A Kidney Transplant Recipient With Coronavirus Disease 2019: Utility of a Prognostication Score

Background

Cytokine release storm (CRS) is a potentially fatal, hyperinflammatory condition common to both coronavirus disease 2019 (COVID-19) and reactive hemophagocytic lymphohistiocytosis (rHLH). We present our experience with the use of a diagnostic score, developed for rHLH, in a kidney transplant recipient hospitalized with COVID-19.

Methods

We applied the H-Score to risk-stratify our patient to help predict his hospital course. This study was exempt from requiring specific Institutional Review Board approval, but met all the criteria required by our institution for this type of study and report including consent from the patient.

Results

The calculated H-Score for our patient fell below the diagnostic cut-off value for rHLH. Because rHLH is characterized by CRS, we expected him to have a milder hospital course with COVID-19. Correlating with his below cut-off H-score, the patient had a more benign than expected hospital course.

Conclusions

Because this is only a single case, we plan to retrospectively review a series of patients to validate our initial experience—that a low H-Score may correlate with a milder hospital course in kidney transplant patients with COVID-19.

Abstract P3-10-28: The impact of HER2-directed targeted therapy on HER2-positive DCIS of the breast

Purpose/Objectives: In invasive breast cancer, HER2 is a well-established negative prognostic factor. However, its significance on the prognosis of ductal carcinoma in situ (DCIS) of the breast is unclear. As a result, the impact of adding HER2-directed therapy to HER2-positive DCIS is unknown and is currently the subject of ongoing clinical trials. In this study, we aim to determine the impact of HER2 status on DCIS patient outcomes as well as the possible impact of HER2-directed targeted therapy on survival outcomes for HER2-positive DCIS patients.

Materials/Methods: The National Cancer Data Base (NCDB) was used to retrieve patients with biopsy-proven DCIS diagnosed from 2004-2015. Only patients with known estrogen receptor (ER) status, progesterone receptor (PR) status, and HER2 status were included in the analysis. Patients were divided into two groups based on the adjuvant therapy they received: systemic therapy (assumed to be HER2-directed targeted therapy) or no systemic therapy. Statistics included multivariable logistic regression to determine factors predictive of receiving systemic therapy, Kaplan-Meier analysis to evaluate overall survival (OS), and Cox proportional hazards modeling to determine variables associated with OS.

Results: Altogether, 1927 patients met inclusion criteria; 430 (22.3%) received HER2-directed targeted therapy, while 1497 (77.7%) did not. Patients who received HER2-directed targeted therapy were likely more likely to be ER-negative. Patients who received HER2-directed targeted therapy had a higher 5-year OS compared to patients that did not (97.7% vs. 95.8%, p = 0.043). This survival benefit remained on multivariate analysis. Factors associated with worse OS on multivariate analysis included Charlson-Deyo Comorbidity Score ≥ 2 and no receipt of hormonal therapy.

Conclusions: In the largest study to date evaluating HER2-positive DCIS patients, the receipt of HER2-directed targeted therapy was associated with an improvement in OS. The results of currently ongoing clinical trials are needed to confirm this finding.

Citation Format: Lewis GD, Haque W, Farach A, Hatch SS, Butler EB, Schwartz MR, Bonefas E, Teh BS. The impact of HER2-directed targeted therapy on HER2-positive DCIS of the breast [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-28.

Abstract P6-07-11: Is the prognosis of lymphotropic invasive micropapillary carcinoma worse than invasive ductal carcinoma?: A population-based study of 645 patients

Purpose: Invasive micropapillary carcinoma (IMPC) is an uncommon distinct variant of breast carcinoma and is associated with an increased risk for regional lymph node metastases. Therefore, IMPC is considered to have an unfavorable prognosis when compared to invasive ductal carcinoma (IDC). The prognostic factors for IMPC are not well characterized due to the relative scarcity of cases reported in the literature.

Methods: We analyzed the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database to evaluate prognostic factors of a population of 645 breast IMPC patients and 300,060 breast IDC patients reported between 2001 and 2008. Using univariate and multivariate analyses, hazard ratios (HR) were calculated for disease-specific (DSS) and overall survival (OS) for these patients using parameters such as patient age at diagnosis, histological grade, ER status, PR status, tumor size, and degree of lymph node positivity. Subset analysis of high grade, lymph node-positive patients was performed to compare DSS and OS between IMPC and IDC.

Results: The 5-year DSS and OS for IMPC patients were 92.1% and 84.6% compared to 5-year DSS and OS of 88.5% and 80.2% for IDC patients. At presentation, TNM staging of IMPC cases was similar to IDC except for a higher percentage of LN metastases (52.4% in IMPC vs. 34.7% in IDC). Of those with known estrogen receptor (ER) status, 84.2% of IMPC cases were ER-positive, which was associated with better DSS (Hazard Ratio (HR) 0.36, p < 0.002) and OS (HR 0.62, p = 0.072). Patients with four or more positive lymph nodes had worse DSS (HR 7.1, p < 0.0001) and OS (HR 3.2, p < 0.0001) than node-negative patients, but those with one to three positive lymph nodes had similar DSS (HR 1.04, p = 0.96) and OS (HR 0.99, p = 0.97) as node-negative patients. In the subset of patients with high grade, node-positive breast carcinoma, patients with micropapillary histology had better DSS (p < 0.03) and a trend towards better OS (p = 0.12) than high grade, node-positive invasive ductal carcinoma. This subset of IMPC patients also had a higher percentage of ER-positive tumors (77%) compared to IDC patients (56%).

Conclusions: While IMPC has a high propensity for lymph node metastasis, it has a disease-specific and overall prognosis that compares favorably to IDC. The higher percentage of hormone-receptor positivity may account for this survival advantage, even in high grade, node-positive disease. Therefore, estrogen-receptor-negativity or having four or more positive lymph nodes at presentation may potentially serve as prognostic markers for IMPC patients. In this study population, patients with one to three positive lymph nodes have DSS and OS similar to node-negative patients. Additional clinical studies are warranted to further investigate this observation. This is the largest study of IMPC to date, and these findings help our understanding of this uncommon histological variant of breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-11.

Carcinoma with thymus-like differentiation arising in the dermis of the head and neck

Carcinoma exhibiting thymus-like differentiation (CASTLE) is a rare, distinct tumor of the thyroid gland or soft tissue of the head and neck that may simulate primary squamous cell carcinoma or lymphoepithelioma, and which contains features reminiscent of thymic differentiation including Hassall's corpuscles, occasional perivascular spaces, and the presence of lymphocytes. Ectopic thymic tissue may result from incomplete descent or persistence of the cervical portion of the thymus and may occur anywhere along the course of the embryonic descent from the angle of the mandible to the sternal notch. Herein, we report two cases of dermal extrathyroidal CASTLE. The differential diagnosis of squamoid carcinoma with features of thymic differentiation includes extrathyroidal CASTLE, a primary squamous cell carcinoma with thymic differentiation, lymphoepithelioma-like carcinoma of the skin, and metastatic squamous cell carcinoma of unknown primary. It is essential that the latter two be ruled out before accepting the diagnosis of an extrathyroidal carcinoma with thymus-like differentiation.

Surface markers expressed by multipotent human and mouse neural progenitor cells include tetraspanins and non-protein epitopes

Surface molecules play important roles in a wide range of cellular functions, yet little has been reported regarding the expression of such markers by neural stem cells. Here, multipotent human neural progenitor cells (hNPCs) were expanded as a monolayer in the presence of fibroblast/epidermal growth factor, harvested, labeled with monoclonal antibodies, and analyzed by flow cytometry. Positive markers included CD9, CD15, CD81, CD95 (Fas), GD(2) ganglioside, and major histocompatibility complex class I and beta2 microglobulin, as well as low levels of the hematopoietic stem cell marker CD34. Of these, mouse NPCs were positive for CD9, CD15, CD81, and GD(2) ganglioside. The markers reported here have been implicated in a wide range of cellular functions including proliferation, migration, differentiation, apoptosis, and immune recognition.

Primary choriocarcinoma of the vulva

Primary extrauterine choriocarcinoma is very rare, found mostly in the genital tract (tube, cervix, ovary, vagina). Other sites such as lungs, gastrointestinal tract, heart, brain and submentum also have been reported. A 31-year-old woman presented with abnormal uterine bleeding 6 weeks after her last menstrual cycle. Her HCG titer level was 900 mIu/ml. She underwent dilation and curettage (D & C). Pathology failed to reveal any chorionic villi. Further evaluation was done, including a second D & C, laparoscopy, exploratory laparotomy, CT, MRI and ultrasound which all failed to define a source for the elevated HCG titer which subsequently rose to 95,000 mIu/ml 130 days after her last menstrual cycle. At that time a vulvar mass was observed. Fine needle aspiration (FNA) was positive for choriocarcinoma. The patient was treated with one course of methotrexate 60 mg intramuscularly every other day for 5 days. Actinomycin-D 0.5 mg given intravenously daily for 5 days was added to courses 2-7. Radiotherapy (4000 rads) was applied concomitant with the chemotherapy. The remainder of the mass was subsequently excised. The patient has remained with no evidence of disease for 10 years. This is the first case report of primary vulvar choriocarcinoma.

Detection of Mycobacterium avium subspecies paratuberculosis in Crohn's diseased tissues by in situ hybridization

OBJECTIVES

Reports about the association between Crohn's disease (CD) and cell wall-deficient (CWD) forms of Mycobacterium avium subspecies paratuberculosis (M. paratuberculosis) are controversial. This may be due to the heterogeneous nature of CD where only about 50% of the patients show granulomatous inflammation. Detection of CWD forms of M. paratuberculosis in tissues from patients with CD would support its association with the disease. To help identify these forms in inflamed tissues, a previously developed and optimized nonradioactive in situ hybridization method was applied on well-defined tissue materials obtained from patients with CD, ulcerative colitis (UC), and controls.

METHODS

Specimens from 37 patients with CD (15 with epitheloid cell granulomas and 22 without granulomas), 21 UC, and 22 noninflammatory bowel disease (IBD) patients were analyzed by the in situ hybridization method based on the digoxigenin-labeled M. paratuberculosis IS900 fragment, previously shown to be species specific. Samples were counterstained with hematoxylin and eosin to show the location of the positive signal. Positive controls made of beef cubes injected with CWD and acid-fast M. paratuberculosis and negative controls were included in each experiment to monitor for nonspecific hybridization or staining.

RESULTS

Six of 15 (40%) patients with CD and granulomas showed positive signals in myofibroblasts and macrophages. Interestingly, no positive signals were observed within granulomas. Only 4.5% of 22 CD samples from patients with nongranulomatous disease, 9.5% of 21 UC, and remarkably, none of the 22 non-IBD patients were M. paratuberculosis positive.

CONCLUSION

The demonstration of DNA from CWD forms of M. paratuberculosis in this limited number of CD tissues further supports and confirms previous reports of its association with the granulomatous type of the disease.

Should the cytologic diagnosis of "atypical squamous cells of undetermined significance" be qualified? An assessment including comparison between conventional and liquid-based technologies

BACKGROUND

The diagnosis of atypical squamous cells of undetermined significance (ASCUS) remains an enigma for the treating physician, because it encompasses both benign, reactive, as well as preneoplastic and possibly neoplastic conditions. To address this problem, The Bethesda System recommends qualifying the ASCUS diagnosis. This study analyzes the difference in the follow-up results between the various groups of patients with an ASCUS diagnosis as outlined by the Criteria Committee: favor premalignant (ASCUS-P), favor reactive (ASCUS-R), and unqualified (ASCUS-C). The outcome, based on follow-up biopsies and/or cytologies, for both the conventional Papanicolaou smear (CS) and liquid-based (LB) methodologies is compared.

METHODS

The CS and LB biopsies and/or cytologies included 590 patients and 137 patients, respectively, who had an initial diagnosis of ASCUS. The final outcome after subsequent biopsy and cytology within a 1-year period for each methodology was tabulated. Furthermore, the addition of qualifiers for each diagnosis was tabulated for both cytology and biopsy follow-up and compared between CS and LB technologies.

RESULTS

For CS, 29 patients (8.6%) were found to have squamous intraepithelial lesions (SIL) on subsequent cytologic smears, and 176 patients (63.7%) had SIL on biopsy follow-up. For LB, these numbers were 17 patients (19.1%) and 56 patients (65.1%), respectively. Regardless of the qualification used in the initial CS biopsy or cytology, over 90% of the subsequent smears resulted in a benign diagnosis. Biopsy outcomes after CS diagnoses of ASCUS-P, ASCUS-R, and ASCUS-C showed SIL in 80%, 53%, and 66% of patients, respectively. For LB diagnoses, subsequent smears detected SIL in 33% of patients with a diagnosis of ASCUS-P, 22% of patients with a diagnosis of ASCUS-R, and 12% of patients with a diagnosis of ASCUS-C. Biopsy outcomes after LB diagnoses of ASCUS-P, ASCUS-R, and ASCUS-C showed SIL in 68%, 64%, and 66% of patients, respectively.

CONCLUSIONS

There appears to be no statistically valid benefit from a clinical point of view in qualifying an ASCUS interpretation by either CS or LB, except for CS evaluation of patients with a diagnosis of ASCUS-P.

Review article: Mycobacterium avium subsp. paratuberculosis as one cause of Crohn's disease

A number of theories regarding the aetiology of Crohn's disease have been proposed. Diet, infections, other unidentified environmental factors and immune disregulation, all working under the influence of a genetic predisposition, have been viewed with suspicion. Many now believe that Crohn's disease is a syndrome caused by several aetiologies. The two leading theories are the infectious and autoimmune theories. The leading infectious candidate is Mycobacterium avium subspecies paratuberculosis (Mycobacterium paratuberculosis), the causative agent of Johne's disease, an inflammatory bowel disease in a variety of mammals including cattle, sheep, deer, bison, monkeys and chimpanzees. The evidence to support M. paratuberculosis infection as a cause of Crohn's disease is mounting rapidly. Technical advances have allowed the identification and/or isolation of M. paratuberculosis from a significantly higher proportion of Crohn's disease tissues than from controls. These methodologies include: (i) improved culture techniques; (ii) development of M. paratuberculosis-specific polymerase chain reaction assays; (iii) development of a novel in situ hybridization method; (iv) efficacy of macrolide and anti-mycobacterial drug therapies; and (v) discovery of Crohn's disease-specific seroreactivity against two specific M. paratuberculosis recombinant antigens. The causal role for M. paratuberculosis in Crohn's disease and correlation of infection with specific stratification(s) of the disorder need to be investigated. The data implicating Crohn's as an autoimmune disorder may be viewed in a manner that supports the mycobacterial theory. The mycobacterial theory and the autoimmune theory are complementary; the first deals with the aetiology of the disorder, the second deals with its pathogenesis. Combined therapies directed against a mycobacterial aetiology and inflammation may be the optimal treatment of the disease.

Expression of the neutral amino acids transporter ASCT1 in esophageal carcinomas

Cancers cells utilize more glucose and amino acids than their benign counterparts. Overexpression of the facilitative glucose transporter Glut1 in human cancers was found to correlate with aggressive biologic behavior. The aim of this work was to determine whether the neutral amino acid transporter ASCT1 is expressed in human esophageal carcinomas, and to correlate the findings with Glut1 expression. Sections of formalin-fixed and paraffin-embedded tissue from 42 cases of esophageal carcinomas were entered in the study. Immunohistochemical staining was performed using a rabbit anti-ASCT1 IgG developed in our laboratory, and anti-Glut1 antibody, using standard avidin-streptavidine immunoperoxidase method. Sections of formalin-fixed and paraffin-embedded HepG2 cells were used as positive controls. The percent of ASCT1-positive cells was scored. Statistical analysis was performed using Fisher's exact test. ASCT1 immunoreactivity was cytoplasmic, whereas Glut1 was membranous. Significantly more adenocarcinomas expressed ASCT1 than squamous cell carcinomas (p < 0.0001), whereas Glut1 expression was similar in both tumor types. There was no association between the expression of either transporter and lymph node metastasis. Glut1 was expressed more often in the better differentiated than the poorly differentiated squamous carcinomas (p = 0.003). These results suggest that unlike in squamous cell carcinoma, ASCT1 plays a significant role in the recruitment of amino acids in adenocarcinoma of the esophagus, and suggest that the metabolic needs, and uptake of nutrients, are regulated differently in these two tumor types. Additional studies with larger number of patients are needed to determine the biological significance of ASCT1 expression in esophageal carcinomas.

Qualitative analysis of value judgments in interpreting cervicovaginal smears using the Bethesda system

CONTEXT

We hypothesize that there are unrecognized value judgments that influence cytopathologists in interpreting borderline cervicovaginal smears and that these judgments contribute to the well-documented variation among cytopathologists regarding such diagnoses.

OBJECTIVE

To identify and map these values.

DESIGN

Survey consisting of Kodachromes and histories for 5 borderline smears. Respondents were asked to give their diagnoses, recommendations for treatment, and reasoning.

RESULTS

We demonstrated a wide variation in interpretation of borderline smears similar to previous studies. We then used inductive qualitative analysis to identify the clinical reasoning and value judgments that influenced the responses.

CONCLUSIONS

We mapped those diagnostic value judgments that should be used in evaluation borderline cases. We believe this map can be used to rigorously manage and standardize the use of such judgments.

Optimized cyclin D1 immunoperoxidase staining in mantle cell lymphoma

Mantle cell lymphoma (MCL) has a worse prognosis than MALT lymphoma (MALTL). Distinction between MCL and MALTL on purely morphologic grounds can be difficult. Cyclin D1 (PRAD1/bcl1) is overexpressed in MCL as a result of a t(11:14) gene rearrangement, which leads to overexpression of cyclin D1 mRNA and protein. The immunohistochemical detection of cyclin D1 in MCL has been reported by several authors to be highly specific with sensitivity ranging from 70%-100%, but diagnostic laboratories have reported difficulty in finding a reliable method for cyclin D1 immunostaining. The aim of this study was to evaluate and optimize a method for detection of cyclin D1 by paraffin section immunoperoxidase staining. Sections of routinely processed tissue from five MCL and one splenic marginal zone lymphoma (MZL) were immunostained using a mixture of two primary monoclonal antibodies and a standard avidin-streptavidin method. Antigen retrieval was performed using 1) steam heat in citrate buffer, 2) as in "1" followed by sonication for one minute, and 3) as in "2" followed by enzymatic digestion. All the above were repeated, with the additional use of catalyzed signal amplification (CSA). Later, sections of the same cases, plus three MALTL were immunostained as in "2". Steam heat antigen retrieval alone produced the best results. All MCL showed positive nuclear staining while the MZL and all MALTL were negative. Sonication did not enhance staining noticeably, whereas enzymatic digestion produced cytoplasmic staining. CSA increased background staining with no significant gain in nuclear stain intensity. We conclude that cyclin D1 immunostaining of formalin-fixed, paraffin-embedded tissue can be reliably achieved by heat induces antigen retrieval and a cocktail of two monoclonal antibodies.

Fas ligand expression in esophageal carcinomas and their lymph node metastases

BACKGROUND

Although esophageal adenocarcinomas (EADCA) have been shown to have substantially reduced or absent Fas expression, the status of Fas ligand (FasL) in these tumors, especially adenocarcinomas, is largely unknown.

METHODS

Using immunohistochemistry, the authors investigated FasL expression in sections of formalin fixed, paraffin embedded tissue from 13 EADCA. They also studied sections of 15 esophageal squamous cell carcinomas (ESCCA) and of lymph node metastases from 7 EADCA and 4 ESCCA. The percentage of FasL positive cells in each tumor was recorded. FasL expression in EADCA was compared with that in ESCCA and with lymph node status. Statistical analysis was performed using the Fisher exact test.

RESULTS

No specific staining pattern was seen in adenocarcinomas. In ESCCA, FasL was often located in the cells at the periphery of tumor nests. All (100%) of EADCA showed FasL expression in greater than 25% of the cancer cells, and all were associated with lymph node metastasis. Fifty-three percent of ESCCA showed FasL expression in greater than 25% of the cancer cells and 33% had lymph node metastasis. Expression of FasL in greater than 25% of tumor cells was associated with a significantly higher incidence of lymph node metastasis (P=0.0001). All lymph node metastases from esophageal carcinomas showed FasL immunoreactivity in greater than 50% of the metastatic tumor cells.

CONCLUSIONS

FasL expression in greater than 25% of cancer cells correlates with a high incidence of lymph node metastasis in esophageal carcinomas. All cancer metastases in lymph nodes express FasL in >50% of the cells. These findings indicate that FasL plays an important role in the immune evasion and metastasis of esophageal carcinomas.

Comparison of thyroid, auricular, and costal cartilage donor sites for laryngotracheal reconstruction in an animal model

OBJECTIVE

To evaluate and compare the use of autogenous thyroid cartilage with that of auricular and costal cartilage in laryngotracheoplasty (LTP).

DESIGN

A blinded comparison of LTP techniques using anterior thyroid, auricular, or costal cartilage as graft material in a rabbit model. Histological and anatomical analyses were performed on the laryngeal specimens 1, 4, and 6 weeks after surgery. The following factors were analyzed in each specimen: graft viability, cartilage proliferation, perichondrial viability, degree of necrosis, inflammatory response, and degree of epithelialization.

SUBJECTS

Fifty-seven New Zealand adult male rabbits, aged 6 months, were divided into 3 study groups (19 animals in each group) initially and equally into the 3 time periods.

RESULTS

No episodes of respiratory compromise occurred in any of the animals in the 3 study groups. Gross inspection of the laryngotracheal complex in the thyroid cartilage group revealed no evidence of laryngeal structural compromise. There was no statistical difference between the 3 types of cartilage used for reconstruction for the variables of graft or perichondrial viability, degree of necrosis, or inflammatory response at 1, 4, or 6 weeks. Cartilage proliferation in the thyroid cartilage group was decreased compared with that in the other 2 groups at 1 week. The amount of proliferation increased in this group and was equal to the amount present in the other 2 groups 4 and 6 weeks after surgery. Complete epithelialization of the graft material was present in all 3 groups at 4 and 6 weeks after reconstruction.

CONCLUSIONS

The use of autogenous thyroid cartilage for LTP compares favorably with that of other methods of reconstruction that use either auricular or costal cartilage in the rabbit model. This technique is a viable alternative for single-stage LTP and has the added advantage of using a single incision.

The role of open rhinoplasty in the management of nasal dermoid cysts

The nasal dermal sinus cyst is one of many midline nasal masses that often pose diagnostic and treatment dilemmas for the plastic and reconstructive surgeon. The differential diagnosis of the midline nasal mass includes both congenital and acquired processes. A thorough understanding of its cause is crucial to treatment. A comprehensive discussion of the pathogenesis, diagnosis, sequelae, and surgical management, and a representative case analysis, of the nasal dermal sinus cyst is presented to delineate the role of open rhinoplasty in optimizing the care of this congenital nasal deformity.

Overexpression of Fas ligand (FasL) during malignant transformation in the large bowel and in Barrett's metaplasia of the esophagus

Esophageal and colorectal adenocarcinomas overexpress Fas ligand (FasL), which can protect them from immune surveillance. The aim of this work was to determine whether FasL expression, and therefore FasL-dependent immune evasion, occurs early during malignant transformation in Barrett's metaplasia (BM) of the esophagus, and in the large intestine. Sections of formalin-fixed and paraffin-embedded tissue from esophageal and large bowel biopsies and resection specimens were immunostained for FasL using standard immunoperoxidase technique. The percentage of positive cells was correlated with the degree of dysplasia in BM and with the size and villous architecture of colorectal adenomas. In BM, FasL was detected in 55% of cases negative for dysplasia, and was associated with inflammation in almost all positive cases. By contrast, all cases of BM (100%) with low- or high-grade dysplasia were FasL-positive. In the large intestine, 25% of small adenomas were negative for FasL, and FasL overexpression was significantly more frequent in larger adenomas and in adenomas with tubulovillous or villous morphology. Our results suggest that (1) FasL overexpression is acquired early during malignant transformation of BM and the large bowel and (2) FasL overexpression occurs relatively earlier during malignant progression of BM than the large bowel, probably as a result of the preceding repeated inflammation.

The role of open rhinoplasty in the management of nasal dermoid cysts

The nasal dermal sinus cyst is one of many midline nasal masses that often pose diagnostic and treatment dilemmas for the plastic and reconstructive surgeon. The differential diagnosis of the midline nasal mass includes both congenital and acquired processes. A thorough understanding of its cause is crucial to treatment. A comprehensive discussion of the pathogenesis, diagnosis, sequelae, and surgical management, and a representative case analysis, of the nasal dermal sinus cyst is presented to delineate the role of open rhinoplasty in optimizing the care of this congenital nasal deformity.

Oncocytic mucoepidermoid carcinoma of the salivary glands

Two parotid mucoepidermoid carcinomas with predominant oncocytic features were initially assessed on frozen section. Because of extensive oncocytic change, it was inferred that the lesions were most likely benign. Permanent sections revealed low-grade mucoepidermoid carcinoma with prominent oncocytic change (in more than 75% of the neoplasms) in both cases. Review of 48 additional consecutive cases of mucoepidermoid carcinoma of the salivary glands revealed prominent oncocytic change (accounting for 60% of the neoplasm) in one high-grade lesion. Phosphotungstic acid-hematoxylin stains revealed strong granular cytoplasmic staining in the oncocytic elements; immunohistochemical stains for antimitochondrial antibodies also showed intense immunoreactivity in these cells. Oncocytic change is not typically a prominent feature of mucoepidermoid carcinoma of the salivary glands, and to our knowledge, only three such cases have been reported previously. Because most salivary gland lesions with oncocytic change are benign, it is important to distinguish mucoepidermoid carcinoma from other entities that may show prominent oncocytic change. We report three additional examples of this rare lesion, two low-grade tumors and one high-grade tumor, and review our experience with oncocytic change in mucoepidermoid carcinoma of the salivary glands.

Completely laparoscopic resection of a rare pyloric tumor with laparoscopically sutured gastroduodenostomy

We report the case of a 31-year-old woman who presented with epigastric pain and weight loss. Esophagogastroduodenoscopy revealed a submucosal mass in the distal antrum and pylorus. Endoscopic biopsy of the mass was nondiagnostic. A CT scan confirmed a 3.0-cm mass in the posterior wall of the distal antrum. She underwent laparoscopic resection of the distal antrum and pylorus with end-to-end gastroduodenostomy. Pathologic examination showed an adenomyoma of the antrum and pylorus. Her postoperative course was uncomplicated, and she continues to do well 38 months postoperatively. Gastric adenomyoma is a rare, benign intramural tumor of the antrum and pylorus. Fewer than 40 cases have been described in the literature. The lesions are generally within 4 cm of the pylorus. Histologically, they are characterized by ductal structures lined by cuboidal to columnar epithelium surrounded by smooth muscle bundles and, occasionally, Brunner's-type glands and heterotopic pancreas. Treatment is by resection, and recurrence has not been reported. Laparoscopic resection of portions of the stomach has been reported. Side-to-side gastrojejunostomies (Billroth II) performed laparoscopically have been reported. This is the first report in the English-language literature of a completely laparoscopically performed sutured gastroduodenostomy. Technical details of the procedure and adenomyomas are discussed.

Fine needle aspiration diagnosis of transitional cell carcinoma metastatic to the brain. A case report

BACKGROUND

Transitional cell carcinoma (TCC) rarely metastasizes to the brain. In this case, aspiration of a cystic brain lesion was performed and a cytologic diagnosis made. To the best of our knowledge, this is the first reported case of TCC metastatic to the brain diagnosed by fine needle aspiration.

CASE

A 72-year-old male with a past medical history of invasive TCC, colonic adenocarcinoma and prostatic adenocarcinoma presented with a large, right, temporal, cystic mass. Fine needle aspiration was performed intraoperatively, and a cytologic diagnosis of metastatic TCC was rendered and confirmed by subsequent tissue examination.

CONCLUSION

Intraoperative fine needle aspiration of cystic tumors can be useful in identifying the primary site. The cytologic features of intracerebral metastatic TCC can differ significantly from those observed in urinary tract specimens of high grade TCC. A predominance of large fragments of malignant cells with numerous mitotic figures and apoptotic bodies was seen in the former. The background showed high grade, single transitional cells similar to those observed in urinary tract samples of TCC.

Metastatic carcinoma of the prostate mimicking primary carcinoid tumor of the lung and mediastinum

Although prostatic carcinomas rarely present as intrathoracic metastases, they may occasionally exhibit clinical and radiographic findings suggestive of a primary pulmonary carcinoid, particularly when they have a cribriform pattern. This report describes three patients who presented with lung and mediastinal neoplasms initially diagnosed as primary carcinoid tumors. These tumors were later proven to be metastatic prostate carcinoma by the use of immunohistochemical studies, including stains for chromogranin, carcinoembryogenic antigen and prostate specific antigen. These findings emphasize the importance of considering metastatic prostate adenocarcinoma in the differential diagnosis of carcinoid or neuroendocrine carcinoma with a cribriform pattern.

Optimizing suicide gene therapy for head and neck cancer

An effective "suicide gene" therapy strategy in experimental studies has been the use of the herpes simplex virus thymidine kinase gene (HSV-tk) to sensitize tumors to the cytotoxic effects of ganciclovir administration. Previous studies using this model have focused on utilizing maximal viral titers and high levels of ganciclovir that are not compatible with human dosing. Because of the high ganciclovir doses and the maximal viral titers, this strategy has limited application to actual clinical scenarios. In the following studies the authors investigate tumor regression in an oral squamous cell carcinoma animal model as a function of variable adenoviral titers and more physiologic ganciclovir dosing. Using adenoviral titers ranging from 1 x 10(8) to 2 x 10(9) plaque forming units (pfu) to treat oral tumors, they found no statistical difference in tumor regression among the different viral doses, despite differences in mitotic activity. Each treatment group, however, demonstrated a significant effect on tumor regression when compared with controls. Furthermore, the authors were able to reduce the level of ganciclovir administration to 10 mg/kg twice daily from established levels of 100 to 150 mg/kg twice daily while maintaining significant tumor responses to the HSV-tk therapy. Mean survival of animals treated with this lower ganciclovir dose was significantly higher than in controls and was equal to established means based on previous studies using higher ganciclovir doses. The optimization of this suicide gene therapy strategy is imperative in order to minimize theoretical and known viral and ganciclovir toxicities while establishing a foundation upon which to design appropriate and effective clinical trials.

Angiosarcoma at unusual sites. A report of two cases with aspiration cytology and diagnostic pitfalls

BACKGROUND

Angiosarcomas are uncommon soft tissue neoplasms with a predilection for skin and superficial soft tissues.

CASES

Two cases of angiosarcoma occurred at unusual sites, the parotid gland and lung. The parotid lesion was characterized by malignant cells present singly, in loose groups, in tight three-dimensional aggregates and in acinar formation initially misinterpreted as an adenocarcinoma. The lung mass showed malignant cells in association with vascular endothelium, suggestive of angiosarcoma. Both cases were negative for Ulex europaeus and Factor VIII-related protein but demonstrated strong immunopositivity for CD31, a highly specific endothelial marker.

CONCLUSION

In the absence of vasoformative structures, important diagnostic pitfalls are pseudovascular adenoid squamous cell carcinoma, poorly differentiated adenocarcinoma, melanoma and lymphoma. Immunocytochemical studies and clinical history are essential to the correct diagnosis.

Eccrine spiradenoma mimicking adenoid cystic carcinoma on fine needle aspiration. A case report

BACKGROUND

Although the cytologic features of salivary gland tumors are well recognized, an adnexal skin tumor occurring in the same region, on occasion, may resemble and be confused with a salivary gland neoplasm.

CASE

A case of eccrine spiradenoma presented as a painful mass in the region of the parotid that mimicked an adenoid cystic carcinoma on fine needle aspiration cytology.

CONCLUSION

Fine needle aspirates of eccrine spiradenoma, a benign cutaneous adnexal tumor, may have findings that mimic those of adenoid cystic carcinoma. Both may have cell balls and rosettelike structures surrounding stromal matrix cores. Recognition of three cell types in eccrine spiradenomas, including epithelial cells, myoepithelial cells and lymphocytes, as compared to a single cell type in adenoid cystic carcinoma, is paramount in avoiding this potential pitfall in cytologic diagnosis.

Stereotactic core breast biopsy of a minimal carcinoma complicated by a large hematoma: a management dilemma

Stereotactic core biopsy of a 4-5-mm, suspicious mammographic lesion was complicated by substantial hematoma formation in a patient with subsequently diagnosed factor XI deficiency. As a result, the small infiltrating ductal carcinoma could no longer be identified at mammography to allow accurate needle localization for lumpectomy. Sufficient resorption of the hematoma at 3 months permitted successful needle localization and lumpectomy. In these cases, expectant management may obviate extensive surgery.

Localized thymic Langerhans' cell histiocytosis and its relationship with myasthenia gravis. Immunohistochemical, ultrastructural, and cytometric studies

OBJECTIVE

It has been suggested that localized Langerhans cell histiocytosis may represent an exaggerated form of a proliferative process that has been reported in a few patients with myasthenia gravis. To evaluate the relationship between thymic Langerhans' cell proliferation and myasthenia gravis, we analyzed a rare case of localized thymic Langerhans' cell histiocytosis and examined thymic Langerhans' cell distribution in myasthenic and control patients.

DESIGN

Immunohistochemical, ultrastructural, and image cytometric DNA analyses were performed on the index case. Immunostaining for S100 was performed on 20 additional thymuses, 10 from patients with myasthenia gravis and 10 from control patients.

RESULTS

Immunohistochemical studies revealed no increase in Langerhans' cells in the surrounding thymic tissue of the index case. No difference was found between the number of Langerhans' cells in the remaining thymuses of myasthenia patients compared with the control group, and no micronodular proliferations were identified in either group.

CONCLUSIONS

Localized thymic Langerhans' cell histiocytosis is an unusual lesion that is associated with myasthenia gravis in some patients. In the few cases reported at present, however, the lesion does not appear to be related pathogenetically to myasthenia gravis.

A new immunocompetent murine model for oral cancer

OBJECTIVE

To develop and characterize a new immunocompetent murine model that attempts to parallel the clinical and biological nature of head and neck cancer.

DESIGN

The growth rate and histologic characteristics of the SCC VII/SF cell line were initially determined in tissue culture experiments. Animal experiments were subsequently performed on C3H/HeJ mice. Using direct injection, 5 x 10(5) SCC VII/SF cells were delivered to the floor of the mouth of each animal. Animals were killed after 1, 2, and 3 weeks, and tumor growth, invasion, and regional and distant metastases were evaluated.

RESULTS

Squamous cell carcinomas that could be palpated and measured externally were identified in the floor of the mouth of C3H/HeJ mice after 5 to 7 days. Local invasion into the mylohyoid musculature and mandible was present. Cervical lymph node and pulmonary metastases were identified between 2 and 3 weeks.

CONCLUSIONS

This study introduces a new oral cancer animal model that shows initial locoregional tumor invasion, direct extension into the neck, early cervical metastases, and pulmonary metastases. These clinical and histopathologic attributes reflect the biological behavior and tumor progression seen in human oral cancer and therefore provide a model for clinically applicable research for primary and metastatic head and neck cancer.

Cytology of gastrointestinal histoplasmosis. A report of two cases with differential diagnosis and diagnostic pitfalls

BACKGROUND

Gastrointestinal (GI) histoplasmosis is a rare manifestation of Histoplasma capsulatum (HC) infection. There are no reports of its cytologic diagnosis in the literature.

CASES

A search of the cytology and surgical pathology files of the Methodist Hospital uncovered two cases of GI histoplasmosis and histiocytes within cytologic specimens. Papanicolaou-stained endoscopic brushings of an obstructing, apple-core, right colonic mass in a 58-year-old, heterosexual male revealed numerous vacuolated single cells interpreted as suspicious for signet ring cell carcinoma. The resected colon showed granulomatous inflammation with numerous histiocytes containing pale, oval yeasts of HC. The patient was subsequently found to be human immunodeficiency (HIV) positive; this was his first manifestation of the acquired immunodeficiency syndrome. The second patient was a 69-year-old, HIV-negative male with a fungating anal mass suspicious for squamous cell carcinoma. Direct smears showed oval histiocytes with intracellular yeasts of HC.

CONCLUSION

Accurate diagnosis is crucial to patient management and therapy. Careful attention to the nuclear and cytoplasmic details of histiocytes and histiocytelike cells is important to avoid interpretive errors. Diagnostic pitfalls include signet ring cell adenocarcinoma, lymphoma, melanoma, goblet cell carcinoid, malakoplakia and such infections as mycobacteria, Entamoeba histolytica and Calymmatobacterium granulomatis. Ancillary studies, such as microbiologic cultures and immunohistochemical and histochemical staining, can be performed in the appropriate clinical setting.

Colonic ulceration associated with the systemic use of nonsteroidal antiinflammatory medication

We report the first case of colonic ulceration precipitated by the intramuscular administration of ketorolac. This report suggests a role for the systemic effects of nonsteroidal antiinflammatory agents in the development of gastrointestinal ulceration.

Percutaneous needle biopsy of the pancreas: when should it be performed?

Is it appropriate for a good risk patient with a clinical history or imaging studies suggestive of an operable pancreatic neoplasm to undergo a percutaneous fine-needle aspiration biopsy (FNAB) prior to operation? A group of 118 patients who underwent percutaneous FNAB of the pancreas between 1987 and 1993 were evaluated retrospectively. The initial readings of the biopsies were positive for neoplasm in 78 patients and negative in 32. Four suspicious biopsies were included with the positive biopsies for analysis, and four unsatisfactory biopsies were added to the negative biopsies. Operation was performed on 57 of the 118 patients; 39 of these patients had a positive and 18 a negative FNAB. Of the 18 patients with a negative biopsy, 12 were proved to have neoplasia at operation. No operation was performed on 61 patients; 43 of these patients had a positive and 18 a negative FNAB. Three patients with a negative biopsy were treated with chemotherapy, and three subsequently died of pancreatic cancer. It was concluded that because the sensitivity of percutaneous FNAB is only 84% the procedure should be limited to patients suspected of having pancreatic cancer deemed technically inoperable or medically unsuitable for operation.

Alpha 1-antitrypsin deficiency and chronic pancreatitis

Alpha 1-antitrypsin deficiency is a genetic disorder commonly associated with pulmonary and hepatic injury. Low serum levels of this glycoprotein result in an imbalance between circulating protease and protease inhibitors, which is thought to play a role in the development of emphysema. In recent studies, a protease-to-protease inhibitor imbalance in patients with alpha 1-antitrypsin deficiency was thought to be a mechanism contributing to the development of chronic pancreatitis. The heterozygous phenotype and low levels of this glycoprotein have been reported to occur more frequently in patients with chronic pancreatitis than in healthy controls. We report a patient with Pi-SS phenotype alpha 1-antitrypsin deficiency and chronic pancreatitis complicated by recurrent pancreatic pseudocysts and chronic abdominal pain. Our case supports the association between chronic pancreatitis and alpha 1-antitrypsin deficiency. Furthermore, this case provides support for the use of pancreatic stent drainage in the management of intractable abdominal pain in patients with chronic pancreatitis and a dominant stricture.

Neuroendocrine neoplasms of the larynx

Neuroendocrine neoplasms of the larynx are a rare group of tumors that include carcinoid tumor, atypical carcinoid tumor, and small cell carcinoma. These neoplasms pose interesting diagnostic, prognostic, and therapeutic dilemmas, and they are, as a whole, aggressive tumors with a tendency for local and distant spread. The authors of this study examined six new cases of laryngeal neuroendocrine neoplasms. One case manifested itself as a primary atypical carcinoid tumor and caused a "carcinoid syndrome." The remaining five cases were small cell carcinomas of the larynx. Histologic, immunocytochemical, DNA flow cytometric, and p53 studies were performed on all cases. The expression of neuron-specific enolase and chromogranin were the most useful markers in this group of tumors. Overexpression of p53 protein was present in the majority of cases, including the atypical carcinoid tumor. The implications of these studies for diagnosis, classification, and treatment are discussed.

Adenovirus-mediated gene therapy for human head and neck squamous cell cancer in a nude mouse model

Adenovirus-mediated transfer of the herpes simplex virus thymidine kinase gene followed by ganciclovir administration was used to treat human head and neck cancer in nude mice. Tumors were generated by transcutaneous needle injection of 6 x 10(6) human squamous carcinoma cells into the floor of the mouth. After 14 days, 10(10) particles of a replication-defective recombinant adenovirus containing the herpes simplex virus thymidine kinase gene (ADV/RSV-tk) were injected directly into the tumors. The mice subsequently received ganciclovir injections for six consecutive days and were sacrificed at 21 days post tumor cell implantation. Clinical response to the treatment was assessed by computer-imaged morphometric analysis of cross sectional area of nonnecrotic tumor and mitotic activity, which were used for the calculation of a tumor index. The median tumor index value of the treatment group was 280- to 2400-fold smaller than controls which did not receive the therapeutic gene (P < 0.001-0.016), and three-quarters of the treatment group had tumor index values that were indicative of near total tumor regression. Survival studies show that 50% of the ADV/RSV-tk-treated mice are free of tumor at 160 days post adenovirus injection, while all controls died or required sacrifice within 43 days. These results demonstrate that clinically effective in vivo treatment of human squamous cell cancer can be achieved using adenovirus-mediated gene therapy.

Fine needle aspiration biopsy in the diagnosis of lymphadenopathy in 1,103 patients. Role, limitations and analysis of diagnostic pitfalls

Fine needle aspiration biopsy (FNAB) is widely used for the assessment of various lesions. The results of FNABs of lymph nodes on 1,103 patients, performed over a 14-year period, from 1978 to 1992, are presented. The patients ranged in age from 1 to 90 years. Cervical nodes were the site sampled most frequently (47%). Of all the aspirates, 593 were diagnosed cytologically as malignant, 61 as suspicious for malignancy and 329 as benign. The material was classified as unsatisfactory in 120 cases. Aspirates from supraclavicular nodes were most likely to be malignant (85%), followed by those from deep nodes (67%). The most challenging lesions to assess using FNAB were lymphomas, accounting for 15 of the 23 false negatives. Most of these were related to difficulty in the interpretation of well-differentiated neoplasms in the early years of this study, prior to the use of immunocytochemistry. Sampling errors accounted for eight false-negative diagnoses; they included all the cases of metastatic carcinomas that had been missed. There were only three false-positive diagnoses; two of these involved the misinterpretation of lipid-rich lesions as metastatic clear cell carcinomas. The results of this study support the accuracy of FNAB and its value in investigating lymphadenopathies. FNAB of nodes provides a high level of diagnostic accuracy, as shown by the 3.4% false-negative and 0.9% false-positive rates. Lymphoid marker studies of cytologic material greatly enhance our ability to diagnose and properly classify lymphomas and reduce the false-negative rate.

Life-threatening presentations of fibrovascular esophageal and hypopharyngeal polyps

Giant fibrovascular polyps of the esophagus and hypopharynx are benign tumors of the upper digestive tract. Although a rare cause of asphyxiation, laryngeal impaction by a regurgitated polyp of the esophagus may be the initial symptom that brings the patient to request medical attention. Two new cases of giant fibrovascular polyps with dramatic and potentially life-threatening presentations illustrate the unpredictable behavior of these unusual tumors. Both patients presented to the emergency center with a history of coughing and eructation followed by temporary airway obstruction that was relieved by clenching a regurgitated fleshy mass between the teeth. Diagnostic and therapeutic intervention requires aggressive airway management, radiographic and endoscopic evaluation, and definitive surgical treatment. Tracheotomy was required in one patient, and successful endotracheal intubation provided satisfactory airway control in the second. Esophagoscopy revealed the origin of both tumors to be near the cricopharyngeal muscle. Complete surgical excision was curative in both cases.

Atypical and malignant lipomatous lesions of the head and neck

Although liposarcoma is the second most common soft-tissue sarcoma in adults, the incidence of liposarcoma of the head and neck is low. There are only 83 reported cases of head and neck liposarcoma. We report four cases of atypical and malignant lipomatous lesions of the head and neck and discuss their histologic classification and treatment implications. The histologic nature of liposarcoma is correlated clinically with treatment outcome. Recently, many authors have adopted the term atypical lipoma to describe well-differentiated lipomatous lesions in superficial extremity locations because of their tendency toward local recurrence only, without metastases or patient mortality. Although we accept the classification atypical lipoma for superficial, well-differentiated lesions, we believe that histologically similar lesions in nonsuperficial locations in the head and neck are best designated "well-differentiated liposarcoma."

Non-specific fluorescent whitener stains in the rapid recognition of pulmonary dirofilariasis: a report of 20 cases

BACKGROUND

Solitary lung nodules in humans caused by the dog parasite Dirofilaria immitis are steadily increasing in number. The organisms can be easily missed in haematoxylin and eosin stained tissue when they are degenerated and pale staining.

METHODS

The value of Tinopal CBS-X (TCBS-X) and Calcofluor white (CFW), two rapid, inexpensive, simple non-specific fluorescent whitening stains, were assessed in the identification of these worms. Deparaffinised rehydrated tissue slides prepared from the pulmonary nodules were stained for one minute in 1% w/v aqueous solutions of TCBS-X or CFW, counterstained, coverslipped, and viewed with a fluorescent microscope.

RESULTS

The stains demonstrated the intact worm and worm fragments in 20 cases of pulmonary dirofilariasis collected from hospitals in Houston. The filariae and fragments of filariae stained bright green while the background tissue stained red, delineating the internal structures of the worm.

CONCLUSIONS

Dirofilariasis should be included in the differential diagnosis of subpleural masses, and non-specific fluorescent whitening stains can help in the rapid recognition of the fragmented organism in cytological or surgical material.

Hürthle cell adenoma arising in a thyroglossal duct cyst

A 18-year-old black woman was initially seen with a 1-year history of a slowly enlarging midline neck mass. On physical examination this was consistent with a thyroglossal duct cyst. Histologic examination following a Sistrunk procedure revealed a Hürthle cell adenoma arising in a thyroglossal duct cyst. This is the second reported case of a Hürthle cell adenoma arising in a thyroglossal duct cyst. Neoplasms of thyroglossal duct cysts are reviewed.

Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis

PURPOSE

Five hundred fourteen consecutive patients with an isolated upper or lower extremity penetrating injury were entered into a prospective study designed to refine the indications for diagnostic arteriography.

METHODS

Twenty-two (4%) patients with limb-threatening ischemia who required immediate operation and 23 (4%) who refused arteriography were excluded from subsequent analyses. The remaining 469 patients were classified as being at high, intermediate, or low risk for an arterial injury.

RESULTS

Two hundred thirteen patients who were at low risk were observed for 24 hours, discharged, and monitored as outpatients. No delayed complications of an arterial injury developed in any patient in this group. The intermediate-risk group of 151 patients and the high-risk group of 105 patients underwent arteriography. Seventy-seven injuries were identified; 24 were major (limb-threatening) and 53 were minor. Fourteen major injuries required operative repair or transcatheter embolization; the remaining 10 nonocclusive major injuries were observed without sequelae.

CONCLUSIONS

By step-down logistic regression only pulse deficit (p < 0.01) and an ankle/brachial or wrist/brachial index less than 1.00 in the injured extremity (p < 0.03) were found to be significant predictors of an arterial injury. The presence of either of these two clinical variables successfully predicted all major arterial injuries. This prospective study supports the proposition that arteriography that is limited only to those patients who have either a pulse deficit or minimum ankle/brachial or wrist/brachial index less than 1.00 successfully detects all significant arterial injuries.

Fine needle aspiration of pancreatic cystic epithelial neoplasms

Pancreatic cystic epithelial neoplasms present diagnostic challenges in cytology. An accurate diagnosis is important since the prognosis and treatment may vary. We report the cytologic features in fine needle aspirates of four cases of cystic neoplasms of the pancreas (two micro-cystic adenomas, one mucinous cystic neoplasm and one mucinous cystadenocarcinoma). Smears were evaluated as to their cellularity, content and predominant cell type. Aspirates from the microcystic adenomas yielded hypocellular material with rare strips of cuboidal cells having bland nuclei and pale cytoplasm. No mucinous material was identified in the background, but the cells stained positively with periodic acid-Schiff stain. Smears from the mucinous cystic neoplasm were moderately cellular and contained abundant mucinous material. The columnar epithelial cells were arranged in tight sheets, clusters and strips. Most cells had benign nuclear features with focal mild nuclear atypia. Key cytologic findings noted in the mucinous cystadenocarcinoma were moderate cellularity, loose clusters of cells, single cells, overt malignant nuclear features and occasional signet ring cells. Pancreatic pseudocysts can be distinguished from pancreatic cystic epithelial neoplasms by the predominance of histiocytes and inflammatory cells and absence or paucity of epithelial cells. To differentiate microcystic adenomas from mucinous cystic neoplasms, the above criteria coupled with periodic acid-Schiff and mucin staining should effectively differentiate these diagnostic entities.

Carcinoma of the gallbladder found during laparoscopic cholecystectomy: a case report and review of the literature

Laparoscopic cholecystectomy has become an accepted appropriate method for removal of the diseased gallbladder. With cancer of the gallbladder to be expected in 1-2% of all biliary tract operations, it is likely that surgeons may be confronted with the unsuspected finding of gallbladder carcinoma during the course of laparoscopic cholecystectomy. We present here a case of gallbladder carcinoma found at laparoscopic cholecystectomy, and discuss the interesting clinical findings associated with this entity, including the preoperative suggestion of Trousseau's syndrome. A review of the pertinent literature is included.

Fine needle aspiration diagnosis of a nasopharyngeal teratoma

A newborn presented with airway obstruction due to a large nasopharyngeal mass extending into the oropharynx. A diagnosis of teratoma was made by transoral fine needle aspiration (FNA) biopsy and confirmed by subsequent histologic studies. The cytologic features of nasopharyngeal teratoma are presented, and the diagnostic utility of FNA biopsy in evaluating such lesions is discussed.

Uterine lithiasis

We report a case of uterine lithiasis in a 73-year-old Latin American woman. The patient underwent vaginal hysterectomy and colporrhaphy for complaints related to secondary uterine prolapse and cystocele. The 70-g, 8 x 5 x 3.5 cm uterus had a normal shape. Ten white, starlike, 0.5 x 0.5 x 0.2 cm, calcified structures were found within the endometrial cavity. Chemical analysis of one of these by x-ray diffraction showed it to be composed of calcite, one of the crystalline forms of calcium carbonate. To our knowledge, this is the first report of human uterine lithiasis in the literature.

Estrogen and progesterone receptors in bronchogenic carcinoma

Although the lung is not usually considered a major target organ of sex hormones, epidemiological observations, studies of pulmonary neoplasms in laboratory animals, and investigations of carcinomas derived from other "nontarget" organs suggest that sex hormones may have a role in the pathogenesis of bronchogenic carcinoma. To confirm that estrogen (ER) and progesterone receptors are present in human lung cancers, 19 resected lung cancers were examined for receptors using a prelabeled sucrose gradient method. Three squamous cell carcinomas were positive for ER (greater than 6.9 fmol/mg cytosol protein). Three squamous cell carcinomas, two adenocarcinomas, and one small cell carcinoma were positive for progesterone receptors (greater than 6.9 fmol/mg cytosol protein). One tumor, a squamous cell carcinoma arising in a woman who smoked, had an ER level of 301 fmol/mg, a highly positive level even for breast cancers. These observations may provide a basis for adjuvant hormonal therapy in selected lung cancer patients.

Pathology of the thyroid and parathyroid glands

Open communication between surgeon and pathologist is key in the area of thyroid and parathyroid pathology. Gross and microscopic examination provides valuable data, including important prognostic information, to guide further clinical management. A number of new techniques are being developed. These will not only enable us to learn more about the pathogenesis of lesions in these organs but may provide additional prognostic data.