Presence or absence of intestinal metaplasia but not its burden is associated with prevalent high-grade dysplasia and cancer in Barrett's esophagus

Universal agreement on the inclusion of intestinal metaplasia to diagnose Barrett's esophagus (BE) is lacking. Our aim was to determine the association of intestinal metaplasia and its density with the prevalence of dysplasia/cancer in columnar lined esophagus (CLE). Patients with CLE but no intestinal metaplasia (CLE-no IM) were identified by querying the clinical pathology database using SNOMED codes for distal esophageal biopsies. CLE-IM patients were identified from a prospectively maintained database of BE patients. Subsequently, relative risks for prevalent dysplasia and cancer were calculated. Since patients with CLE-no IM are not usually enrolled in surveillance, only prevalent dysplasia/cancer on index endoscopy was analyzed. Goblet cell density and percent intestinal metaplasia were estimated. All biopsy slides were reviewed for dysplasia by two experienced gastrointestinal pathologists. Two hundred sixty-two CLE-IM and 260 CLE-no IM patients were included (age 64±12 vs. 60±11 years, P=0.001; whites 92% vs. 82%, P=0.001; males 99.7% vs. 99.3%, P=NS; CLE length 3.4±3.2 vears 1.4±0.4 cm, P=0.001 and hiatus hernia 64% vs. 56%, P=0.013). The odds of finding low-grade dysplasia and of high-grade dysplasia (HGD)/cancer were 12.5-fold (2.9-53.8, P=0.007) and 4.2-fold (95% CI 1.4-13, P=0.01) higher, respectively, in the CLE-IM group. Reanalysis after controlling for important variables of age, race, and length did not significantly alter the overall results. In CLE-IM group, when patients with high (>50/LPF) versus low goblet cell density (<50/LPF) and <10% versus >10% intestinal metaplasia were compared, the odds of HGD/cancer, OR 1.5 (0.5-4.9, P=0.5) and 1.97 (0.54-7.22), respectively, were not significantly higher. Demonstration of intestinal metaplasia continues to be an essential element in the definition of BE, but its quantification may not be useful for risk stratification of HGD/cancer in BE.

Evaluation of the updated confocal laser endomicroscopy criteria for Barrett's esophagus among gastrointestinal pathologists

Previously developed novel probe-based confocal laser endomicroscopy (pCLE) criteria have been found to have high accuracy and substantial interobserver agreement (IOA) for diagnosing dysplasia in Barrett's esophagus (BE) when used by endoscopists. These updated criteria are: (i) epithelial surface: saw toothed, (ii) cells: enlarged, (iii) cells: pleomorphic, (iv) glands: not equidistant, (v) glands: unequal in size and shape, and (vi) goblet cells: not easily identified. The accuracy and IOA among pathologists in the diagnosis of dysplasia using the novel pCLE criteria is not known. The primary objective of the study was to evaluate the accuracy, overall IOA and learning curve among three gastrointestinal (GI) pathologists in diagnosing dysplasia in BE using the updated pCLE criteria. The secondary aim was to compare the accuracy and IOA between GI pathologists and gastroenterology endoscopists. Ninety pCLE videos and respective histology were retrieved from a previously conducted multicenter, prospective, randomized, controlled trial evaluating the utility of pCLE in BE patients. Videos were obtained from 101 BE patients previously enrolled for surveillance or endoscopic treatment of high-grade dysplasia or early esophageal adenocarcinoma. Three GI pathologists reviewed 90 pCLE video clips for dysplasia versus no dysplasia, confidence in their diagnosis, and image quality. The overall accuracy for the diagnosis of dysplasia (low-grade dysplasia/high-grade dysplasia/esophageal adenocarcinoma) was 77.8% (95% confidence interval [CI]: 72.4-82.3). The accuracy was higher when pathologists had 'high confidence' in their assessment of the videos (93.8% vs. 69.3%, P < 0.001). There was no significant difference in accuracy between the first set of 30 and second set of 60 videos (84% vs. 74%, P = 0.065). IOA among GI pathologists was substantial, k = 0.65 (95% CI: 0.53-0.73). The sensitivity for detecting dysplasia was 85% (95% CI: 78.1-90.7) and the specificity was 70% (95% CI: 61.91-77.92). These results were comparable with the evaluation of the same set of videos by endoscopists. GI pathologists have high accuracy and substantial IOA for diagnosing BE dysplasia with pCLE. Pathologists appear to have similar accuracy and IOA as endoscopists. These results provide further support of endoscopists accurately interpreting the in vivo optical histology provided by pCLE.

Cerebral, myocardial and cutaneous ischemic necrosis associated with calcific emboli from aortic and mitral valve calcification in a patient with end-stage renal disease

We report the case of a 57-year-old diabetic male with chronic renal failure who developed secondary hyperparathyroidism and calcification of mitral and aortic valves and interatrial septum. Multiple ischemic lesions developed in the skin of hands, feet and penis, and in the brain, and these were presumed to be due to septic emboli from cardiac valvular infective endocarditis. Multiple blood cultures were negative, however, and despite antibiotic therapy the patient expired. Autopsy (limited to trunk) demonstrated multiple calcific emboli in the heart and spleen, apparently derived from the prominent calcific deformities in the aortic and mitral valves. These were associated with acute and organizing myocardial infarcts and acute splenic infarcts, suggesting that the multiple ischemic lesions in the brain were also due to calcific emboli. A possible contributory component of infective endocarditis, however, was indicated by postmortem cultures of aortic and mitral valves positive for Enterococcus faecium. Calcific embolism is a rarely recognized but potentially lethal complication of end-stage renal disease, and the clinical diagnosis and the preventive therapeutic options for the control of the product of calcium and phosphate and/or parathyroidectomy should be considered.

Scabies associated with radiation therapy for cutaneous T-cell lymphoma

Scabies, infection with Sarcoptes scabiei, is known to be predisposed to by poor body hygiene, environmental exposure, and systemic immunodeficiency. We report the case of an 83-year-old man with Sezary's syndrome who developed scabies limited to the skin of the upper chest, the same location where he had previously received electron beam radiation treatments for cutaneous T-cell lymphoma. Histologic and immunohistochemical studies demonstrated that sections of the previously irradiated right and left chest skin, compared to non-irradiated chest, abdominal, and leg skin, had infestation by scabies, diminished involvement by T-cell lymphoma, and notably reduced numbers of Langerhans cells. These findings suggest that the development of scabies may be predisposed to by local cutaneous radiation therapy, and that it may be mediated by local cutaneous immunodeficiency secondary to reduced numbers of Langerhans cells.

Adenocarcinoid of ileum and appendix, incidentally discovered during exploratory laparotomy for gastric MALT lymphoma, with subsequent diffuse prostatic metastases: report of a case with light, immunohistochemical, and electron microscopic studies

The diagnosis of adenocarcinoid (mucinous/goblet cell carcinoid) is usually unexpected by both clinicians and pathologists. We report here the case of a 74-year-old man with gastric lymphoma (B-cell MALToma) diagnosed by endoscopy, who was found on exploratory laparotomy also to have extensive intraabdominal involvement by adenocarcinoid, arising from the ileum and/or appendix. The patient died two years after diagnosis with bladder outlet and small bowel obstruction due to diffuse metastases. In addition to mucin positivity, immunohistochemical stains demonstrated the tumor to be positive for chromogranin, synaptophysin, serotonin, gastrin, and glucagon. Of histogenetic interest, some individual neoplastic cells appeared to be positive for both mucin and chromogranin, and this was confirmed by the electron microscopic finding of microvilli, intracytoplasmic mucin droplets, and neurosecretory granules involving the same neoplastic cells. This also appears to be the first reported case of adenocarcinoid associated with lymphoma and demonstration of histochemical/immunohistochemical and ultrastructural evidence of cellular components with dual mucinous adenocarcinoma and neuroendocrine features, and the second reported case to have prostatic metastases.

Prospective, multivariate evaluation of CLOtest performance

OBJECTIVES

To determine prospectively the effect of aspirin, nonsteroidal anti-inflammatory drugs, H2-receptor antagonists, proton pump inhibitors, alcohol intake, race, age, history of Helicobacter pylori eradication attempts, and gastric biopsy location on CLOtest performance.

METHODS

Biopsy specimens were obtained from the antrum, greater curve, and proximal stomach. One biopsy specimen from each site (except for the proximal stomach) was used for the CLOtest and two or more specimens were used for histopathology. Giemsa staining was used for the definitive determination of H. pylori status.

RESULTS

One hundred seventeen patients were included in the study, and 50 of these were infected with H. pylori. The sensitivity and specificity of an antral CLOtest, based on the results of Giemsa-stained sections from the antrum alone, were 72.7 and 98.6%, respectively, whereas they were 66.0 and 100% when based on the results of Giemsa-stained sections from all three gastric biopsy sites. The sensitivity and specificity of a body CLOtest, based on the results of Giemsa-stained sections from the body alone, were 80.5% and 93.4%, whereas they were 76.0% and 100% when based on the results of Giemsa-stained sections from all three gastric biopsy sites. Combining CLOtest results from the antrum and body increased CLOtest sensitivity to 82.0%. Univariate analysis revealed only one factor significantly associated with CLOtest concordance: absence of alcohol consumption (p < 0.02). Stepwise logistic regression demonstrated that absence of alcohol use again was independently associated with the concordance between overall CLOtest and all Giemsa-stained biopsy specimen results (p < 0.03) as well as between body CLOtest and body Giemsa-stained biopsy specimen results (p < 0.03). Additional independent and significant associations were noted between antral CLOtest-antral Giemsa-stained biopsy specimen results and no history of H. pylori eradication attempts (p = 0.04) and between body CLOtest-body Giemsa-stained biopsy specimen results and race (African-American) (p < 0.03).

CONCLUSIONS

Obtaining a gastric biopsy specimen from the antrum as well as from the body increased CLOtest detection of H. pylori. CLOtest performance was shown to be affected by several demographic and clinical factors.

Retrospective DNA ploidy analysis by image and flow cytometry in head and neck cancer

A retrospective analysis of DNA content (DNA ploidy) was conducted in formalin-fixed specimens from patients with advanced, unresectable head and neck cancer who were treated on a single defined protocol with accelerated fractionation radiation therapy and concomitant cisplatin (Platinol) chemotherapy. Specimens from 31 tumor sites were analyzed by image cytometry using the Feulgen staining method. Fifteen specimens were analyzed by flow cytometry after deparaffinization, nuclear disaggregation, and staining with propidium iodide. By image analysis, 10 (32%) of 31 specimens contained only diploid tumor cells, while 21 (68%) specimens exhibited at least one aneuploid tumor component. Seven of the eight tumors with a single G0/G1 peak by image analysis had a single peak by flow analysis. Five of the seven tumors with multiple peaks by image analysis had multiple peaks by flow analysis. Histology was also reevaluated, and tumor grade was determined, reflecting tumor cell differentiation based on keratinization, mitotic activity and the degree of nuclear polymorphism. For this well-defined patient population managed according to a uniform therapeutic approach, DNA ploidy status and histology provided a suggestion of prognostic separation; however, statistical significance was not obtained, most likely due to the small number of patients.

Short segment Barrett's esophagus: clinical and histological features, associated endoscopic findings, and association with gastric intestinal metaplasia

OBJECTIVES

To prospectively determine the clinical features, associated esophageal endoscopic lesions, associated gastric intestinal metaplasia, and prevalence of dysplasia and adenocarcinoma of short segment Barrett's.

METHODS

All patients undergoing upper endoscopy over a 5-month period were scrutinized for endoscopic features suggestive of short segment Barrett's, and, if present, multiple biopsies were obtained from the suspicious areas. Prevalence of gastric intestinal metaplasia was determined by obtaining biopsies from the antrum, body, and cardia.

RESULTS

Two hundred thirty seven patients were examined. Short segment Barrett's was suspected in only 42 patients, and traditional Barrett's was noted in 45 patients. Short segment Barrett's was confirmed by biopsy in 48%. Clinical presentation of short segment Barrett's was that of typical or complicated gastroesophageal reflux disease in 53%. A hiatal hernia was the most common associated esophageal endoscopic finding; however, none of the endoscopic findings differed significantly from findings of patients who did not have short segment Barrett's. Diagnosis of short segment Barrett's required histological analysis. A significant difference was noted in the prevalence of intestinal metaplasia between the esophagus and stomach in patients with Barrett's. No dysplasia or adenocarcinoma was detected in patients with short segment Barrett's.

CONCLUSIONS

Short segment Barrett's is a frequent finding in patients undergoing upper endoscopy. All patients with short tongues or patches of red mucosa lying less than 2 cm above the esophagogastric junction should be biopsied to exclude short segment Barrett's. Large scale endoscopic and histological surveillance studies along with long-term follow-up are required to clarify short segment Barrett's prevalence and cancer risk.

Nonfamilial tumoral calcinosis associated with chronic renal failure and secondary hyperparathyroidism: report of two cases with clinicopathological, immunohistochemical, and electron microscopic findings

The clinical and pathological findings, including those of immunohistochemical and ultrastructural studies, of two cases of tumoral calcinosis-like lesion (TCL) are described. Both cases were associated with chronic renal failure and hyperparathyroidism. One case presented as a rapidly growing 20-cm multiloculated, cystic, calcific gluteal mass on the sacrum, which was not clinically suspected to be related to hyperparathyroidism. The other case presented as a 2.5-cm calcific mass on the right foot that recurred after surgical excision as a 7-cm mass, which was clinically presumed to be related to secondary hyperparathyroidism. Light microscopic and immunohistochemical studies on both cases and ultrastructural studies on one case indicated that the calcifying process involved histiocytes and osteoclast-like giant cells of histiocytic origin lining the cystic cavities. Hydroxyapatite crystal formation and calcification appeared to develop predominantly from intracytoplasmic membrane bound vesicles and also from mitochondria. These findings are similar to those recently reported for familial tumoral calcinosis, which support its having a mechanism of calcification comparable with that of a TCL.

Endoscopic and histologic resolution of gastric pseudolymphoma (reactive lymphoid hyperplasia) following treatment with bismuth and oral antibiotics

Gastric pseudolymphoma is a rare disorder of unknown etiology that can undergo transformation into malignant lymphoma. This report describes the first case of a gastric pseudolymphoma associated with Helicobacter pylori infection that underwent complete clinical, endoscopic, and histologic resolution following treatment with bismuth subsalicylate, amoxicillin, and metronidazole. The eradication of Helicobacter pylori may have eliminated ongoing antigenic stimulation that has previously been postulated to be responsible for the development and subsequent progression of gastric pseudolymphoma.

Case reports: heterotopic brain tissue of middle ear associated with cholesteatoma

Heterotopic brain tissue reportedly occurs occasionally in various sites, including rare occurrences in the middle ear. Association with cholesteatoma in middle ear cases, however, has not been reported yet. In this article, the authors describe three cases of heterotopic brain tissue in the middle ear associated with cholesteatoma: a 3-year-old boy with recurrent meningitis resulting in right acute otitis media and bony dehiscence of the right attic; a 36-year-old man with chronic right ear infections, right radical mastoidectomy 2 years previously, and brain herniation through the tegmen tympani; and a 65-year-old man with chronic otitis for many years, right ear surgery 25 years previously, and extensive involvement of right middle ear ossicles and mastoid antrum by cholesteatoma. The heterotopic brain tissue in each of these cases was diagnosed by histologic examination, and its glial component was confirmed by immunohistochemical staining for glial fibrillary acidic protein. After a microscopic review of 40 additional surgical pathology cases of cholesteatoma, no evidence of heterotopic brain tissue was found. With these findings, it is suggested that the unusual occurrence of heterotopic brain tissue in the middle ear associated with cholesteatoma may result from local destruction of bone secondary to the cholesteatoma, otitis media, meningitis, or previous surgery.

Pulmonary mucinous cystic tumor. Case report with review of the literature

Mucinous cystic tumors of the lung are exceedingly rare. We describe the case of a 59-year-old white man with a left upper lobe mass documented on chest radiographs 11 years before thoracotomy. Grossly, the lobectomy specimen contained a 4.5 x 4.5 x 4.0 cm cystic gelatinous mass with complete occlusion of the anterior segmental bronchus by mucinous material. Although microscopically this pulmonary mucinous cystic tumor contained a focus of marked glandular atypia consistent with adenocarcinoma, the patient has remained free of recurrence or metastasis during 5 years of close postoperative follow-up. Pulmonary mucinous cystic tumors appear to have a remarkably favorable prognosis and should be distinguished from other common lung neoplasms.

Case report: gastric angiolipoma with chronic hemorrhage and severe anemia

Lipomas are benign tumors that are common in other sites but rare in the stomach. They are usually submucosal and, when symptomatic, are most often accompanied by gastrointestinal hemorrhage. Angiolipoma is a not uncommon benign lipomatous neoplasm with a characteristic vascular component that almost exclusively occurs in the subcutaneous tissue. A case of gastrointestinal angiolipoma, which appears to be only the second one reported, is discussed. The patient, a 69-year-old man, presented with signs and symptoms of chronic hemorrhage and severe anemia (hemoglobin 6, hematocrit 19.9). The patient's condition was found to have resulted from ulceration of the gastric mucosa overlying a submucosal angiolipoma, and the anemia resolved after local surgical resection of the tumor. Electron microscopic studies supported the light microscopic diagnosis of angiolipoma. The absence of fibrin thrombi in this and other nonsubcutaneous angiolipomas and the possible significance of the vascularity of these tumors is discussed. The literature regarding gastric lipoma and angiolipoma is reviewed.

Histologic features predictive of basal cell carcinoma recurrence: results of a multivariate analysis

Previous univariate analysis of 30 recurrent and 74 non-recurrent basal cell carcinomas identified 6 histologic parameters predictive of recurrence: distance to the closest resection margin, growth pattern, shape of cell groups, contour of invading edge, degree of peripheral palisading, and nuclear pleomorphism. Re-analysis of the data by multivariate analysis to select the few most important independent prognostic variables identified two parameters in each of two final models: resection margin distance and growth pattern (Model 1), and resection margin distance and shape of cell groups (Model 2). Based on these variables, a logistic regression equation could be derived for each model to calculate the predicted probability of recurrence or non-recurrence.

Lipohyperplasia of the ileocecal valve

Submucosal lipohyperplasia of the ileocecal valve (ICV) is reportedly a rarely diagnosed lesion of uncertain significance. Eight cases of ICV lipohyperplasia diagnosed in surgical specimens (seven resections, one biopsy) are reviewed: three cases were associated with right lower abdominal quadrant pain and ICV mass on barium enema or operative examination, two were associated with ICV mucosal acute inflammation and necrosis, and three were incidental in resections for cecal, appendiceal, and sigmoid neoplasia. To evaluate the frequency of ICV lipohyperplasia and any associated processes, a series of 51 autopsies was studied. Regarding lipohyperplasia in these valves, 10 (19.6%) were determined to have none, 14 (27.5%) were mild, 20 (39.2%) were moderate, and 7 (13.7%) were marked cases. Degree of lipohyperplasia correlated statistically with degree of cardiac right ventricular fatty infiltration (p = 0.0001), pancreatic fatty infiltration (p = 0.0314), and greater body weight of patient (p = 0.0009). No definite correlation was demonstrated with left ventricular, adrenal, or lymph node fatty infiltration, or with hepatic fatty change, body height, age of patient, or blood glucose. Various gastrointestinal symptoms and lesions accompanied lipohyperplasia, but no definite causal relationship was identified, except for one case of marked lipohyperplasia associated with marked mucosal necrosis and acute inflammation of ICV. In conclusion, ICV lipohyperplasia is a common finding that occasionally may be associated with clinical symptoms and other valve pathology. It correlates to some extent with right ventricular and pancreatic fatty infiltration and with greater body weight.

Polypoid adenosquamous carcinosarcoma of the epiglottis with blastomatous features

A case is reported of polypoid adenosquamous carcinosarcoma with blastomatous features arising in the epiglottis. A 69-year-old man with hoarseness and sore throat was found to have a six cm pedunculated mass located on the epiglottis. Upon examination by light microscopy, it was found that the tumor was composed of not only well to poorly differentiated in situ and invasive squamous cell carcinoma but also adenocarcinoma with blastomatous features and a malignant primitive stroma, with features of undifferentiated sarcoma and focal chondrosarcomatous differentiation. To the best of our knowledge, this appears to be the second case of laryngeal adenosquamous carcinosarcoma with blastomatous features reported in the English literature and the third case in the world literature.

Histologic evolution of basal cell carcinoma recurrence

The biological behavior and appropriate therapy of recurrent basal cell carcinoma (BCCA) is controversial, with some studies suggesting that this tumor becomes more aggressive with each recurrence, and other studies indicating that the majority are aggressive from the onset. The authors studied the histologic evolution of BCCA by comparing 29 original tumors with their subsequent recurrences to determine if there were any predictable histologic changes. There were borderline statistically significant changes only in degree of fibrosis, prominence of nucleoli, and mitotic frequency. There were no statistically significant changes in any of the other parameters, including those that were shown previously to be predictive of recurrence or aggressive behavior. The results of this study clearly indicate that the majority of recurrent BCCAs are aggressive from the onset, and that in many cases this can be predicted from the histomorphology of the original tumor.

Metastatic basal cell carcinoma: report of a case presenting with respiratory failure

Metastasis from basal cell carcinoma (BCC) of skin is rare. A case of a 58-year-old male presenting with increasing shortness of breath and right pleural effusion is described. Open right pleural biopsy demonstrated metastatic carcinoma consistent with BCC. Review of medical records from another hospital revealed that four years previously a recurrent BCC had been excised from the left back. One and three years prior to this excision, a skin lesion at this same site had been treated with electrocautery. Review of the skin excision slides demonstrated infiltrating BCC histologically very similar to the metastatic pleural neoplasm. The patient died two months after the pleural biopsy. At autopsy, the cutaneous BCC had not recurred and metastatic BCC extensively infiltrated the pleura bilaterally, with focal involvement of underlying lung parenchyma, subcarinal lymph nodes, diaphragm, and pericardium.

Subdural hematoma associated with metastatic neoplasms

Two cases of subdural hematoma, one acute and the other chronic, associated with cancer metastatic to the dura are reported. Various mechanisms of the association of hematomas with cancer are reviewed.

Intradiploic arachnoid cysts. Report of two cases

Two patients are presented in whom cranial arachnoid cysts developed as diverticuli of the arachnoid membrane through small defects in the dura mater, eroded through the inner table, expanded within the diploe, and eroded the outer table of the skull. Based on observations at the time of surgery and the histological examination of these lesions, it is proposed that they are congenital in origin. Previously reported cases of "traumatic arachnoid cyst without fracture," "intradiploic cerebrospinal fluid fistula," and "middle fossa pitholes" appear to represent the same pathological process as the lesions reported in this paper. It is proposed that "intradiploic arachnoid cyst" is the most appropriate term by which these lesions should be described.

Factors predictive of recurrence of basal cell carcinoma

Thirty recurrent basal cell carcinomas were compared with 74 nonrecurrent basal cell carcinomas to identify clinical and histologic features predictive of recurrence. Three clinical parameters were evaluated: age, duration, and location; only location proved to be of prognostic significance. Among the histologic parameters, statistically significant differences between the recurrent and nonrecurrent groups were found in: measured distance to the resection margins, shape of cell groups, growth pattern, contour of invading edge, and degree of peripheral palisading and nuclear pleomorphism. Degree of fibrosis, cystic change, and atypical squamous change were of possible prognostic significance. There were no statistically significant differences between the two groups regarding: measured depth of invasion and diameter, degree of inflammation, actinic change, tumor necrosis, nuclear hyperchromasia, nucleoli, mitoses, amount of melanin or amyloid, and size of cell groups. Based on histologic findings, the pathologist may in many cases be able to suggest to the surgeon which tumors are more likely to recur and therefore require more aggressive therapy.

Aspergilloma within cavitating pulmonary adenocarcinoma

Pulmonary aspergillosis not infrequently occurs secondary to various malignancies and their associated therapies, but the simultaneous occurrence of Aspergillus and lung cancer is rare. The authors report the case of a 64-year-old male, who presented with a cavitating left upper lobe lesion radiologically, consistent with either fungal infection or carcinoma. Pathologically, the lesion was a thin-walled adenocarcinoma with a large central cavity containing an aspergilloma intermingled with highly necrotic tumor. This represents the fifth such reported case.

Dual carcinoid tumors of Meckel's diverticulum presenting as metastasis in an inguinal hernia sac: case report with literature review

Neoplasms arising in Meckel's diverticulum or involving hernia sacs are rare. The authors present a unique case of two asymptomatic carcinoid tumors arising in a Meckel's diverticulum, which were discovered because of microscopic metastasis in a grossly unremarkable inguinal hernia sac. This article describes the clinical and morphologic features of this unusual case, reviews the topic of neoplasms involving hernia sacs and Meckel's diverticula, and includes a brief review of immunocytochemical findings in carcinoid tumors.

Adenocarcinoma of the lung: a comparative diagnostic study using light and electron microscopy

Several techniques for diagnosing adenocarcinoma of the lung are commonly available, but the frequency of their use and diagnostic sensitivity may vary. Twenty cases of primary lung adenocarcinoma obtained at surgery were studied by the following four routine techniques: light microscopy (LM) using hematoxylin-eosin (H&E) stain, mucicarmine stain, and PAS-diastase stain, and electron microscopy (EM). Three observers independently determined the positivity (0 [none], +/- [equivocal], 1 + [slight], 2 + [moderate], 3 + [marked]) of each of these cases for lumen formation in H&E-stained sections (LM lumens), intracytoplasmic (cytoplasmic mucicarmine) or intraluminal (luminal mucicarmine) mucicarmine, intracytoplasmic (cytoplasmic PAS) or intraluminal (luminal PAS) PAS-diastase, and lumen formation (EM lumens) or microvilli (EM microvilli) on electron microscopy. Comparative matching of these seven microscopic determinants (using Wilcoxon signed-rank test) demonstrated significant (P less than .01) sensitivity of EM microvilli over EM lumens, EM microvilli over luminal mucicarmine, cytoplasmic PAS over luminal mucicarmine, EM microvilli over cytoplasmic mucicarmine, cytoplasmic PAS over cytoplasmic mucicarmine, and EM microvilli over LM lumens, and a significant (P less than .05) sensitivity of cytoplasmic PAS over LM lumens, EM microvilli over luminal PAS, luminal PAS over luminal mucicarmine, and cytoplasmic PAS over EM lumens. Friedman's nonparametric test (P less than .05) indicated a significant difference among the microscopic determinants. The most sensitive was EM microvilli (mean rank score, 5.17) followed by cytoplasmic PAS (4.77), luminal PAS (4.02), cytoplasmic mucicarmine (3.62), LM lumens (3.52), EM lumens (3.47), and luminal mucicarmine (3.40). However, each of the diagnostic techniques had case examples positive for one, but not for the others, indicating that maximum yield of adenocarcinoma diagnoses will be obtained by performing all four techniques (H&E, mucicarmine, PAS-diastase, and electron microscopy.

Systemic talc granulomatosis associated with disseminated histoplasmosis in a drug abuser

A 32-year-old intravenous drug abuser was found to have systemic talc granulomatosis and disseminated histoplasmosis. The clinicopathologic findings of this case support the hypothesis that the patient was predisposed to disseminated histoplasmosis by repeated intravenous talc administration. The effects of silica, a close relative of talc, on macrophages and the role of macrophages in recovery from Histoplasma capsulatum infection are described.

Liposarcoma of pleural cavity with recurrence as malignant fibrous histiocytoma

The case of a 54-year-old male, with a massive right pleural liposarcoma weighing over 3200 g, is presented. The tumor was found by light and electron microscopy to be of well-differentiated and pleomorphic subtypes, and it apparently represents the sixth reported case of liposarcoma primary to the pleura. Two years after excision of the primary tumor, it recurred as a neoplasm with histologic and ultrastructural features characteristic of malignant fibrous histiocytoma. The histogenetic and pathologic implications of the above findings are discussed, and the literature regarding intrathoracic liposarcoma and malignant fibrous histiocytoma is reviewed.

Peptostreptococcal vertebral osteomyelitis

The clinical course of a patient with vertebral osteomyelitis caused by Peptostreptococcus micros is described. The organism was isolated on two occasions from lumbar vertebral biopsies and was visualized in histologic sections of one of the biopsies. The patient had no apparent infections at other body sites. The infection was eradicated after 6 weeks of intravenous clindamycin therapy.

Avitene granulomas of colonic serosa

Avitene, microfibrillar collagen hemostat, is an absorbable topical hemostatic agent prepared from purified bovine corium collagen. A case is reported of a 58-year-old man who, one month after sigmoid colectomy for volvulus in which Avitene as used to control bleeding from a splenic capsular tear, developed symptoms of intestinal obstruction. On exploratory laparotomy, the transverse and descending colon had numerous 0.1 to 2.0 cm nodules, adherent to the serosa of the bowel and mesentery, with kinking and partial obstruction of the splenic flexure. Light microscopically, the nodules were found to be composed of chronic inflammatory and granulomatous reaction with numerous deposits of eosinophilic fibrillar material consistent with Avitene. Electron microscopic examination of the lesions and of Avitene confirmed the nature of this material. The practical and pathobiological implications of utilization of Avitene as a hemostatic agent are discussed.

Structural analysis of parathormone fragments elaborated by cells cultured from a hyperplastic human parathyroid gland

Parathyroid cells were obtained by collagenase digestion of 2 g of human parathyroid tissue obtained at surgery from a patient with end stage renal failure and hypercalcemia. Cells were placed into monolayer culture in supplemented Waymouth's MB752/1. Secretion of parathyroid hormone (PTH) from monolayer cultures was inhibited for 3 weeks by 2.5 mM compared to 0.5 mM calcium. The inhibition was 50% on day 3 of culture, and decreased to 19% by day 21. When cultures were incubated with [3H]leucine, radioactive PTH and COOH-terminal PTH fragments were secreted. Sequence analyses were performed on material in radioactive and immunoreactive peaks following gel filtration and high performance liquid chromatography of media. The results indicated that cleavage of PTH or fragments thereof occurred at the 23-24, 27-28, and 33-34 peptide bonds. NH2-terminal fragments of PTH were not detected in media.

Chronic relapsing pancreatitis with pseudocyst erosion into the portal vein and disseminated fat necrosis

A 63-year-old man with the triad of chronic relapsing pancreatitis, disseminated fat necrosis with subcutaneous nodular panniculitis, and polyarthritis was found to have a pseudocyst which had eroded into the portal vein. These lesions were associated with markedly elevated serum pancreatic enzymes. Although recent immunological studies by others suggest a possible contribution of immune-mediated tissue injury, clinical and pathological evidence in the present case including direct tissue immunofluorescent findings do not support an immune pathogenesis of this association. The present study further substantiates the concept of physiochemical tissue injury by circulating pancreatic enzymes as the primary pathogenetic mechanism.

Matrix vesicles in atherosclerotic calcification

Matrix vesicles, small extracellular membranous structures, are known to be the initial loci of calcification of cartilage, bone, and dentin. Calcification is an important complication of atherosclerosis. Using histologic, ultrastructural, and cytochemical techniques, the present study has demonstrated that matrix vesicle-like structures are involved in the calcification of atherosclerotic lesions, as well as in arterial medial calcification. In aortas from autopsied humans and from rabbits and chickens on atherogenic diets, the matrix vesicles appear to be derived from intimal and medial cellular components, mainly smooth muscle cells.

Gastric hyalinization associated with peptic ulceration

Gastric hyalinization, the severe hyaline thickening of the stomach wall that predominantly involves the submucosa, seems to have been described only in autopsy cases. Although initially thought to be a consequence of radiation or chemotherapy, subsequent studies suggested that it results from an artifactual postmortem chemical denaturation of the protein of the gastric submucosa, possibly related to an agonal tear in the gastric submucosa. We studied the clinicopathologic and ultrastructural findings in a case that had morphologic features of gastric hyalinization but that, in contrast with previous reports, was present in a surgically removed stomach and was associated with a small, chronic, peptic ulcer, with clinical manifestations of gastromegaly and borderline gastric retention. Ultrastructurally, the severe submucosal hyaline thickening that focally involved the muscularis and serosa largely consisted of proteinaceous material, ground substance, and collagen fibers, with occasional interspersed fibroblasts and myofibroblasts. This case indicated that gastric hyalinization can be a nonartifactual and clinically significant entity that may be associated with peptic ulcer disease and that should be distinguished from neoplastic (linitis plastica) and other processes.

Basal cell carcinoma of penis

Basal cell carcinoma, common in the head and neck region, rarely occurs on the penis. We report here a case of primary basal cell carcinoma of the penis in a fifty-five-year-old man, apparently representing the eleventh reported case. Review of the literature indicates that most penile basal cell carcinomas were located on the shaft and that the age, race, and other clinicopathologic features were comparable to basal cell carcinomas of other sites. The rarity of penile basal cell carcinomas is probably due in part to the low exposure of this region to sunlight and other predisposing factors. Interestingly, of the 9 reported cases of penile basal cell carcinoma, with available information, 6 were associated with local conditions which could have played a predisposing role.

Malignant transformation of perianal condyloma acuminatum: a case report with review of the literature

A case of squamous-cell carcinoma arising in association with perianal condyloma acuminatum was studied by light microscopy. The eight previously reported cases of malignant transformation of perianal and anorectal condylomata acuminatum are reviewed and the salient features described. Light microscopic examination of the case reported here demonstrated several foci of subtle and abrupt transition from condyloma acuminatum to epithelial dysplasia and to carcinoma in situ with focal frank invasion. This study further substantiates the existence of malignant transformation of condyloma acuminatum, particularly in perianal skin.

Angiolipomas: an ultrastructural and clinicopathological study

The clinicopathologic features of 50 noninfiltrating angiolipomas are presented, with a detailed ultrastructural study of five cases and immunoflourescence study of one case. The clinical presentation, including age, location, and associated symptoms, is discussed. Pertinent light microscopic findings, including features helpful in diagnosing borderline lesions, are described. The first ultrastructural and immunofluorescence study of this entity is presented. Among various ultrastructural findings, there appear to be decreased numbers of Weibel-Palade bodies in the endothelial cells of all angiolipomas studied. The relationship of Weibel-Palade bodies to the functional state of the cell and their possible procoagulative effect are discussed. Immunofluorescence and ultrastructural studies further suggest that endothelial disruption and endothelial fibrinogen contribute to the fibrin thrombus formation typically found in angiolipomas.

The effects of tris(hydroxymethyl)aminomethane and calcium ionophores on the biosynthesis of proparathormone and the formation and degradation of parathormone in bovine parathyroid tissue

A comparative study of ultrastructural and biochemical effects of Tris and ionophores X537A and A23187 on bovine parathyroid tissue is presented. When parathyroid slices were incubated with 3H-leucine and 3H-lysine for 10 minutes alone or with Tris (50 mM), A23187 (9.5-19 microM) or X537A (8.5-17 microM), the incorporation of the amino acids into radioactive proparathormone (proPTH) was similar, indicating that biosynthesis of the hormone was not affected. After 120 minutes of incubation, however, Tris inhibited the conversion of proPTH to parathormone (PTH), judged by a decrease in cellular and secreted radioactive PTH and a corresponding increase in radioactive cellular proPTH. These changes were accompanied by marked dilatation of Golgi membranes. With both concentrations of A23187 and the low concentration of X537A there were no changes in amounts of radioactive proPTH, moderate decreases in cellular and secreted radioactive PTH, and little discernible distension of the Golgi membranes. At 17 microM X537A there was moderate increase in amount of radioactive proPTH, a marked decrease in amount of radioactive PTH and swelling of the Golgi membranes. Taken together, these findings suggest that Tris inhibited conversion of proPTH to PTH by disrupting the Golgi zone-the site of conversion of proPTH to PTH; that A23187 and the low concentration of X537A decreased production of PTH by enhancing its degradation; and that X537A at the higher concentration acted both by inhibiting conversion of proPTH to PTH and by enhancing the degradation of PTH.

An elastic suspension system for Thomas's splint

An elastic suspension system for use with Thomas's splint is described. This avoids difficulties found with the commonly used pulley and weight systems.

Suggested pathological basis of "redundant nerve root syndrome" of the cauda equina

A clinical entity described as "redundant nerve root syndrome" of the cauda equina is reviewed. Eighteen reported cases with typical gross features are analyzed. Considerable speculation has existed regarding the pathogenesis of this syndrome, chiefly because the involved nerve root was not biopsied in the majority of instances. In one reported case, when the redundant root was examined histologically, a plexiform neurofibroma was found to be the cause of the thickening and redundancy of the nerve. In the case presented here, the enlarged nerve roots were part of a malignant plexiform neurofibroma with a short clinical course, and the tumor led to the death of the patient. It is suggested that biopsy of the involved nerve root is crucial in establishing the definitive diagnosis.

Hemorrhage from carcinoma of the lung

During a retrospective analysis of 877 cases of lung cancer, we explored the relationships between cell type, site, cavitation, varying degrees of hemoptysis, and radiation therapy. Massive terminal hemoptysis (29 cases) was found to be significantly associated with cavitated (P less than 0.0001 squamous cell carcinoma (P = 0.0002), ARISING IN EITHER THE RIGHT OR LEFT MAIN BRONCHI (P less than 0.0001). Lesser, nonlethal degrees of hemoptysis (140 cases) were not cell-type associated, occurring in approximately 15% of cases of all major tumor types. Radiotherapy, although employed more frequently in the massive-hemoptysis population, did not appear to be causally related to hemoptysis of any degree. An interesting case, which provoked the above study, is described: a patient with bronchogenic squamous cell carcinoma and terminal hemoptysis due to a tumor fistula between the primary lesion and the left atrial chamber. The forms of cardiac involvement in lung cancer are discussed.

Platelet satellitism: experimental studies

Platelet satellitism (PS), the in vitro phenomenon of platelets rosetting about nonlymphocytic leukocytes, is an uncommon and poorly understood finding reported in the ethylenediaminetetra-acetic acid (EDTA)-anticoagulated blood of patients with a wide variety of clinical conditions. This report presents experimental studies investigating the nature of this phenomenon by utilizing the blood of patients with platelet satellitism. Wet preparation studies and electron microscopy (transmission and scanning) demonstrated the morphologic sequences involved in the phenomenon, including eventual phagocytosis of platelets by neutrophils. The results of varying conditions such as time, temperature, and anticoagulant are described. All of five patients tested were found to have cryofibrinogenemia. Certain blood components from all of three patients tested were capable of inducing PS in normal whole blood, whereas components from normal subjects usually were not. In one patient (A), the PS-inducing capability appeared to be present in both plasma and platelets. In another patient (B) the PS-inducing capability was present in platelets (in both 1966 and 1975) and also in the cryosupernate of serum and plasma; among various antisera, antifibrinogen had the greatest ability to reduce the degree of PS in patient blood; addition of moderate amounts of CaCl2 and/or MgCl2 did not diminish the phenomenon; and two sisters and two daughters demonstrated no PS. In a third patient (C) the PS-inducing capability appeared to be largely concentrated in the cryoprecipitable fraction of plasma. These studies suggest that there are different factors in the patients' blood resulting in PS. Further studies showed PS could be induced in normal blood by adding certain nonprimate antihuman antisera (anti-IgM, antialbumin or antifibrinogen) and also by adding some preparations of normal washed platelets to the same individuals's normal whole blood. This indicates that the phenomenon of PS can be produced by factors other than those specifically present in patients with PS. Antigen-antibody complexes, either formed in vivo (mixed cryoglobulinemia) or in vitro, did not result in PS when mixed with normal blood. These and other studies suggest that PS can result from the presence of several different factors, usually proteins (in conjunction with EDTA), which probably attach to the surface of platelets apparently resulting in some alteration (such as change in surface charge) causing the platelets to be attracted to and phagocytosed by neutrophils.

Misdiagnosis caused by fungal contaminant in a histological stain solution

Silver stains on tissue and cytology specimens are important in the evaluation of patients with suspected fungal infections. Care must be taken, however, to prevent misinterpretation of contamination artifacts. Two cases presenting such a problem are reported. The first patient had granulomatous leg lesions that microscopically showed characteristics of erythema induratum but with budding yeastlike organisms demonstrated by Grocott methenamine silver stain. Cultures and subsequent biopsies were negative for fungi. The second patient had a steroid-dependent chronic obstructive lung disease, and during evaluation for possible Pneumocystis carinii pneumonia, the Grocott methenamine silver stain on expectorated sputum showed budding yeastlike organisms. Sputum cultures were negative for fungi. Examination of the two Grocott light-green counterstain solutions demonstrated black, budding yeast cells similar to those seen in the specimens from the patients. Culture of the counterstain grew Exophiala (Phialophora) jeanselmei. Further studies revealed that this cause of misdiagnosis could be prevented by either filtering or adding thymol to the counterstain solution. Care regarding contamination of histological stain solutions is emphasized.

Obstructive lesions of distal mesenteric arteries. A light and electron microscopic study

Two cases of "nonocclusive" intestinal infarction are reported. No thrombosis or significant atherosclerosis was identified and proximal mesenteric arteries were widely patent. However, distal mesenteric arteries were thickened and had pinpoint lumens. Light microscopic findings suggested that this marked luminal narrowing was due to prominent intimal fibromuscular proliferation, medial hypertrophy and mild structural disarray, focal periarterial fibrosis, and transmural elastosis. Electron microscopic findings indicated that the endothelium was normal but the basal lamina was irregularly thickened. The predominant cellular component of the thickened intima consisted of smooth muscle cells, and smooth muscle cells of the media were seen to migrate through an extensively disrupted and degenerated internal elastic lamina. Deposits of young elastic fibers, collagen, and ground substance were also noted, particularly in the intima. The need for careful sectioning and microscopic examination of small distal mesenteric arteries in cases of so-called nonocclusive intestinal infarction is emphasized.

Functioning oxyphil adenoma of parathyroid gland. An ultrastructural and biochemical study

Oxyphil cells and oxyphil cell adenomas of parathyroid glands are, in most instances, regarded to be nonfunctioning. Although 21 cases of hyperparathyroidism associated with parathyroid oxyphil cell adenoma have been reported, secretion of hormone by these tumors has not been conclusively demonstrated. A parathyroid adenoma, diagnosed by light microscopy as oxyphil type, together with the results from ultrastructural and biochemical studies of the patient's adenomatous tissue, are reported here. The patient, a 64-year-old male, was found to have elevated serum calcium, low serum phosphorus, and elevated serum immunoreactive parathormone: findings consistent with hyperparathyroidism. After excision of two small normal-appearing glands and one greatly enlarged (1.9 g) parathyroid gland, those laboratory values returned to normal. Light microscopy of the enlarged parathyroid indicated that it consisted almost entirely of an oxyphil adenoma. Electron microscopy revealed that the adenoma was composed mainly of mitochondria-rich oxyphil cells but also of interspersed transitional oxyphil cells and rare scattered chief cells. Golgi zones, rough endoplasmic reticulum, and prosecretory and secretory-like granules were observed in some oxyphil cells, in most transitional oxyphil cells, and in the infrequent chief cells. Thus, many of these cells appear to contribute to the production and secretion of parathormone. Biochemical studies performed directly on the adenomatous tissue demonstrated that it was able to synthesize proparathormone and parathormone, although the proportion of hormonal peptide synthesis relative to that of the total protein synthesis in this tissue was much smaller (0.9%) than that found in normal parathyroid tissue (5.7%). There was a small increase in immunoreactive parathormone when the adenoma tissue was incubated in a low-calcium medium. These findings indicate that this oxyphil adenoma of the parathyroid gland synthesized and secreted parathormone, apparently to some extent autonomously, but suggest that its capacity to do so was largely dependent on its component of cells other than fully developed oxyphil cells, such as transitional oxyphil cells.

Isoantigens A, B, and H in morphologically normal mucosa and in carcinoma of the larynx

A modified Coombs' mixed cell agglutination reaction was performed on biopsy specimens of 24 patients with squamous cell carcinoma of the larynx. Isoantigens A, B, and H(O) were absent in 15 cases, partially lost in eight, and completely retained in one case. In four cases the initial biopsy specimens were histologically benign yet negative for isoantigens. In subsequent biopsies these showed the presence of carcinoma. The morphologically normal-appearing squamous mucosa adjacent to a carcinoma was found to be devoid of isoantigens in ten cases. The investigation suggested that isoantigenic alteration as detected by mixed cell agglutination reaction was a sensitive sign, since it occurred in squamous mucosa prior to recognizable morphologic change for malignancy. The reaction may represent a functional dedifferentiation in cancerous tissue, analogous to but sometimes preceding morphologic dedifferentiation. The results were comparable to those in previous studies of neoplasms of various other anatomic sites.

Carcinosarcoma of the adult kidney

Carcinosarcoma of the adult kidney is a very rare tumour and there are only a few well documented cases in the literature. In this report such a tumour is described from a 50-year-old white male, which progressed very rapidly with widespread metastases. Histologically, the tumour consisted of renal cell carcinoma and fibrosarcomatous components. The interesting features in this case were that both the carcinomatous and sarcomatous elements of the tumour exhibited metastases separately to various organs.