Oral metagenomes from Native American Ancestors reveal distinct microbial lineages in the pre-contact era

OBJECTIVES

Limited studies have focused on how European contact and colonialism impacted Native American oral microbiomes, specifically, the diversity of commensal or opportunistically pathogenic oral microbes, which may be associated with oral diseases. Here, we studied the oral microbiomes of pre-contact Wichita Ancestors, in partnership with the Descendant community, The Wichita and Affiliated Tribes, Oklahoma, USA.

MATERIALS AND METHODS

Skeletal remains of 28 Wichita Ancestors from 20 archeological sites (dating approximately to 1250-1450 CE) were paleopathologically assessed for presence of dental calculus and oral disease. DNA was extracted from calculus, and partial uracil deglycosylase-treated double-stranded DNA libraries were shotgun-sequenced using Illumina technology. DNA preservation was assessed, the microbial community was taxonomically profiled, and phylogenomic analyzes were conducted.

RESULTS

Paleopathological analysis revealed signs of oral diseases such as caries and periodontitis. Calculus samples from 26 Ancestors yielded oral microbiomes with minimal extraneous contamination. Anaerolineaceae bacterium oral taxon 439 was found to be the most abundant bacterial species. Several Ancestors showed high abundance of bacteria typically associated with periodontitis such as Tannerella forsythia and Treponema denticola. Phylogenomic analyzes of Anaerolineaceae bacterium oral taxon 439 and T. forsythia revealed biogeographic structuring; strains present in the Wichita Ancestors clustered with strains from other pre-contact Native Americans and were distinct from European and/or post-contact American strains.

DISCUSSION

We present the largest oral metagenome dataset from a pre-contact Native American population and demonstrate the presence of distinct lineages of oral microbes specific to the pre-contact Americas.

Complete mitochondrial genome of the Galápagos sea lion, Zalophuswollebaeki (Carnivora, Otariidae): paratype specimen confirms separate species status

The endangered Galápagos sea lion (Zalophuswollebaeki) inhabits the Galápagos Islands off the coast of Ecuador. We present a complete mitochondrial genome (16 465 bp) of a female paratype from the collections of the Natural History Museum Oslo, Norway, assembled from next-generation sequencing reads. It contains all canonical protein-coding, rRNA, tRNA genes, and the D-loop region. Sequence similarity is 99.93% to a previously published conspecific mitogenome sequence and 99.37% to the mitogenome sequence of the sister species Z.californianus. Sequence similarity of the D-loop region of the Z.wollebaeki paratype mitogenome is >99%, while the sequence difference to the Z.californianus sequences exceeds 2.5%. The paratype mitogenome sequence supports the taxonomic status of Z.wollebaeki as a separate species.

What does it mean to be wild? Assessing human influence on the environments of nonhuman primate specimens in museum collections

OBJECTIVES

Natural history collections are often thought to represent environments in a pristine natural state-free from human intervention-the so-called "wild." In this study, we aim to assess the level of human influence represented by natural history collections of wild-collected primates over 120 years at the Smithsonian Institution's National Museum of Natural History (NMNH).

MATERIALS AND METHODS

Our sample consisted of 875 catarrhine primate specimens in NMNH collections, representing 13 genera collected in 39 countries from 1882 to 2004. Using archival and accession information we determined the approximate locations from which specimens were collected. We then plotted location coordinates onto publicly available anthrome maps created by Ellis et al. (Global Ecology and Biogeography, 2010, 19, 589), which delineate terrestrial biomes of human population density and land use worldwide since the 1700s.

RESULTS

We found that among primates collected from their native ranges, 92% were from an environment that had some level of human impact, suggesting that the majority of presumed wild-collected primate specimens lived in an environment influenced by humans during their lifetimes.

DISCUSSION

The degree to which human-modified environments may have impacted the lives of primates currently held in museum collections has been historically ignored, implicating unforeseen consequences for collection-based research. While unique effects related to commensalism with humans remain understudied, effects currently attributed to natural phenomena may, in fact, be related to anthropogenic pressures on unmanaged populations of primates.

Archaeological mitogenomes illuminate the historical ecology of sea otters (Enhydra lutris) and the viability of reintroduction

Genetic analyses are an important contribution to wildlife reintroductions, particularly in the modern context of extirpations and ecological destruction. To address the complex historical ecology of the sea otter (Enhydra lutris) and its failed 1970s reintroduction to coastal Oregon, we compared mitochondrial genomes of pre-extirpation Oregon sea otters to extant and historical populations across the range. We sequenced, to our knowledge, the first complete ancient mitogenomes from archaeological Oregon sea otter dentine and historical sea otter dental calculus. Archaeological Oregon sea otters (n = 20) represent 10 haplotypes, which cluster with haplotypes from Alaska, Washington and British Columbia, and exhibit a clear division from California haplotypes. Our results suggest that extant northern populations are appropriate for future reintroduction efforts. This project demonstrates the feasibility of mitogenome capture and sequencing from non-human dental calculus and the diverse applications of ancient DNA analyses to pressing ecological and conservation topics and the management of at-risk/extirpated species.

A chomped chimp: New evidence of tooth marks on an adult chimpanzee (Pan troglodytes verus)

OBJECTIVES

To describe and interpret previously unreported marks on the dry cranium of an adult chimpanzee (Pan troglodytes verus) from Côte d'Ivoire at the Smithsonian's National Museum of Natural History (USNM 450071).

MATERIALS AND METHODS

All marks on the cranium were documented and assessed through physical examination of the specimen, photography, micro-computed tomography (micro-CT), and 3D laser scanning. Pits and punctures were measured with digital calipers for comparison with published carnivore tooth mark measurements.

RESULTS

The cranium shows perimortem or postmortem damage to the temporal, occipital, and maxillary regions that is not recent. Size and color variation in the marks suggest two damage events, possibly involving chewing by different animals, at least one of which was a large-bodied mammal. The 22 tooth pits and punctures (0.89-8.75 mm in maximum length and 0.88-6.63 mm in breadth) overlap in size with those inflicted by wild leopards, the most significant predators of common chimpanzees due to their largely overlapping ecological distributions.

CONCLUSIONS

Based on qualitative and quantitative evidence, we conclude that leopards are the most likely cause of the most prominent marks on the cranium. However, we cannot rule out the additional possibility of other chimpanzees, although there are no published studies of chimpanzee tooth marks for direct comparison. This study is the most extensive documentation to date of a modern adult chimpanzee skull exhibiting tooth marks by a large mammal, thus providing new evidence to help identify and interpret other events of predation and scavenging of large-bodied apes in the modern and fossil records.

Cutaneous angiosarcoma in an irradiated breast after breast conservation therapy for cancer: association with chronic breast lymphedema

The authors report a rare case of cutaneous angiosarcoma arising more than 5 years after excision of a 1.5 cm invasive ductal cancer of the breast. All lymph nodes were negative for metastatic breast cancer in this 68-year-old female. The patient had postoperative therapy consisting of 5040 cGy over a 5 week period using a 6 Megavolt linear accelerator. After radiation therapy to the breast and axillae, the patient developed chronic hard, taut edema of the irradiated right breast. Tamoxifen was administered for 5 years and then stopped. Three months after the cessation of tamoxifen, cutaneous angiosarcoma was found by skin biopsy. A complete mastectomy removed all tumor with clear margins. There are less than 60 cases of radiation associated breast angiosarcoma found in the literature. The presence of chronic lymphedema in the breast after radiation therapy possibly contributes to the development and is an early warning sign for later development of secondary angiosarcoma. The characteristic purple nodules and discoloration of the irradiated skin is the hallmark to suspect the diagnosis. The authors recommend long-term clinical surveillance for this tumor for all patients who have received breast conservative surgical therapy with concomitant radiation therapy for primary breast cancer.

Increased detection of epithelial cell abnormalities by liquid-based gynecologic cytology preparations. A review of accumulated data

OBJECTIVE

To review published and other available data comparing the effectiveness of liquid-based cytology preparations in detecting epithelial cell abnormalities in cervicovaginal (gynecologic) cytology as compared to the conventional Papanicolaou test.

STUDY DESIGN

Available split-sample data comparing liquid-based gynecologic cytology preparations with the conventional cervical cytologic test were collated from published studies, unpublished studies reported on at professional meetings or in the press, and from Food and Drug Administration Premarket Clinical Trials on ThinPrep and AutoCyte PREP. Data were stratified with regard to use of newer preparatory instrument models, use of varying collection devices and different split-sample protocols.

RESULTS

Available data from split-sample studies of liquid-based methods showed overall increased detection of epithelial cell abnormalities. Results have varied considerably from study to study and appear to be influenced by collection protocol methods and probably by collection devices' different delivery of cellular material in split-sample studies, first to the conventional smear and second to the liquid-based medium. Newer preparatory instrument models may also enhance detection.

CONCLUSION

Liquid-based gynecologic cytology preparations increase detection of epithelial cell abnormalities, as compared to the conventional, single-slide cervical cytologic smear, based on available data from split-sample studies. The true potential impact of these methods in enhancing detection of epithelial cell abnormalities awaits accumulation of data from direct-to-vial studies, especially data on detection of biopsy-confirmed high grade squamous intraepithelial lesions from a wide variety-of clinical practice settings.

Medicolegal affairs. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial

ISSUES

Increasing litigation over alleged false negative cervical cytologic (CC) smears threatens the viability of this test for cervical cancer detection. The problem appears to be largely American but is beginning to appear in some other countries. In the vast majority of cases there is either a settlement or jury verdict for the plaintiff based largely on the testimony of expert witnesses. Cases are judged on an individual basis without significant consideration of the general performance of the CC smear in laboratories operating in compliance with a wide array of laboratory regulations and with documented and comprehensive quality control practices in place. It is acknowledged that there are problem laboratories and cytology practitioners. There is an emerging issue of automated preparation and screening devices and issues of informed patient consent.

CONSENSUS POSITION

Cytology professionals have done an extraordinary and commendable job of educating the public about the benefits of the CC smear. We have been less successful and conscientious about explaining and defining the limitations of the CC test. There is a need for public and professional education as to the benefits and limitations of the CC smear for cervical cancer detection. The process suggested is to work with women's groups, public health agencies, government agencies, and state and national legislatures and to coordinate professional committees working on liability issues. Contextual information could be included with the CC smear report to indicate that a negative report confers a low probability of developing cervical cancer. It is suggested that appropriate language and a menu of statements be developed. Increased efforts should be directed to physician education with respect to informed consent concerning the benefits and limitations of CC smear testing and the application of new technology to improve smear accuracy. The process should include development of appropriate statements on the use of alternative technology. The profession should develop "process guidelines" for review of CC smears in the context of possible litigation, including standardized methods for blind slide review of smears that reduce or eliminate context and outcome bias. It is suggested that review panels be anonymous, that the process be standardized and that there be limitations on liability for participating organizations. Professional cytopathology and pathology societies should formulate acceptable guidelines for expert witnesses. The standards should be applicable to both defendant and plaintiff experts. All materials to the extent practical, including consultant opinions, should be available for peer review. Professional cytopathology and pathology societies should monitor expert testimony for objectivity and scientific accuracy.

ONGOING ISSUES

For the near future, litigation will continue to focus on false negative CC smears on a case-by-case basis. Laboratories and individuals can reduce the risk of malpractice liability by directing their attention to proactive quality control and quality assurance methods. In the final analysis, consumer education about the benefits and limitations of the test is key to limiting malpractice claims. To stem the tide of continued medicolegal challenges to the integrity of cytology practice, the cytology community has now focused its efforts on developing and utilizing standards that convey to patients, attorneys and cytologists the contemporary status of and reasonable expectations for the practice of cytology. Guidelines such as those for uniform reporting terminology and clinical management of cervical abnormalities form the basis of cytology practice standards on which legal standards of practice can be based. Consensus conference reports, clinical management trials and scientifically valid studies of false negative rates that analyze the type, frequency and cause of missed cases represent sounder methods of establishing defensible

Immunohistochemical staining for Ki-67 antigen, carcinoembryonic antigen, and p53 in the differential diagnosis of glandular lesions of the cervix

Cytoplasmic carcinoembryonic antigen (CEA) positivity assists in the distinction of benign and malignant glandular lesions of the cervix, but some cases remain problematic. The accumulation of p53 protein and an increased proliferative index, as measured by the expression of Ki-67 antigen, have not been used as adjuncts to the diagnosis of these lesions. Immunohistochemical stains for CEA, p53 protein, and Ki-67 antigen were performed on 31 formalin-fixed, paraffin-embedded endocervical lesions including invasive adenocarcinoma, adenocarcinoma in situ, adenoma malignum, tunnel clusters, florid microglandular hyperplasia, mesonephric remnants, florid glandular hyperplasia, atypical glandular hyperplasia, and normal controls. Ki-67 antigen expression was quantitated as negligible, low, moderate, or high on the basis of the percentage (< 5%, 5-10%, 11-40%, > 40%, respectively) of glandular nuclei that were positive with MIB-1 antibody. Strong staining of more than 10% of the glandular epithelial nuclei was interpreted as positive for p53 protein overexpression. CEA positivity was determined by either diffuse or focal cytoplasmic staining of columnar epithelial cells equalling glycocalyceal staining in intensity. The combination of CEA positivity and a moderate-to-high proliferative index was limited to cases of invasive adenocarcinoma, adenoma malignum, and adenocarcinoma in situ, as compared with benign glandular lesions (P = 0.005). A high Ki-67 proliferative index and/or CEA positivity were features of malignant lesions rather than benign mimickers; there were no false positives or false negatives. Similarly, only malignant neoplasms shared a combination of p53 overexpression and CEA positivity (P = 0.043). The combination of cytoplasmic CEA positivity in glandular cells and a moderate-to-high Ki-67 proliferative index is diagnostic of malignancy in endocervical lesions. With the exception of florid microglandular hyperplasia, p53 expression is only seen in neoplastic lesions of the endocervix. An immunohistochemical battery consisting of MIB-1 (Ki-67), p53 protein, and CEA is useful in discriminating between benign and malignant endocervical lesions.

Results of blinded rescreening of Papanicolaou smears versus biased retrospective review

Review of Papanicolaou smear cases that are the focus of litigation typically takes place in a biased setting with foreknowledge of an adverse patient outcome (outcome bias) or litigation and with more time allotted for slide review than is available in normal screening situations. Factors that normally mitigate against overly aggressive slide interpretation, such as concern about false-positive diagnoses and possible unnecessary surgical procedures and expense, are absent. This results in a tendency toward overly aggressive interpretation of questionable or uncertain cytologic abnormalities. These factors can be minimized by a variety of blinded slide review formats with the goal of simulating normal, on-the-job, prospective screening as in actual practice. Despite some limitations, blinded rescreening can provide valuable insight into the relative degree of difficulty involved in interpreting specific slides. The difficulty of a case in question is arguably the second most important factor, after assessment of overall laboratory performance, in determining whether a reasonable standard of practice has been followed.

Chorionic villi or trophoblastic tissue in uterine samples of four women with ectopic pregnancies

The diagnosis of early ectopic pregnancy remains challenging for the gynecologist. Although early detection of a suspected pregnancy has been facilitated by quantitative beta human chorionic gonadotropin studies and ultrasonography, a patient subgroup remains with an ambiguous presentation. In this group of patients, the clinician must rely on microscopic examination of products of conception in a uterine curettage specimen to rule out the presence of an extrauterine pregnancy. The presence of an implantation site, chorionic villi, or trophoblastic tissue in uterine curettage samples is conventionally held as definitive evidence of an intrauterine pregnancy. We present a series of four cases that challenge this convention. In these cases, chorionic villi or an implantation site were identified in uterine samples of pregnant women who each ultimately proved to have an ectopic pregnancy. If clinical suspicion is high, the finding of either chorionic villi or an implantation site should not preclude further workup of a possible ectopic pregnancy. In cases where only a few villi or a single chorionic villus are identified, other signs of intrauterine implantation such as intermediate trophoblastic cells, hyalinized vessels, and a fibrinoid matrix should be sought to establish firmly the diagnosis of an intrauterine pregnancy.

Transitional cell carcinoma of the endometrium

Only one case of endometrial transitional cell carcinoma (TCC) has been previously reported in the literature. We report a second case. In both the previously reported case and in this case there was a separate focus of TCC in the adnexa. Both patients were treated with adjuvant whole pelvic radiation and are alive and without evidence of disease at 5 years and 15 months, respectively. Study of more cases of endometrial TCC is needed to determine whether this type of endometrial carcinoma has a more favorable response to radiation therapy than other types of endometrial carcinoma with extrauterine spread.

Stereotactic core biopsy of nonpalpable breast lesions

We report our experience with stereotactic core breast biopsies (SCBB) for mammographically suspicious, nonpalpable breast lesions. Ninety-seven patients, ages 29 to 94 (mean 57.3 years) underwent SCBB with a 14-gauge Biopty gun. A mean of 5.0 cores was taken from each lesion. Lesions were mammographically categorized by suspicion (high, > 60% chance of malignancy; intermediate, 25-60%; low, < 25%) and according to lesion character (well-defined mass, indistinct mass, spiculated mass, asymmetric density, and clustered microcalcifications [CM]). Histologic and radiographic findings were correlated at the time of biopsy and again retrospectively, with 92 percent correlation and eight percent partial or non-correlation. Of the latter, five of eight lesions represented CM not seen in the histologic samples. Of the 97 sampled lesions, 72 (74%) had been radiographically categorized as low suspicion, 10 (10%) as intermediate, and 15 (16%) as high. The procedure saved 74 women (76%) from open biopsy and added a diagnostic procedure for eight women (8%). Fifteen women (15%) went directly to mastectomy; therefore, the SCBB neither added nor saved a procedure for patients with cancer. Of the 72 lesions categorized as low suspicion, 65 (90%) were potentially saved from open biopsy, while nine of 25 lesions (36%) in the intermediate and highly suspicious groups were potentially spared a procedure. There were no false positive or negative cases among those who had an additional procedure or follow-up. The diagnoses made on SCBB included 15 carcinomas, one case each of atypical ductal and atypical lobular hyperplasia, one reactive lymph node, one intraductal papilloma, one collagenous spherulosis, one membranous fat necrosis, and numerous cases of fibrocystic change and fibroadenoma. In conclusion, we believe that this SCBB method can be an accurate and cost-effective tool in the management of these lesions.

Opportunities for enhanced cervical and breast screening referral in Charleston County

In order to increase awareness of the need for pap smear and mammographic cancer screening, the Professional Education Committee of the Charleston County Chapter of the American Cancer Society (ACS) separately surveyed Charleston County women and physicians regarding their use of women's cancer screening tests. Seven hundred and thirty-one women responded to a Cancer Screening Survey for Women. Women not complying with ACS guidelines for pap smears and mammography, when compared to women complying with the guidelines, were found to be twice as likely to be non-white, much more frequently lacked a regular physician or a gynecologist, more commonly lacked insurance paying at least in part for the test, and more frequently reported that physicians visited did not suggest pap smear or mammographic screening. Almost one-third of 75 responding physicians acknowledged not discussing pap smear and mammographic screening with their patients, a practice most often attributed to "specialization." Among physicians not referring women for needed mammograms or pap smears, roughly half also cited patient refusal, deferral, and oversight as reasons. The survey data suggest that a simple, practical, method is needed in doctors' offices to remind women of the need for periodic pap smear and mammographic screening, especially whenever women lacking a regular gynecologist seek any type of medical care. The authors recognize that these samples of females and physicians are not necessarily representative of those components of the Charleston area overall.(ABSTRACT TRUNCATED AT 250 WORDS)

Fine-needle aspiration cytology of an endometrioid-like variant of yolk sac tumor

A 36-year-old male with a history of immature teratoma and embryonal carcinoma of the testis was admitted to the hospital for abdominal pain and fever. A CT scan revealed a large right abdominal mass. The patient's serum alpha-fetoprotein (AFP) was 46.8 ng/ml (reference < 25 ng/ml). Fine-needle aspiration (FNA) of the mass revealed malignant glandular cells. Chemotherapy was instituted, followed by resection of the large abdominal mass. The tumor was grossly encapsulated, consisting of large areas of necrotic, hemorrhagic tissue surrounded by smaller, multiloculated cysts. Microscopically, the tumor had a villoglandular pattern and variably stratified tall columnar cells. A prominent feature of the columnar cells was supranuclear and subnuclear vacuolization. Intracytoplasmic PAS-positive, diastase-resistant hyaline globules were occasionally present. AFP by immunoperoxidase was prominent within the tumor. This recurrence of the previously diagnosed testicular teratoma with embryonal carcinoma represents a yolk sac tumor with components strongly resembling endometrioid carcinoma, a variant only recently described in eight cases of ovarian origin (Clement et al.: Am J Surg Pathol 1987; 11(10):767-778). We believe this is the first reported case of an endometrioid-like variant of testicular yolk sac tumor and also the first report of the FNA cytology findings in this variant.

Multicentric adult secretory breast carcinoma: DNA flow cytometric findings, prognostic features, and review of the world literature

A case of multicentric secretory breast carcinoma in a 39-year-old white female is described. Mammograms, DNA analysis, touch preparation cytology, and positive estrogen receptors are reported for the first time in this rare favorable mammary carcinoma. A review of the 33 reported cases with follow-up in adult females, including the present case, has revealed lymph node metastases in nine (27%), recurrence in four (12%), and distant metastases leading to death in two cases (6%). In patients treated with less than simple mastectomy there has been local recurrence in 4 (33%) of 12 cases and in three of the four cases (75%) greater than or equal to 2.0 cm. Increased size and lack of gross circumscription of the neoplasm and presentation in the adult age group appear to identify cases with an increased risk of disease progression. In patients over 20 years old, especially with neoplasms greater than 2 cm in diameter, modified radical mastectomy has to date achieved the most favorable outcome. Minimal experience (two cases) is available regarding treatment with limited surgery and radiation therapy, and there is no available data regarding possible benefit from adjuvant chemotherapy.

Histologic sampling requirements in ovarian carcinoma: a review of 51 tumors

In a review of 29 serous and 22 mucinous adenocarcinomas of the ovary, we quantitated the various histologic patterns seen in these neoplasms in order to document histologic variability and assess current anecdotal recommendations (one section per 1-2 cm of maximum tumor diameter) for adequate histologic sampling of epithelial ovarian neoplasms. Mucinous carcinomas showed more histologic variation than serous carcinomas, but both showed substantial portions with benign or borderline histology in many neoplasms. One serous and one mucinous carcinoma were likely to have been classified as borderline tumors if only current sampling recommendations had been followed. The remaining adenocarcinomas were adequately sampled by current standard practice. The two tumors in question had unusual clinical and histological features which prompted additional sampling. Caution is particularly warranted when initial frozen section sampling shows features of borderline tumor histology or low grade epithelial atypia, especially in mucinous epithelial neoplasms where histologic variability is greatest.

Cholecystojejunostomy intussusception

Intermittent prolapse of a jejunal loop into the gallbladder lumen was observed following cholecystojejunostomy in a patient with advanced carcinoma of the pancreas. This unusual complication was documented by cholangiography and sonography.

Malignant Brenner tumor and transitional cell carcinoma of the ovary: a comparison

The clinical and pathologic features of 16 malignant Brenner tumors (MBT) having an associated benign Brenner component were compared with 29 primary ovarian transitional cell carcinomas (TCC), neoplasms differing from MBT only in that a benign Brenner component was absent. Transitional cell carcinoma represented a more aggressive neoplasm. Twenty of twenty-nine (69%) presented in advanced stages (II-IV) compared with only three of sixteen (19%) MBT. Among stage IA tumors, only three of seven (43%) patients with TCC were well at last contact, compared with nine of eleven (88%) patients with Stage IA MBT. In addition to not having a benign Brenner component, TCC lacked the prominent stromal calcification common in most benign and malignant Brenner tumors. Transitional cell carcinoma is sufficiently different from MBT in that it is reasonable to suppose that ovarian TCC arises directly from pluripotential surface epithelium of the ovary and from cells with urothelial potential, rather than from a benign or proliferative Brenner tumor precursor.

Fibromatosis of the breast. A clinical and pathological study of 28 cases

The clinical and pathologic findings of 28 examples of fibromatosis of the breast not involving the deep fascia or chest wall are reported. Five of the 20 lesions treated by local excision recurred. Recurrences developed within a 4 to 8 month period following surgery in four of the five instances, and 6 years after surgery in one instance. One lesion recurred five times over a period of 3 years. None of the patients died from their disease, and none developed a metastasis. Those lesions that recurred had been inadequately excised initially, since surgical margins showed fibromatosis. Specific histological features, such as size, cellularity, atypia, and mitotic figures, were not helpful in predicting recurrence. Although local excision appears to have been adequate in the majority (75%) of the patients, the infiltrative nature of fibromatosis necessitates documentation of tissue margins in order to avoid the possibility of recurrence. The differential diagnosis includes benign reactive processes (such as keloid and nodular fasciitis), fibrous histiocytoma, low-grade spindle-cell (metaplastic) carcinoma, and fibrosarcoma.

Liposarcoma of the breast: a clinicopathologic study of 20 cases

The clinical and pathologic features of 13 patients with pure liposarcomas of the breast and seven patients with liposarcomas that had arisen in cystosarcomas are reviewed. Metastases occurred in three of the 13 patients with pure mammary liposarcomas, and two women died of tumor. One of the patients with a liposarcoma that had arisen in a cystosarcoma had a local recurrence one year after diagnosis but was subsequently lost to follow-up study. Fourteen of the 20 patients for whom follow-up information was available for as long as 14 years had no evidence of recurrence. Features associated with the development of recurrence, based on the cases studied here and previous reports, included the pleomorphic liposarcoma pattern and an infiltrative margin. Features associated with tumor-free survival included the well-differentiated liposarcoma pattern, male gender (two patients), and a circumscribed microscopic tumor margin. There were no axillary lymph node metastases. Follow-up data indicate that complete surgical excision of tumor with tumor-free margins is necessary, but total mastectomy and removal of the axillary tail are not required unless these procedures are needed for complete excision.

Muscle anatomy of the human esophagus

We studied the esophageal musculature of 11 cadavers to assess the distribution of striated and smooth muscle. The lower 54-62% of the esophagus was found to be exclusively smooth muscle, the proximal 4.1-5.6% to be exclusively striated, and the remainder to be mixed. The area in which striated and smooth muscle portions were approximately equal, the 50/50 point, was found to be 4.7 +/- 0.6 cm from the proximal portion of the cricopharyngeus muscle. This point corresponds to the previously described physiologic low pressure zone in the proximal esophagus.

Computed tomographic and ultrasound appearances of a solitary intrahepatic choledochal cyst

A pregnant patient presenting with acute abdominal pain was found to have an intrahepatic mass, the features of which, on computed tomography and ultrasound examination, suggested a solid lesion. At surgery this proved to be a solitary intrahepatic choledochal cyst (Todani Type 5) with areas of malignant degeneration.

Computed tomography of axillary and supraclavicular adenopathy

The normal cross-sectional anatomy of the axillary and supraclavicular regions is demonstrated. One hundred and sixty chest computed tomography scans were reviewed and criteria for differentiating normal axillary and supraclavicular structures from enlarged lymph nodes established. Axillary structures 14 mm or larger are suggestive of axillary adenopathy. Axillary structures 10-13 mm in size raise the possibility of adenopathy.

Catheter hysterosalpingography

The authors describe a 5-F catheter which is simpler to use than the standard vacuum cannula when performing hysterosalpingography.

Leydig cell hypoplasia causing male pseudohermaphroditism: diagnosis 13 years after prepubertal castration

An 11-yr-old patient with male pseudohermaphroditism who was castrated at nine days of age and raised thereafter as a female was evaluated to determine the cause of abnormal sexual differentiation. Stimulation with ACTH for 8 h revealed no abnormality in the biosynthesis of cortisol or adrenal androgens. The administration of fluoxymesterone (10 mg, orally, daily) for 5 weeks at age 13 yr led to significant decrements in serum levels of sex steroid-binding globulin and T4-binding globulin to a degree similar to that found in 2 normal men, but no change in the basally elevated levels of FSH and LH. LH bioactivity was normal in the rat Leydig cell bioassay. Skin fibroblasts cultured from a labial skin biopsy revealed normal 5 alpha-reductase activity and normal androgen receptors. Reexamination of the original testis specimens by light microscopy failed to reveal Leydig cells. Furthermore, when immunoperoxidase staining for testosterone was performed on the tissue sections, only 30-35 positive cells/10 high power fields were seen. In contrast, examination of testis sections from 4 male infants who died of other causes revealed 94-836 cells/10 high power fields that stained positively for testosterone. Although hCG stimulation testing to confirm Leydig cell hypoplasia could not be done in this patient because of previous castration, this patient demonstrates that the diagnosis can be made without it by the use of immunohistochemical stains and in vivo and in vitro tests to exclude other disorders of androgen biosynthesis or androgen action.

Gas collections in the spinal cord on computed tomography

Two examples of gas collections within the spinal canal, noted on computed tomography, are presented. A probable etiology is suggested and possible misinterpretations of such a finding are discussed.

Measurement of red blood cell volume, plasma volume, and total blood volume in baboons

Red blood cell volume was measured directly in baboons by infusion of 51Cr-labeled autologous RBC, and was indirectly estimated from the plasma volume measured with 125I-labeled albumin and the total body hematocrit. The total body hematocrit was calculated from the peripheral venous hematocrit multiplied by a correction factor; for nonanemic baboons the correction factor was 0.87, and for anemic baboons, 0.75. Within 2 weeks after the phlebotomy (150 ml of blood), the baboon's RBC volume was restored to normal. Posttransfusion survival of baboon RBC can be measured accurately in nonanemic baboons; the preserved RBC can be labeled with 51Cr and the RBC volume of the baboon can be measured indirectly from the plasma volume measured with 125I-labeled albumin and the total body hematocrit.

Liquid preservation of baboon red blood cells in acid-citrate-dextrose or citrate-phosphate-dextrose anticoagulant: effects of washing liquid-stored red blood cells

Autologous baboon RBC stored at 4 C in acid-citrate-dextrose (ACD) or in citrate-phosphate-dextrose (CPD) for 3 weeks after collection had 24-hour 51Cr posttransfusion survival values of about 77%. When 20-day-old ACD and CPD baboon RBC were washed and then stored at 4 C for 24 hours before autotransfusion, the 24-hour 51Cr posttransfusion survival values were about 81%. These values were similar to those seen in studies of human RBC preserved in an identical manner. Our results indicated that the baboon can be used to evaluate RBC preservation techniques before human volunteers are studied.

Intussusception and total body opacification

Because of atypical clinical presentations, two children with intussusception had intravenous urography as their initial examination of following plan films. In both patients the intussusception was outlined by an opaque rim due to the total body opacification effect on the bowel wall. One patient had a target-like blush on following films which strongly suggested the correct diagnosis. The authors do not advocate intravenous urography to diagnosis intussusception, but if this study is performed because of atypical clinical findings, the radiographic sign should be recognized and lead to a barium enema.

Infiltrating (intramuscular) lipomas and angiolipomas. A clinicopathologic study of six cases

Infiltrating (intramuscular) lipomas and angiolipomas are benign mesenchymal tumors that usually appear as a deep, nontender mass within soft tissue, particularly in the extremities. The average tumor size in six cases studied was 11.2 cm (range, 2.0 to 22.0 cm). On gross examination, these tumors are circumscribed but unencapsulated, with infiltration of adjacent skeletal muscle. The correct preoperative diagnosis is seldom made, and the characteristic infiltrating pattern seen microscopically can lead to a mistaken diagnosis of sarcoma. Soft-tissue roentgenograms can be helpful in diagnosis and localization. The recommended mode of therapy is complete local excision with tumor-free soft-tissue margins. None of the six patients described here have experienced recurrence of tumor an average of two years after surgical resection. Prolonged follow-up is recommended, however, since inadequate resection can result in late tumor recurrence.