Ileocaecal junction carcinoma: a clinicopathological study of 199 cases.

AIM: The ileocaecal junction (ICJ) region is an epithelial transition zone in which carcinomas are frequently diagnosed. However, it is currently unknown whether ICJ carcinomas (ICJ-CAs) have distinctive features. This study aimed to characterize the clinicopathological features of ICJ-CAs. METHOD: All ileal and colorectal resections for carcinoma, performed in Calgary, Canada between January 2009 and June 2012, were reviewed. Carcinomas in which the epicentre was within 5 cm of the ileocaecal valve (ICV) were defined as ICJ-CAs. Of 1003 carcinomas studied, 199 (19.8%) were ICJ-CAs, including 93 (9.3%) that crossed the ICV. Comparison of clinicopathological features with carcinomas of the other ileo-colorectal regions was made. Survival was also assessed. RESULTS: Clinically, ICJ-CAs were more common in female than male patients (56.3% female) compared with left-colonic (42.9% female) and rectal (37.9% female) carcinomas, and were more common in older age-groups of patients (71.8 ± 12.7 years) compared with appendiceal (62.6 ± 11.3 years), left-colonic (69.4 ± 12.3 years) and rectal (67.1 ± 11.9 years) carcinomas. Macroscopically, ICJ-CAs were similar to other colorectal carcinomas and were mostly described as ulcerated (63.3%). Histologically, ICJ-CAs had more mucinous, signet-ring cell and/or neuroendocrine features (39.7%, 8.0% and 7.5%, respectively) than did carcinomas of the left colon (16.8%, 1.6% and 1.1%, respectively) and the rectum (14.1%, 1.0% and 0.0%, respectively). They were higher grade (20.1% were high grade) than those of the left-colon (10.3%) and the rectum (9.8%). ICJ-CAs presented at a higher T-stage (25.6% were T4) compared with rectal carcinomas (11.6%). Most significantly, ICJ-CAs presented at a higher N-stage (25.6% were N2) than did right-colonic (14.1%) and rectal (16.2%) carcinomas. Although survival of patients with ICJ-CAs did not differ from those with right-colonic carcinomas, those with carcinomas directly involving the ICV did show a significantly decreased survival. CONCLUSION: ICJ-CAs display several distinct clinicopathological features that may require special diagnostic, prognostic and management attention.

Herpes simplex virus type II infection of ileum mesothelium: a case report and review of the literature.

Disseminated herpes simplex virus (HSV) infection usually manifests in the immunocompromised. However, anecdotal examples of visceral HSV disease and viremia have complicated type I diabetes. A case of a 53-year-old type I diabetic patient with bowel obstruction one week subsequent to bronchitis is reported. At laparotomy, a perforated segment of ileum was associated with an adhesive peritoneal band. HSV cytopathic atypia and HSV immunohistochemical staining were confined to fibrocytes and mesothelial cells without involvement of the epithelium. Dissemination of symptomatic HSV pneumonia was verified by histology, immunohistochemistry, in situ hybridization, polymerase chain reaction and direct fluorescence antibody. Intravenous acyclovir resolved symptoms. This is a novel documentation of HSV complicating ileal adhesive band disease. Furthermore, this case indicates that the HSV cytopathic effect is not unique to the epithelium. Disseminated infection can manifest in myofibrocytes and mesothelium, distinguishing it from standard epithelial atypia of localized HSV infection.

Acute acalculous cholecystitis--a clinical-pathological disease spectrum.

OBJECTIVE: To assess the influence of disease setting on clinical and pathological features of acute acalculous cholecystitis (AAC). DESIGN: Analysis of prospectively accumulated clinical data. Blinded histopathological review. LOCATION OF STUDY: Tygerberg Hospital, Western Cape. PATIENTS: Fifty-seven consecutive patients with AAC treated over a 9-year period. MAIN OUTCOME MEASURES: Clinical, ancillary and pathological features of AAC in each of 3 arbitrarily designated types. Type I (N = 24) occurred in patients hospitalised for trauma or critical illness. Patients with type II disease (N = 20) presented primarily with symptoms of acute cholecystitis. Type III AAC (N = 13) was associated with non-calculous gallbladder outflow obstruction. RESULTS: Type I AAC was associated with the highest mortality rate (45.8%), occurred predominantly in males (75%) and was diagnosed pre-operatively in 50% of patients. Acute ischaemic cholecystitis was the most frequent histological diagnosis (66.7%). Only 1 death (5%) was associated with type II AAC despite patients being older, and all but 2 patients (10%) having chronic underlying disease. Acute cholecystitis was diagnosed pre-operatively in 90% of patients. Thirteen patients (65%) were males. Acute-on-chronic cholecystitis was the most frequent histological diagnosis (50%), followed by acute ischaemic cholecystitis in 30%. Type III was associated with an intermediate mortality rate (23.1%) and was the type most seldom diagnosed pre-operatively (15.4%). Histological findings reflected the nature and duration of underlying obstructive pathology. CONCLUSION: The circumstances in which AAC occurs appear to be associated with distinct clinical-pathological variants of the disease. Their recognition could serve to enhance understanding of this challenging condition.

Gastric dysplasia: inter-observer variation, sulphomucin staining and nucleolar organizer region counting.

Gastric dysplasia is regarded as a pre-neoplastic lesion and is generally believed to have higher potential for malignant transformation with increasing grade. To obtain consistency in diagnosis and management, reproducible diagnostic criteria are needed. We have used the classification system of the International Study Group on Gastric Cancer--ISGGC and investigated the interobserver variation in histological diagnosis. A Kappa statistic of 0.579, which reflects moderate agreement, was obtained for variation between two experienced pathologists. The prevalence of type III intestinal metaplasia was studied and found to occur in 55% of dysplastic areas, but in only 9% of hyperplastic areas (P less than 0.01). In addition, the correlation of mean nucleolar organizer region (AgNOR) counts with diagnostic categorization was investigated. A significant inter-observer variation was found between an experienced pathologist and a postgraduate student and only one of the observers obtained statistically significant separation of mean AgNOR counts between the categories of high-grade dysplasia, low-grade dysplasia, atypical hyperplasia, simple hyperplasia and normal.

c-erbB-2 oncogene product staining in gastric adenocarcinoma. An immunohistochemical study.

The c-erbB-2 oncogene has been shown to be amplified in a variety of human adenocarcinomas. Antibodies to the protein product, p185, have been used for immunostaining of paraffin-embedded material, and have demonstrated that high levels of c-erbB-2 protein expression correlate with gene amplification under certain conditions. In studies by others, amplification has been demonstrated in 40 per cent of tubular type adenocarcinomas of the stomach, and an immunohistochemical study on frozen tissue has demonstrated staining in 3 out of 10 cases. Our study, using paraffin-embedded material, demonstrates staining in 19 per cent of 126 cases using a polyclonal antibody. Of the positive cases, 75 per cent were tubular or papillary type (P less than 0.025), and prominent staining was restricted to this group. Three cases showed well-defined positive areas in keeping with clonal expression of p185. No specific staining of normal or dysplastic epithelium adjacent to the carcinomas was found.

Benign prostatic hyperplasia and uterine leiomyomas in a female pseudohermaphrodite: a case report.

A 60-year old female pseudohermaphrodite with congenital adrenal hyperplasia presented with acute retention of urine and a lower abdominal mass. At laparotomy a large uterus with multiple leiomyomas was removed. Transurethral resection of the obstructing bladder neck revealed benign prostatic hyperplasia. This patient demonstrates that benign prostatic hyperplasia may develop in the presence of androgens from an extratesticular source.

Papillary eccrine adenoma. A tubulopapillary hidradenoma with eccrine differentiation.

A slow-growing tumor on the dorsum of the right foot of a 25-year-old female had features that corresponded to papillary eccrine adenoma. The grouping of this entity under the term "tubular apocrine adenoma" in a recent edition of a textbook led to further study of this case in the form of enzyme histochemistry and electron microscopy. The tumor was positive for amylophosphorylase and negative for acid phosphatase, and on electron microscopy showed complex intercellular membrane interdigitation and a possible intercellular canaliculus. No features of apocrine differentiation were found, and we feel that this tumor is distinctly eccrine in its differentiation. The similarity of these two ostensibly separate entities, and the opinion of some authors that intermediate differentiation may be possible in adnexal tumors, would favor them being grouped under the single term of "tubulopapillary hidradenoma," with apocrine or eccrine differentiation as the case may be.

The bleeding gastric ulcer--will it bleed again, and if so, why? A case for repeat endoscopy in evaluating stigmata.

Nine patients qualified for surgery for a bleeding gastric ulcer--all had a 'visible vessel'. Three of these vessels were thrombosed including 2 in patients who had been in shock. The smallest patent vessel was 0,35 mm in diameter, and 6 of the bleeding vessels were subserosal. The features thought to predispose to further bleeding were vessel size, a lateral hole in the main trunk of the vessel and, possibly, previous recanalization or ingestion of a drug which affected haemostasis. Five of 6 patent arteries had a cap of thrombus over the breach forming a false aneurysm. It is suggested that clinically these should pulsate, enlarge, leak--with persistent fresh thrombus in the ulcer crater on repeat endoscopy--and finally rupture. Where the underlying vessel is thrombosed the stigmata of a non-pulsatile 'visible vessel' or thrombus in the ulcer should disappear on repeat endoscopy. The sizes of the arteries in the normal antrum are tabulated.