Neoplasms of the genital tract in a Vietnamese potbellied pig

A 9-year-old, female potbellied pig showed loss of appetite and abdominal distension. After clinical examination and ultrasonography, a tumour was suspected. At laparotomy a large mass was present in the genital tract. Because the mass could not be excised, the pig was euthanized. Pathological examination revealed leiomyoma of the cervix and uterus wall in addition to multifocal adenocarcinomas of the uterus.

Spontaneous lesions in the reproductive tract and mammary gland of female non-human primates

Because of their close phylogenic relationship with humans, the use of non-human primates (NHP) as experimental subjects has a long history in biomedical research. Although research topics have shifted focus and species used have changed, NHP remain vital as models in basic and applied research. While there is a wealth of information available on the spontaneous lesions of NHP, most of this information is fragmented, dated, or narrow in focus, often limited to single case reports. This review attempts to integrate this information to illustrate and enumerate the spectrum of spontaneous pathology of the reproductive tract and mammary gland of NHP. Although not the focus of this review, steroid-related changes are inextricably linked to these tissues, and brief consideration is given to this subject as well.

Steroid receptors in canine and human female genital tract tumours with smooth muscle differentiation

The expression of oestrogen receptor-alpha (ERalpha) and progesterone receptor (PR) was examined in 32 canine genital tract tumours diagnosed as smooth muscle tumours (benign or malignant, pure or mixed). The immunohistochemical expression of calponin was used to assess the smooth muscle differentiation of the tumours. Nineteen human uterine leiomyomas were also examined. Calponin expression was detected in 89.3% of canine and 100% of human genital tract tumours diagnosed as leiomyomas, as well as in the majority of other tumours examined (canine or human, genital or extragenital, benign or malignant) with the exception of canine negative control tumours (cutaneous fibroma and hepatoid gland adenoma). ERalpha was found in 56.3% of canine and 52.6% of human leiomyomas, while PR was found in 84.4% of canine and 94.7% of human tumours. These results indicate that calponin is a good marker for differentiating neoplasia of the canine genital system of uncertain origin, as in human patients. They also show that canine tumours with smooth muscle differentiation of the genital tract of the bitch express steroid hormone receptors, a finding that opens up the possibility of hormone therapy.

Tumors of the urogenital system in dogs and cats. Retrospective review of 138 cases

The aim of the study was to estimate the prevalence and localization of different tumors in the urogenital system in dogs and cats in relation to sex, age and breed of animals. The study was performed on tumors or tissue specimens from tumors of the urinary and genital system obtained during surgery from dogs and cats submitted to the Division of Pathological Anatomy, Department of Clinical Sciences Agricultural University of Warsaw from 1998 to 2005. Most tumors of the urogenital system recognized in the present study derived from dogs (94.20%, 130 cases), and only a few cases were obtained from cats (5.79%). Occurrence and localization of urogenital system tumors in present review is similar to findings reported by other authors. Testicular tumors in males, ovarian lesions in females and urinary bladder tumors in both sexes were most commonly recognized. Older dogs were most often affected, animals with nonmalignant tumors were a bit younger than those with malignant lesions. Any obvious breed predilections were found, but terriers were at increased risk for development of transitional cell carcinoma of the urinary bladder and mixed breed and German shepherd for development of testicular neoplasms.

Spontaneously Occurring Fibroid Tumors of the Laying Hen Oviduct

Spontaneously occurring benign uterine leiomyomas (fibroids) are the most common tumors of reproductive-age women. It is estimated that more than 70% of all women will develop uterine fibroids, and the presence of these tumors is a primary cause of hysterectomies. Research into the causes and treatment of uterine fibroids is hampered by a lack of reliable animal models for the disease. Leiomyomas that appear to be outwardly similar to human uterine fibroid tumors are known to occur on the oviducts of laying hens over 2 yr of age. The objective of this study was to characterize these tumors and compare them to human uterine fibroids to determine the suitability of the aging hen as a model system for the study of the disease. In this study, hens at 5 yr of age were examined for the presence of oviduct-associated fibroid tumors. Tumors were found attached to the internal surface of the oviduct, embedded in the oviduct wall, or attached to the exterior of the magnum and isthmus. Tumor and normal oviduct samples were frozen or fixed in formalin for histological analyses or immunohistochemistry for estrogen and progesterone receptors, proliferating cell nuclear antigen and Bcl-2 protein expression. Human uterine fibroid samples were acquired and evaluated compared with hen oviduct fibroids. The results indicate that laying hen fibroid tumors are similar to human fibroid tumors with respect to estrogen and progesterone receptors, localized cellular proliferation, and expression of the Bcl-2 protein.

Reproductive oncology

The actual incidence of reproductive tract tumors is difficult to ascertain, presumably because a significant percentage of dogs and cats are neutered, particularly in the United States. Data from European countries, where elective neutering is less common, provides insights. Several studies document the relative frequency of reproductive tumors. Larger studies of the more common tumors, e.g., testicular tumors, provide a substantial amount of information on the clinical presentation and response to treatment of dogs, but overall there is less information available on cats. Numerous case reports document the less commonly reported tumors and will be included in the following discussion.

Genital tract smooth muscle tumors are common in zoo felids but are not associated with melengestrol acetate contraceptive treatment

In a survey of gynecologic lesions in female zoo felids conducted to determine if the widely used progestin contraceptive melengestrol acetate (MGA) had adverse effects, numerous leiomyomas and leiomyosarcomas were detected. This current study aimed to characterize the morphologic features of these tumors, determine their prevalence, and assess if MGA was a risk factor for their genesis. Genital tracts from 219 zoo felids representing 23 species were evaluated, and leiomyomas were detected in 24% of the felids. Leiomyomas were often multiple and occurred in the myometrium, ovary, or adjacent broad ligament. The risk of developing leiomyomas increased with age, but MGA treatment or parity had no effect. Five other felids had leiomyosarcomas. Leiomyosarcomas were distinguished from poorly demarcated leiomyomas by the presence of local invasion, metastasis, and cellular atypia, but necrosis and mitotic rate were not distinguishing criteria. Four of five felids with leiomyosarcomas had been treated with MGA. These results indicate that leiomyomas are common spontaneous lesions in the genital tracts of zoo felids and their genesis is not linked to MGA exposure. Whether progression to malignancy is promoted by MGA warrants further investigation.

Histopathological studies on neoplasms in the genital tract of female donkeys in Egypt

The genital tracts of 165 female donkeys were collected and examined with special concern to neoplasms. Ovarian Neoplasms were found in 12 cases (7.72%). A granulosa cell tumor was found in one case (0.61%). A cavernous haemangioma was found in 11 cases (6.67%). Uterine neoplasms were found in 14 cases (8.84%). Endometrial polyps and fibroleiomyoma were found in one case (0.61%) each. Leiomyoma was found in 2 cases (1.21%). Cavernous haemangioma was found in 10 cases (6.06%), and cervical polyps in 5 cases (3.03%).

Common metastatic carcinoma of California sea lions (Zalophus californianus): evidence of genital origin and association with novel gammaherpesvirus

Tissues from 10 adult California sea lions (Zalophus californianus, seven females and three males) that had metastatic carcinoma in sublumbar area lymph nodes were examined histologically. A distinctive epithelial proliferative lesion interpreted as intraepithelial neoplasia was found in genital tracts of all ten animals; in vagina (5/7), cervix (7/7), uterus (3/7), penis (3/3) and prepuce (3/3). Intraepithelial neoplasia closely resembled metastatic carcinomas and was directly contiguous with invasive carcinoma in one animal. Rare eosinophilic intranuclear inclusion bodies were found in penile and preputial intraepithelial neoplasia (one animal), cervical intraepithelial neoplasia (one animal), invasive cervical carcinoma (one animal) and metastatic carcinoma (two animals). Electron microscopic examination of tissues from two sea lions (one with intraepithelial neoplasia and one with metastatic carcinoma) demonstrated viral particles consistent with a herpesvirus. An immunohistochemical stain for the latent membrane protein of Epstein-Barr virus was positive in intraepithelial neoplasia in one sea lion. Herpesvirus DNA sequences were detected by consensus primer polymerase chain reaction (PCR) in metastatic carcinomas from all four sea lions from which unfixed tumor samples were available. Results of sequencing were consistent with a novel gammaherpesvirus in the genus Rhadinovirus. DNA extracted from the four metastatic carcinomas also was tested for papillomavirus by Southern blot and PCR with consensus papillomavirus primers; all samples were negative by both methods. These findings support the genital origin of the sea lion carcinoma and implicate a novel gammaherpesvirus as a possible cause.

Caprine genital leiomyosarcoma

An aged Saanen doe was euthanized following repeated severe hemorrhage from the vulva. Necropsy examination revealed mural thickening of tubular genitalia with firm, protruding intralumenal masses containing blood-filled cavitations, and effacement of normal cervical architecture. Histologically, uterine and cervical masses comprised a variably dense population of mildly pleomorphic spindle cells forming interlacing streams supported by variably dense collagenous stroma. Immunoperoxidase staining of neoplastic cells was positive for muscle-specific actin, supporting the diagnosis of low-grade leiomyosarcoma. Months later, the doe's twin was likewise euthanized due to persistent bleeding from the vulva associated with a large vulvar mass having histopathologic features similar to those of the previous case. The clinical, gross, and histologic findings are similar to five cases of caprine genital leiomyosarcoma identified in retrospectively analyzed case material. Analysis of caprine tumor accessions over 20 years demonstrated a significantly higher incidence of genital leiomyosarcoma within the Saanen breed.

Neoplasia of the female reproductive tract

Granulosa cell tumors of the ovary and SCC and melanoma of the external genitalia are the most common neoplasms in the mare. Tumors of the tubular reproductive tract and the mammary gland are rare.

Spontaneous tumours in tree shrews (Tupaia belangeri): population studies

In a necropsy series at the German Primate Centre, 63 of 1132 tree shrews were found to have tumours. The youngest affected animal was < 6 months old, but the incidence of tumours increased strikingly beyond 2 years of age; of 17 animals aged > 8 years, no less than 14 (82.4%) were affected. The sites of neoplasia were the genital system (22 cases), haematopoietic system (18 cases of malignant lymphoma, many involving the digestive tract), lungs (14 cases), integument (five cases), digestive tract (three cases other than those with malignant lymphoma) and urinary bladder (one case).

Research note: lack of an effect of high levels of menadione on tumor development in Japanese quail females

The objective of the experiment was to study the influence of a high but nontoxic dietary level of menadione (vitamin K3) on the incidence of leiomyomas and leiomyosarcomas in the oviduct of females from various lines of Japanese quail. Analyzed values of vitamin K3 per 1,000 kg of feed were 7.37 g in the control diet, and 149.6, 1,722, and 3,722 g for the experimental diets from 0 to 4, 5 to 8, and after 8 wk of age, respectively. Females were killed after they had been in production for 158 days. Females from three large-bodied lines had a greater incidence of smooth muscle tumors than those from a smaller randombred control line. The high dietary level of vitamin K3 had no influence on tumor development.

Kaposi's sarcoma among AIDS patients: transmissible venereal tumour by cell engraftment?

The epidemiologic findings of Kaposi's sarcoma (KS) among patients with the acquired immunodeficiency syndrome (AIDS) suggest that human immunodeficiency virus (HIV) infection is insufficient for the development of KS. It was speculated that another sexually transmitted infection is responsible for the markedly increased incidence of KS among patients who acquired HIV infection through sexual intercourse. However, no such contributing infectious agent was consistently identified. The canine transmissible venereal tumour (TVT) is a malignant tumour that can be transplanted by viable cells across major histocompatibility complex (MHC) barriers. Recent findings suggest that all canine TVTs originated from the same tumour and were transferred from one animal to the other during sexual intercourse. It is suggested that, in analogy with the canine TVT model, the characteristics of KS epidemic among AIDS patients may be explained by transmission and engraftment of viable malignant cells during intercourse.

Influence of selection for increased body weight on the incidence of leiomyomas and leiomyosarcomas in Japanese quail

Leiomyomas and leiomyosarcomas were observed in adult laying hens from lines of Japanese quail selected solely (HW) or partly (HW-HP; HW-LP) for increased 4-wk BW and the corresponding randombred control (R1). No neoplasms were observed in a line (LW) selected for decreased 4-wk BW based on observations in one generation. Line R1 served as the base population for Lines HW and LW and was maintained without conscious selection for any trait, Lines HW-HP and HW-LP were sublines of Line HW in which the males were selected for increased 4-wk BW and the females were selected for high or low levels of plasma total phosphorus, respectively. Hens of all lines were necropsied after completing a 120-day production period. A high incidence of neoplasms were found in the dorsal and ventral ligaments of the oviduct in the immediate vicinity of the magnum, and the incidence was much greater in the lines selected for increased growth than in Line R1. These results suggest that selection for increased BW in Lines HW, HW-HP, and HW-LP has resulted in genetic changes that are conducive to neoplastic growth. Based on the results of one generation, it appears that selection for decreased 4-wk BW reduced incidence of neoplasms.

Spontaneous tumors in F-344/Jcl rats

The age-related incidence of spontaneously occurring neoplastic and non-neoplastic lesions in untreated F-344/Jcl rats, used as controls in carcinogenicity testing, were studied from the histological examination of tissues from 469 males and 354 females. The incidence of spontaneous tumors was 83.2% in the males and 71.2% in the females. The most common neoplasms were leukemia (males: 24.3%, females: 24.0%), pituitary adenoma (males: 16.0%, females: 45.2%), pheochromocytoma (males: 14.7%, females: 7.3%), testicular interstitial cell tumor (males: 79.1%), and uterine endometrial stromal polyp(females: 16.4%). The incidence of other tumors of almost all the organs and/or tissues was low. Non-neoplastic lesions generally increased with advancing age of the animals.

Concentration of steroid sex hormones in the plasma of hens in relation to oviduct tumours

1. The concentrations of 17 beta-oestradiol (E2) and progesterone (P) were determined in the plasma of layer breeder hens at the end of their first laying season, in relation to neoplasms of the oviduct, including magnum tumours and leiomyomas. 2. The plasma concentration of E2 was higher in tumorous than in non-tumorous hens indicating it may be involved in the development of oviduct tumours. 3. The plasma concentrations of P in tumorous and non-tumorous hens were not significantly different, suggesting no active role of P in the aetiology of the tumours. 4. The E2: P ratio was higher in tumorous than in non-tumorous hens. This ratio could be of value in predicting hens at risk of developing oviduct tumours.

Immunohistochemical demonstration of desmin in canine smooth muscle tumors

Sections of formalin-fixed, paraffin-embedded canine leiomyomas, leiomyosarcomas, or fibrosarcomas were examined by immunohistochemical methods for the presence of desmin. Twenty-two leiomyomas and leiomyosarcomas were stained using the avidin-biotin complex technique, and 14 samples demonstrated positive staining for desmin. The eight negative results obtained may reflect differences in fixation or the affinity of the primary antibody for the tissues examined. Desmin was specific for myogenic tissues. Five canine fibrosarcomas examined immunohistochemically were all negative for desmin staining. The results indicate that desmin is a useful marker for immunohistochemical identification of canine leiomyomas and leiomyosarcomas.

Goat papillomatosis

The present study indicates that the development of caprine mammary gland warts seems to depend on several factors--namely, nonpigmented skin, adult age, excessive exposure to sunlight, and contact with a yet undefined infective agent. Three types of goat papillomas are described: mammary, cutaneous, other than mammary, and genital. Warts on animals lacking pigmented skin are more frequent in adult animals that live in areas where there is abundant sunlight. Mammary gland papillomas are the most numerous and occur in different stages: ie, goats with mammary gland papillomas that regress, never to recur, goats with papillomas that regress in the winter and reoccur in summer, goats with persistent papillomas of which some are from the group that had previous winter time regression, and goats that have progression of persistent papilloma to carcinoma. Saanen, Saanen crossbreeds, and goats of other breeds that lack pigmented skin and live in sunbelt areas are at high risk for papillomatosis. An infective agent was not defined even after electron microscopic, immunocytochemical, and DNA-DNA hybridization studies. Yet, there is high probability that an infective agent is involved, because mammary gland papillomas usually occur in the susceptible herd 4 to 6 months after an affected goat is introduced.

Papillomas and squamous cell carcinomas of horses

In a retrospective study encompassing 13 years of diagnostic work, papillomas and squamous cell carcinomas from horses were screened for papilloma-virus antigens, using the peroxidase-antiperoxidase technique. Papillomas were most commonly found on the penis and vulva, followed by cutaneous, ocular, and oral locations. Squamous cell carcinomas were most frequently located on the third eyelid and cornea, followed by genital, oral, maxillary sinus, and cutaneous sites. Papillomavirus structural antigens were detected in 7 cutaneous and 5 genital papillomas, but not in squamous cell carcinomas.

Gonadal neoplasms in largemouth bass, Micropterus salmoides and Japanese dace (ugui), Tribolodon hakonensis

Massive abdominal enlargement was observed at relatively high incidence in two species of fish kept in two public aquariums for several years. Three seminomas, one dysgerminoma and two fibromas were found in 14 largemouth bass, Micropterus salmoides, kept in a public aquarium for over 80 months. Four seminomas and one nephroblastoma were found in 24 Japanese dace (ugui), Tribolodon hakonensis, kept for more than 57 months in two different aquariums. The seminomas in M. salmoides showed rapid growth, and the affected fish died within a few months. At necropsy, a single large tumor, measuring 10.5-12.0 cm, was found in the abdominal cavity. The seminomas in T. hakonensis were single or multiple tumors, measuring 2.0-4.5 cm in diameter. Histologically, these seminomas were composed mainly of a typical germ cells similar to those in human seminomas or embryonal carcinomas. A nephroblastoma in one T. hakonensis showed extensive metastases to various organs. The cause of these tumors is unknown, but the prolonged longevity of fish kept under artificial conditions may have enhanced their development.

Tumors and tumor-like lesions in the genitalia of sows

Of a total of 1445 sows, tumors were detected in the uterus of 11 animals and in the cervix/vagina of 1 animal. Tumor-like lesions were detected in the ovary of 56 animals. The incidence of tumors was higher than that mentioned in the literature, possibly because of the relatively high age of the sows (mean parity of 6.8) and the accuracy of investigation. Several tumors would not have been detected during routine slaughter examination. The uterine tumors were diagnosed as leiomyoma (6), fibroma (3), cyst-adenoma (1) and fibro-leiomyoma (1). The cervical/vaginal tumor appeared to be a fibroma. The ovarian lesions could not be satisfactorily classified. They consisted of connective tissue, blood vessels, and granulosa cells, which were present in variable quantities in different ovaries and in different sides of the same ovary. Sows with tumors were older than the mean determined age at slaughter (parity 6.8). Sows with uterine and cervical/vaginal tumors had a parity of 11.6; sows with ovarian lesions had a parity of 9.0. Sows with uterine- or a cervical/vaginal tumor were often slaughtered for infertility reasons.

Neoplastic and non-neoplastic lesions in aging Slc: Wistar rats

Spontaneous neoplastic and non-neoplastic lesions in 98 male and 100 female Slc: Wistar rats, which have been widely used in Japan for toxicological studies, were examined. As spontaneous tumors, the most frequent tumors in males were testicular interstitial cell tumors, followed by tumors of the hematopoietic organs, adrenal gland, thyroid gland, preputial gland, pituitary gland, liver and mammary gland. Those in females were tumors of the pituitary gland, mammary gland, hematopoietic organs, uterus and thyroid gland. The organ distribution and histological types of spontaneous tumors observed in Slc: Wistar rats were very similar to those in F-344/DuCrj rats, although the incidences of some tumors differed slightly in the two strains. Various non-neoplastic lesions were also observed in the heart, kidney, liver and many other organs. These results should be useful in evaluating the results of toxicological and carcinogenic studies on this strain of rat.

Spontaneous tumors in F-344/DuCrj rats

Spontaneous tumors in 296 male and 297 female F-34/DuCrj rats used as control groups in six carcinogenicity tests were tabulated and evaluated. In males the most frequent tumors were testicular interstitial cell tumors, followed by mammary fibromas and fibroadenomas, mononuclear cell leukemias, pheochromocytomas, C-cell adenomas of the thyroid, pituitary adenomas, preputial adenomas, neoplastic nodules of the liver, and lung adenomas. In contrast, in females pituitary adenomas, uterine endometrial stromal polyps, mammary fibroadenomas, mononuclear cell leukemias and C-cell adenomas were the most common. Various other tumors of almost all other organs and/or tissues were found, although their incidences were low. Variability in the rates of incidence in some tumors was observed in different control groups.

A survey of neoplasia in domestic species over a 40-year period from 1935 to 1974 in the Republic of South Africa. V. Tumours occurring in the cat

A total of 243 neoplasms were recorded in a survey of all the feline neoplasms which are reported in the registration files of the Veterinary Research Institute, Onderstepoort, Republic of South Africa, covering a 40-year period from 1935 to 1974. The tissues most commonly neoplastic were the skin, followed by the lymphoid tissue, the digestive tract and the genital system, which together accounted for 76,6% of the total tumours. Squamous cell carcinomas, the commonest type of tumour, accounted for 65 (26,7%) of the 243 neoplasms, followed by lymphosarcomas with 50 (20,5%). The majority of squamous cell carcinomas involved the skin, especially that of the ear and nose. A reasonably high proportion of these tumours also occurred on the tongue and eyelid. The commonest form of distribution for lymphosarcomas was the multicentric form, followed by the alimentary, the renal and thymic forms. Squamous cell carcinomas were the most frequent type of skin tumours, followed by basal cell tumours, mastocytomas and melanomas. The digestive tract accounted for 33 (13,5%) of the neoplasms, the 3 most commonly encountered being squamous cell carcinomas, lymphosarcomas and intestinal adenocarcinomas. The mammary gland tumours accounted for 23 (9,5%) of the total, 61% of which were carcinomas. Other tumours encountered were fibromas, fibrosarcomas involving particularly the skin, melanomas of the skin or eye, osteosarcomas, hepatocellular carcinomas and haemangiosarcomas.

Pathology of the clitoral and prepucial glands in aging F344 rats

Clitoral and prepucial glands from 112-week-old untreated F344 male and female rats were studied histologically. Lesions included acinar cell atrophy, fibrosis, duct distension, inflammation, and neoplasms. Acinar cell atrophy and fibrosis were seen in 68% of the males and 58% of the females. More severe acinar cell atrophy, fibrosis, and inflammation were seen in the male rats. The neoplasms were small and circumscribed, cystic, or papillary cystic adenomas derived from acinar cells. One cystic adenocarcinoma was diagnosed.

Successively transplanted canine transmissible sarcoma

Canine transmissible sarcoma has been maintained since 1967 as an allogeneic tumor cell line. The tumor originated from a naturally occurring venereal sarcoma in a 7-year-old female dog, Hokkaido-ken. The animals used for the serial transfer from 1st to 50th passages were 1- to 8-month-old puppies. Histological features and karyological characteristics of the tumor were not modified by the passive transfer. In most of the dogs, the palpable growths in the subcutaneous tissues were present at approximately the same time. These findings suggest that the sarcoma is an only established tumor cell line in dogs.

Multiple primary tumors in domestic animals: a preliminary view with particular emphasis on tumors in dogs

Cattle, horses, cats, and dogs with microscopically confirmed multiple primary tumors were reported to the Veterinary Medical Data Program, a system to collect, store and retrieve veterinary clinical information. Of 2611 tumors diagnosed prior to, concurrent with, or subsequent to other tumors during the period studied, 2361 were in 1062 dogs and 250 were in 120 other animals in all other species categories. The 604 multiple primary malignancies (two or more malignant tumors in one animal) were similarly distributed, by species, with 512 in dogs and 92 in all other species combined. The total number of multiple tumors reported in dogs closely approximated a theoretic model of random distribution, but several site-pairs of tumors seemed to occur excessively; one pair (mammary tumors and tumors of internal female organs) might parallel a similar excessive occurrence in women, suggesting a possible spontaneous tumor model for the latter.

Tumours of the female genital tract

Tumours of the female tubular genital tract are comparatively rare, with the exception of leiomyomas in cows and bitches, uterine carcinomas and vaginal fibropapillomas in cows, and transmissible venereal tumours in bitches. Uterine adenocarcinomas of cows are highly scirrhous, often causing minimal gross lesions that remain undetected until metastatic lesions in pelvic nodes and lungs are found. Cats and bitches also develop uterine carcinomas, but less frequently than cows; when present, they are predominantly discrete masses of well differentiated, non-sclerosing adenocarcinoma. Fibropapillomas are caused by the virus of verrucca vulgaris and can be transmitted to the penis of the bull. Adenomyosis is not uncommon in the cat, cow, and bitch. There is a marked difference in the frequency with which cervical carcinomas occur in man compared with other mammals; in the latter we could find no instance of an unequivocal primary cervical carcinoma. There are a few reports describing invasive carcinomas involving the cervix, but invasion from either a uterine or a vaginal carcinoma could not be ruled out.