Lipoma with osteocartilaginous metaplasia in infrapatellar fat pad: A case report and review of literature

RATIONALE

Lipomas are tumors composed of mature adipocytes, originating from the mesoderm, and are the most common soft tissue tumor. According to the World Health Organization classification of human soft tissue and bone tumors, there are 14 types of benign tumors, including mature adipose tissue. Osteolipoma is known as the rarest subtype of lipoma.

PATIENT CONCERNS

A 63-year-old female presented to our hospital for the evaluation and treatment of a palpable mass with pain in the right knee.

DIAGNOSIS

The diagnosis was confirmed as lipoma with osteocartilaginous metaplasia.

INTERVENTIONS

Surgical removal of the tumor was performed.

OUTCOMES

The main symptoms improved immediately after the surgery and recovered without any complications or recurrence until 2 years after surgery.

LESSONS

Lipoma with osteochondral degeneration is a rare variant of lipoma and it is important to differentiate it from other malignant tumors. Pathological confirmation should be performed after marginal resection of the mass.

Sturge-Weber syndrome-associated glaucoma and intraocular osseous metaplasia: a unique complicated case

A 30-year-old European man was admitted to our centre complaining about severe pain of the right eye (OD) and right part of the face, redness and no vision of the OD. He had an 18-year history of secondary to Sturge-Weber syndrome glaucoma, 6-month history of red eye and 1-week history of pain in OD. The best-corrected visual acuity was no light perception OD and 20/20 OS. Intraocular pressure was 36 mm Hg OD. Examination revealed endophthalmitis, Sturge-Weber syndrome-associated glaucoma and complicated cataract of OD.Unfortunately, no prescribed treatment helped this patient, so evisceration of OD was performed. During the evisceration, a subretinal 20 mm in width and 22 mm in length osseous tissue, partially vascularised, was removed surgically and was sent to the histological laboratory. Histopathologically, there were data of active inflammatory process, retinal detachment due to huge subretinal osseous metaplasia, gliosis and retinal pigment epithelial hyperplasia, and druses with ossification.

[The molecular genetic alterations in mucosa of intestines as markers of oncologic progression and estimate of effectiveness of anti-reflux operations in patients with Barrett's esophagus]

The development of disease of Barrett's esophagus is based on processes of metaplasia of epithelium of esophagus when as a result of reflux of gastric juice and bile acids the normal planocellular epithelium of esophagus is replaced by cylindrical epithelium of intestinal type. Thereupon, Barrett's esophagus is progressing up to dysplasia and adenocarcinoma of esophagus. The progression from precancerous states up to tumor is related to development of genome disorders in cells associated with malignant transformation. The genetic and epigenetic alterations conditioning tumor growth can be used as markers of prognosis of clinical course of disease. To receive possible markers of progression of Barrett's esophagus the study was organized concerning methylation of such genes-suppressors of tumor growth as MGMT, CDH1, p16/CDKN2A, DAPK, RAR-β and RUNX3 in patients with Barrett's esophagus and adenocarcinoma of esophagus. The effectiveness of applied anti-reflux surgical treatment was evaluated too. The abnormal methylation of studied genetic panel in patients with Barrett's esophagus prior to surgical treatment was observed reliably more frequently in altered epithelium as compared with unaltered epithelium (p<0.0001), under dysplasia as compared with metaplasia (p<0.0358) and in the presence of long (>3 cm) segments of altered epithelium as compared with short (<3 cm) segments (p=0.0068). In normal epithelium, prior to operation, abnormal methylation of panel of genes was detected in 7/60 (12%) of patients. Against the background of surgical treatment number of long and short segments of altered epithelium of esophagus reliably decreased (p<0.05). At that, in short segments after operation rate of methylation increased significantly (p=0.0068). Though after operation number of patients with Barrett's esophagus and dysplasia and metaplasia decreased, the rate of abnormal methylation in the other patients increased. It is demonstrated that anti-reflux operation ameliorates condition of mucous membrane of esophagus under Barrett's esophagus. However, in cases without regression significant increasing of rate of abnormal methylation of studied panel of genes is occurred. This is a proof that abnormal methylation of system of genes is related to worse response to application of anti-reflux surgical treatment.

The pathological findings seen in laparoscopic sleeve gastrectomies for weight loss

Sleeve gastrectomy specimens are increasingly common surgical specimens received for examination following bariatric surgery for weight loss. The spectrum of pathological changes seen in these cases is not well documented. Retrospective examination was undertaken of 1463 consecutive sleeve gastrectomy specimens received at Envoi Specialist Pathologists. Most cases showed no pathological changes (80.2%). The most common changes seen were non-specific, non-Helicobacter associated chronic gastritis (7.2%), Helicobacter associated gastritis (6.8%) and benign fundic gland polyps (4.0%). Other, rarer changes were lymphocytic gastritis, autoimmune atrophic gastritis, chronic gastritis with intestinal metaplasia, hyperplastic polyps, pancreatic heterotopia, gastrointestinal stromal tumours (GISTs) and a leiomyoma. A wide range of pathological changes are seen in resection specimens following sleeve gastrectomies for weight loss. Many cases will require further treatment or ongoing investigation and surveillance.

Radiofrequency ablation for Barrett's-associated intramucosal carcinoma: a multi-center follow-up study

BACKGROUND

Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), has been validated as a safe, effective and durable treatment option for dysplastic Barrett's esophagus. Its durability in eradicating Barrett's-associated intramucosal carcinoma (IMC), however, is unclear. We set out to assess the long-term safety and efficacy of RFA for IMC.

METHODS

Retrospective review of two tertiary care facility records for patients undergoing RFA, with or without EMR, for biopsy-proven IMC. Our primary outcome of interest was to quantify the rate of durable complete eradication for intestinal metaplasia and for IMC and associated dysplasia. A multi-variate regression analysis was performed to identify features which correlate with durable eradication of IMC/dysplasia. Our secondary outcome of interest was treatment-related complications.

RESULTS

36 patients (26 male; mean age 64 ± 12 years), with a mean Barrett's length of 3.5 ± 2.5 cm, underwent RFA for biopsy-proven IMC. EMR was performed in 31 (86%) prior to or during RFA. Complete eradication of IMC/dysplasia was achieved in 32/36 (89%) and patients required a mean of 1 ± 1 EMR and 2 ± 1 RFA sessions to achieve eradication. During a mean follow-up period of 24 ± 19 months, durable complete eradication of IMC/dysplasia was achieved in 29/36 (81%) patients. On multi-variate regression analysis, undergoing an EMR prior to RFA was associated with an increased likelihood of maintaining durable eradication of IMC/dysplasia (p = 0.03). Treatment-related complications included: bleeding (3%) and stricture formation (19%).

CONCLUSION

RFA is an effective and durable treatment option for Barrett's-associated IMC. Greater than 80% of patients will achieve and maintain complete eradication of IMC at a mean of 2 years follow-up.

A relation between cell cycle and intestinal metaplasia in oesophageal biopsies using optical and digital microscopy

Protein expression changes in relation to cell cycles provide important information, and it may represent a new method for an early diagnosis of metaplasia - dysplasia - adenocarcinoma sequence. We investigated potential changes in cell cycle genes such as protooncogenes (PCNA, EGFR), tumour suppressor gene (p53), apoptotic TUNNEL (Tdt mediated dUTP nick and labelling) gene, as well as small intestinal mucus antigen (SIMA) and large intestinal mucus antigen (LIMA), which accumulates in metaplastic epithelium due to the inflammatory process in routine oesophageal biopsies using immunohistochemistry. Oesophageal biopsies were taken from patients with Barrett's oesophagus (n = 30), reflux oesophagitis (n = 30), healthy oesophagus (n = 30) and healthy cardia (n = 10). Immunohistochemical signalling was carried out by Streptavidin-Biotin-AEC (aminoetil-carbazol). Expression of PCNA was statistically significantly lower in healthy oesophagus (p < 0.05) versus reflux oesophagitis and Barrett's oesophagus. However, no significant change was detected in the expression of SIMA and LIMA in intestinal metaplasia. Further, EGFR, p53 and TUNNEL levels were significantly different in healthy versus Barrett's oesophagus. Manual counting using virtual microscopy was comparable with the result using conventional light microscopy, but the former is significantly quicker. There was no difference between manual and automated cell counting (p > 0.05).

Identification of lineage-uncommitted, long-lived, label-retaining cells in healthy human esophagus and stomach, and in metaplastic esophagus

BACKGROUND & AIMS

The existence of slowly cycling, adult stem cells has been challenged by the identification of actively cycling cells. We investigated the existence of uncommitted, slowly cycling cells by tracking 5-iodo-2'-deoxyuridine (IdU) label-retaining cells (LRCs) in normal esophagus, Barrett's esophagus (BE), esophageal dysplasia, adenocarcinoma, and healthy stomach tissues from patients.

METHODS

Four patients (3 undergoing esophagectomy, 1 undergoing esophageal endoscopic mucosal resection for dysplasia and an esophagectomy for esophageal adenocarcinoma) received intravenous infusion of IdU (200 mg/m(2) body surface area; maximum dose, 400 mg) over a 30-minute period; the IdU had a circulation half-life of 8 hours. Tissues were collected at 7, 11, 29, and 67 days after infusion, from regions of healthy esophagus, BE, dysplasia, adenocarcinoma, and healthy stomach; they were analyzed by in situ hybridization, flow cytometry, and immunohistochemical analyses.

RESULTS

No LRCs were found in dysplasias or adenocarcinomas, but there were significant numbers of LRCs in the base of glands from BE tissue, in the papillae of the basal layer of the esophageal squamous epithelium, and in the neck/isthmus region of healthy stomach. These cells cycled slowly because IdU was retained for at least 67 days and co-labeling with Ki-67 was infrequent. In glands from BE tissues, most cells did not express defensin-5, Muc-2, or chromogranin A, indicating that they were not lineage committed. Some cells labeled for endocrine markers and IdU at 67 days; these cells represented a small population (<0.1%) of epithelial cells at this time point. The epithelial turnover time of the healthy esophageal mucosa was approximately 11 days (twice that of the intestine).

CONCLUSIONS

LRCs of human esophagus and stomach have many features of stem cells (long lived, slow cycling, uncommitted, and multipotent), and can be found in a recognized stem cell niche. Further analyses of these cells, in healthy and metaplastic epithelia, is required.

[Bony metaplasia of the endometrium. Report of two cases]

We report a 28 year old female consulting for infertility and a 26-year-old woman consulting for severe dysmenorrhea. In both patients a osseous metaplasia of the endometrium was found. Both patients were subjected to a hysteroscopic resection of the osseous material and both achieved spontaneous pregnancies and term deliveries following the procedures. If the bony material is removed, normal pregnancies and deliveries are feasible afterwards, no matter how extensive is the the osseus metaplasia.

Fibroma with osseous metaplasia of external auditory canal in a dog

The present report describes a case of fibroma with osseous metaplasia of the external auditory canal in a 7-year-old male Pomeranian dog. Upon otoscopic examination, the right external auditory canal was almost completely obstructed by a well-circumscribed mass adjacent to the eardrum. The mass was surgically excised. Grossly, it was well demarcated, firm when cut, pink, and measured 0.3 cm x 0.2 cm x 0.7 cm. The cut surface of the mass exhibited a central portion of homogeneously white osseous components surrounded by brown to pink soft tissue. Microscopically, the resected external auditory canal mass mainly consisted of fibroblastic spindle cells showing differentiation to metaplastic osteoblast-like cells. Metaplastic osteoblasts and osteoclasts lining the osteoid bony trabeculae were also observed. Bony trabeculae and spicules were separated by abundant collagen and neoplastic fibroblastic cells. Fibromatous components, irregular formation of woven bone spicules, and the presence of osteoblasts lining bony trabeculae led to a diagnosis of fibroma with osseous metaplasia.

Sebaceous glands - unusual histological finding in the uterine cervix

Sebaceous glands have been extremely rare findings in the female genital system. Excluding the vulva and recent findings, very few cases have been described. The origin of the lesions remains a topic of speculation. However, it appears that prolonged irritation induces a metaplastic response in the ectocervical epithelium. A new case of sebaceous glands in the ectocervix of a 46-year-old woman is reported. The lesions were unexpectedly found in a hysterectomy specimen. The procedure was carried out for multiple leiomyomas of the uterine corpus. Histological examination revealed three mature sebaceous glands located distally to the transformation zone, which opened directly onto the surface epithelium. It could be concluded that sebaceous glands in the ectocervix are rare lesions of unclear origin and low clinical significance. However, the glands could potentially be associated with sebaceous carcinoma of that anatomical site.

Radiofrequency ablation in Barrett's esophagus with dysplasia

BACKGROUND

Barrett's esophagus, a condition of intestinal metaplasia of the esophagus, is associated with an increased risk of esophageal adenocarcinoma. We assessed whether endoscopic radiofrequency ablation could eradicate dysplastic Barrett's esophagus and decrease the rate of neoplastic progression.

METHODS

In a multicenter, sham-controlled trial, we randomly assigned 127 patients with dysplastic Barrett's esophagus in a 2:1 ratio to receive either radiofrequency ablation (ablation group) or a sham procedure (control group). Randomization was stratified according to the grade of dysplasia and the length of Barrett's esophagus. Primary outcomes at 12 months included the complete eradication of dysplasia and intestinal metaplasia.

RESULTS

In the intention-to-treat analyses, among patients with low-grade dysplasia, complete eradication of dysplasia occurred in 90.5% of those in the ablation group, as compared with 22.7% of those in the control group (P<0.001). Among patients with high-grade dysplasia, complete eradication occurred in 81.0% of those in the ablation group, as compared with 19.0% of those in the control group (P<0.001). Overall, 77.4% of patients in the ablation group had complete eradication of intestinal metaplasia, as compared with 2.3% of those in the control group (P<0.001). Patients in the ablation group had less disease progression (3.6% vs. 16.3%, P=0.03) and fewer cancers (1.2% vs. 9.3%, P=0.045). Patients reported having more chest pain after the ablation procedure than after the sham procedure. In the ablation group, one patient had upper gastrointestinal hemorrhage, and five patients (6.0%) had esophageal stricture.

CONCLUSIONS

In patients with dysplastic Barrett's esophagus, radiofrequency ablation was associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia and a reduced risk of disease progression. (ClinicalTrials.gov number, NCT00282672.)

Biphasic metaplastic sarcomatoid carcinoma of the breast: report of a case

A 69-year-old woman was admitted to our hospital with the complaint of a right breast mass. As a result of thorough examinations, she was diagnosed with breast cancer and underwent breast-conserving surgery. The pathological findings of the resected specimen showed that the tumor consisted of intermingled carcinomatous and sarcomatous components with a transition zone. On immunohistochemical study, the sarcomatous cells in this transition zone showed partial positive staining for CD10, the myoepithelial marker, suggesting that the myoepithelial cells had transformed into sarcoma, and then this biphasic tumor was formed. Finally, she was diagnosed with biphasic metaplastic sarcomatoid carcinoma of the breast. Biphasic metaplastic sarcomatoid carcinoma of the breast is a relatively rare but aggressive disease. The pathological diagnosis is often controversial, requiring detailed immunohistochemical analysis. We report our experience with a case of biphasic metaplastic sarcomatoid carcinoma of the breast.

The histopathology analysis of the diffuse sclerosing variant of the papillary carcinoma of the thyroid: a distinctive and rare form

Diffuse sclerosing variant (DSV) is a rare variant of papillary thyroid carcinoma (PTC) and its features have not yet been fully characterized. The aim of this case report is to analyze the immunohistochemistry profile of this disease and to highlight this rare entity. We analyzed the histology and immunohistochemistry of a female patient admitted in the Surgery Department of the "Sf. Ioan" Emergency Hospital, Bucharest, in April 2008. We especially used a wide panel of antibodies (Thyroglobulin mono, Thyroglobulin poly, Ki-67, TTF 1, Cytokeratin 19, Cytokeratin 34betaE12, and p63) in order to point out the follicular origin of the cells and to investigate the extensive squamous metaplasia lesions. The immunohistochemistry (IHC) was performed on 3 mum thick sections from 10% formalin-fixed paraffin-embedded tissues, according to the indirect tristadial Avidin-Biotin-Complex method. Our case report reveals that the DSV of PTC has distinctive pathologic features and its diagnosis importance is suggested by the high incidence of recurrence after operation.

Mucoid metaplastic-degeneration of anterior cruciate ligament

AIM

Mucoid degeneration of the anterior cruciate ligament (ACL) is a pathological state not yet well morphologically defined, involving people without history of knee instability or significant trauma, and causing important pain. The aim of this study was to define the histopathological and radiographic features of this pathological condition.

METHODS

Analysis of 1 215 knee magnetic resonance (MR) examinations found 64 cases (5.3%) of ACL mucoid metaplastic-degeneration (MMD), subsequently all subjects underwent surgical and arthroscopic validation. MR examinations have been performed using a dedicate system provided with a permanent magnet of 0.18 T and with a dedicate coil of 12 cm of field of view (FOV) or an high field instrument with 1.5 T. Radiological criteria to define ACL MMD were based essentially on increased signal intensity in T2W sequences and in STIR ones, as in T1W scans the ligament showed an intermediate signal.

RESULTS

ACL MMD was diagnosed in 36 males and 28 females, with a mean age of 44 years. ''Segmentary MMD'' was found in 11 subjects (17.2%) commonly affecting the postero-lateral bundle of the ligament without femoral or tibial spongious mucoid intrusion. ''Total MMD'' (involving the entire ligament and accompanied with femoral or tibial intrusion) was found in 53 subjects (82.8%).

CONCLUSION

The comparison between histopathological and MR findings suggests that the commonly called ACL mucoid degeneration (ACL MD) should be better defined as mucoid metaplastic degeneration (MMD).

A rat surgical model of esophageal metaplasia and adenocarcinoma-induced by mixed reflux of gastric acid and duodenal contents

Recent clinical data have revealed that mixed reflux (MR) of gastric acid and duodenal contents frequently occurs in patients with gastroesophageal reflux disease and a progressive increase of MR occurs with increasing severity across gastroesophageal reflux disease. Herein we report a novel rat surgical model in which esophageal metaplasia and adenocarcinoma develop as complications of MR. The model was created by performing an esophagojejunostomy and a gastrojejunostomy 5 mm proximal to the esophagojejunal anastomosis in 40 rats. Severe inflammatory and proliferative changes, high prevalence of esophageal metaplasia (78%), and adenocarcinoma (50%) were observed in the lower part of the esophagus of rats 20 weeks after surgery. The resulting esophageal lesions resembled those described in humans and supported a progression from intestinal metaplasia to dysplasia and, ultimately, esophageal adenocarcinoma. Such a model may provide a useful tool in study of human reflux-induced carcinogenesis.

Primary non-gestational uterine cervical choriocarcinoma with metaplastic transformation from squamous cells

BACKGROUND

Primary non-gestational uterine cervical choriocarcinoma is very unusual and although it has been hypothesized that it can arise by metaplastic transformation of cervical epithelium, solid evidence has been lacking.

CASE

Primary non-gestational uterine cervical choriocarcinoma was diagnosed in a 47-year-old, woman undergoing tubal resection 17 years previously. A histologically- and immunohistochemically-confirmed, non-gestational cervical choriocarcinoma could be diagnosed in which there was metaplastic transformation from squamous cells . The patient underwent 5 courses of an actinomycin-D chemotherapeutic regimen and radical hysterectomy with bilateral pelvic lymphadenectomy.

CONCLUSION

Primary non-gestational uterine cervical choriocarcinoma may indeed arise from metaplastic transformation of epithelial tissue.

Gastric heterotopia together with squamous metaplasia in the gallbladder

Heterotopic gastric mucosa in the gallbladder is extremely unusual. In this study, we aimed to report a case of gastric heterotopia together with squamous metaplasia in the gallbladder of a 47-year-old female patient who experienced an intensive abdominal pain. He was admitted to the hospital for clinical treatment without any improvement. Ultrasonography showed a stone located in the gallbladder neck and dilatation of intrahepatic bile ducts, both hepatic ducts and common hepatic duct. Laparoscopic cholecystectomy was performed. In the microscopical examination, the epithelium of the gallbladder revealed an unspecified chronic cholecystitis. Besides, at the level of the gallbladder body, a heterotopic gastric mucosa contain chief, parietal and mucosal cells with cystic glands and squamous metaplasia was found. Actually the patient is in long-time follow-up, asymptomatic. We also review 96 other reports of HGM in the gallbladder in the international medical literature from 1934. As heterotopic tissue may promote carcinogenesis of the gallbladder, close attention should be paid to any occurrence of such lesions in this anatomical region. It appears that laparoscopic cholecystectomy may be unavoidable for patients affected by heterotopic gastric mucosa at the present time and care must be taken when a diagnosis is made based on intraoperative frozen sections.

Recurrent cutaneous metaplastic synovial cyst

Reported here is the first case of a recurrent cutaneous metaplastic synovial cyst (CMSC). The CMSC is a recently described lesion that is histologically characterized by a cystic cavity lined by cells resembling metaplastic synovium overlying villous connective tissue cores. The lesion clinically appears as a tender subcutaneous nodule and may often be misdiagnosed as a suture granuloma. Although the actual cause is unclear, a history of trauma usually precedes its onset. Here we present a case of CMSC in a 34-year-old white male, which recurred at the same site following excision of an epidermoid cyst. CMSCs are unique lesions that should be included in the differential diagnosis of tender subcutaneous swellings following surgical trauma.

[Early duodenal adenocarcinoma arising in gastric metaplasia treated by endoscopic resection]

Early duodenal carcinoma is a rare entity. Most duodenal carcinomas are diagnosed at a more advanced stage. This report describes the case of a 59-year-old lady with an early duodenal adenocarcinoma diagnosed at check-up gastroduodenoscopy in an outpatient clinic who was referred to us for further investigation and management. The initial upper endoscopy at our department revealed a type IIa+c lesion in the proximal duodenum (10 - 12 mm diameter, flat elevated lesion with central depression). Using chromoendoscopy and magnification endoscopy the lesion could be well demarcated and neoplastic changes in the architecture of the intestinal villi could be detected. After submucosal epinephrine-saline injection, the lesion was removed by endoscopic resection without complications. Histopathological examination revealed the rare entity of an early duodenal carcinoma arising from incomplete-type gastric metaplasia in the duodenum. In summary, the presented paper describes a case of successful endoscopic treatment of an early duodenal carcinoma arising from incomplete gastric metaplasia.

Metaplastic carcinoma of the breast: A retrospective review

PURPOSE

Metaplastic carcinoma of the breast represents a rare and heterogeneous group of malignancies that accounts for less than 1% of all breast cancers. The purpose of this study is to better characterize the clinical management of this disease including the role of radiation therapy after surgery. We compared patients that have been treated with either modified radical mastectomy (MRM) or breast-conserving surgery (BCS).

METHODS AND MATERIALS

We performed a retrospective review of 43 patients with metaplastic breast cancer who were evaluated in our regional radiation oncology department between 1987 and 2002. Twenty-one patients were treated with an MRM and 22 with BCS. Five patients from the MRM group received adjuvant radiation, as did 19 patients from the BCS group. Univariate and multivariate analysis of pathologic and treatment-related factors was performed. Local control, disease-free, and overall survival rates were calculated by the Kaplan-Meier method and compared for the two groups.

RESULTS

Mean follow-up for all patients was 44.2 months. Mean tumor size was 3.4 cm. Four patients (9%) had positive estrogen receptors and 20 (25%) had positive nodes. The overall 5-year projected local recurrence-free (88% vs. 85%, p = 0.86), disease-free (55% vs. 84%, p = 0.13), and overall survivals (80% vs. 89%, p = 0.58) were not significantly different for both groups. The only tumor parameter significantly associated with overall survival was nodal status.

CONCLUSION

Our study suggests that breast conservation appears to be a reasonable treatment option for women with metaplastic breast cancer, achieving equal survival to mastectomy. The use of adjuvant radiation seems essential for achieving high local control rates after conservation therapy. Further studies will be needed to determine the impact of chemotherapy on survival outcomes.

Gastric heterotopia together with intestinal metaplasia in the gallbladder: case report and review of literature

Heterotopic gastric mucosa in the gallbladder is extremely unusual. In this study, we aimed to report a case of gastric heterotopia together with intestinal metaplasia in the gallbladder of a 16-year-old male patient who experienced a sudden onset of epigastric pain with nausea. He was admitted to the hospital with a prediagnosis of mild degree obstructive jaundice. Cholecystectomy and hepaticoduodenostomy were carried out. In the microscopical examination of the gallbladder, an antral and pyloric type gastric mucosa together with intestinal metaplasia were clearly evident in the gallbladder submucosa, and the adjacent gallbladder mucosa showed typical features of chronic cholecystitis.

Putative precursors of gallbladder dysplasia: a review of 400 routinely resected specimens

CONTEXT

Dysplasia is thought to be a precursor of invasive gallbladder carcinoma, but it is unsettled whether dysplasia arises from other precursor lesions.

OBJECTIVE

To ascertain the presence and nature of precursors of dysplasia in the gallbladder.

DESIGN

Four hundred consecutive cholecystectomy specimens were processed and stained routinely for diagnosis. We retrospectively reviewed these cases to look for the presence of epithelial changes, including antral-type metaplasia, intestinal metaplasia, and dysplasia.

RESULTS

Antral-type metaplasia, intestinal metaplasia, and dysplasia were found in 238 (59.5%), 39 (9.8%), and 20 (5.0%) cases, respectively. The mean patient age was 47.7 years (range, 15-93 years). The mean ages for patients with antral-type metaplasia, intestinal metaplasia, and dysplasia were 49.4, 50.9, and 52.6 years, respectively. Statistically significant associations were found between antral-type metaplasia and intestinal metaplasia (P = .007, chi2 test) and between intestinal metaplasia and dysplasia (P < .001, chi2 test).

CONCLUSION

These associations, along with the age gradient from antral-type metaplasia to dysplasia, suggest a progression from antral-type metaplasia to dysplasia via intestinal metaplasia.

[The operation of Barrett's esophagus]

The purpose of operation in Barrett's esophagus is to protect against esophageal acid exposure. In Western countries antireflux surgery is positive because Barrett's esophagus is recognized as premalignancy. But in Japan many people have SSBE without intestinal metaplasia. Thus if cancer is not detected in Barrett's esophagus, it is difficult to accept surgery. Besides antireflux surgery is not always successful. So the extra-surgical treatment is more recommended than operation in Japan.

Cystitis glandularis in children

OBJECTIVE

To assess the characteristics of cystitis glandularis in children.

PATIENTS AND METHODS

Three cases of cystitis glandularis in children are described, occurring in boys aged 9-13 years. The presenting symptoms were gross haematuria in the first patient and frequency and urgency in the second. The third patient was asymptomatic and the lesion appeared as a wide thickening of the bladder wall on follow-up ultrasonography for previous surgery. In all patients, a polypoid bladder mass was found at cystoscopy and diagnosed at histology. The endoscopic resection, with long-term antibiotic prophylaxis, was the treatment of choice, with no recurrence at 12-30 months of follow-up.

CONCLUSION

Cystitis glandularis has been rarely described in children, and is probably related to chronic or recurrent infections or an inflammatory reaction. Its potential premalignant significance is still the subject of debate.

Barrett's oesophagus: the new endoscopic modalities have a future

Barrett's oesophagus is defined as the replacement of squamous oesophageal epithelium by intestinal metaplasia in the distal oesophagus. It is a fairly frequent complication of gastro-oesophageal reflux disease (GORD): 5-10% of patients with GORD suffer from Barrett's oesophagus. GORD is essential for the development of Barrett's oesophagus.1 Intestinal metaplasia is a premalignant lesion that may further develop into dysplasia and lead to adenocarcinoma of the oesophagus. The latter now accounts for almost 50% of oesophageal cancer cases in western countries, and the largest increase in its incidence was recorded during the past two decades. Patients with Barrett's oesophagus have a 2-25% risk of developing mild to severe dysplasia and a 2-5% risk of having adenocarcinoma: 30-150 times higher than the risk in the general population. Forty to fifty per cent of Barrett's oesophagus patients with severe dysplasia would present adenocarcinoma within 5 years.

[Osseous metaplasia in colonic adenocarcinoma]

Osseous metaplasia (OM) in colonic adenocarcinoma is a very rare occurrence. This report describes the case of a 59-year-old man with OM occurring with moderately differentiated adenocarcinoma of colon, and is followed by a brief review of the literature.

[A case of squamous metaplasia of the ureter]

This paper reports a 73-year-old man who developed ureteral squamous metaplasia. Preoperative drip infusion pyelography showed a ureteral tumor with a major axis measuring 2.5 cm, which had a smooth surface and a broad base. Computed tomography findings suggested that the lesion might be a submucous mesodermal tumor or inverted papillary transitional cell carcinoma. Therefore, retroperitoneal laparoscopic left nephroureterectomy was performed.

Approach to early Barrett's cancer

Because of effective surveillance programs in patients with known Barrett's esophagus, adenocarcinoma of the distal esophagus is increasingly diagnosed at early stages. With the introduction of limited surgical and endoscopic treatment modalities, the need for radical esophagectomy and extensive lymphadenectomy in such patients has been questioned. When selecting the approach to early Barrett's cancer, the precancerous nature of the underlying Barrett's esophagus, the frequent multicentricity of neoplastic alterations within the Barrett mucosa, the inaccuracy of current staging modalities, and the presence of lymph node metastases should be taken into account. Invasiveness and morbidity of the procedures, as well as quality of life aspects, should also be considered. From an oncologic point of view the minimum extent of a resection for early Barrett's cancer should include a full-thickness removal of the entire segment of the distal esophagus covered by intestinal metaplasia together with a regional lymphadenectomy. In appropriately selected patients this can be achieved by a limited surgical procedure involving transhiatal resection of the distal esophagus, but not by endoscopic mucosal ablation or endoscopic mucosa resection. Our experience with 49 limited surgical resections with regional lymphadenectomy indicates that this procedure is oncologically adequate and safe. Reconstruction with an interposed jejunal loop prevents postoperative gastroesophageal reflux and is associated with good quality of life. In contrast, endoscopic interventions are plagued by a high tumor recurrence rate, probably from persistence of Barrett's mucosa and gastroesophageal reflux.

[Bladder nephrogenic metaplasia: circumstances of discovery, predisposing factors, and clinical course in 7 cases diagnosed between 1988 and 2000]

INTRODUCTION

Nephrogenic adenoma (NA) or nephrogenic metaplasia is a rare, benign urothelial tumour.

MATERIAL AND METHODS

This retrospective study evaluated the circumstances of discovery, predisposing factors, and clinical course of seven patients with nephrogenic adenoma diagnosed between 1988 and 2000. The mean age of these patients was 55.7 years (range: 16 to 88 years). The mean follow-up was 24 months (range: 4 to 108 months).

RESULTS

There are no specific endoscopic findings and the lesion was sometimes flat or papillary with an appearance that can be identical to that of bladder tumour. The diagnosis was always based on histological findings. Suggestive clinical signs were nonspecific and comprised: haematuria, dysuria, or urgency. Treatment was surgical with transurethral resection or electrocoagulation of the lesion, combined with elimination of the factors irritating the urothelial mucosa. In our experience, recurrences were observed in 28.5% of patients and occurred during the year following the initial treatment.

CONCLUSION

Nephrogenic adenoma is a rare, benign urothelial tumour most frequently situated in the bladder. The presenting clinical signs are completely nonspecific and usually related to predisposing factors (infections, inflammation, bladder tumour). Only histological examination can provide the essential proof of the benign nature of this lesion. Endoscopic resection therefore has two objectives: diagnostic and therapeutic. The clinical course is characterized by recurrences.

High-grade dysplasia in Barrett's esophagus. The case for esophagectomy

The main principles for optimal management of HGD arising in Barrett's esophagus are that unequivocal diagnosis of HGD is a prerequisite for making the decision of any kind of treatment. HGD must be resected because of the presence of neoplastic cells in the lamina propria in 40% of patients. No reliable endoscopic or endosonographic feature exists that allows accurate prediction of the existence of neoplastic cells within the lamina propria of a patient having HGD in endoscopic biopsy material. Prompt decision to remove an HGD lesion as soon as unequivocal histologic diagnosis has been settled prevents the development of extraesophageal neoplastic spread. Esophagectomy is preferable to endoscopic mucosal excision because approximately 20% of patients who have HGD in preoperative biopsy material carry neoplastic cells beyond the muscularis mucosae. Esophagectomy can be limited to the removal of the esophageal tube without extended lymphadenectomy because 96% of patients who have HGD in endoscopic biopsy samples have a neoplastic process confined to the esophageal wall. Esophageal resection must encompass all the Barrett's area because of the risk for the further development of a second cancer in the metaplastic remnant. Vagus-sparing esophagectomy with colon interposition or elevation of the antrally innervated stomach up to the neck is preferable to conventional esophagectomy with gastric pull up because the former procedure maintains gastric function intact, whereas the latter exposes patients to the risk for the long-term development of reflux esophagitis and even of metaplastic transformation of the proximal esophageal remnant. Subtle details in the understanding of a given patient's clinical course may be critical for making the decision of the most relevant mode of therapy; therefore, patients who have HGD should be treated in dedicated centers, the experience of which offers the best chances of uneventful recovery if the surgical option is retained.

Nuclear grading of endometrial cancer harbors heterogenous prognostic groups as detected by proliferation activity

OBJECTIVE

Nuclear grading, in addition to the histopathological result of every tumor, is responsible for consecutive treatment designs. Ki-S5 is the monoclonal antibody against a formalin-resistant epitope of the Ki-67 antigen and can be determined in paraffin-embedded samples. The aim of the study was a comparative analysis of the nuclear grading of endometrial cancer and the proliferation marker Ki-S5.

METHODS

In 126 specimens of endometrial cancer the proliferation activity of the monoclonal antibody Ki-S5 was determined (streptavidin-biotin-complex method) in correlation to nuclear grading. In the group of grade 2, stages Ib and Ic andenocarcinomas, proliferation rates were compared to recurrence rates.

RESULTS

Divergent proliferation rates resulted. Adenoacanthomas showed a relatively low proliferation rate (<28%). For the andenosquamous carcinomas the proliferation rate ranged between 28-43%. The largest group of adenocarcinomas showed proliferation rates from 5-74%. A clear dependency between increasing proliferation rates and decreasing differentiation (nuclear grading 2-3) was observed. In the small group of patients with andenocarcinomas, nuclear grading G2 stages Ib and Ic, 38 suffered no recurrence after 6-10 years. However, the six patients with proliferation rates of over 35% all suffered a recurrence.

CONCLUSIONS

The results emphasize the need to differentiate G2 tumors, depending on their proliferation rate, into low risk (KiS5<35%) and high risk cases (Ki-S5>35%).

[Nephrogenic adenoma arising from an urethral diverticulum in a female. Report of a case and review of the literature]

Nephrogenic adenoma is a benign epithelial tumour localised at the level of the urothelium and caused by metaplasia of the urothelium following prolonged aggressive stimulation over time, for example trauma or chronic urinary infection. Even a diverticulum, in whatever site it is localised, is subject to an increased risk of neoplastic transformation of the urothelium. It above all affects male subjects, with a male/female ratio of 3:1 over the age of 20, which is inverted in younger subjects. The most frequently affected site is the vescical trigonum in 72% of cases, followed by the pelvic tract of the ureter (19%) and urethra. The majority of patients is asymptomatic or reports aspecific symptoms: the most frequent picture is macroscopic hematuria, owing to the rich vascularisation of the tumour. This is followed by irritative type signs such as pollakiuria, strangury, posturination dripping and sometimes painful tenesmus. Differential diagnosis is necessary for pale cell adenocarcinoma, parauretral cysts and Gartner duct's cysts which may be associated with urethral diverticulum, localised on the bottom, and rarely symptomatic. Diagnosis is based on retrograde urethrography, cystography and endoscopic tests, with biopsy if necessary. NMR provides further details regarding the site, localisation and benign or malignant nature of the lesion. Treatment is surgical: endoscopic (transurethral) if the dimension are limited, or traditional using a suprapubic or transvaginal route if it is associated with diverticulum. Prognosis is discrete and depends on the timeliness with which the factors predisposing metaplasia are eliminated.

[Osseous metaplasia of the endometrium as a cause of infertility. Hysteroscopic approach]

The osseous metaplasia of the endometrium is very rare cause of infertility. The hysteroscopic approach is a effective method to recover the fertility in most of the cases in a short period. The case of a infertile woman who was previous studied and has indications for laparoscopic and hysteroscopic approach. The infertility workup showed a intracavitary calcification on ultrasonography. During the surgery, the diagnosis of endometriosis and osseous metaplasia of the endometrium were done and treated with histologic confirmation. The patient conceived in her second spontaneous cycle. The hysteroscopy is the first approach in the treatment and should be doing with laparoscopy for the detection of other causes of infertility.

The impact of an antireflux procedure on intestinal metaplasia of the cardia

OBJECTIVE

The aim of this study was to determine whether antireflux surgery is more effective in producing loss of intestinal metaplasia located only at the gastroesophageal junction than it has been in patients with intestinal metaplasia extending up into the distal esophagus.

SUMMARY BACKGROUND DATA

Biopsies of a normal appearing gastroesophageal junction will demonstrate cardiac mucosa containing goblet cells--the hallmark of intestinal metaplasia--in 10% to 15% of patients who are evaluated for symptoms of gastroesophageal reflux. The incidence of adenocarcinoma of the esophagus and cardia is rising faster than any other cancer in America, and most of these cancers are found adjacent to areas of intestinal metaplasia. Antireflux surgery in patients with Barrett's esophagus may provide protection from progression to dysplasia and cancer; however, it does not reliably cause regression of the intestinal metaplasia. Less is known about the potential for intestinal metaplasia limited to the cardia (CIM) to regress.

METHODS

Sixty patients with intestinal metaplasia of the esophagus or cardia had antireflux surgery. Patients in the intestinal (CIM) group (n = 15) had no endoscopically visible segment of columnar epithelium. Patients in the Barrett's group (n = 45) had columnar epithelium visible within the esophagus. Median follow-up was 25 months in each group.

RESULTS

Postoperative biopsies showed complete loss of intestinal metaplasia in 73% of the patients with CIM compared with 4.4% of the patients with Barrett's. Low-grade dysplasia, present in 10 patients preoperatively, regressed in 7 patients (70%). No patient progressed to high-grade dysplasia or cancer.

CONCLUSIONS

Loss of intestinal metaplasia after antireflux surgery is rare in patients with Barrett's, but occurred in most patients with CIM. This suggests that cardiac epithelium is dynamic and that microscopic areas of intestinal metaplasia are able to regress much more frequently than longer, visible segments of intestinal metaplasia.

The role of adjuvant radiotherapy in carcinoma of the endometrium-results in 550 patients with pathologic stage I disease

OBJECTIVES

A retrospective analysis of 550 women with pathological stage I carcinoma of the endometrium who were seen between January 1984 and December 1988 was performed in order to assess the value of adjuvant radiation therapy.

METHODS

Two-hundred twenty-eight patients were treated with surgery alone (S); 97 received adjuvant external beam radiotherapy (S + EXT); 217 received external beam radiotherapy and colpostats (S + EXT + IC); and 8 patients received only colpostats (S + IC). Pelvic radiation therapy, usually 40 Gy in 20 fractions, was administered to 94% of patients whose tumors showed greater than 50% myometrial invasion and to 89% of patients with FIGO grade 3 tumors. Colpostats were used in 40% of patients, the majority of whom had lower uterine segment involvement.

RESULTS

The overall survival rate for the whole group using Kaplan-Meier estimates was 84% at 5 years. The 5-year overall survival rates for each treatment group, excluding the S + IC group, were 90% for S alone, 79% for S + EXT, and 82% for S + EXT + IC. The 5-year disease-free survival rates were 84, 77, and 77%, respectively. Local control rates at 5 years were 93, 94, and 95% in the three treatment groups, but the patterns of relapse were different. Distant metastases occurred more frequently among the patients who received adjuvant radiation therapy (36/49, 73%) than among those who did not (4/19, 21%). Late toxicity was documented in 66 patients. Twelve patients had EORTC/RTOG grade 3 and 4 complications; all had been treated with S + EXT + IC. FIGO grade (P = 0.009), lower uterine segment involvement (P = 0.009), and age (P = 0.03) were significant predictors of worse disease-free survival in a multiple regression analysis.

CONCLUSIONS

The addition of vaginal vault brachytherapy to external beam radiotherapy did not appear to improve local cure rates nor survival, but increased the incidence of late radiation toxicity.

Vulval and vaginal adenosis

Vaginal adenosis is defined by the presence of metaplastic cervical or endometrial epithelium within the vaginal wall, thought to be derived from persistent Müllerian (synonymous with paramesonephric) epithelium islets in postembryonic life. Spontaneous vaginal adenosis appears to be a fairly common (present in about 10% of adult women) but mostly insignificant coincidental finding. In women prenatally exposed to diethylstilboestrol (DES), vaginal adenosis may arise in up to 90% and is associated with a high risk of vaginal carcinoma. Since the withdrawal of DES from the market, vaginal adenosis has virtually disappeared from the medical literature. A case of vaginal adenosis is presented in a middle-aged woman who had not been prenatally exposed to DES. The lesions differed from the spontaneous type by their sudden appearance, their extent and their pronounced subjective symptoms. It is speculated that protracted oral contraceptive intake may have played a causative role.

[Cholecystopathies with mucosal metaplasia of the intestinal type]

In this work we analyse 23 clinical observations on operated cholecystopathies, with intestinal mucosa metaplasia and we present a study hypothesis that remains to be further verified. The clinical cases have been selected out of out of 1263 cholecystopathies carried out within our department between 1987-1993. Most of the patients were females aged of 30-50 years old and were not known to have gallbladder malformations or biliary lithiasis. The authors are in favour of surgical cure at these patients, only when the well-lead medical cure has failed to give positive results, as a final solution. The histopathological examination of the samples indicating intestinal mucosa metaplasia zones of the gallbladder is the only paraclinical findings that shows useful evidence and confirms the opportunity of the surgical solution in these patients.

Ultrasound-guided hysteroscopic management of endometrial osseous metaplasia

In the past, most cases of osseous metaplasia of the endometrium were diagnosed following removal of bone from the endometrium by dilatation and curettage and frequently subsequently treated by hysterectomy. Nowadays, management involves a suggested diagnosis by transvaginal ultrasound examination, confirmation by hysteroscopy and hysteroscopic removal of ectopic intrauterine bone. This is usually carried out under laparoscopic guidance. However, the degree of visual control provided by combined transabdominal and transrectal ultrasonography may prove sufficiently accurate for hysteroscopic guidance. In this report we describe a case of endometrial osseous metaplasia successfully managed by ultrasound-guided hysteroscopy. The advantages of our approach include reduced invasiveness, reduced costs and simultaneous visualization of the abdominal and intrauterine cavities. One limitation, however, is represented by the greater operator dependence of ultrasound guidance as compared to laparoscopy, the former requiring extensive training and state-of-the-art equipment. We suggest that ultrasound guidance for hysteroscopic removal of extensive osseous metaplasia may represent a potentially safer and more effective alternative to laparoscopy and would therefore encourage further clinical evaluation of this technique.

Postoperative radiotherapy in carcinoma of the cervix: treatment results and prognostic factors

In order to assess the role of postoperative radiotherapy and prognostic factors, 126 patients who were treated with radiotherapy after surgery for clinical early-stage carcinoma of the cervix were reviewed. All patients received external pelvic radiotherapy and 37 patients were treated with additional vaginal cuff irradiation. The 5-year overall survival, disease-free survival and locoregional control rates were 71.1, 69.9 and 78.1%, respectively. The 5-year disease-free survival rates were 40% for grade 3 vs. 75.4% for grade 1 tumours (p = 0.05), 76.5% for pathological stage IB versus 54.1% for pathological stage IIA (p = 0.04), 36.6% for node-positive patients versus 82.5% for node-negative patients (p = 0.0017), 54% for full thickness cervical invasion versus 100% superficial cervical invasion (p = 0.01), 34.8% for positive margins versus 78.1 for negative margins (p < 0.0001). After a multivariate analysis, tumour grade (p = 0.026) and presence of positive margins (p = 0.006) were found to independently influence the outcome. Grade II and III complication rate was 5.5% in all patients. In conclusion, postoperative radiotherapy should be used in patients treated with simple hysterectomy as well as those treated with radical hysterectomy with unfavorable pathological findings.

Melanotic oncocytic metaplasia of the nasopharynx

Two cases of melanotic oncocytic metaplasia occurring in the nasopharynx are reported. One presented with serous otitis media and the other with tinnitus. Nasoscopic examination revealed a small brown nodule obstructing the Eustachian tube in both cases. While oncocytic metaplasia of the nasopharynx is not too uncommon, melanin pigmentation of the nasal or nasopharyngeal mucosa is very rare. To our knowledge, their combination has not been described.

[Adenocarcinoma in addition to bladder exstrophy. Apropos a case and a review of the literature]

Herein we describe a case of adenocarcinoma complicating exstrophy of the bladder in a 59-year-old patient. The morphologic, histochemical and immunohistochemical analyses revealed a colonic glandular adenocarcinoma. The two hypotheses relative to its pathogenesis are briefly discussed. To date, 106 cases have been reported in the literature.