Significance of tissue polypeptide specific antigen (TPS) in diagnosis and monitoring of treatment in ovarian cancer

BACKGROUND AND STUDY AIMS: It has recently been reported that in developed countries gastric outlet obstruction now predicts gastric malignancy. The aim of this study was to find out if this is the case in a developing country like India. PATIENTS AND METHODS: Seventy-four patients with gastric outlet obstruction underwent upper gastrointestinal endoscopy and biopsy specimens were obtained from any suspicious looking lesions or from the most distal point at which the endoscope could be positioned. RESULTS: In 56 patients (76%) the cause of the gastric outlet obstruction was malignant. On clinical and endoscopic appearance three patients were wrongly diagnosed as having malignancy when the cause, on endoscopic biopsy, was benign (tuberculosis n = 2, and immunoproliferative small intestinal disease n = 1). Twelve of the 18 patients with benign gastric outlet obstruction were managed conservatively with drugs and endoscopic balloon dilatation. CONCLUSION: Even in a developing country like India, malignancy is the commonest cause of gastric outlet obstruction and endoscopic biopsy specimens should be obtained in all patients with gastric outlet obstruction because the occasional benign lesions can be managed conservatively.     

Mediastinal masses in infants and children

In a group of 93 pediatric patients with mediastinal masses, three quarters of them were diagnosed because they were symptomatic. Approximately one half of the masses were malignant, and of neurogenic or lymphomatous origin. Neurogenic tumors predominated before the age of 4 years, while lymphomas were most common beyond age 4. Two thirds of the malignancies were potentially curable by surgery, irradiation, and chemotherapy; 54% of the patients were salvaged. Enteric duplications, ganglioneuromas, bronchogenic cysts, hemangiolymphangiomas, thymic cyst, and teratomas were the most frequently occurring benign masses. Simple excision was uniformly effective in these lesions.     

Bronchogenic cysts and esophageal duplications: common origins and treatment

BACKGROUND/PURPOSE: Bronchogenic cysts and esophageal duplications are usually considered as separate foregut malformations. Yet, both are thought to arise from the same embryological event, division of the embryonic foregut, and they share common histological characteristics, often making their clinical differentiation difficult. METHODS: A retrospective review of the cases of 68 children treated at a single institution between 1937 and 1995 was performed. Thirty children were girls (44%) and 38 were boys (56%). Ages ranged from newborn to 24 years. Complete records were available in all children. Fourteen of these 68 children were asymptomatic. RESULTS: Respiratory (54%) or gastrointestinal (13%) symptoms were the most frequent presenting problems. The majority of children were treated by resection of the cyst (52 of 68; 76%), while 9 of 68 (13%) required lobectomy for intraparenchymal lesions. Three children underwent marsupialization, with all of these children requiring additional surgery for recurrent disease. Five children (5 of 68; 7%) had multiple cysts. The mortality rate from this series was 10% (7 of 68). Two deaths were caused by perioperative exsanguination, one related to bleeding from a cyst lined with gastric mucosa with subsequent ulceration and hemorrhage into the esophagus. Two deaths occurred secondary to septic complications, one from an esophageal leak and the other from an intraparenchymal abscess. Two deaths were caused by respiratory failure; one was unrelated (SIDS). The majority of cysts found on histological review were lined by respiratory epithelium or bronchial glands (51 of 68; 75%). Gastrointestinal epithelium was present in cysts of nine children, only two of which were clinically diagnosed as esophageal duplications. Twenty-one cases (21 of 68; 31%) were classified as esophageal duplications based on the intramural location of the cyst, yet 15 of 21 (71%) contained respiratory epithelium, substantiating the hypothesis of the common origin of these lesions. CONCLUSIONS: The histological similarity and anatomic proximity of the "bronchogenic cysts" and the intramural "esophageal duplications" supports their common origin. The possible complications of bleeding, ulceration, infection, and obstruction of the esophagus or airway, should generally lead to prompt resection.     

Surgical treatment of primary neurogenic mediastinal tumors

In the years 1968-1989 out of 300 patients with surgically treated mediastinal tumors in 63 (21%) they were of neurogenic origin. Eighteen of these (29%) proved to be malignant. These tumors occurred in 23 males and 40 females, age range 14 months-67 years (mean 36 years). In all 45 patients with benign tumors and in 12 (66.7%) with malignant tumors the tumors were totally resected. In 4 patients the tumor was only partially resected in further two only a biopsy of the lesion was taken. During postoperative period one patient with a malignant tumor died. Ten (71.4%) patients survived 5 years with malignant lesions, while only 8 (61.5%) survived ten years. All patients that underwent resection of the benign tumor survived 10 years.     

Intestinal parasites in the vendors and consumers of street food. A study conducted in the Dakar area

To determine the origin and nature of mucinlike material in fine-needle aspiration (FNA) smears of the breast in noncancerous breast lesions, we studied breast FNA smears from four patients. All smears contained epithelial cells floating in a mucinlike background, which raised suspicion for mucinous (colloid) carcinoma. Mucicarmine stain was performed on one smear from each case. Subsequent tissue biopsy specimens were studied using mucicarmine, periodic acid-Schiff with and without diastase, and alcian blue stains at pH 2.7 and 0.9 on selected tissue sections. Correlation of the cytologic and histologic findings of each lesion was performed. The mucinlike background in all four FNA smears stained strongly with mucicarmine. Corresponding biopsy specimens revealed pseudoangiomatous hyperplasia in the first case, fibroadenoma and atypical ductal hyperplasia in the second, benign phyllodes tumor in the third, and fibroadenoma in the fourth. Each lesion in cases 1 to 3 was associated closely with fibrocystic changes. In case 4, cystic changes were located within the fibroadenoma. On tissue sections of all four cases, the cyst contents and 10% to 50% of normal lobule and duct contents stained with mucicarmine, indicating that the cyst contents were the most probable source of mucin in the FNA smears. The presence of pools of mucicarmine-positive material in FNA smears of the breast is not an exclusive feature of mucinous carcinoma; mucicarmine-positive mucin can arise from benign cystic changes as well as from normal lobules and ducts.     

Benign testicular tumor associated with Klinefelter's syndrome

Testicular tumors associated with Klinefelter's syndrome are rare. We report a benign testicular epidermal cyst that was diagnosed in a patient with Klinefelter's syndrome. The association between testicular tumors and Klinefelter's syndrome, and management of a testicular epidermal cyst are discussed.     

A valid new approach in treating solitary new lesions after resection of hepatocellular carcinoma

Recent studies have suggested that the appearance of solitary new lesions after a curative resection of hepatocellular carcinoma (HCC) may be closely related to the metachronous multicentric development of HCC. It is therefore extremely important to investigate the histological characteristics of solitary new nodular lesions confirmed to be HCC by an ultrasound (US)-guided needle biopsy. Thirty-five patients with small HCC, < or = 3 cm in diameter, who underwent a curative hepatic resection between 1987 and 1992, were observed for possible recurrence over a period of > or = 1 year. Solitary new lesions confirmed to be HCC were noted in 7 (20.0%) out of 35 cases 10-65 months after operation. All solitary new lesions underwent US-guided needle biopsy, and a histological examination of the biopsy specimen was performed. All seven solitary new lesions were then classified into the following two groups according to the histologic differentiation of biopsy specimens and were found to consist of five well-differentiated HCCs (71.4%) and two moderately differentiated HCCs (28.6%). Three of the five well-differentiated HCCs were accompanied by varying degrees of fatty changes. These morphologic observations suggest that approximately 70% of the solitary new lesions confirmed to be HCC after a curative resection of small HCC may thus be related to the metachronous multicentric origin of HCC. However, it is difficult to estimate the exact incidence of such cases. As a result, curative treatment may sometimes be feasible, even when treating solitary new lesions after resection of HCC. Therefore, we can better evaluate such solitary new nodular lesions after a resection of HCC by means of a histologic evaluation using US-guided needle biopsy.     

Immunohistochemical localization of UDP-glucuronosyltransferases in rat brain during early development

OBJECTIVE: Benign tumors account for less than 1% of testicular tumors and the incidence is even lower in children. A rare case of epidermoid cyst of the testis in a child is described. The differential diagnosis and treatment options are discussed. METHODS/RESULTS: A case of unilateral epidermoid cyst of the testis in an 11-year-old boy is presented. The clinical and diagnostic aspects are discussed. Definitive diagnosis could be made only after surgical excision. CONCLUSIONS: Pathological analysis of the entire testis is warranted to make the definitive diagnosis of epidermoid cyst. However, preservation of the testis can be considered, particularly in those cases with bilateral involvement, if supported by solid, consistent diagnostic evidence, including intraoperative biopsy.     

Preliminary evidence for an association of Epstein-Barr virus with pre-ulcerative oral lesions in patients with recurrent aphthous ulcers or Beh?et's disease

In this study we used the polymerase chain reaction (PCR), slot blot and Southern blot hybridization, direct sequencing and in situ hybridization (ISH) to show the possible presence of EBV-DNA in pre-ulcerative oral aphthous lesions of patients with recurrent aphthous ulcers (RAU) or Beh?et's disease (BD). For this purpose, formalin-fixed biopsy specimens were obtained from 13 pre-ulcerative oral aphthous lesions of nine RAU and four BD patients. Five specimens of normal oral mucosa (NOM) from five normal control subjects and 10 specimens of oral erosive or ulcerative lesions from 10 patients with erosive lichen planus (ELP) were also included. EBV-DNA was detected by PCR in 5 of the 13 (38.5%) pre-ulcerative oral aphthous lesions, two from RAU patients and three from BD patients. However, no EBV-DNA was demonstrated in five NOM specimens from normal control subjects and in 10 specimens of oral lesions from ELP patients. EBV-DNA was also demonstrated in patients' peripheral blood lymphocytes and/or plasma, suggesting that the lymphocytes may be the reservoir of latent EBV infection and there is EBV shedding in the plasma. EBV-DNA was detected by ISH in only one PCR-positive case; the reaction product was found to deposit on the nuclei of some of the epithelial cells and lymphocytes. By immunohistochemistry, expression of Epstein-Barr nuclear antigen and EBV/C3d receptors was also noted in some of the epithelial cells and lymphocytes in this ISH-positive case. Therefore, we suggest that the epithelial cells of pre-ulcerative oral aphthous lesions may be infected by EBV through EBV-infected lymphocytes; also, the cytotoxic T lymphocyte-induced lysis of the EBV-infected epithelial cells, but not the virus-induced cytolysis, may be the main mechanism causing oral ulcer formation. Our data provide preliminary evidence for an association of EBV with pre-ulcerative oral aphthous lesions in RAU and BD patients.     

Are stereotaxic breast biopsies adequate?

BACKGROUND: Stereotaxic core breast biopsy (SCBB) has been proposed as a cost-effective and reliable method of evaluating mammographic lesions. This study evaluates an initial experience with SCBB and assesses the adequacy of the biopsy specimens obtained. METHODS: Two hundred forty-one SCBB were performed on 221 patients during 13 months by four radiologists. Mammograms were assigned a suspicion index on a scale of 1 to 5. One pathologist performed a blinded retrospective review of all SCBB specimens and assigned an adequacy score based on the quality and amount of the tissue present. RESULTS: The majority of SCBB were ordered by general surgeons (67%). A suspicion index score of 3 was assigned to 74% of lesion specimens. Twelve percent of specimens were malignant. Overall SCBB adequacy (score > or = 2) was 77%. Adequacy was present in 74% of benign biopsy specimens as compared with 100% of malignant specimens (p < 0.005). Only 62% of specimens reported as benign without specific features were adequate. There were no differences in adequacy between individual radiologists or during the study period. CONCLUSIONS: SCBB is largely used by surgeons to assess indeterminate mammographic lesions. One of four benign specimens was inadequate. Benign SCBB specimens must be interpreted with caution.     

Solitary necrotic nodules of the liver

An experience is reported with solitary necrotic nodules of the liver, rare benign lesions described for the first time in 1983. Two patients were referred to our department because of the presence of hepatic lesions that radiology showed to be suspected secondary liver tumors. At laparotomy, both patients underwent liver resections because the lesions appeared to be malignant. Subsequent histological examination of the surgical specimens revealed that both were solitary necrotic nodules of the liver. These were the only solitary necrotic nodules found in a total of 840 operations carried out in our department since October 1981. Although they are completely benign, solitary necrotic nodules have a similar ultrasound pattern and radiological features to metastases and have been described in the literature during the follow-up of patients with other tumors. Uncertainty remains as to the etiology of these lesions, which still represent an occasional finding in liver surgery.     

The first 300 videothorascopic (VTS) and video-assisted (VATS) operations

To diagnose hepatocellular carcinoma (HCC) functionally and immediately, we examined the usefulness of indocyanine green (ICG) injection during ultrasound-guided liver biopsy. Liver specimens were obtained after intravenous ICG injection by ultrasound-guided biopsy from 251 space-occupying lesions (SOL) in 136 patients. The tissues were immediately examined for ICG uptake using an infrared Vidicon camera and were also subjected to histopathological examinations. Of the 112 ICG-negative biopsy specimens, 105 were histologically diagnosed as HCC, 6 as dysplastic nodules (DN) and 1 as a regenerative nodule (RN). Of the 139 ICG-positive specimens, 18 were diagnosed as HCC, 1 as DN and 120 as RN. The sensitivity of the absence of ICG uptake (SEAIU), the specificity of the absence of ICG uptake (SPAIU), and the positive predictive value of the absence of ICG uptake (PPAIU) for the diagnosis of HCC were 85.3%, 94.5% and 93.8%, respectively. Of the 251 SOLs, 184 were less than 2 cm. SEAIU, SPAIU and PPAIU for the diagnosis of these small HCC were 85.3%, 94.5% and 91.4%, respectively. These results support the reliability of ICG injection during ultrasound-guided liver biopsy to diagnose even small HCC.     

Reproducibility and validity of oral visual inspection by trained health workers in the detection of oral precancer and cancer

A randomized intervention trial is in progress in Kerala, India, to evaluate the effectiveness of oral visual inspection by trained health workers (HWs) in the prevention of oral cancer. Fourteen health workers with college graduation as the basic qualification were trained in oral visual inspection to identify oral cancers and precancers among the participants of the screening trial and to refer them for further confirmation and management. The aim of the present study was to evaluate the reproducibility and validity of the screening test provided by the health worker against the reference oral visual findings of three physicians. A total of 2069 subjects who had already been examined were re-examined by the health workers and physicians. The sensitivity and the specificity of the oral visual inspection were 94.3% and 99.3% respectively. There was moderate agreement between the findings of the initial and the repeat mouth examinations carried out by the health workers, which were on average 6 months apart. There was almost perfect agreement (kappa = 0.85) between the findings of the health workers and the physicians in identifying the different types of oral precancerous lesions. The findings of our study indicate that it is possible to train resource persons to perform the oral cancer screening test as accurately as doctors, although experience appears to be a crucial component of health workers' accuracy. The efficacy of such an approach to reduce the incidence of and mortality from oral cancer, however, remains to be proven.     

Fine-needle aspiration biopsy of synovial sarcoma. A cytomorphologic analysis of primary, recurrent, and metastatic tumors

Thirteen fine-needle aspiration specimens from 10 patients with histologically proven synovial sarcoma are described. The aspiration biopsy specimens were obtained from the primary tumor in five cases, locally recurrent tumors in four cases, pulmonary metastases in three cases, and mediastinal metastasis in one case. Patient's ages ranged from 22 years to 65 years; there were four women and six men. All cases had a confirmation biopsy and/or resection specimen that were reviewed. Histologic subtypes included monophasic fibrous (5 cases), monophasic epithelial (1 case), biphasic (3 cases), and poorly differentiated (1 case). The majority of the aspiration biopsy specimens were similar with moderate to marked smear cellularity dominated by cohesive clusters of spindle-shaped cells with ovoid, hyperchromatic nuclei and scanty tapering cytoplasm. Nucleoli were not prominent. Epithelial tumor cells with ovoid to round, mostly regular, centrally to eccentrically located nuclei, surrounded by scant to abundant cytoplasm predominated in one case (monophasic epithelial) and were admixed with spindle cells in a second (classical biphasic). Multi-nucleated tumor giant cells were not observed in any of the tumors. In biphasic synovial sarcoma, the neoplastic spindle cells are generally more numerous and frequent than the epithelial cells, making distinction from monophasic synovial sarcoma or other spindle cell soft tissue tumors difficult. Although synovial sarcoma may be diagnosed by fine-needle aspiration cytology, clinical correlation, especially in monophasic types, is necessary to minimize errors in sarcoma classification.     

Role of leukocytes in the pathogenesis of trophic venous disorders]

Although intraoral involvement in Crohn's disease (CD) is observed in only approximately 9% of cases, oral inflammation precedes intestinal symptoms of CD in about 60% of these patients. We describe a 20-year-old male with recurrent, painful, intraoral lesions who presented no other signs of systemic disease apart from severe loss of body weight. From the routinely screened serological parameters only the erythrocyte sedimentation rate and the acute phase reactants were elevated. A biopsy from the vestibular mucosa revealed a dense mononuclear infiltrate and, focally, small noncaseating granulomas suggestive of CD. Gastrointestinal endoscopy was performed showing mucosal involvement reaching from the esophagus to the descending colon. The diagnosis of active CD was confirmed by histopathology of intestinal biopsy specimens. As oral lesions are sometimes treated without a definite diagnosis, we emphasize the need to search for underlying systemic illness in the differential diagnosis of recurrent inflammatory lesions of the oral cavity.     

Acute febrile neutrophilic dermatosis (Sweet's syndrome)

BACKGROUND: Sweet's syndrome is well recognized and not infrequently diagnosed in Spain; however, the range of clinical and pathologic expression may not have been fully realized. METHODS: We reviewed 30 consecutive Spanish cases of Sweet's syndrome diagnosed in our department from 1979 to 1990, with special attention to clinical and histopathologic findings. RESULTS: Distinctive clinical features in our series included oral mucosa lesions in four patients (13%), development of pathergy phenomenon in one case, concurrent nodular lesions resembling erythema nodosum on the limbs in nine cases (30%), and lung involvement in two patients. Infectious disease and drug treatment were recorded as possible triggering factors of Sweet's syndrome in eight and seven patients respectively. Associated underlying systemic disorders were present in 15 (50%) of our patients. The most frequent associations were hematologic neoplasia in four patients, solid neoplasia in two, and chronic idiopathic inflammatory bowel disease in three patients. Dressler's syndrome and sicca syndrome were found in one patient each. Histopathologic studies of skin biopsy specimens obtained at presentation disclosed typical features of Sweet's syndrome in all cases. Epidermal involvement, with variable degrees of spongiosis, exocytosis of polymorphonuclear leukocytes and keratinocyte necrosis, was a prominent feature in 83% of biopsy specimens. CONCLUSIONS: Further characterization of the clinicopathologic spectrum of Sweet's syndrome is necessary as the recognition of the full spectrum of this syndrome will improve our diagnostic abilities and provide a solid clinical basis for prospective studies that allow dissection of the intricate patho-mechanisms involved in this fascinating disorder.     

Cystic meningiomas resembling glial tumors

BACKGROUND: Meningiomas can be associated with peripheral or intratumoral cysts. Meningiomas with intratumoral cysts, also called "true cystic" meningiomas, are rare and can frequently be confused with glial or metastatic tumors. METHODS: We report three cases of "true cystic" meningiomas and discuss the preoperative evaluation, etiology, and surgical treatment of these cystic lesions with reference to the literature. RESULTS: Magnetic resonance imaging (MRI) and computed tomography (CT) studies usually display a cystic lesion close to the dura with or without enhancement of the cyst wall. Multiplanar MRI scans are very useful to show the presence of a solid tumor or some dural enhancement. Some cases of "true cystic" meningiomas however, are still erroneously preoperatively diagnosed. Complete surgical removal of the tumors and of the entire cyst wall was performed in our cases. Despite the absence of a typical ring enhancement of the cystic lesion in two cases, histopathologic studies displayed the presence of tumor cells on the cyst wall of both cases. CONCLUSIONS: Tumor cells can be present on the cyst wall and therefore can be one of the causes of tumor recurrence if not totally removed. Accurate preoperative radiologic diagnosis (multiplanar MR images) and intraoperative histopathologic studies are fundamental in that they will definitely influence the surgical strategy and outcome.     

Early detection of breast cancer in Navarra. Diagnostic approach in women sent to a referral hospital

BACKGROUND: Breast cancer screening programs represent an important increase in the number of patients to be evaluated and a higher proportion of subclinical lesions detected in reference hospitals. The authors' experience related to an early detection program initiated in Navarra, Spain (PDPCM) is herein presented. METHODS: The diagnoses made in 319 women referred from the PDPCM to the authors' hospital for mammographic suspicion of malignancy were reviewed. Directed surgical biopsy was carried out in 89 women (27.9%) without previous cytologic study. Fine needle aspiration punction and cytology (FNAP-cytology) were performed as the first diagnostic test in 216 lesions (67.7%) 53 of which were palpable and 163 nonpalpable. Aggressive techniques were not indicated in 14 cases (4.4%). RESULTS: A total of 136 carcinomas (42.6%) were diagnosed and benign lesions were find at biopsy in 112 (35.1%) women. The fifty-seven lesions (17.9%) which did not show malignancy on FNAP-cytology were not biopsied given the insufficient degree of suspicion. Only one false negative has appeared in this group from 27 to 48 months after the first consultation. The global diagnostic reliability was of 99.68%. CONCLUSIONS: Directed surgical biopsy is the most reliable technique for the diagnosis of nonpalpable breast lesions in early stages and is always necessary when there is medium or high radiologic suspicion of malignancy. Fine needle aspiration puncture is a very useful technique to confirm malignancy and to avoid unnecessary biopsies in low suspicion lesions.     

Localization of chromosome 8p regions involved in early tumorigenesis of oral and laryngeal squamous carcinoma

We analysed 30 primary invasive oral and laryngeal squamous carcinomas (SC), with concurrent dysplastic lesions, for genetic alterations at 15 microsatellite loci on the short arm of chromosome 8. Overall, loss of heterozygosity (LOH) was observed, in at least one informative locus, in 27% of the dysplastic lesions and in 67% of the invasive carcinomas. The highest frequency of allele losses in dysplasia (20% and 17%), and invasive carcinoma (40% and 48%) were detected in the same D8S298 and LPL-tet loci located on chromosomes 8p21 and 8p22 respectively. The minimal region with LOH was limited to 4.6 megaBases (mBs) at 8p22 and 7.1 mBs at 8p21. In addition, allelic losses in both dysplastic and corresponding invasive specimens were noted at the same loci in some tumors suggesting their emergence from a common preneoplastic clone. Allele losses correlated significantly with male gender, oral and laryngeal sites and high proliferative index. The data suggest that inactivation of tumor suppressor gene(s), within these loci, may constitute an early event in the evolution of oral and laryngeal SC.