Improving influenza immunization among healthcare workers

Infected cystic duplication of the duodenum is an unusual lesion. We report a case in which pre-operative MR imaging revealed a huge multicystic mass masquerading as a cystic lymphangioma or mesenteric cyst. The differential diagnosis of this unusual appearance is discussed.     

Multiple early gastric stump carcinomas after gastrectomy for peptic ulcer

The remnant stomach after partial gastrectomy is considered to have a predilection for the development of primary gastric carcinoma. However, early gastric stump carcinomas are uncommon because the diagnosis of gastric stump carcinoma is more difficult than that of carcinoma in the intact stomach. Triple early gastric stump carcinomas, as in the present case, are exceedingly rare and may provide some clues for further investigation of carcinogenesis in the gastric stump. We studied about the histological appearance, genetic alterations (P-53 gene, c-erbB-2 gene and K-ras gene), and expression of tumor-associated antigens (carcinoembryonic antigen, carbohydrate antigen 19-9, and sialyl-Tn) in this rare case. The three carcinomas differed from each other histologically. With respect to genetic alterations, c-erbB-2 was amplified in one lesion, but no mutations of K-ras and P-53 gene were detected. The three carcinomas also differed from each other on the expression of tumor-associated antigens. In noncancerous mucosal epithelium at the anastomosis showing hyperplasia and cystic formation of glandular epithelial cells, no genetic alterations were detected, but sialyl-Tn and carbohydrate antigen 19-9 were expressed. These results suggest that there may be different processes of carcinogenesis of the three carcinomas even though they occurred under identical environmental conditions to those that have increased cancer risk.     

The Nobel Prize 1995 in medicine and physiology: embryogenesis and homeotic genes

Seven cases of urachal anomalies are presented. The spectrum of the disorder and the criteria for ultrasound diagnosis are described. Six of seven cases were correctly diagnosed pre-operatively with diagnostic ultrasound, but one case with no cystic component was missed. The appearance of a fixed, midline, cystic, extraperitoneal swelling between the umbilicus and the bladder should suggest the diagnosis.     

Zygomatic salivary cyst with mucocele formation in a cat

An eight-year-old neutered male domestic shorthair cat had a zygomatic salivary cyst with associated mucocele formation. A fluctuating swelling developed ventral to the right eye, causing bulging of the lower eyeild, and a corresponding swelling was present in the caudal vestibule of the oral cavity. Cytological examination of the fluid obtained from aspiration of the swelling was consistent with the appearance of saliva. A tentative diagnosis of zygomatic salivary mucocele was made. Surgical exploration and resection of the swelling demonstrated the presence of a multilobular cystic zygomatic salivary gland. The histopathological appearance of the resected tissue was interpreted as an inflammatory reaction to mucus derived from a multilocular salivary cyst.     

Cardiac cavernous hemangioma mimicking pericardial cyst: atypical echocardiographic appearance of a rare cardiac tumor

Cavernous hemangioma is a rare tumor with infrequent cardiac involvement. Preoperative or antemortem diagnosis may be difficult. Several prior case reports have described echocardiographic findings of cavernous hemangioma. We report here a 50-year-old white female patient with this tumor. Transesophageal echocardiography detected a mass with an echocardiographic appearance not previously described for cavernous hemangioma. The tumor appeared as a large echolucent unilocular cystic mass, leading to an erroneous preoperative diagnosis of pericardial cyst. This previously unreported finding should be recognized by echocardiographers in the evaluation of cardiac masses.     

Prenatal diagnosis of bowel obstruction initially manifested as isolated hyperechoic bowel

Fetal bowel obstruction has a prevalence of 1 in 3000 to 5000 live births. Ultrasonographic diagnosis is made by demonstrating distended loops of bowel. Echogenic bowel, defined as small bowel more echogenic than liver or bone, has been associated with congenital infections, cystic fibrosis, chromosomal abnormalities, and bowel obstruction. Fetal ascites, defined as fluid in the peritoneal cavity partly surrounding the liver and bladder, also has been associated with bowel obstruction. We present a case of jejunal atresia whose presenting appearance consists of echogenic bowel, transient ascites, and massive dilatation of intestinal loops.     

Cigarette smoking: CT and pathologic findings of associated pulmonary diseases

The health risks associated with cigarette smoking are well known. Cigarette smoking is the most important causative factor in the development of bronchogenic carcinoma. Pulmonary diseases such as chronic bronchitis, centrilobular and panacinar emphysema, respiratory bronchiolitis-associated interstitial lung disease (RB-ILD), and pulmonary Langerhans cell histiocytosis are also related to cigarette smoking. In adenocarcinoma and squamous cell carcinoma, the most common manifestation at computed tomography (CT) is a solitary pulmonary nodule; in small cell carcinoma, hilar and mediastinal adenopathy secondary to metastases; and in large cell carcinoma, a mass with central necrosis or cavitation in the lung periphery. For chronic bronchitis, the most common CT finding is bronchial wall thickening, but this finding is nonspecific. Emphysema, both centrilobular and panacinar associated with alpha-1-antitrypsin deficiency, usually manifests as areas of decreased attenuation and may involve bullous changes. However, centrilobular emphysema more commonly involves the upper lungs, whereas panacinar emphysema more commonly involves the lower lungs. Most patients with RB-ILD have normal high-resolution CT scans; however, abnormalities may be present, the most common of which are areas of ground-glass attenuation. CT appearance of pulmonary Langerhans cell histiocytosis varies depending on the disease stage: In the early stage, typical CT findings include multiple nodules, usually accompanied by cystic spaces with thin, well-defined walls. As the disease progresses, the cystic spaces become more numerous and the number of nodules decreases.     

Magnetic resonance features of the enigmatic oligodendroglioma

RATIONALE AND OBJECTIVES: The authors characterize magnetic resonance (MR) features of oligodendroglioma that permit diagnosis. These features may be used to guide MR stereotactic biopsies. METHODS: Fifteen patients with mixed oligodendroglioma and four with pure oligodendroglioma were studied on a 1.5-tesla MR unit with contrast and also by computed tomography (CT). All patients had their diagnosis confirmed by light and electron microscopy, and by immunohistochemical staining. RESULTS: The most characteristic finding was a honeycomb tumor matrix (4 of 19) in oligodendroglioma. The most common finding was an amorphous pattern (12 of 19) and the least common was a large cystic pattern (3 of 19). Contrast enhancement most commonly was minimal and dot-like or lacy in appearance (11 of 19), or absent (5 of 19). Calcification was present in the majority (11 of 19). CONCLUSIONS: The honeycomb and stippled amorphous patterns reflect the cytoarchitecture of oligodendroglioma and were the most characteristic MR features. The amorphous pattern was the most commonly encountered pattern. There was a wider range of imaging findings on MR compared with CT; the flocculent calcification on CT was typical, but it was not always detected on MR. Including these characteristic areas that appear along the path of the stereotactic biopsy may ensure a correct diagnosis of oligodendroglioma because it most often is seen with another tumor, usually of the astrocytic family. Identifying the oligodendrogliomatous portion of the tumor will influence the therapy. No differences could be found in the MR appearance or biologic behavior of pure versus mixed oligodendrogliomas.     

Breast affections requiring surgery: diagnosis from the view-point of a radiologist (author's transl)

Examinations by X-rays are the best method to detect early carcinomas of the breast and precancerous alterations. In many cases it is possible to avoid operations by pneumocystography. An unsuspected result by pneumocytostography permits to depart from the principle to remove every palpable tumor. Nevertheless the X-ray examinations have some limits. Therefore it is necessary for the radiologist to know exactly the clinical state. Furthermore there must be a very good cooperation between the radiologist, the surgeon and the histologist. Problems originated from the appearance of so-called suspicious microcalcifications visible in well made mammograms. The sooner the microcalcifications are excised the more it is possible to discover early carcinomas and precancerous alterations but also harmless variations. Pathological secretion from the nipple is an indication for galactography. If there are pathological alterations in the ducts it is necessary in order to avoid mistakes in diagnosis to excise and examine the specimen by very reliable methods. The results from thermographical and cytological investigations are sometimes of value for the decision to perform an operation but not for the decision to omit the histological examination.     

Cystic meningiomas in children: a diagnostic challenge

Two cases of cystic meningioma in children are presented. The MR imaging features of each case presented difficulties in differential diagnosis because of the cystic nature of the neoplasms and their location. Cystic areas in meningiomas are encountered more frequently in children than in adults. Meningioma must be included in the differential diagnosis of cystic intracranial tumors in children.     

A clinical evaluation of an operational postanesthesia care unit source control system

Ossifying fibromyxoid tumor of soft parts is an unusual benign neoplasm, with a tendency for local recurrence. Its typical microscopic appearance is that of a multinodular proliferation of round to spindle shaped cells separated by fibrous bands in which bone formation is often seen. Herein, we present the clinicopathologic features of 17 examples of this tumor with particular emphasis on some unusual histopathologic features that may place pitfalls in the diagnosis of this tumor, including satellite micronodules, mucinous microcysts, absence of myxoid areas, crush artifact, multiple microcalcifications, epidermoid cysts, atypical chondroid differentiation with binucleate lacunar cells, pericytic growth pattern, and malignant change. Awareness of these unusual morphologic features should lead to a search for areas displaying the more typical features of ossifying fibromyxoid tumor to arrive at a correct diagnosis.     

Thrombosis and hemorrhage in oncology patients

As outlined in this review, patients with cancer may harbor many alterations of hemostasis. These are multifaceted and must be considered when trying to control hemorrhage or thrombosis in cancer patients. Also, hemorrhage or thrombosis is often the final fatal event in many patients with metastatic solid tumor or hematologic malignancies. Patients with malignancy present a major clinical challenge in this new era of oncologic awareness and more aggressive care, which has led to prolonged survival for patients and a longer time frame during which these complications may develop. Therefore, these complications are occurring more commonly. It is important to realize that these alterations of hemostasis exist and must be approached in a sequential and logical manner with respect to diagnosis; only in this way can responsible, efficacious, and rational therapy be delivered to patients. By far the most common alteration of hemostasis in malignancy is that of hemorrhage associated with thrombocytopenia, either drug-induced, or radiation-induced, or from bone marrow invasion. Hemorrhage resulting from DIC, however, is also quite common and may present as hemorrhage, thrombosis, thromboembolus, or any combination thereof. Many antineoplastic drugs and radiation therapy may lead to or significantly enhance hemorrhage in patients with malignancy. Thrombosis, also commonly seen in patients with malignancy, is often a manifestation of low-grade DIC. When approaching the patient with malignancy and either hemorrhage or thrombosis, all the potential defects in hemostasis must be considered, defined from the laboratory standpoint, and treated in as precise and logical manner as possible.     

Metastatic papillary thyroid carcinoma presenting as a typical branchial cyst

Two cases of papillary thryoid carcinoma presenting as a cystic lateral neck mass are reported. This tumour characteristically presents in patients under 40-years-old and in the presence of an occult primary tumour may mimic a branchial cyst. In such cases simple aspiration of the cyst will produce a chocolate-brown serous fluid which excludes the diagnosis of a branchial cyst and is characteristic of papillary thyroid carcinoma. Cytological examination of the fluid has a high degree of sensitivity and specificity in the diagnosis of thyroid malignancy and should avoid delay in diagnosis and unnecessary surgical exploration prior to definitive treatment.     

Mutations in the glucokinase gene of the fetus result in reduced birth weight

Human papillomavirus (HPV) type 60 infection is histologically associated with characteristic homogeneous intracytoplasmic inclusion bodies. However, it remains unclear whether the virus is associated with cystic, pigmented or ridged plantar warts. We report a 51-year-old Japanese female with a HPV-60-induced plantar wart which showed the clinical appearance of both pigmented and ridged warts. Masson-Fontana staining revealed increased melanin granules in the epidermis of the wart. This observation suggests that HPV-60 may be associated not only with cystic warts but also with the specific morphology of ridged warts, and the biological disorder of hyperpigmentation may be controlled by additional unknown factors which differ from case to case.     

Lymphoepithelial cysts of the pancreas: demonstration of lipid component using CT and MRI

We present two cases of surgically proven lymphoepithelial cyst (LEC) of the pancreas that had a lipid component visualized by CT and MRI. Identification of this component in a pancreatic cystic lesion is a key to favor the diagnosis of LEC or splenic epidermoid cyst over other cystic lesions when the lesion is noted in an elderly patient.     

The association of Marchiafava-Bignami disease, cerebral pellagra and cerebellar degeneration in an alcoholic patient

INTRODUCTION: Marchiafava-Bignami disease, cerebral pellagra and alcoholic cerebellar degeneration are a group of diseases included in the alcoholic encephalopathies, although they may also be caused by metabolic or nutritional disorders. The isolated appearance of these diseases usually permits diagnosis during the life of the patient, based on the neuro-radiological findings. However, their combination leads to complex form, with variable neurological expression, which means that precise diagnosis may often be post mortem. CLINICAL CASE: We present a malnourished alcoholic patient with neurological features compatible with alcoholic encephalopathy. The post mortem findings showed lesions typical of alcoholic cerebellar degeneration, cerebral pellagra and Marchiafava-Bignami disease.     

Anatomic variants of the cystic duct and cysticohepatic junction: diagnosis with MR cholangiography

The cystic duct are variable in length, course and site of termination. A knowledge of the variable anatomy of the cystic duct and cysticohepatic junction is important in biliary surgery, because failure to recognize anatomic variations may result in a significant ductal injury. Magnetic resonance cholangiography (MRC) is a recently developed technique that demonstrates the biliary tree noninvasively and without injection of contrast material. Anatomic variants of the cystic duct and cysticohepatic junction that may increase the risk of bile duct injury in biliary surgery are frequently identified with MRC. MRC will be a noninvasive and a useful technique in the diagnosis of anatomic variants of the cystic duct and cysticohepatic junction.     

Treated bacterial endocarditis as a histological mimic of fungal infection

Histological assessment of cardiac valve tissue contributes to the diagnosis of infective endocarditis and is of particular importance in cases in which no organism is cultured. Antibiotic treatment of bacterial endocarditis may lead to abnormal bacterial morphology and staining characteristics. Although in many cases the presence of some residual bacteria of normal appearance makes the diagnosis straightforward, in some only abnormal bacteria may be seen. Unless the appearances of these are interpreted with caution, the presence of larger spherical organisms with the staining properties of a yeast may lead to an erroneous diagnosis of fungal infection.     

Leg blood flow during slow head-down tilt with and without leg venous congestion

BACKGROUND AND STUDY AIMS: Endoscopy and biopsy from a suspicious Vater's papilla may establish an early preoperative diagnosis of a periampullary tumor. However, information regarding the diagnostic accuracy of this procedure is limited and variable. The aim of the present study was to evaluate retrospectively the accuracy of this procedure compared to that of other diagnostic methods. PATIENTS AND METHODS: Among 928 patients referred to our institute for endoscopic retrograde cholangiopancreatography (ERCP), a suspicious Vater's papilla was seen in 28. In each case comparison was made between the pre-ERCP clinical diagnosis, endoscopic appearance, histologic interpretation of endoscopic biopsies, and the final diagnosis. Two patients in whom a final diagnosis was not available were excluded from the study. RESULTS: A final diagnosis of an ampullary or periampullary carcinoma was established in 17 patients (65%), a carcinoma within an adenoma of the papilla in three patients (12%), and adenoma and a metastatic gallbladder carcinoma in one patient each. The remaining four patients (15%) were finally diagnosed as having "pseudotumors" (due to choledocholithiasis). Eight (38%) of the 21 patients with ampullary or periampullary neoplasm also had gallstones. A pre-ERCP diagnosis (by clinical evaluation and non-invasive imaging) of tumor versus choledocholithiasis was accurate in only 65% of all 26 patients. In these, the diagnostic accuracy of endoscopic appearance and endoscopic biopsy was 77% and 85%, respectively. Regarding the 21 patients with carcinomas, the diagnosis by endoscopic appearance was more accurate than that by endoscopic biopsy (90% vs 81%). Unlike the positive predictive values, the negative predictive values for malignancy were weak: 33% for the endoscopic appearance and 50% for the endoscopic biopsy. CONCLUSIONS: Because of a high incidence of concurrent cholelithiasis, many patients with a periampullary tumor seen during ERCP are misdiagnosed earlier (by clinical evaluation and non-invasive imaging) as having choledocholithiasis only. However, the accuracy of endoscopy and biopsy is also limited. This limitation must be considered when evaluating the optimal management of patients with suspected periampullary tumor.