of activated CD4+/OKDR+ T helper cells and CD25+/OKDR+ eosinophils.

[Treatment of primary hepatocarcinoma with chemoembolization and alcohol injection. Personal experience]

The comparative efficacy of transcatheter arterial chemoembolization and percutaneous ethanol injection (PEI) in the treatment of hepatocellular carcinoma (HCC) was investigated in a series of 243 consecutive patients: 146 of them were submitted to 1-6 chemoembolization sessions at 1 and 3 months' intervals and 30 to PEI; the remaining 67 patients refused any treatment. The follow-up ranged 3 to 36 months. Survival rates were statistically analyzed with the life table analysis. Patients' survival was affected by the number of nodules and by Child's and Okuda's classes; no relationship was found between survival rates and histologic grade or nodule vascular feeding. In case of single lesions, chemoembolization was more effective than PEI in Okuda's class I. In case of multifocal HCC, chemoembolization was better than no treatment in Okuda's class I and Child's class A. In conclusion, we suggest chemoembolization as the treatment of choice in Child A or Okuda I patients with multifocal HCCs, while its use seems of little help in Child B-C or Okuda II-III patients. In case of unifocal HCC, PEI or surgical resection should be combined with chemoembolization.

[Primary splenic cysts. Report of 5 cases, 4 of which unpublished and review of the literature]

After a complete review of the literature with an amount of 280 previously reported cases, the authors report on five total cases of primary (true) cysts of the spleen one of which already published. All these cases occurred in pediatric age and were treated by total splenectomy. All were large solitary cysts (size ranged from 4.5 up to 15 cm) but one, the largest of which in addition to the main cavity exhibited some more microscopic cysts of the same type few mm sized. Three of them were lined on their inner surface by a multilayered squamous epithelium, which in one case was also keratinized. The other two cysts showed a single layered epithelium which appeared flattened in one case, cubic in the other one. The discussion concerns the pathogenetic mechanisms which can lead to cyst formation, the imaging diagnosis of these rare lesions prior to surgical intervention, their treatment, and the correct histological recognition of these true cysts versus secondary (false) cysts or pseudocysts which commonly occur following trauma. One of the cases herein presented qualifies as a "pseudo-pseudocysts" due to the fact that a history of trauma was on record and to the fact that almost the entire epithelium was mechanically lost due to hemorrhage which filled the cyst cavity.