A Comparative Study of Three Methods for the Visualization of von Willebrand Factor (vWF) Multimers

This study was performed to compare three visualization methods for the detection of vWF multimers: autoradiography (125I), electroblot with a horseradish peroxidase system (BLOT-HRP), and an avidin-biotin peroxidase system (AV-BIO). Each method was evaluated according to: 1) ability to visually detect bands and subbands thereby identifying von Willebrand’s disease (vWD) subtypes and normals, 2) reagent availability, 3) cost, and 4) time requirements. Additionally, resolvability was evaluated utilizing low, intermediate, and high resolution gels prepared with both low and high gelling temperature agaroses with subsequent visualization by the three detecting systems.

With intermediate resolution gels, our results showed that all three visualization methods could discern pathologic patterns from normal. In addition, the avidin-biotin peroxidase system demonstrated the best band discreteness with low resolution gels used to detect unusually high molecular weight multimers. With high resolution gels used for subtyping type II vWD, we found the internal band structure was best demonstrated using LGT agarose and the electroblot horseradish peroxidase system.

Octreotide scintigraphy in the head and neck

OBJECTIVES/HYPOTHESIS

Octreotide is a somatostatin analogue that, when coupled to a radioisotope, produces a scintigraphic image of neuroendocrine tumors (NET) expressing somatostatin type 2 receptors (SSR 2). Octreotide scintigraphy (OS) may be useful in confirming the preoperative diagnosis of certain head and neck NET. Paragangliomas (PG), like many NET, have been found to have a high density of SSR 2 on the cell surfaces. Other NET of the head and neck include merkel cell carcinomas (MCC), medullary thyroid carcinomas (MTC), and esthesioneuroblastomas.

STUDY DESIGN

A retrospective study that compared the results of OS with the histopathologic diagnosis in 74 patients with head and neck NET.

RESULTS

Of the 60 patients undergoing evaluation for suspected paraganglioma, OS was correctly positive in 36 of the 37 patients with PG. OS was correctly negative in 19 of the 23 patients that did not exhibit PG. For PG, this yielded a sensitivity of 97% and a specificity of 82%. There were 14 patients in the nonparaganglioma group. OS detected or diagnosed all metastases in three patients with MTC, locoregional recurrences in two patients with esthesioneuroblastoma, an extrapituitary adenoma in one patient, and metastasis in two patients with MCC. It failed to detect a paraspinal metastasis in the third patient with MCC.

CONCLUSION

On the basis of this series of patients, OS appears to be a reliable test to detect PG and may be helpful in detecting primary and metastatic disease for NET.

Outcome after radical prostatectomy with a pretreatment prostate biopsy Gleason score of ≥8

OBJECTIVE

To determine the outcome and predictors of recurrence in patients with a pretreatment prostate biopsy Gleason score (GS) of >/= 8 and treated with radical prostatectomy (RP).

PATIENTS AND METHODS

We retrospectively reviewed 1048 consecutive patients who underwent RP by one surgeon (M.S.S.); patients who had a pretreatment biopsy GS of >/= 8 were identified. Information was recorded on patient age, initial prostate specific antigen (PSA) level, clinical stage, biopsy GS, pathology GS, extraprostatic extension (EPE), tumour volume, surgical margin status, seminal vesicle invasion (SVI), and lymph node involvement. The results were assessed statistically using the Kaplan-Meier method, univariate log-rank tests and multivariate analysis using Cox's proportional hazards regression.

RESULTS

In all, 123 patients met the initial selection criteria; 44 were excluded from further analyses (five salvage RP, 23 < 1 year follow-up and 16 adjuvant treatment). Thus 79 patients were included in the uni- and multivariate analyses; 25 (31%) patients had a GS of </= 7 in the RP specimen and 54 (69%) remained at GS >/= 8. The mean follow-up was 55 months, the age of the patients 63 years and the mean (sd) initial PSA level 13 (12) ng/mL. The overall biochemical failure rate was 38% (41% if the final GS was >/= 8 and 32% if it was </= 7). For those with a GS of >/= 8 in the RP specimen, 20% (11/54) were organ-confined; two patients (2.5%) in this group developed local recurrence. If the final GS was </= 7, 52% (13/25) were organ-confined. In the univariate analysis, significant risk factors for recurrence were PSA >/= 20 ng/mL, EPE, SVI, a positive surgical margin and tumour volume. Cox's proportional regression indicated that a PSA of >/= 20 ng/mL (hazard ratio 7.9, 95% confidence interval 2.6-24.2, P < 0.001), the presence of EPE (4.2, 1.6-10.9, P = 0.004) and a positive surgical margin (3.8, 1.5-9.7, P = 0.005) were significant independent predictors in a multivariate analysis.

CONCLUSION

RP is a reasonable treatment option for patients with a prostate biopsy GS of >/=8 and clinical stage T1-2. These patients have a high chance of remaining disease-free if their PSA level is </= 20 ng/mL. Patients with a pretreatment biopsy GS of >/= 8 should be counselled about the potential differences between the biopsy and the RP specimen GS.

Elevated tissue expression of hyaluronic acid and hyaluronidase validates the HA-HAase urine test for bladder cancer

PURPOSE

We examined the expression of 2 bladder tumor markers, hyaluronic acid (HA) and hyaluronidase (HAase), in bladder tissues and correlated tissue staining with the inferences of the HA-HAase urine test, which detects bladder cancer.

MATERIALS AND METHODS

A biotinylated HA binding protein and an antiHYAL1 antibody were used to localize HA and HYAL1 type HAase, respectively, in 83 bladder tissues. Immunoblot analysis was performed using an antiHYAL1 antibody to detect HYAL1.

RESULTS

A total of 12 normal bladder tissues showed no (66%) to 1+ (34%) HA staining and 0 (83%) to 1+ (17%) HYAL1 staining. The staining intensity of HA and HYAL1 increased in 71 bladder tumor specimens on chi-square analysis (p <0.001). Grade 1 tumors demonstrated 1+ (50%) to 2+ (50%) staining for HA and 1+ to 3+ staining for HYAL1 (37%, 37% and 26%, respectively). Grades 2 and 3 tumors showed 2+ to 3+ HA (94%) and HYAL1 (79%) staining. HA was expressed in tumor associated stroma and in tumor cells, whereas only tumor cells expressed HYAL1. In bladder tumor tissues HYAL1 expression was confirmed by immunoblot analysis. In 33 of the 34 patients (97%) with bladder cancer from whom urine and tumor tissue specimens were obtained at the same time 2+ to 3+ staining of HA and/or HYAL1 in 12 and 21, respectively, constituted a positive HA-HAase urine test (kappa = 0.945).

CONCLUSIONS

To our knowledge this is the first report of HA localization in bladder tissues and of HYAL1 in any normal or tumor tissue. A close correlation of elevated HA and HYAL1 levels in tumor tissues with a positive HA-HAase urine test indicates that in patients with bladder cancer tumor associated HA and HYAL1 are secreted in urine, causing the HA-HAase test to be positive.

Intraoperative T staging in radical retropubic prostatectomy: is it reliable?

OBJECTIVES

During radical prostatectomy, wide local excision of the lateral prostatic fascia and neurovascular bundle on the ipsilateral side of the tumor is advocated if nerve sparing is likely to result in a positive surgical margin. Our intent was to validate whether intraoperative T staging can predict the presence of positive surgical margins and aid in the decision of whether to perform nerve-sparing prostatectomy.

METHODS

One surgeon performed 100 consecutive radical prostatectomies, and one pathologist interpreted the pathologic findings. Topographic distribution of tumor within the specimen was assessed intraoperatively by palpation. The margin status was similarly assessed. This tactile clinical impression was compared with the final pathologic findings.

RESULTS

The surgical margins were positive in 39 (39%) of 100 cases. The intraoperative assessment of the margin status had a high false-negative rate and a sensitivity of only 7%. However, the specificity was 96%, because few margins were falsely positive. The overall accuracy was 62%, with a negative predictive value of 62%. The sensitivity of the intraoperative assessment of tumor location was 73%, and the positive predictive value was 65%.

CONCLUSIONS

The results of our study indicate that the intraoperative assessment of the margin status is not accurate and thus cannot help determine which patients require excision of the neurovascular bundle. We believe the decision to preserve the neurovascular bundle should be based on the preoperative prognostic factors and the presence of an intact capsule covering the region of the gland adjacent to this structure.

[Hyaluronic acid and hyaluronidase. 2 new bladder carcinoma markers]

The heterogeneity of bladder cancer concerning progress of recurrence is an essential characteristic of this disease. Hyaluronic acid (HA) and its degrading enzyme hyaluronidase (HAase) are intricately associated with bladder cancer angiogenesis and metastasis. Tumor-associated HA and HAase are secreted in urine. In 513 urine specimens (261 bladder cancer patients, 252 patients without bladder cancer) and 83 bladder tissue specimens (71 bladder tumors, 12 normal bladder tissues), the accuracy of HA and HAase as tumor markers was studied. Elevated urinary HA levels (> or = 500 ng/ml), indicating a positive HA test, suggest the presence of bladder cancer regardless of tumor grade. Elevated urinary HAase levels (> or = 10 mU/mg) indicate high-grade (G2/G3) bladder cancer. The combined HA-HAase urine test showed 91% sensitivity and 84% specificity to detect bladder cancer. The HA-HAase test is equally sensitive for monitoring tumor recurrence. Immunohistochemistry (IHC) staining of HA and HAase in the G1 and G2/G3 bladder cancer specimens was significantly (p < 0.001) higher than in normal bladder tissue. HA and HAase appear to be useful markers in the diagnosis of bladder cancer. When compared with other noninvasive tests, the HA-HAase urine test may be less expensive and more accurate.

Difficulties in interpreting specimens after neoadjuvant hormonal therapy and radiation with illustration of neuroendocrine differentiation

Pattern and cellular changes attributable to neoadjuvant hormonal therapy (NHT) might cause the unwary pathologist to overgrade or fail to recognize a treated prostatic cancer. Overdiagnosis and overgrading of surgical resections and biopsies can be avoided if an appropriate history of therapy is conveyed with the surgical specimen and if the pathologist is aware of the altered morphology of prostatic cancer treated by NHT alone or NHT plus radiation. Study of three prostatectomy specimens with post-NHT predominance of neuroendocrine cells showed positive staining for prostate specific antigen (PSA) and prostatic acid phosphatase (PAP), as well as staining for chromogranin and synaptophysin in Paneth-like and small neuroendocrine cells. Difficult-to-interpret needle biopsies and transurethral resection (TUR) biopsies of prostate, where the urologic pathologist's suspicion of a radiation effect was confirmed by additional history, showed absence of the basal cell layer with 34 beta E12 keratin immunostaining in prostatic cancer glands, while basal cells were present in the nonneoplastic glands with radiation-induced atypia. Postradiation salvage prostatectomy specimens showed greater apoptosis after combined NHT and radiation than after radiation without NHT. Changes attributable to radiation and radiation plus NHT are illustrated.

De novo muscle invasive bladder cancer: is there a change in trend?

PURPOSE

We reviewed our radical cystectomy series to determine whether the majority of patients present with muscle invasive bladder cancer.

MATERIALS AND METHODS

The records of 184 radical cystectomies performed by 1 surgeon from 1992 to 1999 were reviewed, and all slides of presenting pathology were reviewed by 1 pathologist. The pathological stage of the tumor at presentation was noted in each case, and the number of muscle invasive tumors at presentation was compared to 2 earlier series.

RESULTS

Radical cystectomy was performed for muscle invasive transitional cell carcinoma of the bladder in 176 cases and for other histology in 8. There were 101 (57.3%) patients with muscle invasive cancer at presentation compared to 84% and 91% in the 2 earlier series, respectively, which was a statistically significant decrease (p <0. 0001) in the number of de novo muscle invasive bladder cancers. Women were more likely to be diagnosed with muscle invasion primarily than men (85.2% and 50.7%, respectively), and younger patients (younger than 50 years) were more likely to present with superficial bladder cancer compared to those older than 50 years who were more likely to present with de novo muscle invasive bladder cancer.

CONCLUSIONS

Analysis of our data supports the findings of the earlier series that the majority of patients present with muscle invasive bladder cancer. However, there is a significant decrease in the percentage of tumors invading the muscularis propria at presentation. Although this observation is encouraging, we emphasize that it is not as dramatic as the stage migration associated with prostate cancer, which may be largely attributed to the widespread use of prostate specific antigen for early detection. Therefore, we support the suggestion that therapeutic gains might follow from improved education regarding the signs and symptoms associated with bladder cancer, with enhanced focus on women and consideration of screening methods for those at high risk for bladder cancer.

Signet ring cell carcinoma of a pulled-through sigmoid colon mimicking a primary invasive bladder tumor: case report and review of the literature

Primary signet ring cell carcinoma of the urinary bladder and colon are rare disease entities that are aggressive, difficult to manage, and portend a poor prognosis. We present a case report of a 25-year-old man born with an imperforate anus who developed signet ring cell carcinoma of the pulled-through sigmoid colon that mimicked a primary invasive bladder tumor. Despite radical surgery and adjuvant radiation, the patient died of his disease 7 months after surgery.

Positive surgical margins with radical retropubic prostatectomy: anatomic site-specific pathologic analysis and impact on prognosis

OBJECTIVES

To correlate the extent and location of positive surgical margins after radical prostatectomy with disease progression.

METHODS

Data on 495 patients who underwent radical prostatectomy by one surgeon were analyzed. All radical prostatectomy specimens were sectioned entirely using 2 to 3-mm step sections by one pathologist. One hundred fifty-one patients (30.5%) had one or more positive surgical margins and were subjected to further detailed analysis. Recurrence was defined as a serum prostate-specific antigen (PSA) level of 0.2 ng/mL and rising on at least two postoperative measurements.

RESULTS

The mean follow-up was 25.3 months (range 3 to 73). The overall recurrence rate was 13.3%. Neoadjuvant hormonal treatment was given to 37 (25%) of those with a positive margin. Patients with positive surgical margins had a significantly higher incidence of recurrence compared with those with negative margins (27.8% versus 6.9%, P = 0.001). The recurrence rate for various locations was 29% apex/urethra, 30% posterior, 33% anterior, 36% lateral, 48% posterolateral, and 57% bladder neck. Time to recurrence was shorter in patients older than 70 years (P<0.055); with a preoperative PSA greater than 10 ng/mL (P<0.0001); with a biopsy Gleason score greater than 7 (P = 0.02); with a prostatectomy Gleason score greater than 7 (P<0.001); with seminal vesicle invasion (P = 0.0001); having more than 1 location of a positive margin (P = 0.002); or having a positive margin at the bladder neck (P = 0.0003) or the posterolateral surface of the prostate (P = 0.02) compared with other locations. Multivariate proportional hazards analyses indicated that age older than 70 (P = 0.005), a prostatectomy Gleason score of 7 (P = 0.015) or 8 to 10 (P = 0.003), and positive margin(s) at the bladder neck (P = 0.003) were independently associated with a shorter time to recurrence among patients with a positive margin.

CONCLUSIONS

In our study, among patients with positive surgical margins, those with multiple positive margins, or a margin involving the bladder neck or the posterolateral surface of the specimen carried a higher risk of progression. A positive margin at the bladder neck appears to be the most significant adverse prognostic indicator. This information may help in decisions regarding additional therapy.

Age as a prognostic factor for disease recurrence after radical prostatectomy

OBJECTIVES

To assess whether age has an impact on biochemical recurrence after radical prostatectomy for localized adenocarcinoma of the prostate.

METHODS

Four hundred eighty-nine consecutive patients who underwent radical retropubic prostatectomy and did not have metastases to the lymph nodes were retrospectively analyzed. Disease recurrence was defined as a serum prostate-specific antigen greater than 0.2 ng/mL and rising on at least two postoperative measurements. Biochemical progression was compared in patients 70 years old or younger and older than age 70. The Kaplan-Meier estimator and Cox's proportional hazards model were employed to investigate the impact of age on time to recurrence. Neoadjuvant androgen deprivation was treated as a stratification variable in the Cox models.

RESULTS

The mean follow-up was 25.4 +/- 20.8 months. The Gleason score and extent of cancer in the pathologic analyses of the prostatectomy specimen was not significantly different between the two groups. Biochemical recurrence was detected in 12% of patients 70 years old or younger and in 25% of those older than 70 (P = 0.01). In multivariate analyses, after adjusting for all prognostic factors, younger age (70 years or younger) was independently associated with a longer time to recurrence (P <0.02).

CONCLUSIONS

Our results suggest that age per se may be an independent prognostic factor for disease recurrence after radical prostatectomy. This implies that patients 70 years old or younger are more likely to benefit from surgery. This information may be useful when counseling patients with clinically localized carcinoma of the prostate.

Comparison of digital rectal examination and biopsy results with the radical prostatectomy specimen

PURPOSE

Digital rectal examination is integral to staging prostate cancer. Ultrasound guided biopsy establishes the diagnosis, and it may provide useful information regarding disease grade and extent. Treatment decisions are largely based on information gained from digital rectal examination and biopsy but this information is only useful if it correlates with the radical prostatectomy specimen and prognosis. We correlated digital rectal examination and transrectal ultrasound guided biopsy results with a detailed analysis of the radical prostatectomy specimen.

MATERIALS AND METHODS

The accuracy of an abnormal digital rectal examination for predicting the location and extent of cancer was assessed in 89 patients thought to have clinical stage T2 disease. We evaluated 155 patients with clinical stages T1c and T2 disease to correlate the location of positive biopsies with the tumor site in the prostate. Radical prostatectomy specimens were completely sectioned at 2 mm. intervals, and tumor extent and location were recorded.

RESULTS

In 85 patients a unilateral lesion was suspicious on digital rectal examination, that is stage cT2. The final pathological review revealed cancer on the suspicious side in 82 cases (96%) with tumor confined to the same lobe in only 23 (27%), bilateral disease in 59 (69%) and tumor confined to the contralateral lobe in 3 (4%). In 4 patients with a palpable bilateral abnormality a bilateral lesion was confirmed on final pathological evaluation. Digital rectal examination demonstrated a 36 and 31% incidence of extracapsular tumor extension and positive surgical margins, respectively, on the clinically benign side. In 100 patients only unilateral biopsy was positive. The final pathological evaluation revealed cancer in the biopsy positive side in 95 cases (95%) with tumor confined to the ipsilateral lobe in only 26 (26%), bilateral disease in 69 (69%) and tumor confined to the contralateral lobe in 5 (5%). In 46 of the 55 patients (84%) with bilateral positive biopsies tumor involved both sides but the pathologist did not identify cancer in both lobes in 9 (16%). While 100 patients had a unilateral negative biopsy, analysis of the prostatectomy specimen revealed carcinoma in the benign lobe in 74 (74%). Moreover, extracapsular tumor extension and a positive surgical margin were observed on the biopsy negative side in 31% of the patients. The degree to which digital rectal examination and biopsy results confirmed the final pathological evaluation was assessed using the kappa statistic, which revealed only slight agreement with each factor. The correlation of digital rectal examination and biopsy results with the location of extracapsular extension and positive margins was evaluated by the Spearman coefficient of correlation, which indicated poor agreement. When patients with unilateral versus bilateral positive biopsy were compared with respect to prognostic parameters, the difference was statistically significant for initial serum prostate specific antigen, the percentage of surface involved by tumor, biopsy and final Gleason scores, and the incidence of extracapsular extension of tumor.

CONCLUSIONS

Digital rectal examination and the interpretation of prostate biopsy are not accurate clinical tools for defining the location and extent of prostatic carcinoma. Bilateral positive biopsy may be useful as an adjunct to the current clinical staging system.

The value of upper tract cytology after transurethral resection of bladder tumor in patients with bladder transitional cell cancer

PURPOSE

Patients with transitional cell carcinoma of the bladder are at risk for concurrent or subsequent cancer of the upper tract. Traditionally disease is monitored by radiography (excretory or retrograde urography). Some elect to sample the upper tract by obtaining urine for cytology. Are the results meaningful when performed in a patient with bladder cancer?

MATERIALS AND METHODS

We evaluated 27 consecutive patients with transitional cell cancer of the bladder (grade 1 to 3, Ta to T2) with bladder wash for cytology and cystoscopy as well as resection of visible tumor. A 5F ureteral catheter was positioned at each ureteral orifice, flushed with saline and passed into each renal pelvis. Urine was collected for cytology.

RESULTS

Of 19 patients (68%) with high grade (grade 3) bladder cancer 13 had a positive bladder wash, including 6 (32%) with tumor cells detected in the urine from the upper tract. Of 8 patients (38%) with low grade (grade 1 to 2) transitional cell cancer 3 had a positive bladder wash and 2 (25%) had a positive upper tract cytology. All patients had a normal upper tract by excretory or retrograde urography. Ureteroscopy was not performed.

CONCLUSIONS

Given the normal appearance of the upper urinary tract, it is highly unlikely that most, if any, of these patients with bladder cancer have tumor in the upper tract despite tumor cells in urine obtained by retrograde catheterization. Thus, upper tract sampling by a retrograde technique lacks specificity for localizing transitional cell cancer to the upper tract when performed in a patient with bladder cancer.

Fibroepithelial polyp of the renal pelvis: nephron-sparing surgery after false-positive biopsy for transitional cell carcinoma

Benign fibroepithelial polyps of the renal pelvis are extremely rare, with only 23 cases previously reported. The diagnosis is usually made following nephrectomy or nephroureterectomy for an assumed malignancy. This case involves a 66-year-old woman referred with presumed biopsy-proven transitional cell carcinoma of the renal pelvis. Radiographic findings were suggestive of a benign lesion. Pyelotomy and frozen section confirmed these suspicions. The polyp was excised and the kidney spared. The diagnosis and management of fibroepithelial polyps are discussed and the literature reviewed.

The nested variant of transitional cell carcinoma: an aggressive neoplasm with innocuous histology

The nested variant of transitional cell carcinoma (TCC-NV) is a rare neoplasm; only eight cases have been described. This report reviews the clinicopathologic features of 16 additional examples. The cases were collected from consultations received during a 13-year period. In most instances, a consultation was sought because the histologic features suggested an atypical proliferation of Brunn's nests or a lesion similar to the previously published examples of TCC-NV. Clinical data were gathered and tissues were studied to exclude prostatic cancer and adenocarcinoma. TCC-NV is characterized by the presence of irregular nests and/or tubules of transitional cells infiltrating the lamina propria without surface involvement. Neoplastic cells tend to have innocuous features but at least a few cells in every case are cytologically anaplastic. There is a marked male predominance. Synchronous or metachronous TCCs of more usual histologic make-up may occur. After a follow-up averaging 16.6 months, only three patients are known to be alive with no evidence of disease. Clinicopathologic information from our 16 cases combined with the 8 previously reported examples confirms that TCC-NV is a persistent and aggressive neoplasm notable for its innocuous appearance in histologic preparations.

Radical prostatectomy: is complete resection of the seminal vesicles really necessary?

PURPOSE

We determined the frequency of prostate cancer extension into the distal 1 cm. of seminal vesicles, and reconsidered whether complete excision of the seminal vesicles during radical prostatectomy is always necessary.

MATERIAL AND METHODS

After en bloc removal with the specimen in 71 consecutive radical prostatectomies, the distal 1 cm. of each seminal vesicle was transected and separately analyzed for tumor involvement.

RESULTS

Mean patient age was 61.8 years (range 40 to 72). Preoperative prostate specific antigen (PSA) ranged from 0.8 to 37 ng./dl. (median 7.3), and 18 patients had a PSA of 10 or more. Clinical stages were T1b in 1 case T1c in 37, T2a in 12, T2b in 10, T2c in 6 and T3a in 1. Preoperative Gleason sums ranged from 4 to 8 (median 6) with 21 patients (30%) having a sum of 7 or more. Of 71 patients 12 (17%) and seminal vesicle invasion (5 bilaterally). In no case did tumor extend into the distal 1 cm. of the seminal vesicle. PSA at diagnosis ranged from 4.2 to 30 ng./dl., with 4 of 12 patients having a PSA of 10 or more. Preoperative clinical stages were T1c in 5 cases, T2a in 3, T2b in 2 and T2c in 2. Five of the 12 patients (42%) had positive surgical margins and 11 (92%) had a postoperative Gleason sum of 7 or more.

CONCLUSIONS

In 71 consecutive patients undergoing radical prostatectomy no tumor was found in the distal 1 cm. of the seminal vesicles, including 12 with seminal vesicle invasion. We continue to advocate complete excision of the seminal vesicles during radical prostatectomy. However, if dissection is difficult and a small fragment is left behind, the prognosis is unlikely to be altered.

Positive surgical margins with radical prostatectomy: detailed pathological analysis and prognosis

OBJECTIVES

To examine the extent and location of positive surgical margins and their influence on progression.

METHODS

Two hundred fifteen consecutive radical prostatectomy specimens, using 2 to 3-mm step-sections, were reviewed. Particular attention was paid to the location and extent of positive margins. Seventy-three patients (34%) with one or more positive margins were subjected to further detailed analysis. Progression was defined as a serum prostate-specific antigen level greater than 0.1 ng/mL and rising. The mean follow-up period was 23.2 months; median 24 months (range 3 to 40).

RESULTS

Margin-positive patients had a significantly higher biopsy tumor grape (P = 0.05) than did margin-negative patients. Capsular preforation was present in 75%, seminal vesicle invasion in 33%, and nodal metastases in 10% of margin-positive patients; in contrast, these tumor characteristics were present in 47%, 8%, and 1% of margin-negative patients, respectively. The extent of involvement of linked margins was focal in 22% and extensive in 66%. An equivocal margin identified as surgical incision into the specimen (due to hemostatic staples, surgical dissection, or retraction) was present in 12%. Seventy-one percent of patients had a positive margin at only one location. Of all 99 positive-margin locations, 40% were apical, 10% anterior, 8% bladder neck, 16% posterolateral, and 25% posterior. Thirty-four percent of margin-positive and 7% of the margin-negative patients demonstrated biochemical progression. Of the 36 patients with a positive margin as their only major risk factor for progression (seminal vesicle and lymph node negative, Gleason score less than 8), 25% have progressed. Progression occurred in 2 of 9 patients with an equivocal positive margin, and 5 of 16 with a single focal-positive margin. A multivariate analysis of margin-positive patients identified tumor volume and grade as the most significant predictors, with the location and extent of the positive margin not significant.

CONCLUSIONS

Although more frequent at the prostatic apex, tumor at the inked margin at any location is a risk factor for postoperative biochemical progression.

The role of laparoscopy in the diagnosis of cirrhosis

BACKGROUND

A definitive diagnosis of cirrhosis is important in the prognosis and management of patients with chronic liver disease. The diagnosis of cirrhosis is made either by histologic examination of a biopsy specimen or upon visualization of a diffusely nodular and firm surface of the liver at laparotomy or laparoscopy. A liver biopsy, however, may not demonstrate the histologic features of cirrhosis in some cirrhotic patients. Our goal in this study was to compare the accuracy of liver descriptions made during laparoscopy with liver histology found by laparoscopic biopsy in patients with chronic liver disease.

METHODS

A retrospective review of paired laparoscopy and histology reports was performed on 434 consecutive patients who underwent laparoscopy between 1992 and 1994. (M:F ratio, 1.3:1; mean age, 48 +/- 14 years).

ETIOLOGY

52% hepatitis C, 8% hepatitis B, 8% fatty liver, 4% primary biliary cirrhosis, 3% autoimmune hepatitis, and 25% miscellaneous (cancer patients were excluded).

RESULTS

One hundred sixty-nine patients had laparoscopic evidence of cirrhosis; 115 were confirmed by histology, representing a 32% sampling error. Two of 265 patients with histologic evidence of cirrhosis (0.8%) had no macroscopic evidence of cirrhosis at laparoscopy.

CONCLUSIONS

(1) There was a 32% histologic sampling error among patients documented to have cirrhosis by laparoscopy. (2) Using laparoscopy as a gold standard, the sensitivity of liver biopsy was 68% and the specificity was 99%.

Histopathological effects of androgen deprivation in prostatic cancer

Thanks to earlier detection of clinically significant prostatic adenocarcinoma by measurement of serum prostate-specific antigen (PSA) levels, increasing numbers of patients are undergoing radical prostatectomy. However, the curative potential of this procedure is seriously limited by clinical understaging, which results in positive surgical margins and a marked increase in disease progression. In a multicenter study, histopathologic evaluation of radical prostatectomy specimens showed that presurgical androgen deprivation with leuprolide plus flutamide reduced the incidence of surgical margin involvement by 62%. In patients who received androgen deprivation therapy, characteristic and recognizable histopathologic changes in nontumor glands included atrophy, basal cell prominence, vacuolated luminal cell layers, and squamous and transitional cell metaplasia. Androgen deprivation markedly reduced the incidence of prostatic intraepithelial neoplasia (PIN) to 35%. The effects of androgen deprivation on prostatic carcinoma included smaller tumor glands, pyknosis and empty glandular spaces, and vacuolization and degeneration of tumor cells with an inflammatory response. Similar but less pronounced changes with no decrease in PIN were observed in finasteride-treated patients. It is important for pathologists to be aware of these histological changes and process tissue appropriately, because the changes affect the recognition and histological grading of tumors in radical prostatectomy specimens.

The histogenesis of clear cell adenocarcinoma of the lower urinary tract. Case series and review of the literature

Clear cell adenocarcinoma of the lower urinary tract is a rare neoplasm whose histogenesis has not been thoroughly investigated. We have examined six specimens of clear cell adenocarcinomas collected from three institutions using histological, histochemical, and immunohistochemical techniques. Results indicate that almost all clear cell adenocarcinomas of this region express morphological and antigenic features, suggesting müllerian differentiation, and that müllerian differentiation is not a feature of either nonclear cell adenocarcinomas or normal female paraurethral glands. Including the authors' six specimens, 46 specimens have been reported in the available English literature. The accumulated experience confirms the initial impression that these tumors develop predominantly in the urethras of women and occur over a wide age range. Despite high stage at diagnosis, most patients have been alive with no evidence of disease when reported, a prognosis that seems to apply regardless of length of follow-up.

Incidental prostatic adenocarcinoma in patients undergoing radical cystoprostatectomy for bladder cancer

To determine if patients with bladder cancer have a higher incidence of unsuspected prostate cancer, 40 cases were studied. All except one case had no evidence of prostate cancer on preoperative clinical assessment. Detailed pathological evaluation of cystoprostatectomy specimens with sections at 2- to 3-mm intervals was done. Adenocarcinoma of the prostate was identified in 18 of 40 patients (45%). Multifocal prostatic intraepithelial neoplasia (PIN) was present in 19 cases (47.5%); 4 (10%) without an associated prostate cancer and 15 (37.5%) in conjunction with adenocarcinoma of the prostate. Twelve cases of unsuspected prostate cancer were stage pT1a, 4 were pT1b, and 2 were pT3. No patients exhibited nodal or distance metastases by the prostate cancer. At a mean follow-up of 15.2 months (range 3-34 months), 37 of the 40 patients are alive. Among prostate cancer patients, no clinical or biochemical evidence of disease recurrence or prostate cancer related mortality has been observed. Our findings support the previously reported high incidence rate of prostate cancer in patients undergoing cystoprostatectomy for bladder cancer. This, though, may not be higher than the observed incidence in an age-matched general population. We recommend DRE and PSA as part of the bladder cancer workup in males, and complete removal of the prostate at cystoprostatectomy to prevent the dilemma of residual prostate cancer.

Procollagen-III peptide and chronic viral C hepatitis

Chronic hepatitis develops in at least half of persons acutely infected with hepatitis C virus (HCV). Ten to 25% of these patients will develop cirrhosis. Serum procollagen-III peptide (PIIIP) may be of value in predicting the development of chronic active fibrogenic liver disease. It has been reported that in chronic viral C hepatitis, the levels of hepatitis C virus-RNA (HCV-RNA) correlate directly with the severity of hepatic histology and inversely with response to interferon therapy.

OBJECTIVES

The aims of this study were to correlate the level of PIIIP with HCV-RNA concentrations, ALT values, and histological severity in patients with chronic viral C hepatitis.

METHODS

Eighty-six patients with chronic C hepatitis were divided into three groups: group I (n = 34), mild chronic active hepatitis, group II (n = 25), moderate to severe chronic active hepatitis, and group III (n = 27), cirrhosis. HCV-RNA was measured by Quantiplex, and PIIIP was measured by radioimmunoassay-gnostic assay.

RESULTS

Mean +/- SD level of ALT in group I was 114 +/- 48 U/L, group II was 169 +/- 115 U/L, and group III was 160 +/- 94 U/L. The mean +/- SD level of HCV-RNA in group I was 110 +/- 130 x 10(5) Eq/ml, in group II was 140 +/- 140 x 10(5) Eq/ml, and in group III was 70 +/- 80 x 105 Eq/ml. The mean +/- SD level of PIIIP in group I was 0.6 +/- 0.2 U/ml, in group II was 0.9 +/- 0.4 U/ml, and in group III was 1.2 +/- 0.6. There was a significant difference in the levels of PIIIP among the three groups (p = 0.0001). There was no correlation among ALT, HCV-RNA, and PIIIP in any of the three groups.

CONCLUSIONS

PIIIP peptide determinations in patients with chronic viral C hepatitis are reflective of histological severity and may provide relatively noninvasive means of following disease progression.

Pathology of androgen deprivation therapy in prostate carcinoma. A comparative study of 173 patients

BACKGROUND

Leuprolide, an agonist of luteinizing hormone-releasing hormone (LH-RH), and flutamide, an antiandrogen, increasingly are being used in the treatment of clinically localized prostate cancer. Only two small series (of 23 and 12 patients) have been published on the distinctive pathologic changes induced in the prostate by androgen deprivation therapy with discrepancies on the presence of squamous metaplasia, necrosis, and possible tumor destruction by combined androgen deprivation therapy.

METHODS

One hundred and thirteen radical prostatectomy specimens obtained after at least 3 months of leuprolide-flutamide androgen inhibition therapy and 60 nonhormonally treated prostates in randomly selected clinical Stage T2 prostate adenocarcinoma patients were entirely sectioned. Distinctive histologic findings were tabulated and their statistical value determined.

RESULTS

Resection margins of excision were involved by tumor in 43% of untreated and in 19% of androgen-deprived patients. Characteristic changes in androgen-inhibited nontumor glands included atrophy, basal cell prominence, vacuolated luminal cell layer, and squamous and transitional cell metaplasia. Prostatic intraepithelial neoplasia (PIN) was observed in 35% of treated patients. The presence of small tumor glands separated by stroma was the most frequently noted effect of androgen deprivation on prostate adenocarcinoma; pyknosis and branching empty spaces were less frequent. Large clear tumor cells within an inflammatory response was a third histologic pattern. Apparently unaltered tumor areas were observed in 43% of prostates exposed to androgen deprivation therapy.

CONCLUSIONS

Androgen deprivation therapy results in histologically distinctive changes that can be recognized in both nonneoplastic and neoplastic prostate tissue. Residual tumor was present in all 113 treated radical prostatectomy specimens. In addition to glandular shrinkage, therapy was associated with statistically significant reductions in the frequency of high grade PIN and extension of cancer to prostate specimen margins of excisions.

Squamous cell carcinoma of the prostate: a transformation from adenocarcinoma after the use of a luteinizing hormone-releasing hormone agonist and flutamide

We report a primary squamous cell carcinoma of the prostate that developed in a 57-year-old man, 3 years after treatment with leuprolide and flutamide for Stage D1 adenocarcinoma of the prostate. This is the first case that describes this transformation from adenocarcinoma to squamous cell carcinoma following the use of luteinizing hormone agonists.

Bladder neck preservation following radical prostatectomy: continence and margins

Between December 1991 and January 1994, 134 patients underwent radical retropubic prostatectomy with bladder neck preservation. Forty-nine patients had a positive margin. Number and location of positive margins were analyzed. A tumor was identified at the bladder neck in 10 cases (7.5%). In all 10 patients with bladder neck involvement, a tumor was also identified at multiple other sites. These data suggest that preservation of the bladder neck during radical prostatectomy does not appear to compromise the efficacy of the procedure. Using a self-administered patient questionnaire, we evaluated the effect of bladder neck preservation upon continence in 36 patients. At the initial 3-month follow-up, 24 (67%) patients did not wear any pads. Another 7 (19%) wore pads occasionally, while 5 (14%) patients wore pads daily. To date only 1 of the 134 patients has developed an anastomotic stricture. Bladder neck preservation may aid in an earlier return of continence following radical prostatectomy and reduces anastomotic strictures. It does not appear to compromise the removal of the cancer.

Transhyoid resection of tongue base and tonsil tumors

Advanced lesions of the oropharynx are known to have increased survival with surgical excision combined with radiation therapy. Traditional surgery involves either a mandibular resection or, more recently, a mandibular sparing approach primarily through a lip-splitting incision. At our institution posterior oropharyngeal lesions are approached via a combined intraoral and transhyoid technique. Nineteen sequential procedures using this approach were compared with a similar number of previous, stage-matched controls in an attempt to obtain valid comparable information. No significant difference between the groups was noted with respect to surgical margins. A significant difference was, however, seen with respect to the need for flap closure with none required in the transhyoid group and five in the mandibulotomy group. Furthermore, a statistical difference was observed with respect to the presence of significant complications in favor of the transhyoid group. These results indicate that similar cure rates can be achieved with lower morbidity by use of a transhyoid pharyngotomy approach to tumors of the oropharynx.

Androgen deprivation prior to radical prostatectomy for T2b and T3 prostate cancer

OBJECTIVE

In an effort to improve on the results of radical prostatectomy for clinical stages T2b and T3 prostate cancer, a selected group of patients received androgen deprivation for three to sixteen months prior to surgery.

METHODS

Fifteen men with clinical T2b and 22 with small T3 tumors received a luteinizing hormone-releasing hormone analog (n = 34) or a bilateral orchiectomy (n = 3) three to sixteen months prior to radical retropubic prostatectomy. The prostate was evaluated with particular attention to tumor grade, presence of extracapsular extension, tumor at the inked margin, seminal vesicle invasion, and tumor in the lymph nodes.

RESULTS

No patient had clinical or chemical (prostate-specific antigen [PSA]) progression during androgen deprivation. The PSA level declined a mean 90 percent and remained above 4 ng/mL in only two patients. The prostate volume decreased an estimated 30-50 percent. Prostate cancer at the inked margin was found in 15 (41%) and seminal vesicle involvement in 11 (30%) patients. Five (14%) had tumor in regional lymph nodes. There was no difference in regard to positive margins or lymph node metastases between those clinically staged as T2b and those preoperatively staged as T3. Fourteen patients have received adjuvant therapy (13 androgen deprivation, one radiation therapy). None has progressed (mean follow-up, 38.4 months). Of 23 who did not receive immediate additional therapy, six (26%) had progression, as was evident from an increase in PSA and have since been treated. Only one continued to progress. Thirty-five of the 37 patients are alive. Seventeen (46%) are tumor free (PSA < 0.4 ng/mL) without further androgen deprivation.

CONCLUSIONS

Only a prospective randomized trial can determine whether androgen deprivation prior to radical prostatectomy has a role. The results from this trial are encouraging for several reasons. The prostate is much smaller as a result of androgen deprivation and this may facilitate surgery. Although the great majority of these patients were expected to be margin positive, 60 percent had negative margins and only 14 percent had positive lymph nodes.

Significance of androgen deprivation prior to radical prostatectomy, with special reference to prostate-specific antigen

A total of 37 selected patients with clinical stage T2b or T3 prostate cancer received androgen deprivation prior to radical retropubic prostatectomy. A luteinizing hormone-releasing hormone (LHRH) analog alone was given to 15 individuals; 19 received an LHRH analog with flutamide. Three underwent bilateral orchiectomy instead of chemical castration. The duration of androgen deprivation prior to radical prostatectomy varied from 3 to 16 months, with 31 individuals undergoing induction therapy for 3-6 months. Three received androgen deprivation for more than 1 year. In all, 15 patients had clinical stage T2b disease and 22, stage T3 prostate cancer. The prostate size decreased approximately 30%-50% following induction therapy. Prostate-specific antigen (PSA) values decreased in all 19 instances where this was obtained. In all, 6 of 15 (40%) patients with clinical T2b lesions and 9 of 22 (41%) with clinical T3 tumors had a positive surgical margin; 5 (13%) had 1 or more positive lymph nodes. Androgen deprivation was continued following surgery in 13 cases. Only one patient received postoperative radiation therapy. After a mean follow-up period of 33 months, 35 (95%) patients are alive. Two patients died, one of poorly differentiated prostate cancer with subsequent metastasis and one of a myocardial infarction 33 months after surgery without showing any evidence of disease. Of 23 patients without postoperative adjuvant therapy, 6 (26.1%) progressed (PSA level, > 0.4 ng/ml). None of the patients who underwent adjuvant therapy progressed over a follow-up period of 6-75 months (mean, 38 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Bladder neck preservation and its impact on positive surgical margins during radical prostatectomy

To modify the bladder neck dissection during radical prostatectomy, in an effort to improve continence and diminish the incidence of anastomotic stricture, without compromising the primary surgical objective of complete cancer removal. Between December 1991 and August 1992, 50 patients underwent radical retropubic prostatectomy with anatomic dissection and preservation of the bladder neck and most proximal portion of the prostatic urethra, thus creating a mucosal cuff for anastomosis to the urethral stump. There was tumor at the inked margin in 18 patients (36%), however, in only 3 instances (6%) was there tumor at the bladder neck margin. In no instance was the bladder neck margin the only positive margin. At a minimum follow-up of six months, all patients are fully continent during routine activities, and in no patient has an anastomotic stricture developed. Anatomic dissection and preservation of the bladder neck and proximal urethra does not compromise surgical margins. We believe this technique may play a role in preservation of continence after radical prostatectomy and probably decreases the likelihood of anastomotic stricture, by allowing for a circumferential mucosa-to-mucosa anastomosis without the need for bladder neck reconstruction.

Laser-assisted enterocystoplasty in rats

The employment of laser welds to anastomose bowel to bladder in urological surgery has never been described. Using rats, we compared laser-assisted enterocystoplasty (LAE) with conventional sutured enterocystoplasty (CSE). A "patch" ileocystoplasty was performed using distal ileum. Operative time, intraluminal bursting pressure and histologic changes were evaluated. Operative time was 38% less in the LAE (p < 0.001). No statistically significant differences in bursting pressure between LAE and CSE groups was demonstrated (p = 0.654) in rats sacrificed 2 weeks postoperatively. Histologic findings in the laser-assisted enterocystoplasties included early loose granulation tissue and later organization of the granulation tissue with significant collagen deposition. In our preliminary study, laser welding of bowel within the urinary stream was safe, efficacious and rapid and resulted in a mechanically comparable surgical outcome.

Thyroplasty in the functional rehabilitation of neurotologic skull base surgery patients

Definitive management of lesions of the lateral cranial base is surgical. Functional outcome is dependent on cranial nerve preservation. In 1988 an effort was made to decrease the incidence of tracheotomy, the duration of hospital stay, and the period prior to unassisted oral intake, by establishing more immediate acquisition of glottic competence through laryngeal rehabilitation. The experience of one author (JLN) in over 40 phonosurgical procedures under local anesthesia is presented. Although tracheotomy provides excellent airway protection, it is accompanied by substantial morbidity. The technique of phonosurgery has dramatically improved recovery and functional outcomes of neurotologic skull base surgery patients, enabling them to realize "cure" rather than "control" of their disease.

New variant of von Willebrand disease type II with markedly increased levels of von Willebrand factor antigen and dominant mode of inheritance: von Willebrand disease type IIC Miami

A variant of von Willebrand disease (vWD) was identified in six members of a kindred spanning four generations. The proband was a 46-year-old woman with a lifelong history of bleeding, a prolonged bleeding time (> 15 minutes), markedly elevated von Willebrand factor (vWF) antigen (vWF:Ag = 2.09 U/mL), slightly reduced ristocetin cofactor activity, and a plasma vWF multimer pattern similar to that of vWD type IIC. Similar findings were observed in her three children, mother, and brother. In affected family members, platelet and plasma vWF multimer patterns were discrepant with higher molecular weight multimers observed in platelet vWF. Following a 1-Des-amino-8-D-arginine vasopressin (DDAVP) challenge, the proband failed to normalize her bleeding time even though vWF: Ag rose by 70% and higher molecular weight multimers were increased slightly. Genetic studies were consistent with autosomal dominant inheritance of a mutation within the vWF gene. By sequencing of cloned genomic DNA, mutations were excluded in exons 4, 5, 14, and 15, which encode regions of the vWF propeptide proposed to be important in multimer biosynthesis. Mutations also were excluded in exons 28 to 31, which encompass the known mutations that cause vWD types IIA, IIB, and B. This new variant of vWD, characterized by autosomal dominant inheritance, a qualitative defect that resembles vWD type IIC, and increased plasma vWF:Ag, was tentatively designated vWD type IIC Miami.

Temporal meningiomas presenting as chronic otitis media

Two cases of temporal bone meningiomas presenting as chronic drainage ears are presented. One case was indicated by computer tomographic scan at the time of initial surgery to be limited to the middle ear, but recurred 9 months later with extensive cerebellopontine angle extension and cranial nerve palsies. The tumor in the second case extended from the middle ear to the cavernous sinus, with extensive intradural involvement. Meningiomas involving the middle ear must be considered to have intracranial extension, and magnetic resonance is the imaging study of choice.

Malignant fibrous histiocytoma of spermatic cord

Malignant fibrous histiocytoma occurs rarely in the genitourinary organs, and is exceptional in the spermatic cord. The prognosis of deep malignant fibrous histiocytoma not occurring in subcutaneous tissue or fascia is generally poor. We report a case, of malignant fibrous histiocytoma giant cell type, arising around the spermatic cord. The patient is alive without metastasis ten years after initial therapy. To our knowledge, this is the longest reported survivor of this disease. Radical inguinal orchiectomy along with wide en bloc local resection is the therapy of choice.

Sertoli-Leydig cell testicular tumor: case report and review of sex cord/gonadal stromal tumor histogenesis

We describe a case of well differentiated Sertoli-Leydig cell tumor in a testicle. Previously, this tumor has only been illustrated histologically. The existence of a male homologue to the female arrhenoblastoma containing Sertoli and Leydig cells again supports the current hypothesis of gonadal development, and the common steps found in the male and female pathways.

Meningeal carcinomatosis producing bilateral sudden hearing loss: a case report

Meningeal carcinomatosis is characterized by diffuse infiltration of the leptomeninges by metastatic cancer in patients usually with a previous history of malignancy. Primary tumors are usually adenocarcinomas of the breast or lung, or malignant melanoma. Meningeal carcinomatosis can present with headache and/or a variety of cranial neuropathies. We report a case of meningeal carcinomatosis presenting as a complete, bilateral, sudden hearing loss without other cranial nerve findings--a previously unreported presentation. Our patient also exhibited an unusual primary tumor site (esophagus) and histopathology for meningeal carcinomatosis. The case was impressive for the subsequent abrupt onset of a series of cranial neuropathies and the rapid deterioration in the patient's condition.

A comparative study of three methods for the visualization of von Willebrand factor (vWF) multimers

This study was performed to compare three visualization methods for the detection of vWF multimers: autoradiography (125I), electroblot with a horseradish peroxidase system (BLOT-HRP), and an avidin-biotin peroxidase system (AV-BIO). Each method was evaluated according to: 1) ability to visually detect bands and subbands thereby identifying von Willebrand's disease (vWD) subtypes and normals, 2) reagent availability, 3) cost, and 4) time requirements. Additionally, resolvability was evaluated utilizing low, intermediate, and high resolution gels prepared with both low and high gelling temperature agaroses with subsequent visualization by the three detecting systems. With intermediate resolution gels, our results showed that all three visualization methods could discern pathologic patterns from normal. In addition, the avidin-biotin peroxidase system demonstrated the best band discreteness with low resolution gels used to detect unusually high molecular weight multimers. With high resolution gels used for subtyping type II vWD, we found the internal band structure was best demonstrated using LGT agarose and the electroblot horseradish peroxidase system.

Natural history of multiple intrahepatic canine islet allografts during and following administration of cyclosporine

Cyclosporine (CsA) prevented acute rejection of intrahepatic canine islet allografts (IHIA) in 5/5 pancreatectomized dogs. Normal fasting blood glucose levels were sustained in these dogs for 210 +/- 78 days (mean +/- SEM) following withdrawal of CsA. We tested whether combining islets from more than one pancreas would improve function and prolong islet allograft survival during and following administration of CsA. Areas under the glucose disappearance (GDA) and C-peptide response (CPA) curves following i.v. glucose (0.5 g/kg), 1 month posttransplant were not significantly different using islets from 1 or 2 pancreases, whereas GDA and CPA approached normal if islet yields from 3 or more pancreases were combined. Mean islet allograft survival following interruption of CsA decreased with an increase in the number of donor pancreases (one: 210 +/- 78 days, vs. two: 113 +/- 23 days, vs. greater than 2: 57 +/- 5 days). These studies demonstrate that: (1) IHIA uniformly resulted in fasting euglycemia in 36 of 38 diabetic dogs treated with CsA; (2) normal i.v. glucose metabolism required the combined islet yield of 3 or more donor pancreases, suggesting that a substantial number of intrahepatic islet cells are functionally lost despite effective CsA-induced immunosuppression; (3) use of multiple donors to accumulate an increased mass of islets may immunologically compromise allograft survival following discontinuation of CsA (these experiments, however, do not exclude a direct relationship between the duration of CsA therapy and the duration of immune unresponsiveness following interruption of CsA in multidonor islet allografts as an independent variable); and (4) unmodified islets obtained from multiple donors seem to require continuous immunosuppression to prevent rejection.

von Willebrand factor antigen levels in Kaposi's sarcoma

Consistent elevations of plasma von Willebrand factor antigen were observed in otherwise healthy elderly patients with Kaposi's sarcoma. The elevations were predominantly of the endothelial cell--derived antigen, as opposed to the factor VIII procoagulant, with resultant elevations in the antigen/procoagulant ratios. Lesser elevations were seen in a group of age-matched control subjects who did not have Kaposi's sarcoma or intercurrent illness. The greater elevations in plasma von Willebrand factor antigen therefore appear to be the direct consequence of the presence of Kaposi's sarcoma cells. Our findings also suggest that there is a direct relationship between tumor load and degree of von Willebrand factor antigen elevation.

Normal fibroblast mitochondrial malic enzyme activity in Friedreich's ataxia

Mitochondrial and cytoplasmic malic isoenzymes were assayed fluorometrically in digitonin-fractionated fibroblasts from three patients with Friedreich's ataxia (FA). Normal activity was found, failing to verify an earlier report of reduced fibroblast mitochondrial malic enzyme activity in FA. The previously reported disturbance in fibroblast mitochondrial malic enzyme may be an epiphenomenon in patients with the FA phenotype. Further studies are necessary to define the primary genetic defect in this inherited disorder.

Pathobiologic study of pituitary tumors: report of 62 cases with a review of the recent literature

Advances in radioimmunoassay procedures, immunocytochemistry, neuroradiologic imaging, and the surgical and medical treatment of pituitary adenomas have led to reappraisal of their classification as well as refinements in the diagnostic approaches used by pathologists. Sixty-two pituitary adenomas are described, and recent advances in this field are reviewed. Most of the patients were adults, but one of the adrenocorticotropic hormone (ACTH)-producing adenomas occurred in an 11-month-old infant. Endocrine-inactive tumors (43.5 per cent) were less common than hormone-producing tumors (56.5 per cent). Local invasion was most common in the former group, followed by ACTH-producing and other hormone-producing tumors. Ultrastructural features correlated with hormonal levels in the growth hormone(GH)-secreting tumors but not in the prolactin(LTH)- or ACTH-producing tumors. The formation of 7-nm filaments in the cytoplasm of tumor cells, corresponding to Crooke's hyaline change on light microscopy, was characteristic of ACTH-producing tumors. Ultrastructural changes in the ACTH granules suggested that the filaments may be derived from the feedback action of cortisol. Prior to surgery, a Rathke's cleft cyst and a chordoma were mistaken for endocrine-inactive pituitary adenomas. In two additional cases ectopic ACTH-producing tumors of lung clinically mimicked pituitary adenoma. Conversely, one pituitary adenoma mimicked sphenoid wing meningioma. Clinical, hormonal, and radiologic data and immunocytochemical and electron microscopic studies are needed for accurate pathologic interpretation and classification of pituitary adenomas.

Automated fibronectin assay using light-scattering optics on a centrifugal analyzer

We describe an automated, kinetic nephelometric method for fibronectin on the Multistat III F/LS Centrifugal Analyzer (Instrumentation Laboratory Inc., Lexington, MA 02173). Antiserum is diluted with polyethylene glycol. Calibrators and samples are prediluted with potassium phosphate buffer (10 mmol/L, pH 7.0) containing 8.5 g of NaCl per litre. Intensity (I) is read at 5 and 180 s and the resulting delta I plotted against concentration. A non-linear least squares curve fitting and interpolation of results is carried out automatically. Three controls, with values of between 190-370 gave coefficients of variation between 4 and 7 percent, and the sensitivity of the method is to 25 mg/L.

Clear cell variant of thyroid carcinoma

Three carcinomas composed of a variable proportion of clear cells, oxyphil cells, and cells with combined oxyphil and clear cell features are reported. Cytologically, these tumors were included in the category of oxyphil cell variant of follicular carcinoma. In regard to pattern, two were entirely follicular, and one had follicular and papillary areas. The biologic behavior of these tumors, however, was consistent with that of follicular carcinomas. The clear cell change could be the result of chronic TSH overstimulation. This may explain the variable histological patterns, nuclear features, and biologic behavior associated with these tumors. These tumors bear a striking histologic resemblance to metastatic renal cell carcinoma and clear cell neoplasms from other sites. Immunocytochemical stain for thyroglobulin proved to be a specific and sensitive method for identification of these tumors.

Thyroglobulin in carcinoma of the thyroid: an immunohistochemical study

To determine the value of thyroglobulin as an immunohistochemical marker for thyroid neoplasms, we studied 42 primary thyroid carcinomas, 38 metastatic carcinomas, and four sarcomas involving the thyroid gland. All follicular and papillary carcinomas, regardless of their morphologic variation, stained positively for thyroglobulin, whereas the medullary carcinomas, metastatic tumors, and sarcomas showed negative staining reactions. The only small-cell variant of follicular carcinoma and ten of 14 spindle and giant cell carcinomas showed the lowest thyroglobulin reactivity. It is concluded that immunohistochemical demonstration of thyroglobulin is a sensitive and specific method of identifying thyroid carcinomas of follicular cell origin.

Kaposi's sarcoma: absence of cytomegalovirus antigens

Using an immunohistochemical method, we could not detect cytomegalovirus antigens in the tissue of Kaposi's sarcoma but could in the cells of control sections from tissues known to be infected by that virus. Our results are consistent with the hypothesis that high antibody titers to cytomegalovirus found in patients with Kaposi's sarcoma are not due to infection of neoplastic cells by the virus, as a secondary event; our data supports the conclusions of others that exposure to cytomegalovirus may be a primary event in the pathogenesis of Kaposi's sarcoma.