Pericardial mesothelioma following mantle field radiotherapy

A 49-year-old female was referred with recurrent pericardial effusion following mantle field radiotherapy for Hodgkin s lymphoma. She underwent video-assisted thoracoscopy and resection of a pericardial window. Intraoperatively she suffered a cardiac arrest and subsequently died in the early postoperative period despite maximal therapy. Pathological examination revealed extensive myocardial fibrosis and multiple nodules of pericardial mesothelioma. The latter has hitherto not been recognised following mediastinal radiation. The cardiac complications of mantle field radiotherapy are discussed.

Invasive cervical cancer in Southampton and South West Hampshire: effect of introducing a comprehensive screening programme

A study of invasive cervical cancer in Southampton and South West Hampshire is reported, covering three consecutive three year periods during which the screening coverage increased from an estimated 60% to a recorded 87% of eligible women aged 20-64. From the first to the third periods of the study in that age group registrations of fully invasive squamous cell carcinoma (stage lb and above) fell from 64 to 30 (53%), which was largely counteracted by an increase in microinvasive squamous cell carcinoma (linear trend: P<0.0001). In the same age group registrations of adenocarcinoma rose slightly, which resulted from an increase in the number diagnosed at a depth of invasion of less than 3 mm. There were no significant changes in the numbers of stage III and IV cancers or among cancers in women aged 65 and over. A strong inverse association was found between stage of both histological types of cancer and their likelihood of being screen detected rather than symptomatic: 91% of screen detected cancers were diagnosed at stage I compared with 38% of symptomatic cancers. There was a slight downward trend in the incidence of cancer per 100,000 total female population across the three periods of the study with a significant trend towards low stage disease, which is likely to reduce mortality in years to come. The trend towards screen detected cancers and cancers of less than 3 mm depth of invasion is presented as a positive outcome to be expected in early rounds of increasing the screening coverage.

Chrysiasis revisited: a clinical and pathological study

Chrysiasis is a distinctive and permanent pigmentation of light-exposed skin resulting from the administration of parenteral gold salts. We report a study of 40 Caucasian patients with rheumatoid arthritis, treated with intramuscular sodium aurothiomalate, of whom 31 had chrysiasis. Visible changes develop above a threshold, equivalent to 20 mg/kg gold content, and their severity depends upon cumulative dose. Focal aggregates of particulate gold are deposited in the reticular and papillary dermis in amounts that correlate with the degree of pigmentation. Characteristically, initially the periorbital region is affected by a mauve discoloration, which intensifies and deepens into a blue/slate-grey colour, while extending to involve the face, neck and upper limbs. Although chrysiasis develops insidiously and patients may be unaware of the changes, positive identification is important in order to avoid misdiagnosis and medical mismanagement, and afford appropriate reassurance. Prevention is difficult, but measures to reduce sunlight exposure may be helpful.

T-cell-rich B-cell lymphoma presenting as liver disease

We describe a series of eight cases of T-cell-rich B-cell lymphoma diagnosed on liver biopsy and collected over a period of 15 years. Of seven cases that were referred from elsewhere, in only one was the correct diagnosis of B-cell lymphoma suggested. Common errors included misdiagnosis as inflammatory disease on histology, and misinterpretation as T-cell lymphoma on immunohistochemistry. However, the cases had a distinct morphological appearance and immunohistochemical profile. They showed a lymphohistiocytic or granulomatous infiltrate, usually centred on portal tracts and containing abundant small T-cells and scanty B-cell blasts. All patients had an atypical clinical presentation which favoured non-neoplastic liver disease. In seven cases liver involvement represented Stage IV disease and in one case disease was confined to the liver consistent with a primary hepatic lymphoma. Despite combination chemotherapy, the prognosis was poor with no patients surviving beyond 15 months from diagnosis. We believe T-cell-rich B-cell lymphoma to be an under-recognized subset of non-Hodgkin's lymphoma that may mimic primary liver disease.

Assessment of the accuracy of cytology in women referred for colposcopy and biopsy: the results of a 1 year audit

The results of weekly colposcopy review meetings have been audited for 1 year and cases where there was a discrepancy between the referral cervical smear and the initial colposcopy biopsy have been analysed. New referrals (n = 476) for colposcopy were studied. In the final outcome 80% of 326 women referred for moderate or severe dyskaryosis were found to have cervical intraepithelial neoplasia (CIN) grade II or III or invasive carcinoma. Three women found to have invasive carcinoma had been referred for severely dyskaryotic smears. Twenty women were referred for smears with cell changes suggesting glandular neoplasia: five were found to have adenocarcinoma in situ, whereas eight had CIN and seven had negative biopsies. The results justify the referral policy and demonstrate the need for further investigation when initial colposcopic biopsies are negative.

Chronic pancreatitis and biliary fibrosis associated with cryptosporidiosis in simian AIDS

Two Rhesus monkeys infected with simian immunodeficiency virus for 15 and 24 months developed generalized oedema and one became jaundiced. At necropsy, the liver and pancreas were hard and irregular and the gall bladder was thickened. Histopathological examination showed extensive fibrosis of the pancreas, loss of exocrine acini and marked proliferation of ductules. Numerous cryptosporidia were present on the duct epithelium. The liver of both animals had widespread cirrhosis, bile duct proliferation and cholangitis. Cryptosporidia were found in many bile ducts and on the hyperplastic gall bladder epithelium. Lymph nodes and spleen of both animals showed depletion of cortical and paracortical elements characteristic of advanced immunodeficiency virus infection.

Proliferative fasciitis of a finger: a case report

This is the first report of proliferative fasciitis presenting in a finger. This is a benign pseudosarcomatous lesion which normally runs a self-limiting course.

Spontaneous regression of hepatocellular carcinoma

A 63 year old white woman presented with abdominal discomfort, anorexia, and weight loss. Investigations showed hepatocellular carcinoma with pulmonary metastases. The primary and secondary tumours resolved without specific treatment.

Hepatic regeneration and metabolism after partial hepatectomy in normal rats: effects of insulin therapy

The effect of insulin therapy on liver regeneration has been studied in normal fed rats 12, 24 and 48 h after partial hepatectomy. Dry weight of regenerating liver increased between 12 and 48 h after partial hepatectomy and was unaffected by insulin therapy. [6-3H] Thymidine uptake peaked at 24-h (24.7 +/- 2.4% of total liver cells) and insulin treatment had no additional effect. At 12-h after partial hepatectomy, hepatic [ATP] was decreased 15%, while [ADP] and [AMP] were increased 47% and 83% respectively compared with sham-operated animals. Partial hepatectomy also caused an increase in hepatic [triglyceride], a decrease in hepatic [glycogen] and an increase in the levels of glucose and several glycolytic intermediates. The hepatic redox ratios, [lactate]:[pyruvate] and [3-hydroxybutyrate]:[acetoacetate], were elevated. Insulin therapy had only minor effects on hepatic adenine nucleotide levels, intermediary metabolite concentrations or intrahepatic redox ratios after partial hepatectomy. These findings suggest a decreased hepatic intracellular energy state in regenerating liver; insulin therapy in normal rats does not influence this metabolic change nor the regenerative response.

Hepatic regeneration and metabolism after partial hepatectomy in diabetic rats: effects of insulin therapy

The effect of insulin deficiency on liver regeneration has been assessed in untreated v. insulin-treated streptozotocin (65 mg kg-1) diabetic rats, 12, 24 and 48 h after partial hepatectomy. Dry weight of regenerating liver increased from 12 to 48 h after partial hepatectomy and insulin treatment caused a further minor increase at 24 h. [6-3H]Thymidine uptake in untreated rats peaked at 24 h (12.5 +/- 3.4% of total cells labelled). Insulin therapy produced a delayed 168% rise in uptake at 48 h. Insulin deficiency alone in sham-operated animals caused a 33% decrease in hepatic [ATP], while [ADP] rose by 43% and [AMP] by 86% at 12 h. Partial hepatectomy produced only minor further abnormalities in untreated animals. Insulin therapy increased hepatic [ATP] and decreased [ADP] and [AMP] 12 h after partial hepatectomy, but [ATP] remained decreased (15%) and [ADP] and [AMP] increased (45% and 73% respectively) compared with insulin-treated sham-operated controls. Metabolite changes observed after partial hepatectomy in untreated animals, including a decrease in hepatic [glycogen] and increases in [triglyceride] and the ratios of [lactate]:[pyruvate] and [3-hydroxybutyrate]:[acetoacetate], were partially reversed by insulin treatment. Insulin deficiency thus impairs regeneration after partial hepatectomy and magnifies the decline in hepatic intracellular energy state and the metabolite changes associated with liver regrowth.

Oxygen-derived free radicals promote hepatic injury in the rat

We have investigated the possible protective effect of superoxide dismutase and allopurinol in a rat model of mild and severe hepatic necrosis produced by Corynebacterium parvum with or without endotoxin. Histology showed a sinusoidal mononuclear cell infiltrate with multiple granulomata but variable degrees of hepatic necrosis. In the severe hepatic injury model there was a reduction in mortality, associated with a decrease in histologic and biochemical evidence of hepatic necrosis, after treatment with superoxide dismutase. This protective effect was not demonstrated with partially heat-inactivated superoxide dismutase. In the mild hepatic injury model similar trends in reduction of serum levels of hepatic enzymes were observed after treatment with both superoxide dismutase and allopurinol. These results indicate that oxygen-derived free radicals may play an important role in the pathogenesis of hepatic injury in the rat.

Different aetiology of chronic active hepatitis in U.K. and Iraq

We have compared the clinical, biochemical and immunological features of patients with biopsy-proven chronic active hepatitis from Iraq and from the United Kingdom. Clear-cut differences emerge, which can mostly be attributed to the HBV status, as 91% of patients from Iraq were HBsAg-positive compared to only 6% from the U.K. Most patients from Iraq presented insidiously with established cirrhosis, while those from the U.K. presented more acutely and systemic symptoms were more common. Autoantibodies and associated autoimmune conditions were common in U.K. patients but extremely rare in Iraqis.

Complications in methotrexate treatment of psoriasis with particular reference to liver fibrosis

All patients taking methotrexate for treatment of psoriasis over the past 5 yr have been reviewed. Thirty-eight patients have had pretreatment liver biopsies and at least 1 repeat liver biopsy. Of the 38, nine (24%) have developed significant liver fibrosis or cirrhosis, and have stopped treatment. The high incidence of fibrosis is attributed to synergism between methotrexate and other hepatotoxic factors, particularly alcohol, the use of a baseline biopsy to identify subsequent changes, and the early detection of fibrosis by sensitive histological techniques.

Chronic active hepatitis: the spectrum of disease

A five-year study of all newly diagnosed cases of chronic active hepatitis (CAH) from a defined population of 404,000, in which the internationally accepted diagnostic criteria were applied, is reported. A putative aetiological agent was identified in all but 14 (23%) of 61 cases. Alcohol (26%) and hepatitis B (20%) were the commonest aetiological factors. The incidence of CAH was 3 per 100,000 per year. Patients were often elderly, mean age 56, with a third aged over 65. A third were symptom-free at diagnosis, and the disease was biochemically or histologically severe in only a few. 9 of 61 (15%) fulfilled the criteria for treatment used in the Mayo Clinic trials. Even after exclusion of those with CAH unresponsive to corticosteroids (i.e., where hepatitis B, drugs, alcohol are involved in the aetiology) and widening of the criteria, only 7 of the remaining 31 (23%) are likely to benefit from corticosteroids. The variety of aetiological agents, spectrum of clinical features, and range of disease severity are very different in an unselected group from those reported from specialised referral centres.

Alpha-1-antitrypsin deficiency presenting as a bleeding diathesis in the newborn

Three cases of alpha-1-antitrypsin deficiency are reported. Each infant presented in the newborn period with a haemorrhagic tendency which responded to vitamin K. Two of them subsequently developed cirrhosis, and Case 2 is one of the few reported cases in infantile cirrhosis associated with the heterozygous protease inhibitor (Pi) SZ phenotype. On the basis of these 3 patients we feel that the exclusion of alpha-1-antitrypsin deficiency by Pi phenotyping should be considered in any baby presenting with a bleeding diathesis, especially in view of the genetic implications of the homozygous Pi ZZ phenotype.

Alpha-1-antitrypsin in human macrophages

Preliminary studies have suggested that alpha-1-antitrypsin (A1AT) is a useful immunohistochemical marker of histiocytes (monocytes/macrophages) and malignant tumours derived from them. To confirm the reliability of this marker a wide variety of benign and malignant lymphoreticular cells and tissues have been stained by the immunoperoxidase technique for A1AT and positive staining was found to be confined to histiocytes. Immunodiffusion, isotope labelling, and isoelectric focusing studies performed on cell lysates confirmed that the positive staining shown by monocytes and malignant histiocytes is due to the presence of A1AT identical with serum A1AT and that this material is synthesised by these cells rather than taken up from their environment. Positive immunoperoxidase staining for A1AT is thus a reliable marker of lymphoreticular neoplasms of true histiocytic origin.

Heterozygous MZ alpha 1-antitrypsin deficiency in adults with chronic active hepatitis and cryptogenic cirrhosis

To determine the prevalence of alpha 1-antitrypsin deficiency in patients with cirrhosis or chronic active hepatitis, we performed a five-year prospective study of liver-biopsy specimens from 1055 adults. Thirty-four patients whose specimens contained hepatocyte inclusions characteristic of the deficiency were phenotyped, and 25 had phenotype MZ (2.4 per cent). The distribution of patients with this phenotype among the 185 patients with cirrhosis diagnosed histologically was three of 84 patients with alcoholic cirrhosis (3.5 per cent), seven of 34 with non-B chronic active hepatitis (20.5 per cent), six of 28 with cryptogenic cirrhosis (21 per cent), and one of 39 with other kinds of cirrhosis (2.6 per cent). The increased prevalence of MZ in patients with cryptogenic cirrhosis and with chronic active hepatitis is highly significant (P < 0.001). Because serum levels of alpha 1-antitrypsin may be unreliable for identification of the subgroup of patients with chronic active hepatitis or cryptogenic cirrhosis, analysis of serum for the MZ phenotype and meticulous examination of biopsy specimens may be necessary.

Acute liver disease associated with sodium valproate

Five patients, four of them children, had acute liver disease after treatment with sodium valproate. Three died. The liver disease began 3-6 months after the start of treatment and was often associated with other side-effects of sodium valproate such as thrombocytopenia and hair loss.

Hepatic necrosis in rats following halothane administration: protective effect of diethyldithiocarbamate

Foci of necrosis have been observed in the liver of 50% of enzyme-induced rats treated with halothane. The frequency of liver necrosis was significantly reduced by treatment with the free radical scavenger diethyldithiocarbamate. The severity of the lesion was not increased by repeated exposures to the anesthetic, and, although the frequency of liver necroses may be greater, the differences were not statistically significant.

Spindle-cell tumours and hypoglycaemia

The light microscopy and clinical features of two patients with extrapancreatic tumours and hypoglycaemic episodes are described-together with the electron microscopy findings in one patient. The primary tumour of one patient arose within the skull and later metastasized to the liver, while the other patient had a locally recurrent intrathoracic tumour. Neither the intracranial origin nor the ultrastructural features support the concept of a mesothelial origin for these tumours, and they should be referred to as spindle-cell tumours associated with hypoglycaemia. There are ultrastructural similarities between these neoplasms and those of the pancreatic beta cells.

Alpha-1-antitrypsin deficiency and liver in adults

Thirteen adult patients (aged 16 to 73 years) form 12 families are described with liver disease and alpha- 1- antitrypsin deficiency. Long-term observation of several of these patients suggests that the liver disease may be only slowly progressive, but review of possible factors aggravating this has failed to reveal any obvious clues. Progression to death from hepatic failure was the commonest outcome, but one patient developed a malignant hepatoma and two others died because of intraperitoneal haemorrhage due to ruptured cirrhotic nodules--a complication not hitherto described in association with this condtion. Diagnosis of alpha-1-antitrypsin deficiency was based on serological, histological, immunopathological and genetic studies. The most useful screening test in liver disease was found to be the demonstration of PAS positive globules in liver biopsy material which is diagn by immunofluoresence or immunoperoxidase, the latter being a superior technique. Serum estimation of alpha-1 -antitrypsin deficiency was performed by immunoelectropharetic and immunodiffusion techniques, the former being preferred because it gave more consistent results. Both methods, however, were of limited value since wide variations in the serum values are commonly found in normal and abnormal states. Genotyping was carried out using starch gel electrophoresis and although of value in family studies, its value as a diagnositc aid is limited because of technical difficulties and also because alpha-1-antitrypsin accumulation in the liver may be found in both homozygous and heterozygous states. It is suggested that adult liver disease associated with abnormalities in alpha-1-antitrypsin may be more common than has hitherto been reported. This condition should be systematically sought in all cases of liver disease of uncertain aetiology.

Desquamative fibrosing alveolitis unresponsive to steroid or cytotoxic therapy

A case of desquamative fibrosing alveolitis beginning in early infancy is described. The disease was characterized by tachypnoea, hypoxia relieved by O2, absence of signs in the chest or clubbing, and radiological and physiological evidence of hyperinflation. The diagnosis was made by needle biopsy of the lung. Treatment with steroids and immunosuppression was without effect and the infant died at 9 months. The disease has a high mortality in infancy, only 2 out of 9 reported cases having survived. The difference from the usual course in adults and older children is noted.

Malignant haemangioendothelioma involving the liver

The features of four cases of malignant haemangioendothelioma involving the liver and other organs are described. Two cases were associated with a microangiopathic haemolytic anaemia. The nature of the tumours and possible pathogenesis for the anaemias are discussed.