Symptomatic glial cysts of the pineal gland.

Small asymptomatic cysts of the pineal gland represent a common incidental finding in adults undergoing computerized tomography or magnetic resonance (MR) imaging or at postmortem examination. In contrast, large symptomatic pineal cysts are rare, being limited to individual case reports or small series. The authors have reviewed 24 cases of large pineal cysts. The mean patient age at presentation was 28.7 years (range 15 to 46 years); 18 were female and six male. Presenting features in 20 symptomatic cases included: headache in 19; nausea and/or vomiting in seven; papilledema in five; visual disturbances in five (diplopia in three, "blurred vision" in two, and unilateral partial oculomotor nerve palsy in one); Parinaud's syndrome in two; hemiparesis in one; hemisensory aberration in one; and seizures in one. Four lesions were discovered incidentally. Magnetic resonance imaging typically demonstrated a 0.8- to 3.0-cm diameter mass (mean 1.7 cm) with homogeneous decreased signal intensity on T1-weighted images, increased signal intensity on T2-weighted images, and a distinct margin. Hydrocephalus was present in eight cases. The cysts were surgically excised via an infratentorial/supracerebellar approach (23 cases) or stereotactically biopsied (one case). Histological examination revealed a cyst wall 0.5 to 2.0 mm thick comprised of three layers: an outer fibrous layer, a middle layer of pineal parenchymal cells with variable calcification, and an inner layer of hypocellular glial tissue often exhibiting Rosenthal fibers and/or granular bodies. Evidence of prior hemorrhage, mild astrocytic degenerative atypia, and disorganization of pineal parenchyma were often present. Postoperative follow-up review in all 24 cases (range 3 months to 10 years) revealed no complications in 21, mild ocular movement deficit in one, gradually resolving Parinaud's syndrome in one, and radiographic evidence of a postoperative venous infarct of the superior cerebellum with ataxia of 1 week's duration in one. Of the patients referred for study, the cysts were most often initially misdiagnosed as a pineocytoma in eight and a pilocytic astrocytoma in three. Only two patients were correctly diagnosed as having pineal cysts. This stresses the importance of recognizing the histopathological spectrum of pineal cysts, as well as correlation with radiographic findings, if a correct diagnosis is to be attained.

Benign glial cysts of the pineal gland: unusual imaging characteristics with histologic correlation.

PURPOSE: To describe the spectrum of MR and CT findings in clinically symptomatic pineal cysts and to determine whether there are certain diagnostic imaging features that allow one to distinguish a benign pineal cyst from other neoplasms of the pineal region. METHODS: MR and CT scans of 19 patients with clinically symptomatic pineal cysts were retrospectively reviewed. Age range was 15 to 46 years with a mean age of 28 years. There were five male and 14 female patients. RESULTS: Presenting features included headache (15 patients), diplopia (four), nausea and vomiting (four), papilledema (four), seizure (three), Parinaud syndrome (two), ataxia (one), and hemiparesis (one). All cysts were resected or biopsied to provide histopathologic confirmation of the diagnosis. Preoperative diagnoses included pineal neoplasm (14 of 19), pineal cyst (3 of 19), and dermoid cyst (2 of 19). The lesions ranged from 0.8 to 3.0 cm, with a mean diameter of 1.6 cm. Three cysts showed fluid/fluid levels consistent with hemorrhage. Slightly less than half (9 of 19) had evidence of hydrocephalus. The MR signal changes were variable but typically demonstrated low signal on T1-weighted images and high signal on T2-weighted images. More than half (7 of 12) demonstrated enhancement with gadolinium. Calcification of the cyst wall was observed in only four of nine patients who had CT studies but identified histologically in all cases. CONCLUSION: The MR appearance of benign pineal cysts is variable, ranging from that of an uncomplicated cystic mass to a mass associated with hemorrhage, enhancement, or hydrocephalus. This variability may make them indistinguishable from other pineal-region tumors.

Nonepiphyseal giant cell tumor of the long bones. Clinical, radiologic, and pathologic study.

BACKGROUND: Giant cell tumors (GCT) usually involve the epiphyses of long bones and only rarely involve the metaphysis or diaphysis without epiphyseal extension. METHODS: This report presents the clinical and pathologic features of 14 patients with metaphyseal and diaphyseal GCT. Of these tumors, 10 were metaphyseal; 2, metadiaphyseal; and 2, diaphyseal. RESULTS: The sites of involvement included the proximal tibia in six patients, distal radius in three, proximal fibula in one, distal fibula in one, distal ulna in one, proximal humerus in one, and distal femur in one. Radiographically, the tumors were lucent, and the majority were sharply marginated without sclerosis. By contrast with conventional epiphyseal GCT, which generally appear in the mature skeleton, a large proportion (50%) of the GCT in this series were in patients who had open epiphyseal growth plates. Despite the unusual clinical presentation, the behavior of metaphyseal and diaphyseal GCT was similar to that of the typical epiphyseal GCT. There was a 43% recurrence rate after curettage in this series. CONCLUSIONS: It is important to distinguish this subset of GCT from other giant cell-rich lesions more common in these sites, including aneurysmal bone cyst, osteosarcoma, and nonossifying fibroma.

Extraskeletal telangiectatic osteosarcoma.

The first three well-documented cases of pure, extraskeletal telangiectatic osteosarcoma of the soft tissues are presented in this article. The distinctive gross features were a predominance of large, blood-filled spaces, which, on histologic examination, were large blood-filled cavities in association with cyst-like walls containing anaplastic spindle cells and definite osteoid production in two of three cases. One of the cases is of additional clinical interest because the teen-aged daughter of the woman patient had died 1 year previously of a high-grade intramedullary osteosarcoma of bone.

Fluoroscopically guided incision of ureteral strictures in pigs with the cautery-wire balloon catheter: a phase 1 study.

We investigated a catheter that can longitudinally incise ureteral strictures under fluoroscopic guidance without the need for ureteroscopy and its attendant risks. The catheter consists of a low-pressure balloon and an overlying cautery wire; the balloon allows precise localization of the stricture, seen as a waist in the balloon, and the overlying cautery wire can be fluoroscopically oriented at the stricture. One to two centimeter ureteral strictures were created in 6 swine. Two to four weeks later strictures were incised in a retrograde or antegrade fashion with the cautery-wire balloon catheter, and double J stents placed for a duration of three weeks. In 5 of 6 renal units strictures improved anatomically with resolution of hydronephrosis at 3 to 4 months' follow-up. Urodynamic absence of obstruction was verified by Whitaker testing. In one animal, the tip of the catheter dislodged in the ureter with subsequent loss of the renal unit. The engineering error that lead to this complication has since been rectified. With correction of the aforementioned problem, this Phase 1 study has demonstrated the feasibility, safety and preliminary efficacy of the cautery-wire balloon catheter for endourologic management of ureteral strictures.

Cystosarcoma phyllodes of the seminal vesicle.

An unique case of high-grade phyllodes tumor (cystosarcoma phyllodes) arising in the seminal vesicle is reported. A 61-year-old man had symptoms of urinary obstruction, and ultrasonography and computed tomography showed a large mass posterior to the bladder. Using cystoprostatoseminovesiculectomy, a high-grade phyllodes tumor of the left seminal vesicle was found that did not involve the bladder or prostate. Histologically, the tumor consisted of benign irregular slit-like glands set in a mitotically active cellular sarcomatous stroma. The epithelium displayed intense cytoplasmic immunoreactivity with all keratin proteins (AE1/AE3, CAM 5.2, and high-molecular-weight keratin [clone 34 beta E12]). The stromal cells were strongly positive for vimentin, and approximately 30% were positive for muscle-specific actin and desmin. Four years after resection, a lung metastasis was removed, which was histologically and immunohistochemically identical to the seminal vesicle tumor. This case represents the malignant end of the range of phyllodes tumors (cystosarcoma phyllodes). Like similar tumors in the breast and prostate, phyllodes tumors of the seminal vesicle should be considered high-grade lesions (malignant) in which there is significant mitotic activity, stromal pleomorphism, and stromal overgrowth.

Chronic lymphocytic leukemia presenting as a pituitary mass lesion.

We describe a unique case of chronic lymphocytic leukemia (CLL) in a patient who presented with bitemporal hemianopsia, adrenal insufficiency, and gonadotrophin deficiency. Studies revealed an enhancing intrasellar mass with suprasellar extension and displacement of the optic chiasm. Peripheral blood and cerebrospinal fluid (CSF) studies disclosed a monoclonal IgM kappa expressing B-cell CLL. Biopsy of the pituitary mass revealed dense infiltration of the pituitary gland by leukemic cells. This is, to our knowledge, the first reported case of CLL presenting as a pituitary mass lesion.

Pleomorphic fibroma of skin. A case report and immunohistochemical study.

An immunohistochemical study of a clinically benin but cytologically atypical mesenchymal lesion of the skin is presented. This lesion has been previously reported as pleomorphic fibroma and was shown to follow a benign course with a potential for local recurrence. These lesions contain occasional markedly atypical enlarged spindle cells with anaplastic-appearing nuclei. Nonmirror image mitotic figures may be present. Histogenesis of this neoplasm remains controversial with a fibroblastic origin being favored by previous authors. Our immunohistochemical findings would support this conclusion.

Rapid diagnosis of Legionella infection by a nonisotopic in situ hybridization method.

The authors report a nonradioactive adaptation of DNA hybridization technology for the direct detection of Legionella organisms in situ in routinely processed histologic specimens. The probe used consisted of synthetic oligodeoxynucleotides, complementary to the ribosomal RNA of all clinically relevant Legionella species, labeled with biotinylated dUTP at their 3' ends. By in situ DNA hybridization and detection with an avidin-alkaline phosphatase complex. Legionella was visualized by light microscopy within the alveoli of lung specimens in 9 of 13 direct fluorescent antibody- or culture-positive cases of Legionnaires' disease. No cross-hybridization was observed in lung specimens infected with Pseudomonas aeruginosa, Klebsiella pneumoniae, Streptococcus pneumoniae, or other pathogens. The authors' results illustrate a novel adaptation of in situ DNA hybridization techniques, usually used for viruses, to the detection of a bacterial organism. The method enables direct visualization of bacterial nucleic acid in infected tissues and may facilitate early diagnosis and treatment of legionellosis.

Intrahepatic biliary cysts in congenital biliary atresia.

A case of pronounced cystic dilatation of the intrahepatic bile ducts with biliary atresia is presented. Intrahepatic biliary cysts have been described in biliary atresia, although, as far as we are aware, none as extensive as in this case. The cysts represent end-stage obstruction with irreversible liver injury; thus, drainage of these cysts does not alleviate the condition. The differential diagnosis includes Caroli's disease, congenital hepatic fibrosis, and polycystic liver disease.