Unusual gastric mucosal infiltration by a medullary thyroid carcinoma: a case report

Background

Medullary thyroid carcinoma accounts for approximately 1 to 2 % of all thyroid carcinoma cases. The most common route of dissemination is to locoregional lymph nodes. Distant metastases commonly affect bones, lungs, and liver. We present a case of a white woman with a 25-year history of medullary thyroid carcinoma on multiple medications including tyrosine kinase inhibitor therapy for the last 11 months, who exhibited unusual diffuse infiltration of advanced stage medullary thyroid carcinoma to her gastric mucosa.

Case presentation

A 53-year-old white woman presented with increasing fatigue, loss of appetite, and severe epigastric pain radiating to her back. She had a history of medullary thyroid carcinoma (pT2pN1b), diagnosed 25 years ago and treated by complete thyroidectomy and repeated bilateral cervical lymph node dissection. Medical therapy included octreotide 20 mg every 4 weeks, which was switched to the tyrosine kinase inhibitor vandetanib 300 mg/day 11 months ago when computed tomography scanning revealed progressive mediastinal lymph node and diffuse and symptomatic pulmonary metastases. Of note, she demonstrated macroscopically stable pulmonary and mediastinal lymph node metastases; however, her calcitonin serum levels dramatically increased. Computed tomography scanning revealed a single new intrahepatic lesion (4 mm) as well as multiple (>10) new supraclavicular lesions suggestive of medullary thyroid carcinoma progress. As proven by gastric biopsy and immunohistochemical evaluation, her epigastric pain was explained by a diffuse infiltration of her gastric mucosa by metastatic medullary thyroid carcinoma. Subsequently, she rapidly deteriorated and died.

Conclusions

The current case report shows for the first time an unusual metastatic infiltration of the gastric mucosa by medullary thyroid carcinoma. When treating these patients, it is important to include this differential diagnosis during follow-up.

Electronic supplementary material

The online version of this article (doi:10.1186/s13256-016-0981-9) contains supplementary material, which is available to authorized users.

[Bethesda classification of fine needle punctures of the thyroid. Much ado about nothing really new?]

The Bethesda system for reporting thyroid cytopathology was published in 2008 (Baloch et al. 2008, Cytojournal 5:6; Baloch et al. 2008, Diagn Cytopathol 36:425-437) offering a classification system which is closely related to clinical data. The aim was to ensure adequate terminology without risk of errors in understanding, to advise clinicians concerning therapeutic options in relationship to cytological diagnoses as well as to facilitate the comparison of cytology data at national and international levels. However, mainly due to specific US American (both medical and legal) demands, this classification system is not yet fully appreciated in most European countries. The reasons are various: (a) Criteria for representative material are much more restrictive than those commonly used and in Germany a higher number of (unnecessary) repunctures would be the consequence. (b) It remains doubtful whether the introduction of a new and rather heterogeneous category of "atypia of undetermined significance or follicular lesion of undetermined significance" would contribute to a substantial decrease of findings classified as "follicular neoplasia". Furthermore it is unlikely that clinicians would be willing to accept the recommended conservative approach with repuncture if a new diagnostic category is associated with a calculated risk of malignancy in 5-15% cases. (c) Until now an integration of new developments in molecular markers into the Bethesda system is missing. Thus, for experienced cytologists the Bethesda system for reporting thyroid cytopathology offers very limited benefits in comparison to the currently used, established and highly accepted classification systems. However, a positive argument remains the fact that an internationally accepted classification system may improve the comparability of the results of national and international studies on thyroid findings.

Is it possible to prepare the second component of a movement before the first one?

Experiment 1 utilized a choice reaction time paradigm to examine whether advance information about the second component of a movement has similar effects upon movement initiation and execution as advance information about the first component. Four stimuli were assigned to four goal keys. Subjects responded with the index finger of their preferred hand. They had to press on of two intermediate keys before pressing the assigned stimulus goal key. Advance information signaled one pair of goal keys in such a way that either the first or the second movement component was unequivocally specified before the response signal appeared. Shorter reaction times resulted when the first component was precued. Further control conditions showed that advance information about the second movement component could not be utilized for movement preparation. Experiment 2 ruled out a perceptual interpretation of this effect. Experiment 3 showed that preparation time for two-component movements are longer than for one-component movements. The study permits the conclusions that speeded two-component movements are controlled by motor programs and that advance information about the first movement component is required before the second movement component can be programmed.

Immunocytological analysis of leukocyte subpopulations in urine specimens before and after prostatic massage

OBJECTIVE

To evaluate the presence of leukocyte subpopulations in urine after prostatic massage (VB 3) in symptomatic patients with > or =10 leukocytes/high power field (magnification x1,000) in expressed prostatic secretions, and who were classified as suffering from chronic bacterial prostatitis or inflammatory chronic pelvic pain syndrome.

METHODS

115 consecutive patients were investigated. Granulocytes in centrifuged midstream urine (VB 2) and VB 3 were counted after Papanicolaou stain. Macrophages, B and T lymphocytes were analyzed after immunocytological staining with monoclonal antibodies according to the alkaline phosphatase anti-alkaline phosphatase method. The counts were quantified as the number of cells per view field at a magnification of x400. In all patients, acute or chronic urethritis had been excluded before enrollment in the study. 16 men without signs or symptoms of urogenital inflammation served as controls.

RESULTS

Of the 115 patients, 101 men demonstrated > or =10 leukocytes/view field in VB 3. In comparison to VB 2, the leukocyte subpopulations in VB 3 demonstrated an increase in granulocytes (9.2-fold), macrophages (7.6-fold), T lymphocytes (7.6-fold), and B lymphocytes (4-fold). The increase was statistically significant (p<0.001 each). The proportion of these cells in VB 3 was 81.6, 11.1, 5.5, and 1.8%, respectively. As compared to controls, all leukocyte subsets in VB 3 were significantly elevated (p>0.001 each).

CONCLUSION

Elevated numbers of leukocytes in VB 3 are indicative of prostatitis provided that urethral inflammation and leukocyturia in VB 2 are excluded. Granulocytes are the predominant cell type of inflammation. The increase in macrophages, T and B lymphocytes in prostatic secretions indicate the participation of both the cellular and humoral immune system in the inflammatory process.

[Purulent pericarditis as an initial manifestation of esophageal carcinoma]

HISTORY AND ADMISSION FINDINGS

A 71-year old heavy smoker was admitted because of chest pain unrelated to physical activity, radiating into the left arm and neck as well as exertional dyspnoea and dizziness. Physical examination was unremarkable except for mild venous congestion over the upper part of the body. Myocardial infarction was excluded. A haemodynamically significant pericardial effusion developed a few days later and required emergency pericardiocentesis.

INVESTIGATIONS

Laboratory tests indicated marked inflammatory disease. Echocardiography demonstrated the pericardial effusion. Needle aspiration revealed coagulase-negative staphylococcus and plant cells. Chest X-ray showed a pneumopericardium. Computed thoracic tomography suggested malignant tumour of the oesophagus with spread to the surrounding lymph nodes and pericardial fistula. Proximal endoscopy showed a highly malignant looking ulcer, 30 cm in diameter, in the anterior wall of the oesophagus with a central fistula. The endoscopic biopsy indicated a poorly differentiated non-cornified squamous cell carcinoma.

TREATMENT AND COURSE

An uncovered self-expanding metal stent was placed into the fistula, whereupon the perimyocarditis quickly healed. When the patient was discharged he was able to take food by mouth and the signs of inflammation subsided. He died at home 6 weeks later.

CONCLUSION

An oesophageal carcinoma with fistula should be included in the differential diagnosis of purulent pericardial effusion even in the absence of dysphagia. Implantation of a self-expanding metal stent into the fistula is the treatment of choice for palliation.

[Is the elimination of osteosarcoma cells with intraoperative "mesh autotransfusion" and leukocyte depletion filters possible?]

Intraoperative autotransfusion is contraindicated in cancer surgery because of the possible risk of systemic tumor spread. The aim of the present study was to investigate whether a cell saver in combination with a white blood cell depletion filter can remove osteosarcoma cells.

METHODS

A defined number of osteosarcoma cells from an established cell line were added to red cell concentrates and Ringer solution. The tumor cell concentration was 1000/ ml in the first five experiments, 7111/ml in test no. 6, 1667/ml in test no. 7 and 167/ml in test no. 8. Following thorough mixing, each unit was processed separately by a cell saver (DIDECO BT 795/P) in its normal operation mode to produce a red cell concentrate. This red cell concentrate was filtered using a leukocyte depletion filter (PALL BPF 4). Samples were taken before and after processing with the autotransfuser and after filtration with the white cell depletion filter. Cytospin specimens from all samples were examined for osteosarcoma cells by three different methods (Papanicolaou stain, Vimentin antibodies, DNA analysis).

RESULTS

After processing with the autotransfuser, tumor cells were identified in the red cell concentrate. No osteosarcoma cells were evident after the combined use of cell saver and leukocyte depletion filter.

CONCLUSION

The sole use of the autotransfuser DIDECO BT 795/P during osteosarcoma surgery is not recommended because of the potential danger of retransfusion of malignant cells. In combination with the leukocyte depletion filter PALL BPF 4, no osteosarcoma cells were identified in the red cell concentrate. Since the adhesiveness of tumor cells from established cell lines may be different from that of tumor cells in the intraoperative salvaged blood, further studies with blood from the surgical field are necessary to determine the efficacy of white cell depletion filters to eliminate osteosarcoma cells.

[Intrapulmonary tumor cell spread and intraoperative pleural lavage as prognostic factors in bronchial carcinoma?]

Tumor cell detection in lavage fluids might be a prognostic factor in solid tumors. Therefore, 342 patients with the first manifestation of lung cancer underwent intraoperative pleural lavage (lavage I = after opening the chest; lavage II = after resection of lung cancer). Tumor cells were found in lavage I in 132 patients (38.6%), in 99 of them also in lavage II. We found tumor cells in only nine cases in lavage II cytologically. The cumulative 5 year survival rate of non-small cell lung cancer in stage I (n = 164) was 25.9% if lavage was positive (lavages I and II, n = 47), and 69.2% if lavage was negative (n = 117) (p < 0.05). Additionally, we performed tissue cultures of tumor-free parenchyma in 23 cases of lung cancer. In 16 cases (69.6%), we detected tumor cells by histology and immunohistology. Cytologic tumor cell detection in intraoperative pleural lavage in lung cancer seems to be an additional prognostic factor and should be done when assessing the final tumor stage. A positive result should be added to the pTNM classification.

[The value of urine phosphohexose isomerase activity in comparison with urine cytology. First diagnosis and tumor after-care in patients with cancer of the urinary bladder]

The importance of phosphohexose (PHI) activity in the urine of patients with carcinoma of the urinary bladder is examined on the basis of enzyme-histochemical studies in tumor cell homogenizates after transurethral resection for transitional cell carcinoma. The results gave rise to the question of whether the enzyme-histochemical activity patterns were reflected in the urine in the form of photometrically measurable activity, and thus whether the PHI activity can be used in screening as a marker to complement the standard urine cytological procedure. The sensitivity of PHI measurement was determined at 89%. The measurement of PHI in the urine of patients with an ileum neobladder or of patients with urinary tract infections does not provide any useful information.

Effects of preliminary information in a Go versus No-go task

A series of studies using a Go versus No-go task examined the question of whether preliminary information available early in the recognition of a stimulus is made available to later processes before stimulus recognition is finished, a question relevant to the controversy between discrete and continuous models. Experiment 1 showed that a Go response is faster following a cue indicating that the response probably would be required than following a cue indicating it probably would not be required. Experiments 2-7 were conducted to find out whether analogous preparation occurred when probability of the Go response was signalled by easily discriminable features of a single stimulus rather than a separate cue. The effect was observed when the easily discriminable features uniquely determined the name of the stimulus letter, but not when they merely indicated that the stimulus name was one of two visually similar letters. These results are consistent with the Asynchronous Discrete Coding model, in which the perceptual system makes available to later processes only preliminary information corresponding to discretely activated stimulus attributes.

Distinction of mesothelioma from carcinoma in pleural effusions. An immunocytochemical study on routinely processed cytoblock preparations

The study was designed to find out whether the commercially available antibodies BMA 130 c, BMA 120, V 9, KL 1, B 72.3 TAG, HEA 125 and Ber-EP 4 would be of help in distinguishing carcinomas from a mesothelial process (mesothelioma/pleuritis) in pleural effusion specimens routinely processed by the cytoblock method. All of the 20 carcinomas included in the study but also 19 of the 20 mesotheliomas expressed cytokeratin (KL 1), whereas vimentin expression was found in 7 of the 20 carcinomas and 19 of the 20 mesotheliomas. 19 of the 20 carcinomas reacted with the epithelial markers B 72.3 and HEA 125, and 18 of them with Ber-EP 4. In contrast, only a few of the 20 mesotheliomas showed a weak reaction to these markers (1 with HEA 125, 2 with B 72.3, and 3 with Ber-EP 4). BMA-130 c was detected in 10/20 carcinomas but in none of the mesotheliomas. BMA-120 was observed in the effusions from 17/20 mesotheliomas and in cover cells which had undergone reactive changes, but also in 2 cases of ovarian carcinoma. The results show that reaction to the "epithelial markers" B 72.3, HEA 125 and Ber-EP 4 is strongly indicative of carcinoma and not of mesothelioma, whereas a positive reaction with the antibody BMA-120 in the absence of reaction to the epithelial markers makes a mesothelial process very likely. However, immunocytochemical distinction cannot be made as yet between mesothelioma cells and pleuritic cells. If simultaneous positivity for BMA-120 and an "epithelial marker" in a pleural effusion is observed the primary tumor could be an ovarian carcinoma.

Preparation for Donders' type B and C reaction tasks

Several variants of a precued reaction time experiment were performed to assess preparation for Choice (Donders' type B) or Go/No-Go (type C) reaction tasks. On each trial, the imperative stimulus could necessitate either a keypress with the left forefinger, the right forefinger, or no response. A precue given at lead times of 50-750 ms either informed the subject whether the task was a type B task (left or right forefinger response), a type C task (e.g., left forefinger or No Go), or carried no information (all three possibilities remained open). The noninformative cue produced minor facilitation of reaction time at long lead times only. At lead times of 50-250 ms, the other two precues speeded reactions by about 50 ms. At precue intervals of 400-750 ms, Go/No-Go reactions averaged 25 ms faster than Choice reactions in an experiment which utilized appropriate controls for stimulus and task parameters. The mixed-trial design rules out gross motor (e.g., postural) adjustments as an explanation for the advantage of C over B reactions. An interpretation in terms of a two-stage theory of motor preparation is discussed.

Brown bowel syndrome with manifestation in the gastrointestinal tract and thyroid gland

Brown bowel syndrome (BBS) is a rare disease accompanied by deposits of lipofuscin predominantly in smooth muscle cells of the gastrointestinal tract. To determine whether cells other than smooth muscle cells show pigment deposition we studied biopsies of the stomach, small and large intestine, and thyroid gland of a 52-year-old male with malabsorption syndrome. Light and electron microscopy found lipofuscin pigment in vascular endothelial cells and in smooth muscle cells of the muscularis mucosae, arterioles and venules of the gastrointestinal tract and thyroid gland. All other cells of bowel and thyroid gland, such as epithelial cells, Schwann cells, nerve fibers, fibroblasts, macrophages and leukocytes, showed no such pigment inclusions. Intracellular lipofuscin deposition is thought to be caused by a deficiency of vitamin E. Such a deficiency existed in our patient and was attributed to a six year history of malabsorption syndrome with complete atrophy of the villi of the intestinal mucosa. Lipofuscin pigmentation has been reported in numerous organs of patients with BBS but not, until now, in the thyroid gland or in endothelial cells of lymph vessels. The origin of lipofuscin pigment is not known exactly. The prevailing opinion is that it derives from degenerating mitochondria. Our findings, however, suggest that autophagocytotic processes may also play a role in the formation of lipofuscin.

On-line transmission electron microscopic image analysis of chromatin texture for differentiation of thyroid gland tumors

Nuclei of the cells from the thyroid gland were analyzed in a transmission electron microscope by direct TV scanning and on-line image processing. The method uses the advantages of a visual-perception model to detect structures in noisy and low-contrast images. The features analyzed include area, a form factor and texture parameters from the second derivative stage. Three tumor-free thyroid tissues, three follicular adenomas, three follicular carcinomas and three papillary carcinomas were studied. The computer-aided cytophotometric method showed that the most significant differences were the statistics of the chromatin texture features of homogeneity and regularity. These findings document the possibility of an automated differentiation of tumors at the ultrastructural level.

Sigmoid carcinoma mimicking an intra-abdominal abscess in an 111In-labeled white blood cell scan

A 61-year-old white female with ulcerative carcinoma of the sigmoid exhibited an abscess-like pattern on a white blood cell scan using 111In-oxine-labeled 'pure' granulocytes. Constant 111In activity could be seen in the tumor 0.5, 3, and 20 h after the reinjection of the labeled cells. The absence of an abscess was proven by surgery and histological investigation.

Computer-based cytophotometric classification of thyroid tumors in imprints

This study of 14 follicular adenomas, 10 papillary carcinomas and 11 follicular carcinomas of the human thyroid gland demonstrates the possibility of a cytological tumor classification using digital picture processing. Routinely prepared, HE-stained imprints of surgical specimens were scanned under a light microscope at high resolution with a colour TV camera. The cell nuclei were segmented and analysed with an image processing system. The computer-aided cytophotometric methods detected the most significant differences in the chromatin texture with a criteria variance of texture line distances and texture points per texture knots. Using these criteria benign and malignant tumor types could be successfully differentiated.

[Diagnosis and therapy of large intestine endometriosis]

Six cases (1981/82) with endometriosis of the bowel are reported on. There was a gynecological and surgical examination after 6-12 months. Intestinal symptoms associated with dysmenorrhea, dyspareunia and nodules, involving the cul-de-sac, the uterosacral ligaments and the anterior surface of the rectum are important symptoms of colonic endometriosis. Problems in diagnosis were illustrated by extramucosal radiologic appearance and normal mucosa and extrinsic pressure by proctosigmoidoscopy. Five patients were treated with resection of the involved bowel. Endometriosis is sufficiently common that it should always be considered in the differential diagnosis of colon lesions of women of childbearing age. In all cases characteristical symptoms were related.

[Metastatic differentiated thyroid cancer. Diagnostic accuracy of thyroglobulin-RIA in comparison with 131I-whole body scintigraphy]

In a retrospective analysis in patients with differentiated thyroid carcinoma, the diagnostic validities of 131I whole-body scans and radioimmunologic determinations of thyroglobulin (hTg) are compared with special regard to late metastases. Metastases were found in 83 out of 311 patients with differentiated thyroid carcinoma. In two thirds of the cases, these were primary metastases while in the remaining third of the cases, metastases developed in later follow-up with a mean time of latency of 3.3 years. While about 70% of the early metastases could bei detected by 131I scintigraphy, this percentage amounted to only 40% in late metastases. With a diagnostic sensitivity of 90%, hTg-RIA was clearly superior in the detection of early as well as of late metastases. hTg was measurable, however, only in iatrogenous hypothyroidism in 4 out of 49 cases. Based on these results and an analysis of the literature, a program for follow-up of differentiated thyroid carcinoma is proposed. The hTg-RIA is thereby used as an alternative to 131I scintigraphy in the late phase of follow-up after complete ablation of any thyroid tissue.

Cytological findings in medullary carcinoma of the thyroid

In six cases of medullary carcinoma of the thyroid rather characteristic findings were seen in cytological specimens obtained by aspiration or imprint. The roundish-polygonal or spindle-shaped cells were predominantly disseminated, but occasionally arranged in small groups. The nuclei were frequently found in an excentric position; binuclear cells were sometimes encountered. In addition, five of the six cases showed intranuclear cytoplasmic inclusions which were also investigated by electron microscopy in specimens of two cases. Such inclusions in aspiration biopsies of the thyroid have so far been regarded, as characteristic for papillary carcinoma. In smears as well as in histological sections amyloid and calcitonin could be demonstrated by congo red staining and by immunocytochemistry, respectively. The cytomorphology of the tumor cells, their pattern of arrangement, and the peculiar nuclear inclusions make up a combination of findings that may justify the diagnosis of medullary carcinoma in aspiration biopsies. In smears the diagnosis can already be confirmed when (immuno-) cytochemical methods are applied to smear preparations.

Electron microscopic demonstration of calcitonin in human medullary carcinoma of thyroid by the immuno gold staining method

In a human medullary carcinoma of thyroid gland containing calcitonin in light microscopic demonstration by the avidin biotin complex (ABC) method characteristic secretory granules were found electron microscopically in the cytoplasm of the tumour cells. They consisted in so-called type I granules (270 +/- 25 nm) and type II granules (135 +/- 17 nm). By the immuno gold staining (IGS) method the content of many secretory granules measuring 85-270 nm (152 +/- 18 nm) in diameter could be identified as calcitonin. These granules seemed to be predominantly of type II because of their nearly corresponding size and feature. The type I granules were less frequent in number and they showed no or little immunoreactivity. The results indicate that the IGS-method is practicable to demonstrate the ultrastructural localization of calcitonin and to identify clearly the nature of intracytoplasmic granules in electron microscopy.

Computer analysis of chromatin arrangement and nuclear texture in follicular thyroid tumours

The differentiation of the thyroid glands follicular neoplasias into adenomas and carcinomas is currently done using the histological criteria recommended by WHO. This pilot study of 10 human follicular carcinomas and 10 folliculars adenomas demonstrates the possibility of a cytological classification using digital picture processing of high resolution cell images. Giemsa stained paraplast sections were scanned with a Colour-TV-camera, different channels were used with respect to staining and analyzing methods and computed with an image processing system. The computer aided cytophotometric methods detected significant differences in the chromatin arrangement and structure.

[Immunohistochemic detection of factor VIII antigen in malignant hemangioendotheliomas of the thyroid. A contribution to histogenesis]

The hemangioendothelioma of the thyroid gland is regarded as a special type of malignant goitre in view of its characteristic morphology and epidemiological behaviour. The histogenetic origin of these tumors (endothelial cells versus a special type of undifferentiated carcinoma of the thyroid) is still unresolved. By an immunoperoxidase method six hemangioendotheliomas were immunocytochemically investigated with an antibody to factor VIII-related antigen, a specific marker for endothelial cells and tumors thereof. In four of these tumors a strongly positive reaction was demonstrated, whereas control sections of undifferentiated and differentiated carcinomas, as well as two hemangioendotheliomas, remained negative. The demonstration of factor VIII-related antigen in four of six hemangioendotheliomas appears to offer evidence that most of these characteristic malignant tumors originate from endothelial cells or endothelial precursor cells. There is a histogenetic difference from true carcinomas originating from thyroid epithelial cells.

[Combined disease picture of an autonomous thyroid adenoma with acute and chronic thyroiditis]

This is a case report of a 20 year old woman suffering from a single toxic hot nodule of the thyroid gland. Following inflammation of the neck a cystic nodule with a thick fibrotic capsule was resected. Histology revealed a follicular adenoma with central necrosis surrounded by chronic fibrosing thyroiditis with intima proliferation of the blood vessels similar to Riedels thyroiditis.

The use of monoclonal antibodies against thyroglobulin in immunoperoxidase techniques

A monoclonal mouse antibody to human thyroglobulin was used in a modified biotin-peroxidase-complex method to demonstrate thyroglobulin in different tissues and tumors of the thyroid gland. Mouse ascites fluid containing monoclonal antibodies could be diluted up to 1:1,600 for detection of thyroglobulin, whereas no staining was observed in a medullary carcinoma. Nonspecific background staining was negligible. These results demonstrate that monoclonal antibodies against thyroglobulin are suitable in the immunohistochemical localisation of thyroid hormones.

Absorption of N-nitroso-bis-(2-hydroxy-propyl)amine (BHP) from subcutaneous layers

Nodules developing under the skin of rats after repeated injections of N-Nitroso-bis-(2-hydroxy-propyl)amine (BHP) are shown to contain no unchanged BHP.

On the development of metastasizing tumors of the rat thyroid gland after combined administration of nitrosomethylurea and methylthiouracil

Seventy-five female Wistar rats of 150 g each were given 3 X 40 mg/kg body weight nitrosomethylurea (NMU) and 4 weeks later until death (in the 9th-60th week) methylthiouracil (MTU), as a 0.1% solution in their drinking water. After 2 months, in the almost colloid-less thyroid gland individual foci appeared which consisted of sometimes colloid containing follicles with increased cytoplasmic and nuclear basophilia; they increased in number during the subsequent weeks and finally resulted in nodes with different morphologic structures. From the 16th week on there were tumors infiltrating the capsule, and after the 24th week there were angioinvasive carcinomas. Thirteen rats had developed lung metastasization after the 30th week. Cytology could only distinguish between the follicular carcinomas of low differentiation and the follicular adenomas. If these findings are applied to human pathology, one would have to reckon with adenomas which can develop their malignant characteristics without necessarily changing their histologic and cytologic appearance.

[Clinical experiences with diazepam (Valium) - fentanyl combination anesthesia in neurosurgery. A study of circulation and oxygen consumption]

This clinical study was performed on 13 neurosurgical patients. The mean age was 56 years (range 45-70 years). After induction of anesthesia the heart rate diminished by 21.4%, the mean pressure by 12.2% in the same time decreased the cardiac output by 19.3%, the calculated total peripheral resistance increased by 13%. The oxygen uptake decreased by 16%. The advantages and contraindications of this technique in neuroanesthesia are discussed.

Cerebral arterial air embolism due to an esophago-atrial fistula seen on CT

A case of cerebral air embolism from a rather unusual cause is reported; an esophago-cardiac fistula permitted food particles and air to enter the systemic arterial circulation. Massive embolization caused the patient to become deeply comatose rather suddenly. The computed tomogram (CT) revealed massive cerebral edema with the contradictory finding of wide superficial subarachnoid spaces. These subarachnoid spaces on further evaluation proved to be air in the cerebral vessels.