Cryomyolysis in the management of uterine fibroids: technique and complications

Uterine fibroids are common benign tumors of the uterus and a major public health problem. Between 20 and 25% of women over 35 years of age are estimated to have fibroids. Three subtypes of fibroids are recognized depending on their relationship to the myometrium, namely, submucosal, subserosal and intramural. Fibroids are frequently asymptomatic, but may be associated with menorrhagia, dysmenorrhea, pregnancy loss or infertility. They are composed predominantly of smooth muscle, with a variable amount of connective tissue, and they have a characteristic smooth white whorled appearance on cross sectional examination.

Intraplacental smooth muscle tumor: a case report

We present the second reported case of a smooth muscle neoplasm involving the placental parenchyma. On gross examination, the tumor easily separated from the uterus and had a whorled cut surface with finger-like extensions into the villous parenchyma, very similar to the previously described case. The differential diagnosis included a primary smooth muscle tumor of the placenta (placental leiomyoma), a primary uterine neoplasm incorporated into the placenta, and a metastatic sarcoma. In this case, the infant was male, and the polymerase chain reaction technique demonstrated the presence of Y chromosome gene in the placental parenchyma and its absence in the placental neoplasm. Thus, this neoplasm, despite its gross appearance of a primary placental tumor, actually represented an incorporated benign uterine leiomyoma.

Epstein-Barr virus RNA detection and glandular differentiation in nasopharyngeal carcinoma: report of 2 cases

Most tumors arising in the nasopharynx are either squamous cell carcinoma or so-called undifferentiated carcinoma of the nasopharyngeal type. Primary adenocarcinomas of the nasopharynx are rare, and glandular differentiation in undifferentiated carcinoma of the nasopharyngeal type has not been reported to date. We report 2 cases of undifferentiated carcinoma of the nasopharyngeal type that show distinct glandular differentiation by light microscopy, histochemistry, immunohistochemistry, and ultrastructure. Both tumors showed equal positivity for Epstein-Barr virus latent membrane protein and in situ hybridization for Epstein-Barr virus genome in the undifferentiated areas of the tumor and those featuring glandular differentiation.

Pathogenesis of placental site trophoblastic tumor may require the presence of a paternally derived X chromosome

Placental site trophoblastic tumor (PSTT) is a neoplastic proliferation of intermediate trophoblasts that invades the myometrium at the placental site after a pregnancy. Less than 100 cases have been reported. Information of the sex assignment of the antecedent gestation is available in 21 cases: 18 of these were female. To explore this interesting phenomenon, we have determined the sex chromosome composition of the tumor tissue preserved in paraffin blocks for five new cases of this condition. The last documented gestational event included a normal vaginal delivery of female infants in three cases, normal vaginal delivery of an infant of unknown sex in one case and a molar gestation in one case. Using the X-linked human androgen receptor (AR) gene as a polymorphic marker, we showed that in all five cases the tumor had a likely XX chromosomal composition; and in four cases it was possible to determine that one of the X chromosomes was of paternal origin. In one case, the paternal X chromosome showed no polymorphism to either maternal X chromosomes. In addition, sensitive semi-nested PCR failed to show a human Y chromosome element in any of the five cases of PSTT. Overall, of 21 cases from the literature and 5 cases of ours, 89% (23 of 26) showed an XX genomic composition in PSTT, either by history or genetic analysis. These results suggest that most PSTT were derived from the antecedent female conceptus and were likely to have possessed a functional paternal X chromosome. Methylation status analysis at the AR locus was performed in the three PSTT in which the paternal X chromosome was identifiable. In two cases, the paternal AR locus was hypomethylated while the corresponding maternal locus was hypermethylated. The methylation status of other loci was not investigated. Collectively, sex chromosome analysis of five cases of PSTT with literature support suggests a unique genetic basis for the development of PSTT that involves the paternal X chromosome. Although largely speculative, an active paternal X chromosome may be of importance in the pathogenesis of PSTT.

Cytogenetical diagnosis in paraffin-embedded fetoplacental tissue using comparative genomic hybridization

Comparative genomic hybridization (CGH) is a FISH-related technique used to assess global chromosomal aberrations in a variety of human tumours. Recently CGH has been applied to cytogenetic analysis of fresh frozen fetoplacental tissues. Here we report the application of CGH to paraffin-embedded placental samples. Ten samples from paraffin-embedded blocks of 6 control placentas and fetoplacental tissue from 10 aneuploidies, and 2 unbalanced aberrations were evaluated. Balanced karyotype profiles were obtained from samples of healthy placentas and all samples from the same placenta appeared to have similar confidence intervals. CGH analysis of four cases of trisomy 21, three cases of trisomy 18, one case of trisomy 13, one case of trisomy 15 and one case of trisomy 7 all showed overrepresentation of the respective trisomic chromosome. The CGH profile was also in accordance with the karyotyping of a case with isochromosome 21. The CGH profile of a case with der (2)t(2;6)(q37.3;q22.2) revealed partial trisomy for chromosome 6 between q21 and q27. CGH may be a useful adjunct in prenatal genetic diagnosis when retrospective diagnosis is needed from archival samples.

Benign mesothelial cells in mediastinal lymph nodes

Inclusions of benign tissues in lymph nodes are most often aberrant glandular tissue, including endosalpingiosis, the thyroid, parotid, breast, and pancreas. Nonglandular inclusions are rare and include nevus cells and decidua. Mesothelial cells in lymph nodes are exceedingly rare; only eight cases have been reported in mediastinal lymph nodes and three cases in abdominal lymph nodes. The incidence of benign mesothelial cells in mediastinal lymph nodes in patients with a history of pericarditis or pleuritis is reported in this study. A retrospective search showed eight cases with removal of mediastinal lymph nodes in the absence of neoplasm. Hematoxylin and eosin-stained sections were examined in all cases. Immunohistochemical stains for CAM 5.2 were performed in all cases, and stains for AE1/AE3, Ber-EP4, carcinoembryonic antigen, Leu-M1, B72.3, and S-100 were performed in one case. CAM 5.2-positive cells with features of mesothelial cells were present in five of eight cases. In all cases, the cells were present in nodal sinuses and appeared as single cells or small clusters. The cells were missed on routine hematoxylin and eosin sections in all cases but one, in which they were numerous and mimicked metastatic carcinoma. Malignancy was not found in any of the cases preoperatively, at the time of surgery, or during the follow-up period. Benign mesothelial cells may embolize to regional lymph nodes in pleuritis or pericarditis. In most cases, these cells are few and undetectable on routine sections. Rarely, hyperplastic mesothelial cells may be present and must be distinguished from metastatic carcinoma, mesothelioma, and melanoma.

Immunohistochemical localization of inducible nitric oxide synthase on human fetal amnion in intra-amniotic infection

OBJECTIVES

Amniotic fluid levels of nitric oxide metabolites are significantly elevated in intra-amniotic infection. We hypothesized that fetal amnion is a possible site for the production of nitric oxide. Because inducible nitric oxide synthase is the key enzyme responsible for the generation of nitric oxide in patients with intra-amniotic infection, we used immunohistochemistry to localize it on human fetal amnion.

STUDY DESIGN

Human fetal amnions were obtained from patients with and without intra-amniotic infection (n = 5, respectively). Intra-amniotic infection was diagnosed by positive amniotic fluid cultures and placental pathologic features. Human fetal amniotic membranes were processed into tissue blocks and embedded in paraffin. A rabbit polyclonal antibody against human inducible nitric oxide synthase was used as the primary antibody, followed by avidin-biotin immunoperoxidase localization. Normal rabbit serum was used as a negative control and ovarian carcinoma cells were used as the positive control.

RESULTS

Anti-inducible nitric oxide synthase labeling of human fetal amniotic membranes in patients with intra-amniotic infection showed positive immunostaining of epithelial cells, specifically in the cytoplasm of the perinuclear area. In contrast, no anti-inducible nitric oxide synthase immunostaining on human fetal amniotic membranes could be identified in patients without intra-amniotic infection.

CONCLUSIONS

Our data provide important evidence that inducible nitric oxide synthase can be induced on human fetal amnion in intra-amniotic infection. These findings strongly support our hypothesis that human fetal amnion may be a possible site for the synthesis of nitric oxide after inducible nitric oxide synthase is induced in response to infectious products in intra-amniotic infection.

Liesegang rings and endometriosis

Liesegang rings (LRs) are acellular, ringlike structures that may from within and around inflamed or necrotic tissue. LRs are most commonly found within the kidneys, synovium, and eyelid and in association with pelvic inflammatory disease and other infectious processes. LRs are only rarely found within the female genital tract, usually within endometriotic cysts or around areas of chronic inflammation. Three additional patients with LRs associated with endometriosis are described. In one of them, LRs occurred at the edge of an endometriotic cyst adjacent to a well-differentiated endometrioid adenocarcinoma of the ovary. All cases were characterized by the presence of multiple eosinophilic, sharply demarcated ringlike structures that were highlighted by the periodic acid-Schiff method. LRs within the female genital tract, which appear to be closely related to endometriosis, should be distinguished from both benign or malignant processes.

Immunohistochemical detection of Listeria antigens in the placenta in perinatal listeriosis

Listeria monocytogenes, a worldwide pathogen, causes significant perinatal mortality and morbidity and has been implicated in spontaneous abortions, still-births, premature delivery, and neonatal sepsis, often with meningitis. Maternal symptoms are frequently minimal, and diagnosis is made only if the suspicion is high and diagnostic maternal blood or amniotic fluid cultures are performed. Because cultures are not routinely performed on spontaneously aborted fetuses, many authors feel that the true incidence of the disease may be underestimated. To date, the absence of a test to retrospectively diagnose Listeria infection has contributed to the lack of accurate estimates of the incidence of the disease. Seven cases in which immunohistochemical stains were used to confirm the diagnosis of placental listeriosis are described. All placentas showed the characteristic lesions with severe chorioamnionitis, numerous microabscesses, and focal necrotizing villitis. Immunohistochemical localization of Listeria antigen was made to the amnion (focally in areas with no inflammatory infiltrate), the abscesses, and the areas with villitis. In general, the antigen was extracellular and intracellular, predominantly within macrophages or the amnion epithelium. Listeria antigen was often found where definite identification of the organism was not possible on Brown-Hopps or Warthin-Starry stains. The immunohistochemical technique may therefore show an increase in sensitivity of detection of L monocytogenes compared with routine bacterial stains. Moreover, the ability to retrospectively evaluate placental specimens for evidence of this organism should permit the true incidence of perinatal listeriosis to be determined.

Necrosis of myometrial choriocarcinoma with fulminating sepsis complicating chemotherapy for trophoblastic tumor

We report a patient who developed metastatic gestational choriocarcinoma following delivery of a normal, healthy child that, however, was anemic and required blood transfusion. The patient developed secondary postpartum hemorrhage over a period of several weeks and required curettage and myometrial contractants to control the bleeding. At the time of diagnosis the patient had extensive pulmonary metastases and ultrasound showed full penetration of the myometrium by tumor. Immediately following the second course of chemotherapy with etoposide, methotrexate, and actinomycin D, alternating with cyclophosphamide and vincristine, the patient developed sepsis associated with a uteroperitoneal fistula and required hysterectomy. The sepsis was associated with disseminated intravascular coagulopathy and adult respiratory distress syndrome. However, the patient's tumor was exquisitely sensitive to chemotherapy and with good intensive care unit support and chemotherapy the survived without residual scar except for the loss of reproductive function. There are two lessons to be learned from these events: (1) The syndrome of secondary postpartum hemorrhage with a fetus that is anemic spells a diagnosis of choriocarcinoma; and (2) color Doppler flow vaginal ultrasound performed at the time of presentation of trophoblastic tumors may be useful to show full penetration of the myometrium by tumor which may be a warning of possible scar rupture in a subsequent pregnancy.

Subcapsular tubercular liver abscess

A young female married for the last 2 years but without any issue presented with lump in the right upper abdomen. This was proved to be a subcapsular liver abscess on USG and CT scan and proved to be tubercular on needle aspiration cytology. She was given four drugs antitubercular treatment (ATT). After four months of ATT she conceived and it was decided by both parents to continue the pregnancy. The three drug ATT was continued throughout the pregnancy and she delivered a perfectly healthy baby. Upto three months follow up the mother and baby were perfectly healthy. The subcapsular tubercular liver abscess is extremely rare and conception during treatment may be the first case in literature.

Fetal but not maternal serum cytokine levels correlate with histologic acute placental inflammation

Our objective was to determine if placental histologic acute inflammation is related to maternal and fetal serum cytokine levels in preterm labor, using a data set previously constructed blinded to histopathologic information. To this goal in 1992, 32 consecutive patients at 20-36 weeks with progressive labor and tocolytic failure were recruited. Maternal serum sampled during the active phase of labor, and fetal (umbilical vein) serum were assayed by ELISA for levels of soluble interleukin-1 beta (IL-1 beta), soluble interleukin-2 receptor (IL-2 R), and interleukin 6 (IL-6) (T-Cell Diagnostics). Acute placental inflammation was scored by two groups blinded to clinical data, and the average scores analyzed for relationships to serum cytokine levels. Weighted kappa values, reflecting interobserver agreement in scoring of acute inflammation, were: amnion 0.84; choriodecidua 0.84; umbilical cord 0.85; and chorionic plate 0.73. Fetal levels of IL-1 beta and IL-2 R were higher with grade 3-4 acute amnionitis than with grades 0-2 (p = 0.022 and p = 0.023). Fetal levels of all three cytokines were higher in grade 3-4 umbilical vasculitis (IL-1 beta p = 0.008, IL-2 R p = 0.01, and IL-6 p = 0.03). In contrast, maternal serum cytokine levels were not associated with presence or severity of histologic evidence of acute placental inflammation. Histologic acute inflammation was not related to duration of labor, interval from membrane rupture to delivery, and presence or duration of antibiotic therapy. We conclude that fetal serum, but not maternal serum cytokine levels, are correlated with histologic evidence of acute placental inflammation, and may reflect a predominant placental origin of the cytokines.

Endometrioid endometrial adenocarcinoma with psammoma bodies

Since the wide acceptance of serous carcinoma as a distinct subtype of endometrial carcinoma, almost all endometrial carcinomas with psammoma bodies have been classified as such. We describe eight cases of endometrioid endometrial adenocarcinoma with psammoma bodies and discuss their clinicopathologic features. The patients ranged in age from 37 to 79 years. Psammoma bodies were present in the curettage material in three and in the hysterectomy specimens in all cases. The tumors were well to moderately differentiated with at least focal squamous metaplasia. Four of eight cases also showed a focal villoglandular architecture. Inflammation and necrosis were present in all cases, and four had features of pyometra. Deep myometrial invasion was present in six cases. Diffuse lymphatic invasion was present in six, and one showed perivascular lymphocytic infiltrate in the absence of myometrial invasion. The tumors metastasized to lymph nodes in four of eight cases. One case showed intranodal psammoma bodies in the absence of endosalpingiosis or tumor. Intra-abdominal recurrence was present in only one case and was endometrioid with rare psammoma bodies. All patients are alive, six with no evidence of disease, one with stable periaortic lymphadenopathy, and one with progressive disease. This report suggests that endometrioid endometrial carcinoma may rarely be associated with psammoma bodies, the formation of which is most likely due to inflammation and necrosis. It also suggests that endometrioid carcinoma with psammoma bodies has a higher surgical stage and is more likely to have lymphatic invasion and lymph-node metastases and hence require surgical staging. The pattern of spread appears to be different from uterine papillary serous carcinoma, and the rate of survival is similar to stage-matched endometrioid carcinoma without psammoma bodies.

Quantitative differences in arterial morphometry define the placental bed in preeclampsia

The purpose of this study was to quantitatively analyze normal and preeclamptic uteroplacental vasculature. Myometrial arteries from eight placental bed biopsies from uncomplicated term deliveries and 12 from proteinuric preeclampsia were characterized as uteroplacental, spiral, or basal arteries. Basal lumens within 0.2 mm radius and spiral/uteroplacental lumens within 0.4 mm radius were considered as the same artery. The biopsy area, lumen density, and arterial density (after correction for multiple lumens), lumen area, lumen perimeter, mean wall thickness, inflated diameter, and a slant factor, measuring the obliqueness of arterial transection, and ratios of lumen characteristics to mean wall thickness were analyzed. In preeclamptic cases, there were more basal lumens/mm2 and basal arteries/mm2 (P=.003, P=.03), and more spiral lumens/mm2 and spiral arteries/mm2 (P = .01, P = .03). Basal lumen area (P = .0003) and wall thickness (P = .007), and basal and spiral artery lumen perimeters and inflated diameters (for each, P = .0001, P = .048, respectively) and inflated diameter/wall ratios (P = .04, P = .05) were reduced compared with normal cases. Preeclamptic spiral and basal arteries are more tortuous or densely distributed than normal placental bed arteries, with smaller-caliber lumens and thicker walls. Failure of proper placentation may result in abnormal spatial anatomy in the placental bed. Alternatively, an anatomic variant of spiral and basal arteries may be more susceptible to hemodynamic stresses and endothelial damage and may predispose to preeclampsia.

Transformation of ovarian dysgerminoma to yolk sac tumor: evidence for a histogenetic continuum

Dysgerminoma has traditionally been considered an end-stage neoplasm without potential for further differentiation. Although there have been several reports of transformation of testicular seminoma to yolk sac tumor, a similar event has not been previously reported in dysgerminoma of the ovary. Three cases of ovarian germ cell tumor (two pure dysgerminomas and one mixed germ cell tumor with dysgerminoma and yolk sac components) that revealed histologic changes compatible with early transformation to yolk sac tumor are described. In general, the areas of transformation were located at the periphery of the tumor lobules which otherwise had features of typical dysgerminoma. They were characterized by the presence of microcysts and small glandular structures, which though not readily identified on H&E became more evident with stains for keratins, alpha-fetoprotein, and blood group-related antigen. The small size and focal nature of change, and the apparent transition favor the interpretation that this change represents transformation rather than admixture of two germ cell components. The relationship of dysgerminoma to the solid variant of yolk sac tumor is discussed and an alternate histogenetic scheme in which dysgerminoma represents the stage of earliest differentiation from which other non dysgerminomatous tumors may arise is presented. Although previously proposed for testicular germ cell neoplasia, this scheme has not yet been applied to their ovarian counterparts.

The fate of the skin graft in laryngoplasty

In laryngoplasty procedures, laryngotracheal soft tissue defects are often repaired using skin grafts. While stenting is necessary to approximate and immobilize the graft, prolonged stenting causes increased bacterial counts, granulation tissue formation, tissue ischemia, and graft failure. Optimal time for stent removal has not been experimentally defined. Using the ferret animal model, 24 laryngoplasty procedures were performed. The subjects were stented by group for 0, 3, 7, 14, or 28 days. Analysis consisted of quantitative bacteriology, dye perfusion, and quantitative histologic assessment of graft viability. Tissue culture results revealed that by 3 days after the procedure all groups had 10(5) CFU of bacteria per gram of tissue. Graft viability in successful procedures was maximal in the 7-day group and statistically significant from the 3-day to the 28-day groups. In conclusion, while stenting is necessary for graft adherence, prolonged exposure to local tissue sepsis leads to progressive graft destruction.

Desmoplastic small round cell tumor of the pleura

Three cases of desmoplastic small round cell tumor (DSRCT) with multiphenotypic differentiation, primary in the pleura, are presented. This is a previously unrecognized site for this tumor type. Two patients were male and one female aged 29, 24, and 17 years. All presented with chest pain and were found to have pleural-based tumors associated with pleural effusion. Abdominal involvement was not present in any of the cases. Histologically, the tumor showed the characteristic features of intra-abdominal DSRCT, including angulated nests of small cells embedded in a vascular fibroblastic stroma, focal rhabdoid phenotype, and areas of central necrosis. The neoplastic cells showed evidence of epithelial, mesenchymal, and neural differentiation with characteristic dot-like positivity for vimentin and desmin topographically corresponding to perinuclear aggregates of intermediate filaments identified on electron microscopy in one case. Two patients died of disease 2 years and 15 months after presentation, respectively, and one patient is alive with disease 18 months after presentation. The histogenesis of DSRCT is unknown. Most previously reported cases involved the peritoneum or tunica vaginalis, suggesting a histogenetic relationship to the mesothelium. The occurrence of these tumors in the pleura lends further support to this theory.

Uterine papillary serous carcinoma after radiation therapy for carcinoma of the cervix

This article describes the clinicopathologic features of six cases of uterine papillary serous carcinoma (UPSC), which developed several years after radiation therapy (RT) for cervical carcinoma. The possible etiologic role of radiation is discussed, and the literature on endometrial carcinomas developing after RT is reviewed.

Action of kinetin on cotyledons of fenugreek

Isolated cotyledons of fenugreek (Trigonella foenum graecum L.), which respond rapidly and specifically to the application of cytokinins with stimulated expansion, have been used to study the primary action of kinetin. Gross chemical analysis showed that ribonucleic acid increased within 24 hours in response to kinetin application. 8-Azaguanine inhibited both kinetin-induced expansion and RNA synthesis; 5-fluorodeoxyuridine inhibited only the RNA synthesis.Cotyledons produced nitrate reductase activity in response to 20 mm nitrate only in the presence of either light or kinetin and especially in the presence of both. Abscisic acid and inhibitors of RNA and protein synthesis depressed this response. Inhibitors affecting chloroplast development and function did not reduce the response in the presence of light and kinetin.In vitro incorporation of (14)C-l-leucine and (14)C-l-phenyl-alanine into protein by various recombinations of microsomal and 160,000g supernatant fractions varied according to the pretreatment which the cotyledons had received before the preparation of the fractions. Stimulatory effects were mainly associated with the microsomal fractions.The formation of leucine-, valine-, and tyrosine-tRNA complexes by high speed supernatant fractions from differently pretreated cotyledons was also compared. The sharp stimulation of the process by adding tRNA was found to be independent of the kind of preincubation that the cotyledons used for the tRNA extraction had received.It is concluded that the evidence is not in favor of kinetin correcting specific tRNA deficiencies. Kinetin removes a limitation that prevents the synthesis of RNA and genome expression.