Acceptance, reliability and confidence of diagnosis of fetal and neonatal virtuopsy compared with conventional autopsy: a prospective study

OBJECTIVES

To compare prospectively maternal acceptance of fetal and neonatal virtuopsy with that of conventional autopsy and to determine the confidence with which magnetic resonance (MR) virtuopsy can be used to diagnose normality/abnormality of various fetal anatomical structures.

METHODS

MR and/or computed tomography virtuopsy and conventional autopsy were offered to 96 women (102 fetuses/neonates) following termination of pregnancy (TOP), intrauterine fetal death (IUFD) or neonatal death. Multivariable logistic regression analysis was used to investigate the effect on maternal acceptance of virtuopsy and/or conventional autopsy of the age of the mother, gestational age at TOP or delivery after IUFD, order of pregnancy, parity, religion, type of caregiver obtaining consent and reason for death. When parents consented to both MR virtuopsy and conventional autopsy of fetuses ≥ 20 weeks of gestation or neonates, the confidence with which MR virtuopsy could be used to diagnose normality/abnormality of various anatomical structures was determined on a scale in which conventional autopsy was considered gold standard. On autopsy we classified fetuses/neonates as having either 'normal' or 'abnormal' anatomical structures; these groups were analyzed separately. At virtuopsy, we indicated confidence of diagnosis of normality/abnormality of every anatomical structure in each of these two groups defined at autopsy, using a scale from 0 (definitely abnormal) to 100 (definitely normal).

RESULTS

Of the 96 women, 99% (n = 95) consented to virtuopsy and 61.5% (n = 59) to both conventional autopsy and virtuopsy; i.e. 36 (37.5%) consented to virtuopsy alone. Maternal acceptance of conventional autopsy was independently positively related to singleton pregnancy, non-Moslem mother, earlier gestation at TOP or delivery afer IUFD and a maternal-fetal medicine specialist obtaining consent. Thirty-three fetuses ≥ 20 weeks of gestation had both conventional autopsy and MR virtuopsy, of which 19 had a full autopsy including the brain. In fetuses with normal anatomical structures at conventional autopsy, MR virtuopsy was associated with high diagnostic confidence (scores > 80) for the brain, skeleton, thoracic organs except the heart, abdominal organs except the pancreas, ureters, bladder and genitals. In fetuses with abnormal anatomical structures at autopsy, MR virtuopsy detected the anomalies with high confidence (scores < 20) for these same anatomical structures. However, in three cases, virtuopsy diagnosed brain anomalies additional to those observed at conventional autopsy.

CONCLUSION

MR virtuopsy is accepted by nearly all mothers while conventional autopsy is accepted by about two-thirds of mothers, in whom refusal depends mainly on factors over which we have no control. Although conventional autopsy remains the gold standard, the high acceptance of virtuopsy makes it an acceptable alternative when the former is declined.

Mutation analysis of the Vangl2 coding region revealed no common cause for Tetralogy of Fallot

Vangl2 (Van Gogh-like 2) protein acts via non-canonical Wnt signalling to regulate polarized cell movements during development of the proximal outflow tract in vertebrate embryos. Recently, it has been shown that mutations of the Vangl2 gene cause aortic arch defects that are characteristic of the loop-tail (Lp) mouse and they have also became a strong candidate for causing congenital outflow tract defects in humans. Thus, in this study Tetralogy of Fallot (ToF), which comprises a group of syndromes that constitutes the most frequent cause of congenital cardiac outflow abnormalities in humans, was analysed for mutations within all coding regions of the Vangl2 gene. Based on direct sequencing data from a combination of 20 patients with ToF and 22 healthy people, three polymorphisms have been identified in exon 6 and exon 7 which do not change the amino acid sequence. It was concluded, therefore, that there is no specific mutation responsible for the ToF phenotype in the Vangl2 gene.

Influence of neuropeptide Y (NPY) on food intake and growth of penaeid shrimps Marsupenaeus japonicus and Penaeus semisulcatus (Decapoda: Penaeidae)

The effects of neuropeptide Y (NPY) administered intramuscularly or orally on postlarvae (PLs) of two penaeid species were investigated in this study. In experiment 1, food intake (FI) of Marsupenaeus japonicus PLs (0.96 g), injected with NPY at 0.6 microg per g BW, was investigated within 48 h posttreatment. In experiment 2, oral administration of NPY (at doses of 0, 0.125, 0.25, 0.5 microg g(-1) food) on feed intake and growth performance of Penaeus semisulcatus PLs (0.27 g) was examined for 6 weeks. In experiment 1, NPY injection significantly increased average daily FI of M. japonicus PLs within the first 24 h compared to the control (P<0.05), but its stimulatory effect decreased on the second day (P>0.05). The increase in FI was 33% during the first 24 h and 17% during the next 24 h. In experiment 2, significant (P<0.05) differences were found among the groups in terms of weight gain and food utilization (P<0.05). Mean FI significantly increased (as much as 1.3-fold over the control) when NPY was orally administered at doses from 0.125 to 0.5 microg g(-1) feed. There was a positive relationship between FI and final weight (y=-0.972+2.098x, R(2)=0.81) and between FCE and NPY doses in the diets (y=45.37+3.46x, R(2)=0.91). The present findings indicated for the first time that NPY is a potent stimulator of food intake when administered either intramuscularly or orally to penaeid shrimps.

Diagnostic problems on frozen section examination of myometrial invasion in patients with endometrial carcinoma with special emphasis on the pitfalls of deep adenomyosis with carcinomatous involvement

Frozen-section and paraffin section diagnoses were compared in 55 patients with Stage I endometrial adenocarcinoma. In 44 patients (80%), a corresponding depth of myometrial invasion and in 54 (98%) patients the same tumor grade were found. Regarding the depth of myometrial invasion and histologic grade, sensitivity, specificity, positive and negative predictive values were 70%, 86%, 73%, 83% and 92%, 100%, 100%, 94%, respectively. Concerning myometrial invasion 9% false-positivity and 10% false-negativity rates were noted. The histopathologic characteristics of false-positive and false-negative patients are emphasized because carcinomatous involvement of deeply situated adenomyosis and advanced grade tumors are the main diagnostic pitfalls. It is important for pathologists to be able to identify carcinomatous involvement of adenomyosis and adjacent foci of minimal myometrial invasion during frozen-section examination which can prevent aggressive surgery.

Endometrial involvement by intra-abdominal diffuse malignant mesothelioma

A 49-year-old patient presented with an adnexal mass. Endometrial curettage showed a proliferative phase and suspicious fragment resembling Arias Stella reaction. Laparotomy revealed an extensive nodular intra-abdominal tumor involving the bilateral ovaries. Microscopic findings were similar to the suspicious endometrial fragment in the curettage specimen. Histochemical and immunohistochemical studies confirmed the diagnosis of diffuse malignant mesothelioma with metastasis to the endometrium. This is the first reported case to our knowledge in the English literature.

Hyperplastic mesothelial cells in pelvic and abdominal lymph node sinuses mimicking metastatic ovarian microinvasive serous borderline tumor

Hyperplastic mesothelial cells within pelvic and abdominal lymph nodes were encountered in the staging procedure of a 32-year-old woman with a left ovarian microinvasive serous borderline tumor. Mesothelial hyperplasia was noted in the pelvic and abdominal peritoneum. Intranodal mesothelial cells occupied the subcapsular sinus with subadjacent interfollicular sinuses involved less strikingly. These mesothelial cells were originally misdiagnosed as a metastatic serous borderline tumor. Histologic review and immunohistochemistry confirmed mesothelial origin. This case represents the second reported example of mesothelial cells within the lymph nodes of patients with ovarian serous tumors. Similar involvement of the mediastinal, cervical and internal mammary lymph nodes has been described in several patients with pleural effusions without neoplastic cells. Intranodal mesothelial cells should be distinguished from metastasis--an error ending in upper staging of a case.

Estrogen and progesterone expression of vessel walls with intravascular leiomyomatosis; discussion of histogenesis

We report seven cases of intravenous leiomyomatosis. Growth beyond the uterus occurred in two of the seven cases in the broad ligament. One 21-year-old patient is one of the youngest reported cases in the literature. Five patients had total abdominal hysterectomy with removal of the adnexa and two patients underwent myomectomy. One of the myomectomy cases had abdominal hysterectomy and bilateral salpingo-oophorectomy one year later due to recurrence. The other one was disease free six months after the operation. Vessel walls harboring intravascular tumor were investigated immunohistochemically for Factor VIII, CD 34, estrogen and progesterone receptors with the hope of making the histogenesis of intravenous leiomyomatosis clear. Immunohistochemical analyses of estrogen receptors, progesterone receptors, vimentin, desmin, smooth muscle actin, CD 10 and h-caldesmon were performed on intravascular tumor cells. Endothelial and subendothelial cells expressed none to scant, very weak progesterone and estrogen receptor positivity. Intravascular tumor cells showed weak (10%) to strong (70%) progesterone receptor positivity and weak (10%) to strong (60%) estrogen receptor positivity. These results do not support the hypothesis of a vessel wall origin for intravenous leiomyomatosis.

Leiomyosarcoma of the broad ligament arising in a pre-existing pure neurilemmoma-like leiomyoma

A 35-year-old woman presented with an adnexal mass which came out as a leiomyosarcoma of the broad ligament arising in a pre-existing pure neurilemmoma-like leiomyoma. This is the first reported case of leiomyosarcoma arising in a pure neurilemmoma-like leiomyoma, the third reported case at an unusually young age showing evidence of a pre-existing leiomyoma and the 12th reported case of leimyosarcoma of the broad ligament. Is the likelihood of malignant transformation, especially in large leiomyomas of the broad ligament, a rare event?

Comparison of exercise stress testing with dobutamine stress echocardiography and radionuclide ventriculography for diagnosis of coronary artery disease

Dobutamine stress echocardiography, Tc-99m radionuclide ventriculography (RNVG), and exercise stress testing were performed prospectively in 63 patients with suspected coronary artery disease to compare the values of exercise testing, dobutamine stress echocardiography and RNVG in the non-invasive diagnosis of coronary artery disease. The sensitivities of dobutamine stress echocardiography and RNVG were found to be higher than that of exercise testing (93-62%, p < 0.001; 83-62%, p < 0.05). The sensitivities of dobutamine stress echocardiography and RNVG were similar (p > 0.05). There were no differences between the sensitivities of the three techniques in multiple vessel disease (p > 0.05). The specificities of dobutamine stress echocardiography and RNVG were higher than that of exercise testing (for both of the tests 86-62%, p < 0.05). The diagnostic accuracy of dobutamine stress echocardiography and RNVG were similar (p > 0.05). The results of dobutamine stress echocardiography RNVG were concordant with each other in 46 patients (76%, kappa = 65%) in sectional analysis. Dobutamine stress echocardiography and RNVG tests were comparable with each other in 85% of the 189 segments (kappa = 64%). The expected 5% decrease at peak doses of dobutamine was not detected in stress echocardiography in 25 patients and in RNVG in 26 of the patients. Dobutamine stress echocardiography and RNVG are superior to exercise testing in the diagnosis of single vessel disease and there is no significant difference between the two techniques. When the ejection fraction is considered in dobutamine stress echocardiography and RNVG, it does not make an additional contribution to the diagnosis of coronary artery disease.

Histopathological and functional effects of radiation therapy in obstructive uropathy

Leukocyte influx into the cortex and medulla of the kidney is seen following acute ureteral obstruction. To investigate the macrophage influx and alterations in glomerular filtration rate (GFR) and to evaluate the effects of early radiation therapy on these parameters, we evaluated 20 rabbits in four groups. In the first group preoperative technetium-99m scanning preceding bilateral ureteral complete obstruction was performed. All rabbits received whole body irradiation of 1316 rads. Then the bilateral ureteral obstruction was released after 24 hours. Two hours after releasing, the last scanning was performed. The kidneys were immediately removed and histopathological examination was done. In the second group, all procedures except radiotherapy were done. The third group underwent sham laparotomy to assess the effects of surgical trauma on renal functions. The fourth group of rabbits was considered as control. We have observed an apparent macrophage influx into the cortex and medulla of the kidney following bilateral ureteral obstruction (p=0.000). However, irradiation reduced the infiltration significantly (p=0.000). Also in cases who received radiotherapy GFR was preserved to a significantly higher degree (p=0.000). We concluded that irradiation following acute ureteral obstruction has protective effects on renal function through abolition of the infiltrating cells.

The effects of tissue expansion on skin lymph flow and lymphatics: an experimental study in rabbits

Histomorphological, physiological, and biomechanical changes of the skin and tissue that are being expanded have been extensively studied in the past. The purpose of this study was to investigate whether the skin lymph flow and lymphatics may be influenced during tissue expansion, and also to study different pattern of vascular supply of skin on lymph flow during tissue expansion. The skin lymph flow was quantitatively assessed by 99mTc-dextran lymphoscintigraphy, and the structure of dermal lymphatics was evaluated by histological examination in 12 rabbits. Lymphoscintigraphic results showed that lymph flow is significantly reduced both in expanded and non-expanded (sham-operated) skin. Histologically, we saw widespread lymphatic distension in both expanded and non-expanded skin. There were no quantitative differences in the number of lymphatic vessels compared with control skin. We did not see any lymphatic capillaries in the subdermal capsule of either expanded or non-expanded skin. These results show that lymphostasis has an obstructive (mechanical) aetiology, and the tissue expander itself reduces the lymph flow regardless of expansion, and interferes with the formation of new lymphatic vessels.

Comparison of exercise stress testing with dobutamine stress echocardiography and exercise technetium-99m isonitrile single photon emission computerized tomography for diagnosis of coronary artery disease

To compare the value of exercise electrocardiography with dobutamine stress echocardiography and exercise technetium-99m isonitrile single-photon emission computed tomography for coronary artery disease, 70 patients with either suspected or proven coronary artery disease underwent dobutamine stress echocardiography, exercise technetium-99m isonitrile single-photon emission computed tomography (mibi-SPECT) and treadmill exercise electrocardiography (ECG). Dobutamine echocardiography and exercise mibi-SPECT revealed a higher overall sensitivity than exercise testing (90 vs 57%, p < 0.001; 96 vs 57%, p < 0.001, respectively). Dobutamine stress echocardiography showed a higher specificity than both exercise mibi-SPECT and treadmill exercise electrocardiography (90 vs 71%, p > 0.05; 90 and 62% p < 0.05, respectively) but the difference between dobutamine stress echocardiography and exercise mibi-SPECT was not statistically significant. Diagnostic accuracy of dobutamine stress echocardiography and exercise mibi-SPECT was higher than that of exercise testing (90 vs 59%, p < 0.001; 89 vs 59%, p < 0.001, respectively). Dobutamine stress echocardiography and exercise mibi-SPECT have superiority over exercise testing in the diagnosis of coronary artery disease and dobutamine stress echocardiography is an alternative for exercise mibi-SPECT.

Comparison of exercise stress testing with simultaneous dobutamine stress echocardiography and technetium-99m isonitrile single-photon emission computerized tomography for diagnosis of coronary artery disease

The object of our study was to compare the value of exercise stress testing with simultaneous dobutamine stress echocardiography and technetium-99m isonitrile single-photon emission computed tomography for the diagnosis of coronary artery disease. Sixty-nine patients with either suspected or proven coronary artery disease underwent simultaneous dobutamine technetium-99m isonitrile single-photon emission computed tomography and stress echocardiography, and treadmill exercise electrocardiography. Dobutamine echocardiography and technetium-99m isonitrile single-photon emission computed tomography revealed a higher overall sensitivity than exercise testing (94 vs 60%, P < 0.001), but dobutamine stress echocardiography showed a higher specificity than both technetium-99m isonitrile single-photon emission computed tomography and exercise testing (86 vs 64%, P < 0.05, for both tests). In addition, the diagnostic accuracy of dobutamine stress echocardiography and technetium-99m isonitrile single-photon emission computed tomography was higher than that of exercise testing (91 vs 61%, P < 0.001; 86 vs 61%, P < 0.001, respectively). Dobutamine stress echocardiography and technetium-99m isonitrile single-photon emission computed tomography are superior to exercise testing in the diagnosis of coronary artery disease, and dobutamine stress echocardiography can act as an alternative to technetium-99m isonitrile single-photon emission computed tomography.

Clinical experience with Tc-99m MIBI imaging in patients with malignant tumors. Preliminary results and comparison with Tl-201

Tc-99m MIBI imaging was performed in 34 patients with histopathologically proven malignant tumors. The study was performed in two steps. In the first step, only Tc-99m MIBI imaging was performed (Group 1). In the second step, both Tc-99m MIBI and Tl-201 imaging were performed for comparison (Group 2). Seventeen patients were studied in each step. The size of the smallest primary tumor (breast cancer) was 15 x 10 mm, and that of the largest (lung cancer) was 145 x 130 mm. Of the 34 patients, 26 showed Tc-99m MIBI uptake at the tumor site. In Group 1, 12 patients showed Tc-99m MIBI tumor uptake, but no uptake was detected in five patients (squamous cell carcinoma of the esophagus, teratoma of the testis, nonHodgkin's lymphoma, and squamous cell carcinoma of the lung). In Group 2, 13 patients showed both Tc-99m MIBI and Tl-201 uptake at the tumor site, but one patient with breast cancer showed only Tc-99m MIBI uptake, and three patients showed no Tc-99m MIBI and Tl-201 uptake (embryonal cell carcinoma of the testis, hepatocellular carcinoma). The overall sensitivity of Tc-99m MIBI imaging was 76.4%. In Group 2, the sensitivity was 82.3% for Tc-99m MIBI and 76.4% for Tl-201. Our preliminary clinical experience suggests that Tc-99m MIBI can be helpful in localizing malignant tumors and that its sensitivity is slightly higher than Tl-201.

Technetium-99m-MIBI and thallium-201 uptake in pulmonary actinomycosis

A patient with pulmonary actinomycosis who unexpectedly showed focal uptake of technetium-99m-hexakis-2-methoxy isobutyl isonitrile and thallium-201 is presented. The appearance of the lesion on the chest radiograph and x-ray CT scan resembled a mediastinal tumor. The diagnosis of pulmonary actinomycosis was achieved by histopathologic examination of the surgically removed mass.