Anorectal miscellany: pilonidal disease, anal cancer, Bowen''s and Paget''s diseases, foreign bodies, and hidradenitis suppurativa

BACKGROUND: Metastatic adenocarcinoma in the liver with an unidentified primary tumor site is a common clinical problem. Pathologists often are asked to identify the primary tumor site. The histologic picture itself usually is not helpful, because the histology may be similar in the metastases of tumors with different primary localizations. Immunohistochemistry can be helpful, but the previously recommended antibody panels are too complicated for everyday use. METHODS: A simple immunohistochemical algorithm with two monoclonal cytokeratin (CK) antibodies, CK20 and CK7, was tested on 93 autopsy cases of adenocarcinomas metastatic to the liver. Sections of the liver metastases were stained automatically and evaluated as negative (no staining), focally positive, or diffusely positive. Statistical comparison of the staining results for a single antibody was calculated as an odds ratio. RESULTS: Thirty-six of 93 (39%) metastases proved to be CK20 positive (+). In this group, the CK20+/CK7 negative (-) pattern was highly characteristic for colorectal localization of the primary tumor, having been observed 17 of 21 of the cases (81%). The CK20+/CK7+ pattern of the metastatic liver adenocarcinomas was highly suggestive of primary localization in the pancreas or biliary tract (11 of 14 cases; 79%). Exclusion of the tumors originating in the stomach raised these values to 94% and 92%, respectively. The statistically calculated predicted probability of primary tumor site being in the colon or rectum for CK20+/CK7- metastasis was 78,41%, the probability of a primary tumor being located in the pancreas or biliary tract was 74,85%, if calculated for the whole study group. CONCLUSIONS: The tested simple algorithm proved to be useful in CK20 positive (+) cases, predicting a primary tumor localization in the colon, rectum, pancreas, or biliary tract with high accuracy. The CK20- group was too heterogeneous to be classified adequately by these two antibodies.     

Carcinoid tumor metastatic to the breast

Breast metastases from nonmammary malignant neoplasms are uncommon, accounting for approximately 2% of breast tumors. There are 13 cases reported in the literature of carcinoid tumor metastatic to the breast, and more than half of these cases were misdiagnosed pathologically and treated as primary breast carcinoma, even in cases with a medical record of carcinoid tumor. We describe a patient with a history of asthma and diarrhea who presented to the University of Arkansas for Medical Sciences, Little Rock, with an exacerbation of the asthma. The results of routine physical examination revealed a mass in the left breast. A diagnosis of carcinoid tumor metastatic to the breast was made after a partial mastectomy was performed. The differential diagnosis between primary carcinoid tumor of the breast and carcinoid tumor metastatic to the breast is often controversial in surgical pathology. Diagnoses need to be made correlating clinical and histological examination in difficult cases in which there is not a diagnosis of carcinoid tumor elsewhere. Accurate diagnosis of breast metastases is important to avoid unnecessary treatment.     

Patients'' requests and satisfaction with services in an outpatient psychiatric setting

Teratomas are embryonal neoplasms consisting of tissues from at least two of the three germ layers. Teratomas can occur in almost any region of the body and in any organ, but they are most commonly observed in the paraxial and midline locations. Excluding teratomas of the testes, 75% to 80% of teratomas occur in females. Approximately 80% are benign and 20% are malignant. The presenting location of teratomas correlates with patient age. Teratomas occurring in infancy and early childhood are usually extragonadal, whereas older children predominantly present with gonadal teratomas. The most common site of occurrence in neonates is in the sacrococcygeal and presacral region. Prognosis depends on patient's age, the resectability of the tumor, and the presence of metastases or metastatic potential.     

The face of Job

PURPOSE: To describe the microcirculation architecture of metastatic choroidal and ciliary body melanoma. METHOD: Histologic sections of 35 metastases from 19 primary melanomas were stained to demonstrate microcirculation. RESULT: The appearance of microcirculatory networks in metastases is independent of the target organ but associated with the size of the metastatic deposit (estimated coefficient = 0.5959; SE = 0.3024; P = .0488). CONCLUSION: The microcirculatory patterns of primary uveal melanomas that are associated with metastatic behavior appear in foci of metastasis, regardless of the site of dissemination.     

Assessment of self-injurious behavior maintained by access to self-restraint materials

Metastatic tumor is one of several etiologies of space-occupying masses in the orbit that accounts for 1%-13% of all orbital masses (1). In the adult patient population, breast cancer is the most common tumor to metastasize to the orbit followed by metastases from the lung, prostate and gastrointestinal tract (2). It is rare for carcinoid tumors to metastasize to the eye or to the orbit. Carcinoid tumors arise from Kulchitsky cells that originate in the neural crest. Histologically, these tumors resemble, but are not as aggressive as, adenocarcinomas. Most carcinoids arise in the gastrointestinal tract or the lung. The most common site for carcinoid metastases is the liver. On anatomical imaging studies, such as CT and magnetic resonance imaging, metastatic orbital carcinoid tumors appear as nonspecific tumor masses. Carcinoid tumors have an affinity for uptake of the radiopharmaceutical 131I-metaiodobenzylguanidine (MIBG) (3). We report a case of a patient with a known carcinoid tumor who developed a left orbital mass that demonstrated abnormal uptake of 131I-MIBG indicative of metastatic carcinoid tumor to the orbit.     

Cancer metastases to the cervical lymph nodes in an unknown primary location of the tumor

Out of 120 patients hospitalized with the diagnosis of metastases to the cervical lymph nodes and unknown primary location of the tumor, tumors were detected in 29 and lymphosarcoma in 10. In 24 (82.7%) patients the tumor was located in the upper respiratory tract and gastrointestinal tract. Malignant tumors of the naso- and stomatopharynx and vestibular part of the larynx most often metastasize into the lymph nodes. Radiotherapy was administered to all 81 patients with metastases and unknown location of the primary tumor and to 10 patients with lymphosarcoma of the cervical lymph nodes. The protocol of radiotherapy took account of the site of the metastases and probable primary tumor. A radical course provides cure in 15% of cases, as shown by follow-up of at least 2 years.     

Intrabiliary growth of metastatic colonic adenocarcinoma: a pattern of intrahepatic spread easily confused with primary neoplasia of the biliary tract

Because of its propensity to spread along epithelial surfaces, colonic adenocarcinoma can mimic other neoplasms. For example, colonic adenocarcinoma can grow along the surface of the urinary bladder and can simulate primary bladder neoplasia, and metastatic colonic adenocarcinoma can grow along alveolar walls and can mimic primary lung neoplasia. Intraepithelial spread along bile ducts, however, is not a well-recognized behavior of hepatic metastases. Indeed, dysplastic change in the epithelium lining the biliary tract is sometimes used to discriminate primary biliary neoplasms from metastatic adenocarcinoma. We report on eight cases of colonic adenocarcinoma metastatic to the liver that demonstrated prominent spread throughout the biliary tree along intact basement membranes. Morphologically, this pattern closely resembled high-grade dysplasia (i.e., carcinoma in situ) of the extrahepatic and intrahepatic bile ducts. Clinically, two of the tumors were mistaken for primary biliary neoplasia because of the common radiologic finding of intrabiliary masses with distended bile ducts. A definite diagnosis of metastatic carcinoma was established by careful attention to the medical history, thorough evaluation of the morphologic features, and histologic comparison with the primary colon cancer. For patients with a history of colonic adenocarcinoma, consideration of a liver metastasis is appropriate even when certain histologic and radiographic features point to a neoplasm of biliary origin.     

Uveal metastasis from carcinoid tumor. Clinical observations in nine cases

BACKGROUND: Carcinoid tumor is a low-grade malignancy that usually arises in the gastrointestinal tract or bronchus and rarely metastasizes to the eye. Metastasis of carcinoid tumor to the uvea can be confused clinically with other primary and metastatic uveal tumors. METHODS: The authors reviewed the records of 410 consecutive patients with uveal metastases referred to the Ocular Oncology Service at Wills Eye Hospital to identify those in whom carcinoid tumor was the primary neoplasm. The authors evaluated the clinical features of these metastases. RESULTS: Of 410 consecutive patients with uveal metastases, the primary neoplasm was a carcinoid tumor in 9 (2.2%). There were four men and five women. The mean age at ocular diagnosis was 50 years. In five patients (56%), the primary tumor was undiagnosed at ocular presentation. In the other four patients, the mean time interval from diagnosis of the primary carcinoid tumor to uveal metastasis was 89 months (range, 55-180 months). The site of the primary carcinoid tumor was the bronchus in seven patients, the esophagus in one, and the thymus in one. The site of intraocular metastasis was the choroid in six patients, the ciliary body in two, and the iris in one. All choroidal tumors had a characteristic orange color. Initial ocular treatment included external beam radiotherapy in five patients, plaque radiotherapy in two, argon laser photocoagulation in one, and local resection in one. Ocular tumor control was achieved in each patient. After a mean follow-up of 34 months, four patients (44%) are still alive. Five patients have died, with a mean survival of 34 months (range, 2-104 months) after the diagnosis of uveal metastasis. CONCLUSIONS: Uveal metastasis from carcinoid tumor is rare and tends to arise from the bronchus. Clinically, it has a distinctive orange color and may be associated with a longer systemic survival, compared with uveal metastasis from other primary sites.     

Massive lower gastrointestinal haemorrhage secondary to metastatic squamous cell carcinoma of the lung

Clinically significant symptoms due to gastrointestinal metastases from primary lung cancers is rare. A case of life-threatening lower gastrointestinal haemorrhage secondary to metastatic squamous cell carcinoma of the lung is reported. Previous reports of such metastases are reviewed, with reference to management and prognosis. After resection of colonic metastases from squamous cell lung cancer, survival is similar to that for primary disease. It is suggested that patients with known or suspected squamous cell lung cancer presenting with lower gastrointestinal symptoms be managed as aggressively as those with no previous history of disease.     

Catheter ablation of ventricular tachycardia associated with remote myocardial infarction: utility of the atrial transseptal approach

BACKGROUND: To determine the magnetic resonance (MR) imaging features of hepatic metastases from leiomyosarcoma and determine the pathologic basis for the MR appearance of these neoplasms. METHODS: MR examinations of eight patients with a total of 16 hepatic metastases from leiomyosarcoma were retrospectively reviewed. Hepatic metastases originated from a primary gastrointestinal (n = 6), uterine (n = 1), or retroperitoneal (n = 1) leiomyosarcoma. Correlation between MR features and pathologic findings was performed in 11 metastases from which histologic material was obtained. RESULTS: Among the 10 metastases seen on T1-weighted MR images, nine were homogeneous and one was heterogeneous. The latter contained areas of necrosis and hemorrhage on pathologic examination. Among the 16 metastases seen on T2-weighted MR images, 12 were well delineated and completely homogeneous, with a marked hyperintense signal ("hemangiomalike" pattern). These neoplasms were composed of smooth fibrous tissue without macroscopically visible areas of necrosis on pathologic examination. The remaining four metastases were heterogeneous and contained varying degrees of necrosis and hemorrhage or gelatinous tissue. CONCLUSION: A hemangiomalike pattern is the most common feature on T2-weighted MR images. We found that homogeneous hyperintensity of hepatic metastases from leiomyosarcoma on T2-weighted MR image does not reflect cystic changes.     

Radical resection of primary malignant melanoma of the gallbladder with multiple metastases: report of a case

We present herein an usual case of primary malignant melanoma of the gallbladder in a 51-year-old man in whom an exploratory laparotomy for melena revealed six malignant melanoma lesions located in the gallbladder, main pancreatic duct, stomach, duodenum, jejunum, and a mesenteric lymph node. Total pancreatectomy was performed and histologically, junctional activity was seen only in the gallbladder, suggesting that this was the primary site. No melanotic lesions were found on the skin or eyes. The metastases to the main pancreatic duct and gastrointestinal tract appeared likely to have occurred as a consequence of the mucosal dissemination of the tumor cells shed into the bile. The post-operative course was uneventful and combined chemotherapy was administered for 16 months. No new metastatic lesions were found until 21 months postoperatively, when metastases were detected in the brain and thoracic spinal cord. These metastatic tumors were removed surgically, but the patient died from cerebral disturbance 26 months after the initial operation. Thus, we consider that aggressive surgical therapy was effective for extending the survival time and improving the quality of life of this patient.     

Metastatic carcinoma to the mandible. Report of two cases

Two cases of rare metastases from malignant neoplasms to the posterior mandible in young adults are reported. Multiple imaging modalities were necessary to identify the many metastases and, in one case, the suspected primary site. Many of the radiographic images are presented for that case.     

Malignant tumors of the small intestine

Primary malignant tumors of the small intestine are uncommon. The average annual incidence rate over a period of 30 years in Saskatchewan was 0.7 and 0.6 per 100,000 for male and females, respectively. The 209 patients who comprise the series represent 1.6% of the total number who had gastrointestinal cancers over the same period. The distribution of the tumors by site and histologic type is described. Both carcinoid and adenocarcinomatous tumors of the small intestine are associated with a high incidence of primary malignant neoplasms in other sites (17.0 and 20.3%, respectively). One patient with Peutz-Jeghers syndrome is of interest because of the malignant change which occurred in more than one of the small bowel polyps and because of consequent liver metastases. The reason for the poor prognosis in noncarcinoid small bowel malignant neoplasms is probably due to late diagnosis. The five-year disease-free survival in these tumors was 22.5%. Malignant carcinoids had a better overall five-year survival rate of 64%. For those confined to the bowel wall, the five-year survival rate was 73%, compared to 59% for those extending to nodes or metastasizing to distant organs.     

The choice of alloplastic materials for oral implants: does it really matter?

The clinical and bacteriological results of treatment for 429 patients who had intra-abdominal infection were analyzed to determine whether the anatomical origin of peritonitis influenced outcome. All patients had received effective broad spectrum antimicrobial therapy and operation in four multicenter trials. The diagnoses of infection were categorized into three sites: upper gastrointestinal tract, complicated appendicitis, and lower gastrointestinal tract. Clinical response rates were excellent for complicated appendicitis and were lowest for infections related to the upper gastrointestinal tract. Bacteriological response rates were also lower for upper gastrointestinal tract organisms and were highest for isolates associated with complicated appendicitis. There were no deaths in the 213 patients who had infection associated with appendicitis. Seven deaths occurred in the 86 patients (81%) with an upper gastrointestinal site of infection, and nine deaths occurred in the 130 patients (6.5%) with lower gastrointestinal site of infection. Mortality was related to recurrent intra-abdominal infection after an unsuccessful primary operation and a serum albumin less than 25 g/l. Clinical trails of antimicrobials for intra-abdominal infection should consider stratification of patients according to these three levels of alimentary tract perforation when the site is known preoperatively. Patients who have infection secondary to previous surgery or who are malnourished represent a higher risk group even with appropriate antibiotics.     

Metastases from testicular carcinoma. Study of 78 autopsied cases

The necropsy records of 78 patients with histologically proved germ cell tumors of the testis, who died as a direct result of their malignant disease, were reviewed to determine the usual modes of spread, distribution of metastasis, the histologic characteristics of the metastatic foci as compared with the morphology of the primary tumor and the specific cause of death. The sites of metastases in order of decreasing frequency for all cases were lung, retroperitoneal lymph nodes, liver, mediastinal lymph nodes, brain, kidney, gastrointestinal tract, bones, adrenals, peritoneum and spleen. The absence of metastases solely in the anterior mediastinum without involvement of other mediastinal nodes (middle/posterior) strongly supports the premise for a primary extragonadal origin whenever the anterior mediastinum alone is involved with malignant disease having the histologic appearance of a primary germ cell tumor. The histologic features of the metastatic lesions were usually similar in nature to those of the primary tumor except for seminoma in which the metastatic lesions proved to be of a different histologic pattern in almost one third of the patients dying from the disease. It should be axiomatic that whenever a patient with seminoma fails to respond appropriately to radiotherapy that his treatment be immediately discontinued and that appropriate biopsies be obtained to substantiate the histologic pattern present.     

Testicular calcifications: incidence, histology and proposed pathological criteria for testicular microlithiasis

PURPOSE: Testicular microlithiasis is a clinical syndrome in which men present with innumerable testicular calcifications. Indirect evidence suggests that this syndrome may be associated with an increased risk of germ cell neoplasia. The incidence and types of testicular calcification in normal and diseased testes is unknown. MATERIALS AND METHODS: A series of 131 orchiectomy specimens were reviewed, including 79 germ cell tumors, and 100 entirely embedded autopsy testes in men with no known testicular pathology. RESULTS: Two types of calcifications were identified. Hematoxylin bodies, consisting of amorphous calcific debris, were present in 6 cases associated with germ cell tumors. In contrast, laminated calcifications were found not only in association with germ cell tumors (35 cases), but also in 2 of 4 cryptorchid testes and 6 of the remaining 145 testes (4%). Of these calcifications 61% were multiple. When laminated calcifications were associated with germ cell tumors there was an increased incidence of extension beyond the tunica albuginea (43 versus 21%) and lymphatic invasion (52 versus 17%, p = 0.046 and 0.012, respectively). CONCLUSIONS: Testicular calcifications are heterogeneous. Hematoxylin bodies are specific for germ cell tumors but laminated calcifications, while more common in germ cell tumors, also occur in otherwise normal testes. The pathological criteria for testicular microlithiasis should include the identification of multiple laminated calcifications within seminiferous tubules.     

Antioxidant systems in rat epididymal spermatozoa

Down-regulation of KAI1 mRNA expression has been shown to be associated with the formation of metastases or disease progression in pancreatic cancer. Whether KAI1 possesses similar characteristics in other malignancies of the gastrointestinal tract is not known. Here, we compared the patterns of KAI1 mRNA expression in 41 esophageal cancers and 35 stomach cancers to assess whether KAI1 might also be of biological relevance in the metastatic ability of these tumors. By Northern blot analysis, KAI1 mRNA levels ranged widely in both normal and cancerous esophageal and gastric tissue samples, with no statistical differences. No association between KAI1 mRNA expression and tumor stage or tumor differentiation was seen in these tumors. In addition, KAI1 mRNA expression was similar in primary esophageal and gastric cancer samples with or without metastases. By in situ hybridization, KAI1 mRNA expression was evident in the cytoplasm of most squamous epithelial cells in the normal esophagus and in nonmucosal epithelial cells of the normal stomach. The staining intensity in the esophageal and gastric cancer cells was similar to that in the normal controls. This differential pattern of KAI1 mRNA expression in esophageal and gastric cancers in comparison to pancreatic cancer indicates that KAI1 seems to influence the potential of gastrointestinal cancer cells to metastasize differently. In esophageal and gastric cancers, the formation of metastases is not dependent on the reduction of KAI1 in the cancer cells.     

Apolipoprotein E and A-IV polymorphisms in the Estonian population

A 41-year-old man was admitted to our hospital with chief complaints of painless tumor in the left scrotal contents and loss of body weight. As the tumor was suspected of being a neoplastic lesion, left radical inguinal orchiectomy was carried out. Histopathological examination showed metastatic adenocarcinoma of the bile duct. Metastatic carcinoma to the testicle, epididymis, and their tunics is unusual and testicular metastases from adenocarcinoma of the bile duct is extremely rare. A case of testicular metastases from carcinoma of the bile duct is reported and the literature reviewed.