Gastric calcifying fibrous tumor

Intramucosal gastric tumours are most commonly found to be gastrointestinal stromal tumours or leiomyomas (smooth muscle tumours); however, a variety of other uncommon mesenchymal tumours can occur in the stomach wall. A rare benign calcifying fibrous tumour is reported and the endoscopic appearance, ultrasound findings and morphology are documented. A review of the literature found only two similar cases.

Capsule endoscopy findings in patients with established and suspected small-bowel Crohn's disease: correlation with radiologic, endoscopic, and histologic findings

BACKGROUND

Little is known about the accuracy of capsule endoscopy (CE) in evaluation of small-bowel Crohn's disease.

METHODS

Symptomatic eligible patients had ileocolonoscopy and biopsies from the terminal ileum, followed by small-bowel radiologic studies before CE. Endoscopic, radiologic, CE, and histologic findings were compared. Histology (terminal ileum biopsy specimens or a tissue sample after small-bowel resection) served as a criterion standard.

RESULTS

Fifty-four patients were enrolled; 15 of the 54 patients were excluded from data analysis (critical small-bowel strictures, 14, identified on radiology; incomplete CE, 1). Data were analyzed for 39 patients. All patients had histologic evaluation of the small bowel. Final diagnosis of active small-intestine Crohn's disease was made in 29/39 patients (74.4%). When calculated, CE yielded a sensitivity and a specificity of 89.6% and 100.0%, respectively, and a positive predictive value and a negative predictive value of 100.0% and 76.9%, respectively, whereas small-bowel series were 27.6%/100.0% and 100.0%/32.3%.

CONCLUSIONS

CE is more accurate in detecting small-bowel inflammatory changes suggestive of Crohn's disease than conventional studies. CE, combined with ileocolonoscopy, may be proposed as a first-line investigation of the small intestine in cases of uncomplicated known or suspected Crohn's disease.

Given capsule endoscopy in celiac disease: evaluation of diagnostic accuracy and interobserver agreement

BACKGROUND AND AIMS

Capsule endoscopy (CE) has been increasingly used for diagnosing diseases of the small bowel. It is an attractive technique for assessing celiac disease (CD) because it is noninvasive and provides a close and magnified view of the mucosa of the entire small bowel. In this study, we evaluated the accuracy of CE and interobserver agreement in recognizing villous atrophy (VA) using histopathology as the reference. We also explored the extent of small bowel involvement with CD and the relationship between the length of the affected bowel and the clinical presentation.

METHODS

Ten CD patients with histologically proven VA and the same number of controls were subjected to CE. Four, blinded to histology findings, investigators (two with and two without prestudy CE experience) were asked to diagnose VA on CE images.

RESULTS

Based on assessment of all four investigators, the overall sensitivity, specificity, PPV, and NPV of CE in diagnosing VA were 70%, 100%, 100%, and 77%, respectively. The sensitivity and the specificity of the test was 100% when the reports of experienced capsule endoscopists only were analyzed. The interobserver agreement was perfect (kappa= 1.0) between investigators with prestudy CE experience and poor (kappa= 0.2) between the investigators who had limited prestudy exposure to CE. Celiac patients with extensive small bowel involvement had typical symptoms of malabsorption (diarrhea, weight loss) as opposed to mild and nonspecific symptoms in patients whose disease was limited to the proximal small bowel. CE was tolerated well by all study participants with 95% reporting absence of any discomfort.

CONCLUSIONS

Although based on a small sample size, the study suggests that CE may be useful in assessing patients with CD. Familiarity with CE technology appears to be a critical factor affecting the accuracy of the test. Larger studies are warranted to more precisely define the advantages and limitations of CE in CD.

Malignant paraganglioma of the urinary bladder: Immunohistochemical study of prognostic indicators

Using various immunohistochemical markers, the objective of our study was to assess whether correlation exists between growth potential of paraganglioma (pheochromocytoma) cells and formation of metastasis. The patient was a 28-yr-old man who presented with intermittent episodes of gross hematuria due to a mass in the urinary bladder. He had no constitutional symptoms to suggest paraganglioma. Histologic, immunohistochemical, and electron microscopic investigation of the surgically removed tissue proved that the tumor was a malignant paraganglioma with metastases in the regional lymph nodes. The immunohistochemical tests were not supportive of high cell proliferation index, indicating that metastases can develop in the absence of rapid multiplication of the tumor cells. Abnormalities in vascular architecture and marked expression of VEGF in the tumor cells may be regarded as prognostic signs to predict the formation of metastases.

Does Whipworm Increase the Pathogenicity ofCampylobacter jejuni?A Clinical Correlate of an Experimental Observation

Campylobacter jejuniis a leading cause of acute diarrhea worldwide, usually mild and self-limiting. No adequate hypothesis has yet been formulated to explain why in an otherwise healthy host this infection is occasionally severe. In a pig model,C jejunihas been shown to be pathogenic only in the presence of swine whipworm. A human case of life-threateningC jejunicolitis leading to toxic megacolon and acute renal failure, associated with concomitant whipworm (Trichuris suis) ova in the feces, is reported. The potential of T suis to potentiateC jejuniin humans deserves further study.

Recurrent Crohn's disease in the duodenum and jejunum following extensive small bowel resection and jejunocolonic anastamosis: radiologic findings in twenty-five patients

BACKGROUND

To evaluate the radiologic features of recurrent Crohn's disease after extensive enteric resection and jejunocolostomy.

METHODS

We reviewed the small bowel studies of 25 patients with recurrent enteritis and less than 125 cm of jejunum following enteric resection and jejunocolostomy and the studies of 27 patients with jejunitis in an intact jejunum.

RESULTS

Twenty-three patients with recurrences had neoterminal jejunitis, six under 10 cm, 10 over 10 cm and continuous, and seven with skip lesions (six jejunal, one duodenal). Two had isolated jejunitis or duodenitis. Three with continuous disease had lengthy recurrences. Enteritis showed only one or two abnormalities in 12 of 25 patients with recurrences and in two of 27 with disease in the intact jejunum. Recurrent jejunitis and jejunitis in the intact jejunum showed similar frequencies of mucosal thickening, strictures, ulceration and its complications, skip lesions, sacculation, obstructive dilatation, featureless mucosa, and polyps, and significantly different frequencies only of mesenteric masses. Recurrent jejunitis and terminal ileitis showed significantly different frequencies of mucosal thickening, strictures, ulceration and its complications, skip lesions, sacculation, obstructive dilatation, and mesenteric masses, and similar frequencies only of a featureless mucosa.

CONCLUSIONS

The neoterminal jejunum is the most common site of recurrence and the only site in almost 25%. Jejunitis remote from the fecal stream is also frequent, but duodenitis is not. Recurrences are seldom extensive and often show only one or two radiographic findings. The frequencies of most lesions in recurrent jejunitis do not differ significantly from those in jejunitis in the intact jejunum but do differ from those in terminal ileitis.

NSAID injury to the small intestine

PURPOSE

To identify the clinical and radiologic findings in patients with diaphragm-like strictures in the small bowel.

PATIENTS AND METHODS

We reviewed the histories, radiologic findings, and pathologic findings in two men and two women, all in their sixties, with a history of long-term nonsteroidal antiinflammatory drug (NSAID) or aspirin (ASA) usage and one or more radiologically demonstrated diaphragm-like strictures in the small bowel.

RESULTS

Two patients had long histories of NSAID usage, and two of ASA usage. One NSAID user had a long segment of jejunal involvement, and the other three had short segments of duodenal involvement. The ASA users presented with symptoms of esophageal disease, the small bowel lesions were unexpected, and ASA usage was not initially elicited. In one NSAID user and one ASA user, broader strictures with humps rather than diaphragms were also seen producing a lifesaver-like or bagel-like configuration.

CONCLUSIONS

Multiple diaphragm-like strictures can occur in NSAID injury and are pathognomonic except in the rare patient with ulcerative enteritis complicating celiac disease. Single or few diaphragm-like strictures can occur in NSAID injury and peptic ulceration. ASA should be considered an NSAID with regard to small-bowel toxicity. A careful medication history is required when an unexplained small bowel abnormality is seen radiologically, and a dedicated small bowel examination is required when NSAID injury is suspected.

Kayexalate (sodium polystyrene sulphonate) in sorbitol associated with intestinal necrosis in uremic patients

BACKGROUND

Kayexalate (sodium polystyrene sulphonate) in sorbitol is commonly used to treat hyperkalemia in patients with renal insufficiency. Isolated case reports and one recent large series have documented intestinal necrosis following administration of kayexalate in sorbitol.

METHODS

Two patients with luminal kayexalate crystals associated with intestinal pathology were first identified in the pathology department, and clinicopathological correlation was carried out.

RESULTS

Both patients were seriously ill, had prior cardiac surgery and were in renal failure (uremic). Examination of autopsy and colonic resection showed luminal kayexalate crystals associated with underlying mucosal necrosis, submucosal edema and transmural inflammation.

CONCLUSION

Although occurring in complex clinical settings, the pathological findings provide additional evidence that kayexalate in sorbitol may be associated with intestinal necrosis and inflammation in uremic patients and that this may be a clinically and pathologically under-recognized iatrogenic bowel injury.

The histopathological changes in irradiated vs. nonradiated tissue-expanded skin in the porcine model

This study examined the histological changes following irradiation on nonexpanded and tissue-expanded pigskin. Six Yorkshire pigs received 4860 cGy radiation to one flank with the opposite side serving as the control. A histopathological comparison of tissue expansion in irradiated tissue to nonradiated tissue showed a reduction in the thickness of the dermal and subcutaneous layers, with less prominent rete ridges and a thicker stratum spinosum (p < 0.05). Nonexpanded irradiated tissue showed a reduction of thickness in the dermis and subcutaneous layer, less prominent rete ridges, and a thicker stratum spinosum layer (p < 0.05) when compared with nonradiated tissue. Tissue-expanded irradiated tissue showed no significant differences (p > 0.05) in any of these parameters when compared with nonexpanded irradiated tissue. This study demonstrates that radiation produced a significant change in porcine skin, but tissue expansion did not further alter the histological changes associated with irradiation.

Osteogenic sarcoma metastatic to the kidney: spontaneous subcapsular hemorrhage with renal artery thrombosis

The authors describe an occult metastatic deposit in the kidney of a 22-year-old woman; such lesions are not usually detected until autopsy. They postulate that after the development of acute subcapsular hematoma, a "renal compartmental syndrome" occurred, leading to renal artery thrombosis. Primary vascular involvement by the metastatic osteosarcoma, which was remote from the renal hilus, was not identified pathologically.

Testicular seminoma presenting with features of androgen excess

A 32-year-old white man presented with worsening acne and noticeable increase in muscle bulk. On examination, a firmer area with a granular consistency was noted in the right testis. A right radical orchiectomy was performed and the histologic findings were those of a typical seminoma associated with marked Leydig cell hyperplasia. A solitary right iliac lymph node metastasis, but not the primary seminoma, contained human chorionic gonadotrophin- (HCG) producing syncytiotrophoblast, which was regarded as the hormonal stimulus for Leydig cell hyperplasia and elevated serum testosterone. This seems to be the first report of testicular seminoma presenting with symptoms of androgen excess.

Hepatoid adenocarcinoma of the papilla of Vater

An adenocarcinoma of the papilla of Vater showing hepatoid differentiation similar to that described for hepatoid adenocarcinoma of the stomach is reported. The tumor was a poorly differentiated adenocarcinoma with clear cells containing occasional hyaline droplets and exhibiting bile secretion. Alpha-fetoprotein (AFP), alpha 1-antitrypsin (alpha 1-AT) and carcino-embryonic antigen (CEA) were demonstrated by immunoperoxidase staining. This appears to be the first report of a hepatoid adenocarcinoma at this location.

Splenic abscess caused by Blastomyces dermatitidis in association with peritoneal involvement: case report and review

We report a rare case of a patient with blastomycosis who presented with splenic abscess and peritoneal involvement. This case is unique in that no historical or radiographic evidence of antecedent pulmonary infection was apparent and therapy with orally administered ketoconazole was effective. We reviewed the English-language literature on blastomycotic splenic abscess and compared findings from other cases with findings from the current case.

Aseptic loosening in total hip implants: the role of polyethylene wear debris

Radiologic and routine histologic examinations, transmission electron microscopy and scanning electron microscopy were carried out on membranes retrieved from the following hip implant prostheses: loose cemented metal-on-polyethylene, resorptive cysts around fixed cemented metal-on-polyethylene, cemented without polyethylene (Thompson), noncemented without polyethylene (Moore), loose ceramic-on-ceramic and loose noncemented metal-on-polyethylene. From histologic analysis the most common factor in the membranes reviewed, in terms of production of multinucleated giant cells, is the presence of polyethylene wear debris. Neither loosening of the implant nor the presence or absence of bone cement produces such cells within the membrane.

Crohn's disease of the small intestine with polypoid configuration

We describe three patients with Crohn's disease of the small intestine with a polypoid configuration. In two patients, the polypoid masses were the only radiologic abnormalities and were suggestive of jejunoileal lymphoma and terminal ileal adenomas. The diagnosis of Crohn's disease was established only at laparotomy. In the third patient, a polypoid mass simulating a sessile adenoma was seen along with other typical features of ileitis and was recognized preoperatively as a manifestation of the ileitis. The resected ileal segments of all three patients showed mural thickening, luminal narrowing and distortion, and mucosal ulceration and fissuring. The asymmetry of the mural thickening and the resultant luminal narrowing simulated sessile polyps to which mucosal ulceration and fissuring gave a lobulated appearance.

Linitis plastica of the alimentary tract and scrotum

We present a unique case of diffuse linitis plastica involving the gastrointestinal tract and the scrotal skin of a 63-year-old man. The radiologic and pathologic features of this entity are discussed together with a review of the pertinent literature.

Nasal cryosurgery and cautery: should the septum be treated and is a diagnosis relevant?

Posterior rhinometric measurements of nasal resistance were conducted on two groups of patients with perennial rhinitis: those whose symptom of nasal stuffiness responded to a topical steroid spray and those in whom it did not. The anterior ends of the inferior turbinates in 48 patients were treated with either cryosurgery or cautery, and in half of the subjects the erectile tissue of the septum was also thermally ablated. Measurements were made before and 10-16 weeks after therapy. It is concluded from statistical comparison that there is no benefit to treating the septum, and that cryosurgery is more effective in those whose symptoms respond to topical steroids, while cautery works better in those who do not. Histology showed no change in the capacitance vessels (sinusoids) after either modality, and xylometazoline caused a marked decrease in nasal resistance, suggesting that vascular smooth muscle function was intact. Irrespective of the change in airway resistance, most subjects felt that there had been an improvement. The mechanism is discussed.

Duodenal somatostatinoma with psammoma bodies

A duodenal somatostatinoma was found incidentally in a 60-year-old woman undergoing cholecystectomy. Microscopically, the tumor had a glandular architecture with abundant psammoma bodies. Electron microscopy revealed tumor cells resembling D-cells of the pancreatic islets. Immunohistochemically, there was staining for neuron-specific enolase, chromogranin, and diffuse cytoplasmic positivity for somatostatin only. By immunoelectron microscopy, somatostatin was identified predominantly in lucent membrane-bound secretory granules. X-ray-dispersive microanalysis showed the psammoma bodies contained calcium apatite crystals. This case is compared with other reported cases with a description of cellular localization of somatostatin and development of psammomatous calcification.

Myeloma-like cast nephropathy associated with acinar cell carcinoma of the pancreas

Obstruction of renal collecting tubules by protein cats inciting a giant cell reaction is usually characteristic of myeloma cast nephropathy. Rarely other causes of proteinuria may result in a similar morphology. We report a rare case of 'myeloma-like' tubular casts in the kidney of a patient who was subsequently found at autopsy to have acinar cell carcinoma of the pancreas with peritoneal carcinomatosis. Only two similar reports could be found in the English literature.

Fine-needle aspiration biopsy of the thyroid gland: results of a five-year experience and discussion of its clinical limitations

The results of a five-year experience with fine-needle thyroid aspiration cytology are reported to assess the value, accuracy and limitations of this biopsy procedure. The cytologic diagnoses on 1,465 thyroid aspirates are listed, and correlation of cytology with histology on 207 cases undergoing surgery is reported. The incidence of malignancy among the atypical and malignant cytology aspirates with histologic confirmed diagnosis was 65% (28/43) while a false negative rate of 11.5% (15/131) was found. Fine-needle aspiration biopsy is a safe and useful procedure with an acceptable accuracy rate that complements other investigations in the screening of patients for thyroid surgery.

Atypical carcinoid tumor of the small bowel complicating celiac disease

An atypical carcinoid tumor of the small bowel in a patient with celiac disease is described. Although an increased incidence of malignancy has been observed in celiac disease, this seems to be the first report of a carcinoid tumor of the small intestine associated with this condition. Although the significance of this association is unclear, the implications with regard to gastrointestinal endocrine cell proliferation and tumor histogenesis are discussed.

Watermelon stomach, or antral gastritis

Images

Papillary carcinoma of the thyroid associated with sarcoidosis

A case of papillary carcinoma of the thyroid occurring in association with systemic sarcoidosis is reported. Although benign thyroid disorders occurring in conjunction with sarcoidosis have previously been documented, a search of the literature found no report of thyroid carcinoma occurring in association with sarcoidosis. Diagnosis and therapeutic management prove difficult when thyroid carcinoma and sarcoidosis co-exist. Transbronchial biopsy of lung lesions is warranted in staging thyroid carcinoma in order to exclude the possibility of unknown co-existent disease. The management of cervical lymphadenopathy in thyroid carcinoma should not be altered because of the presence of sarcoidosis, and should include a neck dissection.

Adenocarcinoma and colitis cystica profunda in a radiation-induced colonic stricture

A case of adenocarcinoma of the rectum occurring 17 years after pelvic irradiation for squamous carcinoma of the cervix is reported. Earlier colonic resection had shown localized colitis cystica profunda in a radiation-induced colonic stricture. Colorectal cancer is an infrequent sequel to radiotherapy, which may occur many years after treatment of the primary tumor. Prolonged follow-up of these patients is essential.

Colonic carcinoma associated with an abnormal collagen table. Collagenous colitis

A case of cecal adenocarcinoma with the typical histopathologic features of collagenous colitis throughout the resected colon is described in a 67-year-old woman. Collagenous colitis has not previously been reported in association with adenocarcinoma of the colon and the relationship of these findings appears to be unprecedented. A review of 100 randomly selected Duke's B adenocarcinomas of the colon revealed no similar case.

Colitis cystica profunda occurring in a radiation-induced colonic stricture

Localized colitis cystica profunda developed in a fibrotic radiation-induced colonic stricture 17 years after pelvic radiation for squamous carcinoma of cervix. This uncommon pathologic entity must be distinguished from invasive adenocarcinoma of colon, and colonic radiation injury should be included with other conditions associated with colitis cystica profunda.

Inverted ductal papilloma of the parotid gland

A case of inverted ductal papilloma arising in a major salivary gland is reported. To the best of the authors' knowledge, no similar case could be found in the literature. Histologic appearance and cytologic origin of this neoplasm, unique at this site, are discussed.

Angiolymphoid hyperplasia with eosinophilia: a bone lesion pathologically resembling Kimura's disease of skin. A report of two cases

Primary osseous lesions morphologically identical to the soft tissue entity known as angiolymphoid hyperplasia with eosinophilia were diagnosed by means of light and electron microscopy in two men, ages 20 and 27 years, respectively. The characteristics of the lesions were reactive rather than neoplastic. The soft tissue counterpart of this lesion has shown no indication of aggressive behavior nor of a potential to metastasize. Further investigations are necessary to determine whether a similar benign behavior can be established for angiolymphoid hyperplasia with eosinophilia arising primarily in bone.

Nodular regenerative hyperplasia of the liver associated with macroglobulinemia. A clue to the pathogenesis

Nodular regenerative hyperplasia of the liver is an infrequent condition characterized by transformation of the hepatic parenchyma into nodules with only mild fibrosis. Little is known about the etiology except that there is usually an underlying chronic disease, such as Felty's syndrome, which antedates the development of clinical liver disease. It is poorly understood how the associated diseases contribute to the pathogenesis of nodular regenerative hyperplasia. Presented are four cases of nodular regenerative hyperplasia in which macroglobulinemia was also present. This new association suggests to us a hypothesis for the pathogenesis of nodular regenerative hyperplasia. Histologic examination of the livers in these and other cases of nodular regenerative hyperplasia reveals widespread obliteration of the small portal veins. Postmortem angiography of one liver in the present series demonstrated that the nodules were well perfused and that the atrophic areas were poorly perfused with portal blood. This supports the view that atrophy of lobules results from a lack of portal blood supply and that nodules develop from lobules well supplied with portal blood. In each of the clinical conditions associated with nodular regenerative hyperplasia, including macroglobulinemia, inflammatory or thrombotic vascular lesions are found in many organs. Therefore, nodular regenerative hyperplasia may be the hepatic expression of a more widespread vascular disease.

Crohn's disease in an isolated rectal stump

A case is reported which illustrates the development of Crohn's disease in an isolated rectal stump occurring four-and-a-half years after subtotal colectomy for multiple polyposis coli. There was no evidence of more proximal small-bowel or colonic Crohn's disease. To our knowledge no similar occurrence has been reported in the literature.

Giant cell arteritis with small bowel infarction. A case report and review of the literature

This case report documents gangrene of the small intestine caused by giant cell arteritis of the regional mesenteric arteries, as an uncommon presentation of generalized giant cell arteritis. The literature concerning similar cases and the etiology is discussed.

Lymphomatoid granulomatosis of the larynx in a renal transplant recipient

This is a case of lymphomatoid granulomatosis in a renal transplant patient, which presented as an ulcerating pharyngeal lesion and caused death by exsanguination from carotid artery erosion. The diagnosis was established at limited necropsy on the basis of a characteristic vaso-infiltrative and atypical lymphoreticular infiltration as defined by Liebow, et al, in 1972. As far as can be ascertained, this is the second reported case of lymphomatoid granulomatosis in an immunosuppressed patient and also is a presumed localized extrapulmonary form of this disorder which has recently been reported. The striking histologic similarities to midline malignant reticulosis are discussed.