Bursal cyst: an unusual axillary mass

We discuss an unusual case of a bursal cyst presenting as an axillary mass in a previously healthy individual. Although both bursal and ganglion cysts not uncommonly arise from other joints, they also rarely occur in the axilla as well. Clinicians should include cysts in their differential of diagnoses when examining axillary masses and deciding on their appropriate treatment.

Percutaneous needle biopsy diagnosis of benign neurogenic neoplasms

Preoperative diagnosis of benign neurogenic neoplasms (BNNs) provides useful information in guiding management. To assess the effectiveness of fine-needle aspiration (FNA) and needle core biopsy (NCB) in diagnosing schwannomas and neurofibromas, 40 percutaneous biopsies interpreted as BNNs or obtained from lesions subsequently shown by excision to be BNNs were reviewed. The 13 aspirates diagnostic of BNN revealed spindle cells arranged haphazardly in irregular tissue fragments and in parallel as elongated ropy fascicles, with a myxoid to fibrillary background. The nuclei were buckled, often with intranuclear cytoplasmic inclusions. Four lesions showed nuclear pleomorphism without mitoses. Of 19 schwannomas evaluated by FNA, four (21%) were diagnosed as schwannomas and seven (37%) as BNNs. Ten neurofibromas were aspirated, revealing two (20%) BNNs. Of seven nondiagnostic FNAs accompanied by NCB, three (43%) indicated a BNN. The sensitivities of FNA, NCB, and both modalities in diagnosing BNNs were 43,60, and 71%, respectively. For the 16 FNAs showing features of BNNs, subsequent excisions revealed 11 schwannomas, two neurofibromas, one neurogenic sarcoma, one fibromyxoid neoplasm of uncertain malignant potential, and one unclassified low-grade myxoid sarcoma. FNA can be effective in diagnosing BNNs. If collagenous or myxoid lesions yield paucicellular nondiagnostic aspirates, NCB is helpful. Lowgrade sarcoma and neurofibromatous areas of neurogenic sarcoma may be misinterpreted as BNNs by percutaneous biopsy. BNNs may show nuclear pleomorphism without mitotic activity, and should not be mistaken for sarcoma.

Avulsion fracture of the anterior inferior iliac spine with abundant reactive ossification in the soft tissue

Patients who have sustained an avulsion fracture and present clinically during the healing phase of the injury may manifest a mass that clinically and radiographically mimics a malignant neoplasm. A 15-year-old male soccer goalkeeper presented with a large ossified mass in the soft tissues overlying the right hip 6 months after experiencing a popping sensation in his hip joint during a game. Although an osteosarcoma was suspected clinically and radiographically, a Tru-Cut needle biopsy of the lesion revealed reactive bone formation. Correlation of the clinical, radiographic, and pathologic findings indicated an avulsion fracture of the anterior inferior iliac spine with abundant reactive ossification in the soft tissues. The healing phase of an avulsion fracture may clinically and radiographically be mistaken for neoplasia. In such cases, a Tru-Cut needle biopsy may reveal the reactive nature of the process.

Cervical lymph node status and survival in laryngeal carcinoma: prognostic factors

Elective cervical lymphadenectomy often is performed for laryngeal carcinoma to eliminate metastatic disease that escapes clinical and radiographic detection. We investigated characteristics of the primary tumor that might predict cervical lymph node status. We obtained archival tissue from 88 laryngectomies--65 with concurrent cervical lymphadenectomies. Of the 40 clinically negative necks that were dissected, 17% showed lymph node metastasis by pathologic examination. The primary tumors were examined immunohistochemically for expression of epidermal growth factor receptor (EGFR), p53, cathepsin D, proliferating cell nuclear antigen (PCNA), and Ki-67-specific antigen, and by flow cytometry for DNA ploidy-cell cycle analysis. Seventy-seven percent of the cases showed aberrant p53 staining, 99% expressed EGFR, 40% produced cathepsin D, 29% were aneuploid, and 54% had a moderate or high synthesis phase fraction (SPF). High grade, aneuploidy, and tumor vascular invasion independently predicted cervical node metastasis (p < .04 each). Supraglottic locale (p < .16) and a raggedly infiltrating invading margin (p < .13) were weakly associated with node positivity. Advanced clinical T status, the expression of EGFR, p53, and cathepsin D, the PCNA and Ki-67 indices, and SPF did not correlate with node metastasis. The presence of cervical node metastasis predicted poor disease-free (p < .005) and overall survival (p < .04). Advanced clinical T status correlated with brief overall survival (p < .02). Tumor site, histopathologic parameters, ploidy, SPF, PCNA and Ki-67 indices, and the expression of p53, EGFR, and cathepsin D did not affect survival. The presence of vascular invasion, high grade, and aneuploidy may help identify which patients would benefit from elective cervical lymphadenectomy. The correlation of cervical lymph node status and clinical T category with survival confirms the results of previous studies.

A microwave method that enhances detection of aberrant p53 expression in formalin-fixed, paraffin-embedded tissues

OBJECTIVE

Detection of aberrantly accumulated p53 protein by immunohistochemistry may have prognostic significance in many human neoplasms. We wished to identify a technique applicable to formalin-fixed, paraffin-embedded sections that would reliably yield results equivalent to frozen-section immunohistochemistry.

DESIGN

We compared the frequency of p53 immunostaining obtained by applying monoclonal antibodies PAb1801, DO7, or DO1, a 1:1 PAb1801-DO7 cocktail, and a 1:1 PAb1801-DO1 cocktail to fresh-frozen and formalin-fixed, paraffin-embedded tissues from 36 lung and upper aerodigestive-tract carcinomas. With the formalin-fixed tissues, we compared pepsin predigestion with microwave irradiation in citrate buffer as means of enhancing the sensitivity of p53 detection.

SETTING AND PATIENTS

All tissues were obtained from surgical resections of tumors, from patients who underwent surgery at the Minneapolis Department of Veterans Affairs Medical Center between 1990 and 1992.

MAIN OUTCOME MEASURES

The sensitivity of different paraffin section techniques for immunohistochemical detection of accumulated p53 protein was determined in reference to the optimal frozen section method (defined as the method that yielded the greatest number of p53-positive cases in frozen tissue).

RESULTS

Microwave antigen retrieval markedly enhanced staining with PAb1801 and DO7 in paraffin sections, as compared with pepsin predigestion and no pretreatment. This technique was 100% sensitive relative to the optimal frozen tissue method. In contrast, staining with DO1 alone was not enhanced by microwaving.

CONCLUSIONS

Microwave pretreatment in conjunction with the use of either PAb1801 or DO7 is highly efficacious in the immunohistochemical detection of aberrant p53 expression in formalin-fixed, paraffin-embedded tissues.

Association of immunohistochemical staining for p53 with metastatic progression and poor survival in patients with renal cell carcinoma

BACKGROUND

Mutations of the p53 gene have been found in many types of human tumors. In some tumors, p53 gene mutations are associated with advanced disease and poor prognosis. There is wide variation in the reported incidence of p53 mutation in renal cell carcinoma, and its prognostic significance for this tumor is unknown.

PURPOSE

This retrospective immunohistochemical study was designed to examine associations between p53 immunostaining and histologic type, tumor grade, clinical behavior, and survival.

METHODS

Paraffin-embedded nephrectomy specimens collected from 1978 through 1986 from 175 patients were immunostained for p53 using the D07 monoclonal antibody. Positive staining for p53 has been linked to the accumulation of mutant p53 protein. Thirteen specimens of concurrent metastatic lesions were available from 11 primary cases. Clinical follow-up information was available on 164 patients.

RESULTS

Immunostaining for p53 suggested the presence of p53 mutation in 49 (28%) of 175 renal tumors studied. Staining was associated with high tumor grade and stage but not with cell type or histologic pattern. Eleven (85%) of 13 metastatic lesions stained positively for p53, versus only four (36%) of the 11 paired primary tumors. Immunostaining for p53 was strongly associated with poor survival among patients without distant metastases at presentation. In this group, 10-year disease-specific survival was 78% for patients with nonstaining tumors versus 48% for those with p53-positive tumors (P < or = .003). There was an 87% 10-year disease-specific survival rate for patients with nonstaining Robson stage 1 tumors versus a 62% 10-year survival rate for patients with p53-positive Robson stage 1 tumors (P < .01). Multivariate analysis showed p53 immunoreactivity to be an independent predictor of survival for patients with nonmetastatic renal cell carcinoma, whereas tumor grade was not.

CONCLUSIONS

Positive p53 immunostaining in renal cell carcinoma is associated with metastatic disease and poor survival in patients with early-stage disease.

IMPLICATIONS

In renal cell carcinoma, mutations of the p53 gene may allow or contribute to the acquisition of metastatic potential.

Light and electron microscopic features of the liver in mucopolysaccharidosis

The mucopolysaccharidosis (MPS) diseases lead to the accumulation of glycosaminoglycan in many tissues. In this study 19 MPS I, one MPS II, five MPS III, and two MPS VI patients underwent liver biopsy for light and electron microscopic examination. Electron microscopy was performed for all 27 specimens. Twenty-six specimens were studied by light microscopy, and the slides were stained with colloidal iron and alcian blue in 26 and six biopsy specimens, respectively. By hematoxylin-eosin stain 20 of 26 cases showed hepatocellular dilatation with rarefaction of the cytoplasm; the Kupffer cells were unremarkable. Twenty-four and 25 of the 26 biopsy specimens showed substantial colloidal iron staining of hepatocytes and Kupffer cells, respectively. The six biopsy specimens prepared with alcian blue stain showed no reactivity of any cell type. Electron microscopy revealed characteristic membrane-bound inclusions within the hepatocytes and Kupffer cells of all 27 biopsy specimens. Of 19 cases in which Ito cells were identified, 18 included cells containing similar inclusions. Twenty of 27 biopsy specimens also demonstrated the hepatocellular accumulation of lipid droplets. Although there were no absolute distinguishing features among the various MPS diseases, the two MPS VI cases showed glycosaminoglycan inclusions that were fewer in number, smaller, and contained more abundant lipofusion than those associated with the other MPS types.

Immunohistochemical characterization of teratomatous and fetal neuroendocrine pancreas

Six extragonadal teratomas that contained pancreatic tissue were retrieved from archival material at the University of Minnesota Hospital, Minneapolis. The neuroendocrine cells were studied immunohistochemically for insulin, glucagon, somatostatin, pancreatic polypeptide, vasoactive intestinal polypeptide, gastrin, chromogranin, and synaptophysin. Pancreatic tissue from autopsies of 10 stillbirths (20 to 40 weeks' gestational age) was evaluated similarly. The features of the teratomatous pancreatic tissue were compared with those of the fetal pancreata and with data from previous studies of normal pancreatic development and adult pancreata. The pancreatic tissue in all six teratomas contained abundant mature islets that contained beta, alpha, delta, and pancreatic polypeptide cells; however, they also showed widespread nesidioblastosis with the same cell types, resembling third-trimester fetal and neonatal pancreata. Increased proportions of alpha and delta cells were observed in three and five cases (relative to those of adult tissue), respectively, providing further evidence of immaturity. Two cases showed a lack of alpha cells. None of the teratomas contained pancreatic cells that were positive for vasoactive intestinal polypeptide or gastrin. Mechanisms that regulate neuroendocrine cell differentiation in the normal pancreas also seem to operate in the teratomatous pancreas; they may eventuate in features similar to those of the late fetal and neonatal pancreas. Abnormal differentiation in teratomas may result in deficient hormone production.

Postmortem angiography of catheter-induced pulmonary artery perforation

A case of pulmonary artery perforation by the placement of a balloon-tipped, flow-directed (Swan-Ganz) catheter, as demonstrated postmortem by angiography and confirmed by conventional autopsy method, is reported. Angiography is an effective adjunctive modality in the postmortem diagnosis and localization of pulmonary artery perforation. In cases of suspected catheter-induced pulmonary artery perforation and death, postmortem angiography may prove useful to the forensic pathologist.

Pathology of the liver in mucopolysaccharidosis: light and electron microscopic assessment before and after bone marrow transplantation

Serial liver biopsies were obtained in 20 patients undergoing bone marrow transplantation (BMT) for mucopolysaccharidosis (MPS). The 13 patients with MPS I, one with MPS II, four with MPS III, and two with MPS VI underwent liver biopsy prior to and from 1 to 37 months after BMT. The amount of accumulated glycosaminoglycan (GAG) was assessed by semiquantitation of Kupffer cell staining with colloidal iron and by counting the number of hepatocellular GAG-containing lysosomes in electron micrographs. Eleven of 13 patients with MPS I achieved engraftment, and 10 of the 11 cleared the Kupffer cells and hepatocytes of GAG by 3 to 19 months post-BMT. Two patients with autologous recovery demonstrated persistent hepatocyte inclusions. The three patients with MPS II and MPS VI engrafted and showed clearance of hepatocyte and Kupffer cell GAG by 7 months after BMT. All four patients with MPS III engrafted. Although the Kupffer cells in these patients were cleared of GAG by 12 months after BMT, hepatocellular inclusions persisted in all four. For MPS I, II and VI, donor engraftment was associated with resolution of lysosomal storage material in donor-derived Kupffer cells and untransplanted hepatocytes, indicative of transcellular metabolic correction. Failure of hepatocyte clearance in one case of MPS I and all patients with MPS III suggested a diminished capacity of the graft-derived enzyme to enter the hepatocyte lysosomes in these patients.