Lymphoid Polyps of the Palatine Tonsil

Tonsillar lymphoid polyps are uncommon lesions that have rarely been studied. The authors describe the clinical, histopathologic, and immunohistochemical features of 6 tonsillar polyps in which lymphoid tissue represented more than 80% of the lesion. Presenting symptoms were tonsillar mass and/or dysphagia. No predisposing factor was detected. Microscopically, all polyps contained follicles with germinal centers, crypts lined by lymphoepithelium, and a small amount of fibrous tissue in the center of the lesion. B cells (CD20+), T cells (CD45RO+), plasma cells (κ+ and λ+) and vessels (lymphatic, D2-40+; blood, CD34+) presented distribution and architectural patterns as expected for lymphoid tissue of a palatine tonsil. Tonsillar lymphoid polyps are possibly hamartomas characterized by overgrowth of lymphoid elements, which maintain an architectural pattern and cellular composition similar to those of the palatine tonsil.

Rectal tonsil: A case report and literature review

The rectal tonsil, a reactive proliferation of lymphoid tissue located in the rectum, is rare. Histologically, benign lymphoid hyperplasia of the rectum is usually characterized by large lymphoid follicles with active germinal centers and a narrow surrounding mantle zone and marginal zone. This lesion is benign, but must be differentiated from the polypoid type of mucosa-associated lymphoid tissue lymphomas. In the current paper, we present a case of rectal tonsil in a 59-year-old woman. We describe the endoscopic ultrasound imaging findings with literature review.

Robotic partial adrenalectomy using indocyanine green dye with near-infrared imaging: the initial clinical experience

OBJECTIVE

To present the initial clinical experience with robot-assisted partial adrenalectomy using indocyanine green dye with near-infrared fluorescence (ICG-NIRF) imaging.

METHODS

Three consecutive patients with solitary adrenal masses with worrisome features were referred for treatment. The preoperative workup included dedicated axial imaging and adrenal function studies. All patients underwent purely robotic partial adrenalectomy with ICG-NIRF guidance. Relevant steps of the technique included a transperitoneal approach, gross identification of the adrenal gland, administration of 5 mg intravenous ICG, and finally, mass resection guided by ICG-NIRF and white light visualization in an effort to completely excise the mass while sparing uninvolved adrenal tissue.

RESULTS

Robotic partial adrenalectomy was successfully performed with negative margins in all patients. All masses were hypofluorescent relative to normal adrenal tissue with ICG-NIRF and included a pheochromocytoma, lipoadenoma, and follicular lymphoid hyperplasia.

CONCLUSION

Robotic partial adrenalectomy with intraoperative ICG-NIRF is safe and feasible. The addition of ICG-NIRF may help mass identification, excision, and promote the use adrenal-sparing surgery.

[The application of the cryosurgical and lymphotropic technologies for the combined treatment of postintubation tracheal stenosis]

The combined treatment of 10 patients presenting with postintubation thracheal stenosis was carried out with the application of the cryosurgical and lymphotropic technologies. Cryogenic treatment of ciatrical stenosis was performed through the tracheostoma using a titanium nickelide cryoappliactor. The effect of the cryogenic treatment was enhanced by a lymphotropic mixture composed of diprospan and longidaza and administered retrosternally as a course of up to three injections once in a week. In the intervals between the injections and after the termination of the course, the patients were asked to inhale longidaza dissolved in a broncho- or mucolytic preparation through a nebulizer (up to 5 inhalations). All the treated patients reported the recovery of normal breathing through the natural airways.

[Peculiarities of surgical interventions in the nasopharynx of patients presenting with lymphoid tissue hypertrophy and exudative otitis media]

A total of 118 patients presenting with exudative otitis media and lymphoid tissue hypertrophy in the nasopharynx were examined and treated. A classification of different variants of lymphoid tissue hypertrophy and pharyngeal tonsil hypertrophy was developed and used as a basis to plan the strategy of surgical interventions in the nasopharynx.

Secretory immunoglobulin A (sIgA) deficiency in serum of patients with GALTectomy (appendectomy and tonsillectomy)

INTRODUCTION

In adult human beings, 80-85% of the immune cells are located in the digestive tract mucosa; hence the importance of the Gut Associated Lymphoid Tissue (GALT) in host defence. We studied the influence of the surgical removal of two important parts of the gut associated with lymphoid tissue (tonsillectomy and appendectomy) on immune parameters.

METHODS

One hundred and sixty patients were enrolled in this study. They were divided into four groups of forty patients each and matched for gender and age: group 1, appendectomized and tonsillectomized; group 2, only appendectomized; group 3, only tonsillectomized; and group 4, control group, neither tonsillectomized nor appendectomized. We analysed in blood: hemogram, protein electrophoresis, lymphocytic populations (T4 cells, T8 cells, NK cells), IgG, IgM, IgA immunoglobulin, and their fractions IgA1, IgA2, and secretory IgA.

RESULTS

Levels of secretory IgA in serum of patients in group 1 were significantly lower than in the other three groups (1.89 mg/dl, group 1; 2.32 mg/dl, group 2; 2.19 mg/dl, group 3 and 4.97 mg/dl, group 4; p<0.0001). Also, the values found in the two groups that had undergone only one of the operations were clearly lower than in control patients (p<0.0001). In this study, the reduction was sustained for a period of between 3 months and 3 years in appendectomized patients, and more than 20 years in tonsillectomized patients.

IN SUMMARY

GALTectomy (appendectomy and tonsillectomy) significantly decreases secretory IgA levels in serum. The decrease is more intense when both operations have been done.

Colonic lymphoid aggregates in slow transit constipation

Information available on colonic lymphoid aggregates, apart from data of patients with inflammatory conditions, is scarce in other pathologic conditions. We investigated colonic lymphoid aggregates in patients with severe slow transit constipation, unresponsive to conventional therapeutic measures, and undergoing surgery for relief of their symptoms. Tissues from 27 patients with intractable slow transit constipation were obtained and compared with 10 controls. The number, diameter, lymphocyte distribution, and proliferative index were calculated and compared in both groups. Constipated patients displayed a significantly increased number of colonic lymphoid aggregates compared with controls. No differences were found concerning the other variables. The increase of colonic lymphoid aggregates found in severely constipated patients may represent a protective mucosal mechanism toward the chronic fecal stasis.

Variant Creutzfeldt-Jakob disease: a cause for concern. Review of the evidence for risk of transmission through abdominal lymphoreticular tissue surgery

BACKGROUND

Concern has long existed regarding the possible iatrogenic spread of variant Creutzfeldt-Jakob disease (v-CJD) through surgery. This had been fueled by recent reports of bovine spongiform encephalopathy in U.S. cattle and the first probable case of blood transmission of v-CJD in the UK.

METHODS

Systematic review of experimental and nonexperimental studies. Studies identified from searches of Medline, Embase, Cochrane Library, Science Citation Index medical databases, searching bibliographies of retrieved papers, and personal communication with international experts in the field.

RESULTS

Six articles satisfied our search criteria. Evidence stems from case reports, case series, and cross-sectional studies. There are no published cases of surgically transmitted v-CJD.

CONCLUSION

We found evidence of v-CJD prion agents in the spleen, appendix, rectum, and adrenal glands of affected patients and evidence of v-CJD prion in the appendix of patients in the preclinical stage of the disease. The risk of transmission of v-CJD prion during abdominal surgery is currently unquantifiable.

Does surgical removal of mucosal associated lymphoid tissue protect against adult coeliac disease? A case controlled study

BACKGROUND AND AIMS

Surgical resection of mucosa associated lymphoid tissue has been suggested as a protective mechanism against the development of inflammatory bowel disease. Mucosal T-cell activity plays a pivotal role in coeliac disease pathogenesis. We aimed to determine if the development of adult coeliac disease is influenced by appendectomy or tonsillectomy.

METHODOLOGY

Three hundred patients over 16 years of age with biopsy proven coeliac disease were identified from two hospital databases in South Yorkshire. From these databases, appendectomy and tonsillectomy status was determined and compared with 1033 coeliac disease antibody-negative controls (volunteers recruited from general practice). Logistic regression was performed to correct for the age differences between the two groups; cross-table analysis was performed.

RESULTS

Thirteen percent of coeliac disease patients and 12.2% of controls had previous appendectomy (P = 0.71; odds ratio 1.08; 95% confidence interval 0.72-1.62). 20.7% of coeliac disease patients and 24.5% of the controls had previous tonsillectomy (P = 0.17; odds ratio 0.80; 95% confidence interval 0.59-1.10).

CONCLUSIONS

No significance was demonstrated in either the appendectomy or tonsillectomy group. Surgical removal of mucosal associated lymphoid tissue does not appear to prevent the development of adult onset coeliac disease.

Follicular cholangitis: another cause of benign biliary stricture

The case of a 57-year-old woman with a benign biliary stricture is described. Radiological examinations showed granularly elevated lesions in the common hepatic duct and severe stenosis at the hepatic hilum. Under a tentative diagnosis of hepatic hilar bile duct cancer, the patient underwent extended right hepatectomy with bile duct resection. However, pathological and immunohistochemical studies revealed a benign stricture with remarkable formation of lymph follicles with germinal centers, which could be termed "follicular cholangitis". This is the first case report of this uncommon presentation of inflammatory changes of the bile duct. Its etiology was unknown, and more investigation is encouraged to clarify its relationship to systemic disorders and malignancies. As difficulty remains in discriminating between benign and malignant strictures by nonsurgical modalities at present, surgical resection without complications provides a feasible approach to such a benign lesion.

[Lymphoid nodules of the breast. Report of 10 cases observed in Cameroon]

The aim of this study was to present clinico-pathological aspects of breast lymphoid nodules in Cameroon. From the collection of the pathology laboratory of the Yaounde Central Hospital, all the cases of breast lymphoid nodules diagnosed between 1st January 1993 and 30th June 1998 were recorded. For each case, the following data were noted: age of the patient, clinical informations (signs and symptoms), microscopical aspects and histological description. 10 cases of breast lymphoid nodules were recorded. These were observed in women aged 19 to 50 and most of them were painless. All were mobile and felt by the patients before excision-biopsy. They were mostly found on the right and were less than 1 cm in diameter. Histologically, they presented as diffuse lymph node hyperplasia.

Lymphoepithelial cyst and epidermoid cyst of the accessory spleen in the pancreas

We report here two rare cystic lesions, a lymphoepithelial cyst (LEC) and an epidermoid cyst of the accessory spleen (ECAS) occurring in the pancreas. Histologically, the LEC was lined by stratified squamous epithelium and surrounded by a layer of lymphoid tissue with germinal centers. The ECAS showed similar histologic features with scattered lymphoid tissue, but splenic pulp tissue was present in the wall. In both cysts, some small pancreatic islets and ducts were seen in the fibrous tissue surrounding the lymphoid layer or the splenic pulp, respectively. The lining epithelia of the LEC and the ECAS, as well as those of retention cysts of the pancreas and epidermoid cysts of the spleen used for comparison, were similarly positive with AE1/3, CAM5.2, CK7, CK13, and carcinoembryonic antigen. CA19-9 was also detected in the epithelial cells of the LEC, the ECAS, and the retention cyst of the pancreas, but not in those of the splenic epidermoid or branchial cleft cysts used for comparison. These findings indicate that LECs and ECASs might develop from the pancreatic ducts protruding into a lymph node or accessory spleen located in the pancreas, respectively. Some of both cysts might cause elevated levels of serum carcinoembryonic antigen and/or CA19-9 and should be distinguished from malignant cystic tumors.

The impact of surgical technique on the development of graft versus host disease in a rat small intestinal transplant model

The small intestine and its mesentery contain a large amount of lymphoid tissue that can mediate graft-versus-host disease (GVHD) in small intestinal transplant recipients. To assess the impact of surgical technique and the retention of the recipient's small intestine on GVHD intensity, 12 adult Lewis rats received heterotopic small bowel transplants and 12 received orthotopic small bowel transplants from Brown Norway donors. Twelve Lewis to Lewis heterotopic small-bowel-transplanted animals served as the control group. All recipients were given cyclosporine (10 mg/kg/alternate days) subcutaneously. The parameters followed were: weight gain and feed intake; clinical signs of GVHD; relative spleen weight; popliteal lymph node enlargement assay; and histological evaluation of spleen, liver, skin, native intestine, and transplanted intestine. According to the clinical scoring system, heterotopically transplanted animals were found to have a more severe GVHD than the orthotopic group. There were statistically significant differences between the relative spleen weights of the heterotopic transplant group and the control group (P = 0.001, 0.004, and 0.007 on days 7, 14, and 21, respectively) and between the heterotopic and orthotopic groups at 7 days (P = 0.037). Lymph node enlargement assays were statistically different between heterotopic and orthotopic groups (P = 0.019, 0.020, and 0.007 on days 7, 14, and 21, respectively). Histological evaluation of skin biopsy specimens also demonstrated that GVHD was indeed more severe in the heterotopic transplanted group when compared with orthotopically transplanted animals. These findings confirm that retention of the native small intestine in the heterotopic intestinal transplant model significantly increases the severity of GVHD following transplantation.

Evaluation of cellular proliferation in human biopsy samples of lymphoid tissue according to the expression of AgNORs

The proportions of cells with a high expression of AgNORs, as directly assessed under the light microscope, and those of Ki-67-immunoreactive cells were divided into three categories (low, < 25%; intermediate, 25-50%; high, > 50%) and compared to a series of 41 human biopsy samples of lymphoid tissue. Irrespective of histological features a strong correlation was found between both variables (contingency coefficient = 0.8; P < 0.001). It is concluded that direct evaluation of cells with a high expression of AgNORs may serve as an index of proliferative activity in biopsy samples of lymphoid tissue.

History of tonsillectomy and appendectomy in Hodgkin's disease

The study comprised all 113 clinically and histologically confirmed cases of Hodgkin's disease aged 15-39 years who were treated at the Department of Hematology of the Faculty of Medicine in Belgrade from January, 1 to June, 30, 1987. For each patient, two individually matched controls were selected. Neighbourhood controls were the first neighbours of the same sex, age, and residence history. Hospital controls consisted of accidentally injured individuals, and they were matched in terms of sex, age, place of residence, and educational level. Comparison of cases and controls revealed that removal of the lymphoid tissue (either tonsils or appendix) did not affect the risk of developing Hodgkin's disease in any way. An association found by some previous studies has been explained by the confounding effect of socioeconomic status.

Chronic lymphocytic leukemia and acquired disorders affecting the immune system: a case-control study

The relationship of a number of subacute or chronic infectious diseases, connective tissue or autoimmune disorders, allergic conditions, and surgical excision of lymphoid tissue with chronic lymphocytic leukemia (CLL) was examined in a case-control study involving 342 cases and 342 matched controls. In both analyses of all matched pairs and those pairs in which both subjects were respondents, no statistically significant association was found between a history of subacute viral infections or subacute and chronic bacterial infections and CLL. Connective tissue or autoimmune disorders also were found not to be associated with CLL. Examination of the association between several allergic conditions and CLL suggested a protective effect as did a "dose-response" analysis, although none of the individual disorders showed a statistically significant relationship; however, a test for linear trend was significant (P = .04). Similarly, examination of the relationship between surgical excision of lymphoid tissue in several anatomic locations and CLL showed a protective effect, statistically significant for tonsillectomy-adenoidectomy (odds ratio = 0.69; 95% confidence interval = 0.48, 0.98). A statistically significant negative dose-response relationship, substantiating the protectiveness of the effect, was found.

Influence of antecedent lymphoid surgery on the odds of acquiring rheumatoid arthritis

The occurrence of rheumatoid arthritis (RA) and the extent of antecedent lymphoid surgeries was examined using case control study methods. Two hundred sixty-four patients with definite or classic RA were considered and 283 patients with rheumatic diseases presumably of nonimmunologic origin were used as controls. The odds for developing RA were found to be significantly higher for patients with multiple lymphoid surgeries (tonsillectomy and adenoidectomy or tonsillectomy and adenoidectomy plus appendectomy) and exhibited a gradient, increasing with more extensive surgery. Significant rank correlations were found in patients with RA between the age at tonsillectomy and the rheumatoid factor (RF) titer. An earlier tonsillectomy correlated with lower titers of RF. A significant decrease of serum RF titer was also seen in patients with RA subjected to tonsillectomy, adenoidectomy and appendectomy. We conclude that antecedent removal of lymphoid tissue from the tonsils, adenoids and appendix constitutes a risk factor predisposing to RA. Moreover, this risk seems related to the quantity of lymphoid tissue removed.

Gastric pseudolymphoma. A challenging clinical problem

Gastric pseudolymphoma is a benign inflammatory condition that is usually associated with chronic gastric ulcer and often mimics gastric carcinoma or malignant lymphoma. Our experience with 12 histologically documented gastric pseudolymphomas at the Medical College of Virginia is presented with an emphasis on the approach to both diagnosis and surgical management. Preoperative diagnoses in this series ranged from benign gastric ulcer to gastric cancer. Treatment was by gastric resection in all cases and it included, as a minimum, antrectomy and excision of the lesion with an adequate gross margin. Of 11 cases with adequate follow-up, there are eight asymptomatic patients without recurrence and one patient who died of other causes without recurrence 5 years after gastrectomy. One patient developed recurrent pseudolymphoma in the proximal gastric remnant 39 months after a distal subtotal gastrectomy for pseudolymphoma. Another patient subsequently developed Hodgkin's disease of the gastric remnant, with regional lymph node and liver involvement, and died 35 months after the earlier subtotal gastrectomy for pseudolymphoma. Our clinical experience with this confusing and uncommon entity is compared with that previously reported in the medical literature.

Pancreatic Castleman disease simulating pancreatic carcinoma on computed tomography

A patient with a pancreatic body and tail mass caused by Castleman disease and visible on computed tomography is described. This entity simulated pancreatic carcinoma in this clinical setting. Theories of etiology of Castleman disease and differential diagnosis of pancreatic masses are discussed. Proper examination technique is stressed.

Microlymphatic surgery in management of lymphoedema of the upper limb

Microlymphatic surgery is a recent addition to the range of surgical procedures for lymphoedema. Lymphaticovenous anastomosis is the most direct approach to the basic cause of obstructive lymphoedema bypassing the obstruction of the axilla or groin. With increased experience the overall results have improved and, in selective cases, segmental reduction is carried out either at the same operation or at a later date. Microlymphatic surgery in conjunction with segmental reduction of the upper arm is aesthetically and functionally most acceptable. The most significant effect of lymphaticovenous anastomosis in relieving the lymphoedema of the upper limb is over the dorsum of the hand and lower forearm. At least two, or more if possible, lymphaticovenous anastomoses are required for effectiveness of the procedure. Besides subjective and objective improvement in the lymphoedema there is significant reduction in frequency of cellulitis following lymphaticovenous anastomoses. The technique, along with the results and follow-up over 5 years is presented.

Cryosurgery in benign conditions of the nose and throat

Images

Subcutaneous nodular lymphohistiocytic hyperplasia

Five cases of a subcutaneous lymphohistiocytic lesion arising in relation to the deltoid muscles are described. The histological appearances are described and the differential diagnosis is discussed.

Treatment of malignant melanoma--a review of 111 cases

In a study of 110 patients with 111 malignant melanomas, the most important factors in determining the ultimate prognosis were: the sex of the patient, the site of the lesion and the clinical stage of the melanoma at the time initial treatment was carried out. When there was no spread beyond the primary area, the five-year survival rate was 64%. Excisional biopsy is preferable even though the dangers of incisional biopsy may have been overestimated in the past. The value of prophylactic lymph node dissection has not yet been unequivocally proved. The rationale for isolated perfusion therapy in the treatment of malignant melanoma is sound; nevertheless, the effect of this adjunct on survival and cure must await future critical analysis.