Basaloid Carcinoma of the Lung with Bronchiolo-alveolar Cell Differentiation. A Case Report

Aims

We report a case of pulmonary basaloid carcinoma with bronchiolo-alveolar cell differentiation.

Patients and Results

A 75 year-old presented with a tumor measured 2.0 cm and was located in the periphery of the left upper lobe. Histologically, the lesion consisted of nests of basaloid cells, and lumina and clefts lined by tumor cells with features of mucous cells or type II pneumocytes or with mixed features.

Conclusions

Previously reported basaloid carcinomas of the upper aero-digestive tract and lung have been purported to have an aggressive behavior. The tumor in the present study had features of a histopathological low grade tumor including a low mitotic rate, no tumor necrosis and a growth pattern at the periphery similar to that of bronchiolo-alveolar carcinoma.

Cholesterol efflux capacity, carotid atherosclerosis, and cerebrovascular symptomatology

OBJECTIVE

To investigate the association of cholesterol efflux capacity with carotid atherosclerosis and cerebrovascular disease.

APPROACH AND RESULTS

Patients with high-grade carotid stenosis (n=154) were recruited from Vascular Surgery clinics and 9 healthy controls from the McGill University Health Network, Montreal, Canada. Cerebrovascular symptomatology history was obtained. Stenosis was assessed by carotid ultrasound. Fasting blood samples were collected and depleted of apolipoprotein B particles by polyethylene glycol precipitation from serum. Cholesterol efflux was determined by incubating apolipoprotein B-depleted serum in cAMP-stimulated J774 cells for 6 hours. Carotid specimens were classified by 2 vascular pathologists using the American Heart Association atheromatous plaque classification. Differences in efflux were assessed according to (1) stenosis, (2) American Heart Association classification, and (3) cerebrovascular symptomatology. Normalized efflux was significantly lower in patients with carotid atherosclerosis compared with controls (0.97±0.16 versus 1.5±0.46; P<0.0001). Efflux was inversely associated with stenosis; the odds ratio for 80% to 99% versus 50% to 79% stenosis of tertile 1 (lowest) versus tertile 3 (highest) of efflux was 3.78 (95% confidence interval, 1.18-12.06) after adjusting for age, sex, low-density lipoprotein, and high-density lipoprotein. There were significant differences in cholesterol efflux between American Heart Association fibroatheroma (Va, 0.91±0.13), mainly calcific (Vb, 0.97±0.15), and mainly fibrotic (Vc, 1.03±0.21; P=0.05). There were no significant differences in efflux according to symptomatology.

CONCLUSIONS

Cholesterol efflux capacity is inversely associated with increasing carotid stenosis and is associated with more advanced carotid plaque morphology, suggesting that cholesterol efflux capacity may be a biomarker for severity of carotid atherosclerotic burden. Whether therapies targeting high-density lipoprotein quality could be useful for stabilizing carotid atherosclerosis needs to be assessed.

Assessment of cyclosporine pharmacokinetic parameters to facilitate conversion from C0 to C2 monitoring in heart transplant recipients

BACKGROUND

Cyclosporine (CsA) 2-hour postdose (C2) monitoring is recommended to assess CsA exposure and predict clinical outcomes among heart transplant recipients. We correlated pharmacokinetic parameters and clinical outcomes in stable long-term heart transplant recipients monitored with C0 to develop an algorithm to convert patients from C0 to C2 monitoring.

METHODS

Paired CsA C0-C2 measurements and serum creatinine levels were obtained from 35 heart transplant recipients more than 2 years posttransplantation (mean 8.8+/-4.7 years).

RESULTS

The mean CsA dose and C0, C2, and C0/C2 ratio were 85+/-23 mg/12 hours, 123+/-41 ng/mL, 572+/-274 ng/mL and 4.8+/-2.1, respectively. C0 correlated weakly with C2 (r=.42, P=.011). The CsA dose correlated better with C2 (r=.58; P<.001) than with C0 (r=.37; P=.026). A good correlation was noted between C2 and the C2/C0 ratio (r=.73; P<.001), but none between C0 and the C2/C0 ratio. A borderline significant inverse correlation was noted between C0 and the worst endomyocardial biopsy score (r=-.34; P=.045), whereas none was noted with C2. Serum creatinine level did not correlate with either C2 or C0. Among patients with C0 within our target of 100 to 150 ug/L, six had C2 above 300 to 600 ug/L as suggested by the literature.

CONCLUSIONS

In long-term heart transplant recipients, we could not identify a single pharmacokinetic parameter that could be used to develop an algorithm to convert from C0 to C2 monitoring; however, C2 may be better than C0 for identifying patients at risk of overexposure to CsA.

In vivo and in vitro examination of the functional significances of novel lamin gene mutations in heart failure patients

CONTEXT

Lamin A/C (LMNA) gene variations have been reported in more than one third of genotyped families with dilated cardiomyopathy (DCM). However, the relationship between LMNA mutation and the development of DCM is poorly understood.

METHODS AND RESULTS

We found that end stage DCM patients carrying LMNA mutations displayed either dramatic ultrastructural changes of the cardiomyocyte nucleus (D192G) or nonspecific changes (R541S). Overexpression of the D192G lamin C dramatically increased the size of intranuclear speckles and reduced their number. This phenotype was only partially reversed by coexpression of the D192G and wild type lamin C. Moreover, the D192G mutation precludes insertion of lamin C into the nuclear envelope when co-transfected with the D192G lamin A. By contrast, the R541S phenotype was entirely reversed by coexpression of the R541S and wild type lamin C. As lamin speckle size is known to be correlated with regulation of transcription, we assessed the SUMO1 distribution pattern in the presence of mutated lamin C and showed that D192G lamin C expression totally disrupts the SUMO1 pattern.

CONCLUSION

Our in vivo and in vitro results question the relationship of causality between LMNA mutations and the development of heart failure in some DCM patients and therefore, the reliability of genetic counselling. However, LMNA mutations producing speckles result not only in nuclear envelope structural damage, but may also lead to the dysregulation of cellular functions controlled by sumoylation, such as transcription, chromosome organisation, and nuclear trafficking.

An approach to endomyocardial biopsy interpretation

The endomyocardial biopsy (EMB) remains the gold standard mode of investigation for diagnosing many primary and secondary cardiac conditions. Through a percutaneous and transvenous route, tissue fragments are generally procured from the right ventricular septum, with very few complications. Widespread use of EMB followed the development of heart transplantation as a means to follow allograft rejection. It has since been useful in helping to diagnose conditions affecting the heart, including cardiomyopathies, myocarditis, infiltrative lesions, arrhythmias, and drug toxicities. The procedure has also been used as a research tool to investigate the natural history of disease and the cardiotoxicity of new medications. This review presents an approach to the evaluation of the EMB, which is particularly directed towards those who may be asked to interpret such biopsies, but are not dedicated cardiovascular pathologists. Through a systematic evaluation of the endocardium, myocardium, interstitium, and intramural vessels, in the context of a complete clinical history, enough information can be deduced to diagnose or exclude specific conditions of clinical value.

Endometrioid adenocarcinoma of the uterus with a minimal deviation invasive pattern

AIMS

Minimal deviation adenocarcinoma of endometrioid type is a rare pathological entity. We describe a variant of typical endometrioid adenocarcinoma associated with minimal deviation adenocarcinoma of endometrioid type.

METHODS AND RESULTS

One 'pilot' case of minimal deviation adenocarcinoma of endometrioid type associated with typical endometrioid adenocarcinoma was encountered at our institution in 2001. A second case of same type was received in consultation. We reviewed 168 consecutive hysterectomy specimens diagnosed with 'endometrioid adenocarcinoma' specifically to identify areas of minimal deviation adenocarcinoma of endometrioid type. Immunohistochemistry was done with the following antibodies: MIB1, p53, oestrogen receptor (ER), progesterone receptor (PR), cytokeratin 7 (CK7), cytokeratin 20 (CK20), carcinoembryonic antigen (CEA), and vimentin (VIM). Four additional cases of minimal deviation adenocarcinoma of endometrioid type were identified. All six cases of minimal deviation adenocarcinoma of endometrioid type were associated with superficial endometrioid adenocarcinoma. In two cases with a large amount of minimal deviation adenocarcinoma of endometrioid type, the cervix was involved. The immunoprofile of two representative cases was ER+, PR+, CK7+, CK20-, CEA-, VIM+. MIB1 immunostaining of four cases revealed little proliferative activity of the minimal deviation adenocarcinoma of endometrioid type glandular cells (0-1%) compared with the associated 'typical' endometrioid adenocarcinoma (20-30%). The same four cases showed no p53 immunostaining in minimal deviation adenocarcinoma of endometrioid type compared with a range of positive staining in the associated endometrioid adenocarcinoma.

CONCLUSIONS

Minimal deviation adenocarcinoma of endometrioid type more often develops as a result of differentiation from typical endometrioid adenocarcinoma than de novo. Due to its deceptively benign microscopic appearance, minimal deviation adenocarcinoma of endometrioid type may be overlooked and may lead to incorrect assessment of tumour depth and pathological stage. There was a tendency for tumour with a large amount of minimal deviation adenocarcinoma of endometrioid type to invade the cervix.

Residual sinus venosus atrial septal defect after surgical closure of atrial septal defect

We describe residual atrial septal defects in 3 patients who had previous surgical repair. The residual defects were the sinus venosus type near the orifice of the inferior vena cava. Preoperative and intraoperative transesophageal echocardiography may aid in the detection and facilitate the successful repair of these defects.

Abundance of plaque microvessels is associated with constrictive remodeling in angioplastied human coronary arteries

This study investigated if specific histological features correlate with remodeling in human coronary arteries treated by balloon angioplasty (PTCA). Segments of perfusion-fixed coronary arteries that had undergone antemortem PTCA were obtained from 15 patients and primary atherosclerotic (CAD) lesions obtained from these hearts were used as control lesions. Arterial segments were serially divided to yield 108 sub-segments for PTCA lesions and 38 sub-segments for CAD lesions. A linear regression analysis was used to determine the relationship between 14 histological parameters and an arbitrary index of compensatory arterial enlargement, the external elastic lamina (EEL) index (EELI), defined as the ratio of the area encompassed by the EEL to the sum of the intimal area (IA) + medial area (MA). In PTCA arteries the abundance of plaque microvessels negatively correlated with the EELI (p=0.04), but in CAD arteries there was no relationship between histology and the EELI. The abundance of plaque microvessels correlates with the magnitude of constriction in coronary artery lesions subjected to PTCA. This study provides descriptive insights into the biology of remodeling in human coronary arteries after angioplasty, and suggests that the endothelium may play an important role.

Percutaneous removal of pulmonary artery emboli with Hydrolyser catheter in pigs

OBJECTIVE

To evaluate the efficacy and safety of the Hydrolyser catheter for percutaneous treatment of massive pulmonary embolism in pigs.

MATERIALS AND METHODS

Twelve pigs, each weighing between 55 kg and 89 kg, were used. Radioopaque 9 cm x 0.8 cm and 4.5 cm x 0.8 cm clots, produced by mixing pig blood with iodinated contrast agent in vacutainers, were injected via the jugular vein until central pulmonary embolism (main and proximal lobar arteries) was obtained with significant systemic and pulmonary hemodynamic modifications. From a femoral approach, the 7-French Hydrolyser thrombectomy catheter was run over a 0.025-inch (0.64-mm) guide wire to remove the pulmonary emboli. Hemodynamic, gasometric and angiographic monitoring was performed before and after treatment. The procedure's safety and completeness of emboli removal was assessed by cardiopulmonary autopsy.

RESULTS

Three of the 12 pigs died during embolization. Thrombectomy was therefore performed in 9, and central emboli could be obtained in 7 of the 9. The Hydrolyser could be manipulated only in central pulmonary arteries and could aspirate only central emboli in 5 of the 7 pigs that had them. Despite minimal angiographic improvement seen in these 5, there was no significant hemodynamic and gasometric improvement after treatment. The procedure induced an increase in free hemoglobin blood levels. Autopsies revealed an average of 2 endothelial injuries per pig (mainly adherent endocardial thrombi) in both nontreated (n = 3) and Hydrolyser-treated (n = 9) groups.

CONCLUSION

The Hydrolyser thrombectomy catheter can be promptly positioned and easily steered in central pulmonary arteries. It can be used to partially remove central emboli, but not peripheral pulmonary emboli. Most of the injuries observed may not have been strictly related to Hydrolyser use. The pig might not be a suitable animal model for treatment of massive pulmonary embolism.

Prosthetic valve fungal endocarditis due to histoplasmosis

Fungal endocarditis is associated with severe patient morbidity and mortality. Unfortunately, fungal endocarditis is difficult to diagnose because fungal pathogens are uncommonly isolated from routine blood cultures. Histopathological examination of surgically excised cardiac valves, peripheral emboli and systemic ulcers may be useful in identifying pathogens as etiological agents of culture-negative endocarditis. The authors describe a 63-year-old man who had culture-negative endocarditis. Multiple echocardiograms showed progression of the vegetations with valve stenosis despite treatment with multiple antimicrobials. He had multiple peripheral emboli before surgery. Disseminated histoplasmosis was diagnosed by bone marrow culture. Yeast organisms consistent with histoplasma were shown in the vegetations of his excised mitral valve prosthesis. The patient was treated with amphotericin and has been doing well in the two years since his surgery. The diagnosis and management of fungal endocarditis are emphasized.

The histologic estimation of coronary artery stenoses: accuracy and the effect of lumen shape

The authors have recently investigated the histologic estimation of coronary artery stenoses (CAS) to determine its reproducibility and the effect of training on reproducibility. The present study extends this work, examining the accuracy, the sensitivity, and the specificity of the estimation of CAS. Further, the effect of one histologic variable (i.e., arterial lumen shape) on the evaluation of CAS is examined. As described previously, 20 randomly selected Movat-stained coronary artery cross-sections were reviewed three times, at 3-month intervals, by six clinical pathologists (CPs), six pathology residents (Res), seven anatomic pathologists (APs), and two cardiovascular pathologists (CVPs). Before the third iteration, training in CAS assessment was provided. In the present study, for comparison with observer estimates, image analysis was used to establish the actual percent CAS and determine observer accuracy. The results of this study showed, paradoxically, that greater experience did not correlate with greater accuracy: The CPs consistently had the highest accuracy scores and the CVPs consistently had the lowest. Training, however, improved the accuracy scores of all groups. Stenotic arterial cross-sections with residual lumens showing concentric or eccentric polymorphous shapes were consistently underestimated compared to image analysis, while lumens with a eccentric slitlike shape were consistently overestimated.

Post-traumatic left ventricular false aneurysm

Most false aneurysms of the heart represent contained ventricular free wall ruptures after myocardial infarction. Post-traumatic aneurysms also may follow penetrating or non-penetrating trauma to the chest. Regardless of the origin of the false aneurysm there is a propensity for aneurysm rupture. We report a patient who developed a false aneurysm of her left ventricle that developed post-motor vehicle accident. Her orthopedic problems were the clinical problems identified and after a hospital admission of 10 days she was discharged home. Four weeks later she died suddenly from anterior left ventricle false aneurysm rupture and tamponaide. Patients with significant chest wall trauma should be assessed for cardiac pathology prior to discharge. Presentation may be delayed and be overshadowed by more evident pathology. Trauma-related aneurysms may cause sudden death, and this may occur some later time after the trauma. Attributing the cause of death to the trauma, which may be remote, is important for the forensic investigator to remember.

Focal and patchy cardiac valve lesions: a clinicopathological review

Pathologists and surgeons often encounter cardiac valves with focal or patchy abnormalities either at postmortem examination or during the assessment of a valve removed at surgery. Many health professionals including nurses, cardiologists, echocardiographers, sonographers and radiologists may be called upon to assess these lesions. With the development of increasingly more sophisticated and sensitive imaging techniques, including transesophageal echocardiography and magnetic resonance imaging, more valve lesions are being discovered. Many patients with metabolic abnormalities, systemic diseases or storage disease have valvular findings. Some are characteristic and distinctive for the specific disease, while others are seen in numerous diseases. Most patients develop age-related valvular changes, and these are more frequently encountered with the aging population. A practical approach the health professional should take to assess these valve lesions is given. The major categories of disease that produce focal lesions of the cardiac valves are presented.

Metastatic calcification of the cardiac conduction system with heart block: an under-reported entity in chronic renal failure patients

Systemic metastatic calcification is a common complication of chronic renal failure. Cardiac involvement is particularly ominous, especially when the cardiac conduction system is affected. Conduction defects, arrhythmias, and sudden death have all been reported with conduction system calcification; however, these are relatively under-reported or unrecognized causes of cardiac morbidity and mortality. We describe a 40-year-old man with Von Hippel-Lindau disease who had been maintained on hemodialysis for two years following bilateral nephrectomies for renal cell carcinoma. The patient presented with symptomatic complete heart block that had progressed from Mobitz type I atrioventricular block. Two months later, while being internally paced, the patient died unexpectedly after a complicated hospital admission. Postmortem revealed extensive vascular, myocardial, and conduction system calcification. Conduction system calcification may cause sudden death in chronic renal failure patients during hospital admission, or unexpectedly while the patient is in the community. Knowledge of this condition is necessary to detect it, as the conduction system is not routinely examined. A routine abbreviated conduction system examination is warranted for patients with systemic metastatic calcification, especially if they have sudden death or a known history of heart block.

Interatrial conduction of atrial tachycardia in heart transplant recipients: potential pathophysiology

Surgical suture lines formed at the site of anastamosis have been considered to be electrically inert and thus present a line of block to conduction. However, a number of reports have suggested that conduction is occasionally possible across suture lines. Most of these cases have reported conduction between donor and recipient atria following cardiac transplantation. We report an illustrative case successfully treated with radiofrequency ablation, and present pathology findings that may give insight into the pathophysiology.

Histologic estimation of coronary artery stenoses: reproducibility and the effect of training

Histologic estimation of coronary artery stenoses (CAS) provides the 'gold-standard' for clinicopathologic correlations and medicolegal investigations, yet little evidence supports histology as a reproducible diagnostic measure, and none addresses the effect of training on its use. To study these questions, 20 randomly selected Movat-stained coronary artery cross-sections were reviewed 3 times, at 3-month intervals, by six clinical pathologists (CPs), six pathology residents (Res), seven anatomic pathologists (APs), and two cardiovascular pathologists (CVPs). Before the third iteration, a guide to CAS assessment with illustrations was provided. Inter- and intraobserver reproducibility were determined using interclass correlation coefficients (ICC) (0.40-0.75 = fair-good; > or = 0.76 = excellent agreement beyond chance). Surprisingly, all study groups had excellent interobserver reproducibility. Before training, at Time 1, the scores were CPs, 0.77; Res, 0.89; APs, 0.93; and CVPs, 0.93. After training, at Time 3, the results were CPs, 0.81; Res, 0.91; APs, 0.86; and CVPs, 0.88. Intraobserver reproducibility for CPs overall was good (ICC, 0.74), and excellent for Res, APs, and CVPs (0.89, 0.94, and 0.97, respectively). In conclusion, statistical analysis failed to demonstrate any significant effect of training or experience on observer reproducibility.

Hyperplastic mesothelial cells in mediastinal lymph node sinuses with extranodal lymphatic involvement

We describe a patient with hyperplastic mesothelial cells localized to mediastinal lymph node sinuses. These mesothelial cells were originally misdiagnosed as metastatic carcinoma, and the patient received radiotherapy. Histologic review, immunohistochemistry, and ultrastructural studies confirmed mesothelial cell origin. These nodal mesothelial cells were associated with pericardial and pleural effusions. Extranodal lymphatics also contained hyperplastic mesothelial cells, confirming their mode of lymphatic transport to node sinuses. This finding supports the theory that hyperplastic mesothelial cells derive from reactive serosal mesothelium and are dislodged into draining lymphatics. This is the first report, to our knowledge, that demonstrates the pathogenetic significance of this lymphatic transport mechanism. Awareness of intralymphatic and nodal benign hyperplastic mesothelial cells and their mimicry of invasive malignant neoplasms is important for accurate diagnoses and appropriate therapy.

Correlation of antemortem serum creatine kinase, creatine kinase-MB, troponin I, and troponin T with cardiac pathology

BACKGROUND

Spurious increases in serum troponins, especially troponin T, have been reported in patients with and without acute myocardial syndromes.

METHODS

We studied 78 autopsied patients without clinical myocardial infarction (MI) and correlated histologic cardiac findings with antemortem serum creatine kinase (CK), its MB isoenzyme (CK-MB), cardiac troponin I (cTnI), and cardiac troponin T (cTnT).

RESULTS

There was no significant myocardial pathology in 15 patients. Cardiac pathologies were in five groups: scarring from previous MI or patchy ventricular fibrosis (n = 9), recent MI (n = 27), healing MI (n = 7), degenerative myocyte changes consistent with congestive heart failure (CHF; n = 12), and other cardiac pathologies (n = 8). The median concentrations in the five groups were not significantly different for either CK or CK-MB. Compared with the no-pathology group, only the MI group was significantly different for cTnI, and the MI and other pathology groups were significantly different for cTnT. For patients with MI, 22%, 19%, 48%, and 65% had increased CK, CK-MB, cTnI, and cTnT, respectively; for CHF and other cardiac pathologies combined, the percentages were 28%, 17%, 22%, and 50%. For patients with increased cTnI, 72% and 28% had MI and other myocardial pathologies, respectively; patients with increased cTnT had 64% and 36%, respectively. Patients without myocardial pathology had no increases in CK-MB, cTnI, or cTnT.

CONCLUSIONS

All patients with increased serum CK-MB, cTnI, and cTnT had significant cardiac histologic changes. The second-generation cTnT assay appears to be a more sensitive indicator of MI and other myocardial pathologies than the cTnI assay used in this study.

Günther Tulip filter: preliminary clinical experience with retrieval

PURPOSE

The Günther Tulip filter is a permanent filter that has a hook to permit retrieval. The authors report their preliminary clinical evaluation of the filter with regard to feasibility and safety of retrieval.

MATERIALS AND METHODS

Nine men and six women who ranged in age from 17 to 79 years (mean, 51 years) underwent treatment with use of the Günther Tulip filter. Patients judged to require caval interruption for < 14 days were selected to receive the filter and retrieval was planned for all patients. Indications for filter placement were: recent pulmonary embolism (PE) or proximal deep vein thrombosis (DVT) with a contraindication to anticoagulation (11 patients), massive PE treated with thrombolytic therapy (one patient), PE with heparin-induced thrombocytopenia (one patient), and prophylaxis after major trauma (two patients). Patients were followed for inferior vena cava (IVC) thrombosis, bleeding, and recurrent DVT or PE.

RESULTS

In all nine patients in whom it was attempted, the filter was successfully snared and retrieved via a jugular approach. The mean implantation period was 8.6 days (range, 5-13 days). Retrieval required 2.2-13 minutes (mean 5.3 minutes) of fluoroscopy. No caval injuries occurred as a result of retrieval. All retrieved filters had strands of organized thrombus on the filter struts. The patients were followed for 52-285 days (mean, 115 days) after retrieval. One patient developed a recurrent DVT 230 days after retrieval. No other patients developed a recurrent DVT and no patients developed IVC thrombosis, bleeding, or PE. Six filters were not retrieved: five because of an ongoing contraindication to anticoagulation and one because the patient died of causes unrelated to the filter.

CONCLUSION

This preliminary study confirms the feasibility and safety of retrieval of the Günther Tulip filter up to 13 days after implantation.

Aortic medial changes associated with bicuspid aortic valve: myth or reality?

OBJECTIVE

To determine whether aortic medial changes are more severe in patients who require aortic valve replacement of congenitally bicuspid aortic valves (BAV) than in patients who require replacement of tricuspid aortic valves and acquired valvular disease (AVD).

DESIGN

Aortas from autopsies of 14 patients with BAV and 25 with AVD were histologically assessed by two 'blinded' cardiovascular pathologists and analyzed independently with computer-aided morphometry. The aortic valves were examined for valvular fibrosis and calcification.

SETTING

The patient population was from a tertiary-care facility.

PATIENTS

Patients were selected by retrospective review of autopsy records for patient deaths after aortic valve replacement, over the period 1984 to 1995.

RESULTS

There were no significant differences in age (P=0.89), sex (P=0.94), prevalence of systemic arterial hypertension (P=0.37), valvular degenerative changes (P=0.10 and P=1.0) or heart weights (P=0.60) between the two groups. Histological scores for aortic medial degenerative changes including elastic fragmentation, fibrosis and medionecrosis were not statistically different between the groups. However, morphometry demonstrated less elastic tissue in patients with BAV (P=0.003).

CONCLUSION

Routine microscopy shows no significant difference in the degree of aortic medial degenerative changes between patients with BAV and AVD. However, morphometry shows less elastic tissue in the aortas of BAV patients. This may explain the anecdotal increase in aortic fragility and propensity for aortic dissection in these patients.

Increased mortality in hemodialyzed patients with elevated serum troponin T: a one-year outcome study

OBJECTIVES

To determine the significance of elevated serum troponin T (cTnT) occurring in hemodialysis patients in the absence of clinical evidence of acute coronary ischemia.

DESIGN AND METHODS

Twelve-month follow-up of cohort of 172 hemodialyzed patients with known serum cTnT concentration. The cohort consisted of patients undergoing hemodialysis in a hospital unit over a 5-month period, with one to four measurements of cTnT. The main outcome measure was death. Cause of death was determined by autopsy in six patients.

RESULTS

Of the 31 deaths, 12 were due to acute coronary disease, 14 were noncoronary, and 5 were undefined. Death rates of patients with cTnT <0.1, 0.1-0.2, and >0.2 microg/L were 9.9% (11/111), 32.4% (12/37), and 33.3% (8/24), respectively. The increase in death rate with cTnT > or =0.1 microg/L was significant (p<0.001) for noncoronary deaths, but not for acute coronary deaths. The risk ratios for noncoronary deaths in the subgroups were: nondiabetics 6.6 (95% CI 1.9-23.6), patients with no coronary artery disease 7.3 (1.6-32.4), patients with no peripheral vascular disease 8.9 (2.0-39.7), and hypertensives 9.0 (1.1-76.5). Significant increase in coronary deaths was seen only in patients without hypertension and those aged > or =50 years. The risk ratios for these groups were 9.3 (1.2-74.3) and 3.3 (1.0-10.6), respectively.

CONCLUSIONS

Serum cTnT is a potential prognostic marker of mortality in hemodialyzed patient, with increase in death from coronary and noncoronary causes.

Aortic dissection: a rare complication of osteogenesis imperfecta

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder, a group that includes Ehlers-Danlos syndrome, Marfan's syndrome and pseudoxanthoma elasticum. OI is a heterogeneous disease of collagen I biosynthesis characterized by variable clinical phenotypes, including skeletal and cardiovascular manifestations. A 65-year-old man with OI who had extensive prior successful cardiac valve surgeries is described. He survived for 18 years after his initial valve surgery, but died of multiorgan failure and sepsis after repair of a spontaneous type A aortic dissection. This is the fourth reported case of aortic dissection secondary to OI and illustrates the extensive cardiovascular pathology associated with OI. Aggressive management of arterial dissection risk factors, such as systemic arterial hypertension, is advocated for patients with OI.

Inhaled nitric oxide protects against hyperoxia-induced apoptosis in rat lungs

Inhaled nitric oxide (NO), frequently administered in combination with hyperoxic gas mixtures, was recently shown to protect against the injurious consequences of prolonged hyperoxia. We investigated the possibility that this protective effect is attributable to the ability of NO to block pulmonary apoptosis. We show that rats exposed to 100% O2 for 60 h develop severe lung injury consisting of pronounced vascular leak and alveolar apoptosis as inferred from the presence of positive terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling and DNA ladders in agarose gels and a decrease in constitutive procaspase-3 levels. However, the inclusion of NO (20 parts/million) in the hyperoxic gas mixture significantly attenuated both the vascular leak and apoptosis. NO reversed the hyperoxia-associated changes in the activity of the redox-sensitive transcription factors nuclear factor-kappaB, activator protein-1, and Sp1 after 24 h, lowered intercellular adhesion molecule-1 levels, and increased glutathione content. We therefore show, for the first time, that NO can protect against both hyperoxia-induced apoptosis and inflammation. The data suggest that this protection may occur at the transcriptional and caspase-activation levels.

Ochronosis: an unusual finding at aortic valve replacement

The condition known as ochronosis refers to the accumulation of oxidized homogentisic acid in the connective tissues of alkaptonuric patients. The diagnosis is usually made from the triad of degenerative arthritis, ochronotic connective tissue pigmentation and urine that turns dark brown or black on alkalinization. Cardiovascular disease is a less well appreciated aspect of this disorder. A patient with ochronosis of his stenotic aortic valve is reported. The role of the pigment in the genesis of the valve degeneration is discussed.

Discoordinate modulation of natriuretic peptides during acute cardiac allograft rejection in humans

BACKGROUND

Increased circulating levels of the cardiac polypeptide hormones atrial natriuretic factor (ANF) and brain natriuretic peptide (BNP) may be observed after orthotopic cardiac transplantation. Both the hypertrophic and inflammatory processes in the allograft may contribute to this increase, but no mechanistic explanation has been suggested for this observation.

METHODS AND RESULTS

Plasma immunoreactive ANF and BNP determinations were performed in 10 consecutive transplant patients. These were correlated with degree of rejection as reflected by histopathological findings at serial endomyocardial biopsies. Three patients had associated hemodynamic measurements and blood samples 24 hours before and after transplantation. All rejection episodes that received treatment were accompanied by a marked increase in BNP plasma levels to > approximately 400 pg/mL. Steadily increasing BNP levels preceded overt rejection as assessed by histopathological criteria. The increase in plasma BNP was not always accompanied by an increase in ANF, which suggests the specific upregulation of BNP gene expression during acute rejection episodes. Treatment of the acute rejection episodes led to a substantial decrease of BNP plasma levels.

CONCLUSIONS

The significant selective increase in plasma BNP levels found in the present study has not been previously described. This finding provides a new insight into the mechanism of allograft rejection and the modulation of natriuretic peptide synthesis and release. Furthermore, although preliminary, the data suggest that BNP plasma levels could form the basis for a new, noninvasive screening test to predict acute cardiac allograft rejection. Because treatment with the antilymphocyte monoclonal antibody OKT3 (murine monoclonal antibody to the CD3 antigen of the human T-cell) decreased BNP plasma levels, cytokine production by T-cells may mediate the selective increase in circulating BNP.

Beta3 integrin--a promiscuous integrin involved in vascular pathology

OBJECTIVE

To determine whether beta3 integrin is present in blood vessels involved by atherosclerosis, Mönckeberg's medial calcinosis, vein graft atherosclerosis, transplant graft vascular disease and arterial restenosis.

DESIGN

Retrospective histological and immunohistochemistry examination of tissues obtained from autopsy and surgery.

SETTING

Tertiary care hospital.

PATIENTS

The patients had surgical excisions of limbs, grafts, veins and arteries for the treatment of ischemic heart disease and peripheral vascular disease. Other tissues were derived from autopsies of the same patient populations.

MAIN RESULTS

Beta3 integrin was found in the blood vessels involved in all of the vascular diseases examined. The location of the integrin varied among the diseases. Osteopontin, a bone sialoprotein involved in atherosclerosis and vascular repair, was also commonly detected.

CONCLUSIONS

Beta3 integrin expression noted in the present study confirms the presence of this integrin in arteries with restenosis and atherosclerosis, which expands its involvement to the processes of transplant graft vascular disease, peripheral vascular disease and vein graft disease. The integrin may influence cell migration and adhesion by its interaction with noncollagenous matrix proteins, including osteopontin.

Cardiac neoplasms at the Canadian Reference Centre for Cancer Pathology

OBJECTIVE

To review the Canadian Reference Centre for Cancer Pathology's experience with cardiac neoplasms by reviewing all cases with tumours involving the heart referred to the Centre from 1949 to 1995. Referred patient records, panel and consensus statement submissions and glass slides were reviewed in all cases. In selected cases additional immunohistochemical stains were obtained from paraffin block tissues.

SETTING

National referral centre for difficult or interesting cancer pathology-related cases.

PATIENTS

All cases were derived from referral of autopsy material and/or surgically resected neoplasms. Material was referred from 35 patients during 1949 to 1995. The group consisted of 17 males, 17 females and one infant patient in whom the sex was not specified. The patient age ranged from infancy to 85 years.

RESULTS

The neoplasms referred consisted of 12 myxomas, 10 sarcomas, five lymphomas, two carcinomas, two papillary fibroelastomas and one each of rhabdomyoma, mesothelioma of the atrioventricular node, lipomatous hypertrophy of the intra-atrial septum and fibroma. The sarcomas were difficult to classify even with the use of additional immunohistochemical stains. All the lymphomas were of non-Hodgkin's type and were not of primary cardiac origin.

CONCLUSIONS

The series of neoplasms referred to the Canadian Reference Centre for Cancer Pathology reflects changes in cardiac surgery, cardiac imaging and cardiac pathology as disciplines. Even with modern pathological techniques some cases, especially sarcomas, are still difficult to diagnose. The clinical presentation often reflects the chamber of origin of the neoplasm rather than being indicative of a specific tumour type.

Gaucher's disease with valve calcification: possible role of Gaucher cells, bone matrix proteins and integrins

Gaucher's disease, an autosomal recessive storage disease, leads to deposition of glucocerebrosides in various organs, especially those of the reticuloendothelial system. The heart is not thought to be frequently involved and studies of patients with cardiac involvement have concentrated on myocardial involvement. Despite careful prior investigation Gaucher cells have never been detected in the valves of these patients. Pathological findings of a patient with Gaucher's disease, type IIIc, with prominent cardiac valvular involvement are reported and, for the first time, the presence of Gaucher cells in the valve tissue is documented. There is evidence that the pathogenesis of the valvular injury may be by way of a cell-mediated mechanism involving bone matrix proteins and integrins.

Aortitis with multiple aneurysms mimicking infective endocarditis

Aortitis usually produces aortic insufficiency by aortic root dilation. In rare cases the inflammation may involve the aortic valve cusps, causing valvular insufficiency. A patient in whom aortitis produced valvular masses, with aortic and peripheral arterial aneurysms, embolic episodes and aortic insufficiency is described. Valve replacement for suspected infective endocarditis was complicated by homograft dehiscence and multiple false aneurysms. Although immunosuppression was successful in decreasing the patient's vasculitis, he became infected and died of complications of aspergillus infection.

Reliability of transthoracic echocardiography in the assessment of aortic valve morphology: pathological correlation in 178 patients

OBJECTIVE

To examine patient characteristics affecting the utility of transthoracic echocardiography in determining aortic valve morphology, particularly for the diagnosis of congenital bicuspid aortic valve (BAV).

DESIGN

A retrospective comparison of preoperative echocardiographic determination of aortic valve morphology with pathological findings of the explanted valves.

SETTING

A tertiary referral centre.

PATIENTS

Consecutive patients who had aortic valve replacement between July 1994 and April 1996, and had preoperative echocardiograms.

RESULTS

Of 313 patients, 181 (58%) had preoperative echocardiography. Three of the valves were excluded because they were too fragmented for pathological determination of valvular morphology. In the remaining 178 patients, aortic valvular morphology was determined by echocardiography in 104 (58%). Multivariate analysis showed that echocardiography was successful less often in women (odds ratio 0.44, P = 0.03) and in patients with densely calcified valves (odds ratio 0.69, P = 0.02), whereas age had no effect (odd ratio 0.99, P = 0.42). In those with adequate echocardiographic images, echocardiography had both a high sensitivity (0.92) and a high specificity (0.96) for the diagnosis of BAV.

CONCLUSIONS

Echocardiography is a useful tool for the diagnosis of BAV, although suboptimal images may pose a problem in many patients, particularly women and patients with heavily calcified valves. When adequate images are obtained, transthoracic echocardiography can reliably identify aortic valvular morphology in most patients.

Compression of anomalous circumflex coronary artery by a prosthetic valve ring

Anomalous origin of the circumflex coronary artery from the right aortic sinus, with a retroaortic course, is usually without consequence. We report a patient who underwent aortic valve replacement for bicuspid aortic valve. The prosthesis sewing ring distorted the circumflex, producing myocardial infarcts and sudden death during exercise.

Preliminary clinical experience with the pullback atherectomy catheter and the study of proliferation in coronary plaques

BACKGROUND

Clues to the biology of coronary artery disease can be obtained through the study of proliferation in human coronary artery plaques. Previously, immunocytochemistry has been used to detect the proliferating cell nuclear antigen to demonstrate low levels of proliferation in directional coronary atherectomy tissue fragments resected from human coronary arteries.

OBJECTIVES

To describe the proliferative profile of coronary artery tissue by using a more sensitive marker for cell replication.

PATIENTS AND METHODS

Ten patients with unstable or stable angina pectoris underwent coronary atherectomy with a newer coronary atherectomy device, the Arrow-Fischell pullback atherectomy catheter. The histological features of the specimens were studied by using light microscopy, and cell proliferation was assessed with the use of in situ hybridization for the S phase-specific mRNA species, histone H3.

RESULTS

Pullback coronary atherectomy immediately followed by percutaneous transluminal coronary angioplasty resulted in angiographic improvement in the lumen diameter in all but one patient, who required insertion of a stent. The atherectomy specimens consisted of a combination of atheromatous plaque and media. Four specimens had a small amount of adventitia. Five of the 10 specimens had no proliferating cells. Three specimens had between one and five proliferating cells per slide, while two specimens had relatively high proliferation indexes (2.5% and 4.2% of all cells per atherectomy cross-section). Both smooth muscle cells and macrophages were identified in areas with proliferating cells. The histology and proliferation profiles of the tissue resected from patients with stable and unstable angina were similar.

CONCLUSIONS

Pullback atherectomy can be used effectively to debulk coronary artery lesions. By using a sensitive marker for cell replication, it was determined that the majority of the tissue specimens have low proliferation indexes.

Melanosis thyroidi

Despite many studies on melanosis thyroidi, there is no consensus concerning the nature of the pigment or its pathogenesis. Here the past literature on this subject is reviewed and results are reported on a case of melanosis thyroidi that provides fresh insight into the nature of the pigment and its genesis. Briefly, the conclusion is that while a few of the pigment granules are classic lipofuscin granules (i.e., single-membrane-bound structures containing electron-dense material in the form of particles, granules and masses, and electron-lucent lipid droplets), a majority of the pigment granules also contain colloid, which is easily identified by its particulate substructure similar to the colloid in the lumen of follicles. Thus, these pigment granules are, in fact, ambilysosomes, where degradation of both endogenous (organelles) and exogenous (colloid) material occurs. Several phagosomes containing colloid were also seen in the thyroid epithelial cells.

Implantable cardioverter-defibrillators and the pathologist: comment and cautionary notes

This paper briefly reviews the components of, the clinical uses of, the techniques to place, and the complications related to implantable cardioverter-defibrillators (ICDs). Information useful in the specific identification of ICDs is presented. A series of recommendations for the autopsy examination or postmortem explantation of ICDs by the pathologist is given. Because of the serious risk of injury to the pathologist possible with postmortem discharges of ICDs which have not been deactivated, and because of the risk of device explosion if the ICD is incinerated, a number of cautionary notes are provided. A brief case with occurrence of accidental postmortem discharge of an active ICD is also presented.

Chloroquine related cardiac toxicity

Chloroquine, an agent used in treatment and prophylaxis of malaria, and also known for its antiinflammatory effects in dermatological, rheumatological, and connective tissue disorders, has been reported to cause toxicity, most commonly in the retina and the cardiovascular system. We describe a 60-year-old woman with longstanding rheumatoid arthritis receiving multidrug treatment, including prolonged administration of chloroquine. She developed complete heart block requiring a permanent pacemaker, congestive heart failure, and progressive myopathy. During hospital investigations for her myopathy, she died of acute pulmonary thromboembolism. Although hypertension and possibly amyloidosis were thought to be the cause of her cardiac disease, cardiac and skeletal muscle changes characteristic of chloroquine toxicity were observed. Chloroquine may be an important unsuspected contributing cause of cardiac dysfunction in patients with rheumatological disease. Endomyocardial biopsy should be considered early in the course of diagnosis and management.

Cardiac sarcoidosis--an occult cause of sudden death: a case report and literature review

Sarcoidosis is a multi-systemic granulomatous disease of unknown cause. It commonly involves lymph nodes, lungs, eyes, and skin. Cardiac sarcoid may be isolated, or associated with systemic involvement. Cardiac involvement is found in 20-50% of autopsied patients with sarcoidosis. However, it only gives rise to clinical manifestations in about 5% of patients. Cardiac involvement by sarcoid has been reported to manifest as complete heart block, papillary muscle dysfunction, congestive heart failure, pericarditis and/or effusion, conduction abnormality or arrhythmia, chest pain, and sudden death. The most common site of involvement is the interventricular septum base, which when involved may lead to heart block or arrhythmia. We report a case of sudden death in a 33-year-old male with a history of surgically repaired congenital heart disease. Although his congenital heart disease was originally postulated to be important in his death, autopsy examination revealed cardiac sarcoid with prominent involvement of the conduction system.

Soft tissue Rosai Dorfman disease mimicking inflammatory pseudotumor: a diagnostic pitfall

Rosai Dorfman disease, or sinus histiocytosis with massive lymphadenopathy (SHML), may be a difficult diagnosis to make, especially in extranodal sites. With soft tissue involvement the characteristic diagnostic features of large histiocytic cells with emperipolesis may be overshadowed by a fibroinflammatory component. In these cases it is easy to confuse this lesion with reactive nodules and benign and malignant neoplasms. We report a case in which soft tissue SHML was confused with an inflammatory pseudotumor. Only after review, when other extranodal sites became apparent, was the correct diagnosis made. Pitfalls in the diagnosis of soft tissue SHML are discussed.

Anatomy of the normal left atrial appendage: a quantitative study of age-related changes in 500 autopsy hearts: implications for echocardiographic examination

BACKGROUND

Transesophageal echocardiography (TEE) is the diagnostic modality of choice for visualizing the left atrial appendage (LAA). This study defined the morphology of the LAA in normal autopsy specimen hearts and considered the implications of these findings for TEE studies.

METHODS AND RESULTS

Five hundred normal autopsy hearts were reviewed (25 male and 25 female subjects from each decade for 10 decades). LAA length, width, orifice size, and number of lobes were recorded. Number of lobes was compared between sexes with the rank sum test and regressed against age. Mean length, width, and orifice size increased with age, up to age 20 years, in both sexes. Rates were significantly different between sexes for LAA size (P=.011) and width (P=.006). After age 20, statistically significant but clinically insignificant age-related changes were observed. Fifty-four percent of LAAs had two lobes (range, 1 to 4), with no age or sex differences. Lobes exist in different planes of the heart. Most pectinate muscles were > or = 1 mm in width. Pectinate muscles < 1 mm (2.6% of cases) were seen in only the first and last decades.

CONCLUSIONS

Age- and sex-related differences in LAA dimensions exist. These differences and the existence of multilobed appendages are important in the accurate TEE evaluation of LAA. Because lobes exist in different planes, imaging must be done in multiple planes to visualize the entire LAA.