Mammogram screening of Chinese women in Kwong Wah Hospital, Hong Kong

The incidence of primary carcinoma of the breast in Hong Kong has been rising. A screening team including radiologists, breast surgeons, cytopathologists, a full-time gynaecologist and mammographers was set up at Kwong Wah Hospital. The screening method includes a clinical breast examination (CBE) and two-view mammography. The target age group is 40-70. A total of 13,033 women were screened from March 1993 to March 1995 and 8504 mammograms were performed. A double reading system was used, with an experienced mammographer as the first reader. The films were then read by radiologists and were reported. All abnormal films and normal films with palpable masses or clinical symptoms were reviewed in a weekly meeting. A total of 113 biopsies were performed including 86 stereotactic-guided fine needle aspirations (FNA) and 27 stereotactic-guided hook-wire biopsies. Four FNA showed malignant cells and another five showed suspicious cells. Eleven hook-wire biopsies showed carcinoma. The benign to malignant ratio of the hook-wire biopsies was 16:11 (< 1.5). The total number of carcinomas disclosed was 42, and 16 of these were not palpable. Four palpable tumours were not detected by mammography. The overall carcinoma of the breast detection rate was 4.94/1000, with a rate of 4.61/1000 for the 40-49-year age group and a rate of 6.46/1000 for the over 50 years of age group. The incidence of ductal carcinoma in situ plus T1 tumours was 2.82/1000.

Clinical predictors of non-diabetic renal disease in patients with non-insulin dependent diabetes mellitus

BACKGROUND

Several studies had suggested that non-diabetic renal disease (NDRD) was common among non-insulin dependent diabetes mellitus (NIDDM) patients with renal involvement.

METHODS

We prospectively studied the prevalence of NDRD among a Chinese NIDDM population. Renal biopsy specimens were evaluated with light-, immunohistological and electron-microscopy. The cohort consisted of 51 patients who had NIDDM and proteinuria > 1 g/24 h.

RESULTS

Patients with both isolated diabetic nephropathy (DN, n = 34) and NDRD (n = 17) had comparable duration of DM, creatinine clearance, serum creatinine, albumin and glycosylated haemoglobin levels, as well as incidences of retinopathy, neuropathy and hypertension. Significantly more patients with NDRD had microscopic haematuria (P = 0.043) or non-nephrotic proteinuria (P = 0.004). IgA nephropathy accounted for 59% of the NDRD identified.

CONCLUSIONS

In this study, microscopic haematuria and non-nephrotic proteinuria predicted the presence of NDRD among NIDDM patients presenting with renal disease.

Cutaneous epithelioid angiosarcoma: a potential diagnostic trap for cytopathologists

We report on the cytologic features of a rare case of cutaneous epithelioid angiosarcoma of the scalp occurring in a 65-yr-old Chinese male. The prominent epithelioid features may cytologically mimic poorly-differentiated carcinoma, malignant melanoma, and even epithelioid sarcoma. Recognition of subtle cytologic features of vasoproliferation, immunohistochemical demonstration of endothelial markers, and ultrastructural examination are necessary before a final conclusion may be drawn.

'Spontaneous' regression of advanced leiomyosarcoma of the urinary bladder

A case of advanced leiomyosarcoma of the urinary bladder is reported in a 25-year old man who, in a short time, experienced a complete 'spontaneous' regression of his fatal illness. He first presented with severe haemoperitoneum resulting from an unresectable bleeding tumour of the urinary bladder. Debulking surgery was performed, followed by salvage chemotherapy. Histological and ultrastructural examinations of the tumour confirmed a poorly differentiated leiomyosarcoma. The residual disease failed to respond to salvage chemotherapy, but regressed 'spontaneously' 5 months after cessation of therapy. The patient is alive without evidence of disease 51 months after the diagnosis. This remarkable phenomenon and relatively long survival in a poor-risk leiomyosarcoma of the urinary bladder has never been reported previously.

Stereotactic fine needle aspiration in the management of mammographic abnormalities detected in breast screening

BACKGROUND

Fine needle aspiration (FNA) is used routinely in the management of palpable breast lumps; with the implementation of the stereotactic technique its use has been extended to the investigation of mammographic abnormalities. The advent of breast screening means that many mammographic abnormalities will be detected; because routine open biopsy is impractical and undesirable, stereotactic fine needle aspiration becomes the method of choice for investigation.

METHOD

Within a 28 month interval, 81 Chinese women underwent stereotactic FNA in Kwong Wah Hospital, Hong Kong.

RESULTS

Fifty-one women (62.9%) had a benign cytology result and no further investigations were required. Inconclusive results were obtained in 18.6% of the aspirates. Open biopsy was required in 16 women (19.8%).

CONCLUSION

Stereotactic FNA is very useful in the exclusion of malignancy and the avoidance of open biopsy in asymptomatic women who have mammographic abnormalities.

Tubular adenosis of the breast. A distinctive benign lesion mimicking invasive carcinoma

Tubular adenosis, a term first coined by Oberman, is an uncommon benign lesion of the breast that may mimic invasive carcinoma. There is no formal description of this condition in the literature. We report the findings on six specimens from five patients (one with bilateral disease), including three that showed cancerization by intraductal carcinoma (DCIS). The ages of the patients ranged from 40 to 82 years. One patient presented with a 3-cm breast mass, and the others were found in specimens resected for infiltrating ductal carcinoma (two specimens) or DCIS (three specimens). The histologic hallmark of tubular adenosis was haphazard proliferation of elongated tubules that were noncrowded, narrow, and sometimes branching. There was no lobular arrangement or, at most, vague lobular grouping, with some tubules often extending into the fat. The tubules contained basophilic or granular eosinophilic secretion. The stroma was sclerotic to edematous. The tubules were lined by bland-looking ductal cells and were surrounded by an intact myoepithelial layer, a phenomenon well highlighted by immunostaining for muscle-specific actin (HHF-35) or S-100 protein. In three specimens, the tubular adenosis was cancerized by noncomedo DCIS, producing a pattern strongly mimicking infiltrating carcinoma; the in situ nature of the carcinoma was confirmed by actin immunoreactivity in the residual myoepithelium as well as by the presence of architecturally similar tubular adenosis in the vicinity. Tubular adenosis shows an infiltrative growth similar to microglandular adenosis and adenomyoepithelial adenosis, but it differs from them by the interdigitating tubular configuration and also differs from microglandular adenosis by the presence of myoepithelium. Tubular adenosis can be distinguished from sclerosing adenosis by the lack of obvious lobular architecture or whorled arrangement and wider separation of the tubules. Tubular adenosis appears to be a benign lesion per se, but whether it has premalignant potential remains to be determined. The importance of recognizing this entity lies in its being potentially mistaken for invasive carcinoma, especially at intraoperative frozen section or when the lesion is cancerized by DCIS.

Dysembryoplastic neuroepithelial tumor. A tumor with small neuronal cells resembling oligodendroglioma

Dysembryoplastic neuroepithelial tumor (DNT) is a clinicopathologically unique group of tumors, mostly located in the temporal lobe, associated with intractable complex partial seizure in young patients. We report two unusual cases with multifocal involvement of diverse sites in the central nervous system. Case 1 is that of a 50-year-old man with 9-year history of grand mal seizures, who died of acute myocardial infarction. Case 2 is that of a 10-year-old girl with intractable complex partial seizures and behavioral disorder. Postmortem examination in case 1 showed multifocal tumor in the left temporal lobe, third ventricle, and basal ganglia. Magnetic resonance imaging in case 2 showed tumor in the right temporal lobe, both thalami, right cerebellar hemisphere, and pons. Histologically, both tumors were characterized by a multinodular appearance with a predominant component of alveolar arrangement of oligodendroglial-like cells around delicate capillaries, with mucoid matrix containing floating ganglion cells. There were also astrocytic nodules resembling pilocytic astrocytoma in case 1, and a gangliocytoma-like area merging with surrounding cortical dysplasia in case 2. Ultrastructural examination showed ganglionic differentiation in the oligodendroglial-like cells in case 2. They possessed dense core neurosecretory granules and many slender neuritic processes with microtubules arranged in parallel and terminating in synaptic junctions. The periventricularly located tumor with nodular extension to the periphery suggests an origin from subependymal germinal matrix with nests of primitive neuroblasts arrested in their embryonal migration. DNTs are related to ganglioglioma based on their common location and clinical behavior and on the presence of both ganglionic and astrocytic cells. They are also related to pilocytic astrocytoma by morphological and behavioral similarity. Together with cerebral neuroblastoma and central neurocytoma, they form a spectrum of tumors harboring small neuronal cells. The differentiation of DNT from oligodendroglioma is important so as to avoid unnecessarily aggressive therapy.

Clinicopathologic study of 16 cases of primary tubal malignancy

Sixteen cases of primary carcinoma of the fallopian tube were diagnosed and treated at Queen Mary Hospital, Hong Kong from July 1972 to June 1992 constituting 0.26% of the total gynecologic malignancies seen during that period. The average age was 61 years and the most common presenting symptom was abnormal vaginal bleeding. Preoperative diagnosis is difficult; in only one case was a diagnosis of malignancy made by cervical smear. An adnexal mass was detected in 13 of the cases (81.3%) either by clinical examination and/or ultrasonography. Therapy consisted of surgical resection, usually followed by various combinations of adjuvant radiation therapy and chemotherapy. The cumulative survival was 62%. In addition to the typical form of adenocarcinoma, one case of squamous cell carcinoma and a case of multifocal endometrioid adenocarcinoma were observed. One case of an apparently usual form of adenocarcinoma recurred as a heterologous malignant mixed Müllerian tumor 2 years after diagnosis. This series further emphasises the wide range of differentiation possible in the Müllerian system and the variety of neoplasms which may arise from it.

Epithelial damage by Helicobacter pylori in gastric ulcers

On review of 136 consecutive biopsies of benign gastric ulcer, Helicobacter pylori was detected in 78 cases (57.3%). The gastric epithelium colonized by Helicobacter pylori showed a characteristic constellation of changes, including loss of apical mucous portion of individual cells, drop-out of epithelial cells, epithelial pits, erosions and cellular tufts, indicative of cellular injury and regeneration. Among the 58 Helicobacter-negative cases, similar changes were not observed in the ulcer edges, except for two cases which exhibited some cellular tufts. Thus, the topographic association of Helicobacter pylori with epithelial damage in the gastric ulcer edges in more than half of the cases suggests that this organism probably plays an aetiological role in ulcerogenesis, at least in these cases. Furthermore, the epithelial changes are so distinctive that they can serve as a helpful histological indicator for the presence of Helicobacter pylori in gastric biopsies.

Columnar cell carcinoma of the thyroid. Fine needle aspiration findings in a case

Columnar cell carcinoma is a recently described rare tumor of the thyroid. The fine needle aspiration cytologic findings of one example are reported. In the smears, the tumor fragments showed papillary and glandular patterns. The tumor cells were columnar and exhibited pseudostratification of the nuclei. The nuclei were oval to elongated and possessed stippled chromatin and inconspicuous nucleoli; occasional ones exhibited longitudinal grooving. It is important to distinguish this tumor from papillary carcinoma of thyroid because of its much more aggressive behavior, from metastatic adenocarcinoma for obvious treatment considerations, and from medullary carcinoma.

Epithelioid haemangioma (angiolymphoid hyperplasia with eosinophilia) and Kimura's disease in Chinese

Although Kimura's disease has often been considered to be identical to angiolymphoid hyperplasia with eosinophilia (epithelioid haemangioma), recent studies suggest that they are different clinicopathological entities. In this study, we have made a detailed morphological comparison of 10 cases of epithelioid haemangioma and 40 cases of Kimura's disease occurring in the Chinese population. The epithelioid haemangiomas occurred in the subcutaneous tissue, skin and maxillary antrum, whereas Kimura's disease affected the subcutaneous tissue, major salivary glands and lymph nodes. Distinctive features of epithelioid haemangiomas were exuberant proliferation of vessels lined by cuboidal to hobnail endothelial cells with irregular nuclei and cytoplasmic vacuoles, fibromyxoid matrix, involvement of muscular coat of blood vessels and zonation of inflammatory infiltrate towards the peripheral portion of the lesion. Distinctive features of Kimura's disease were florid lymphoid infiltrate with prominent lymphoid follicles, vascularization of germinal centres, germinal centre necrosis, marked eosinophilia with or without eosinophil abscess formation, proliferation of high endothelial venules, and sclerosis. The histological features suggest that epithelioid haemangioma is a proliferation of atypical endothelial cells, possibly neoplastic, that is associated with a variable inflammatory infiltrate, whereas Kimura's disease is primarily an inflammatory condition in which high endothelial venules are usually found.

Lymphadenopathy of Kimura's disease

Kimura's disease is an important category of reactive lymphadenopathy in the Oriental population. The enlarged nodes are mostly located in the head and neck region. Salient pathological changes include florid germinal centers, Warthin-Finkeldey type polykaryocytes, vascularization of germinal centers, increased postcapillary venules in the paracortex, eosinophilic infiltration, and sclerosis. The pathology of Kimura's disease is quite different from that of angiolymphoid hyperplasia with eosinophilia (epithelioid hemangioma). Immunoperoxidase studies show IgE reticular networks in germinal centers. Nondegranulated surface IgE-positive mast cells are present in the paracortex. The authors propose that Kimura's disease represents an aberrant immune reaction to an as yet unknown stimulus. Although the individual histological features are nonspecific, the constellation of features is highly characteristic of Kimura's disease. Since lymphadenopathy can herald involvement of other tissues and the prognosis is excellent, accurate diagnosis of this disease in lymph node biopsies may spare the patients unnecessary radical surgery.

Aspiration cytology in the management of breast lesions

In a group of patients with breast lumps, diagnosis made by pre-operative aspiration cytology was compared with that obtained by histological section of excised specimens. Results showed that aspiration cytology correctly diagnosed 89% of malignant lesions and 92.6% of benign lesions based upon histological diagnosis. Cytological diagnosis of benign disease had a false negative rate of 6% while cytological diagnosis of malignant disease had a 2.7% false positive rate. Only 3.5% of cytologies returned an inadequate diagnosis. This study shows that aspiration cytology should be useful in allowing a better psychological preparation of patients before surgery as well as better utilization of operation theatre facilities.

Kimura's disease with salivary gland involvement

Fourteen cases of Kimura's disease involving parotid and submandibular glands in Chinese patients are described to draw attention to this unique lesion which has been reported mainly in the Chinese and Japanese literature. Blood eosinophilia is almost always present, there is a male preponderance and the aetiology is unknown. Surgical excision is recommended though irradiation and steroid therapy have also been used.