Massive localized lymphedema with unusual presentations: report of 2 cases and review of the literature.

Massive localized lymphedema is a benign soft tissue lesion that usually presents as a large mass in morbidly obese adults. The diagnosis may be challenging as it can mimic other lesions, including well-differentiated liposarcoma. We report 2 cases of massive localized lymphedema with unusual presentation. The first case is a recurrent massive localized lymphedema in the right thigh of a 40-year-old morbidly obese woman. In addition to typical massive localized lymphedema features such as prominent edema and vascular proliferation in the adipose tissue, we observed prominent and abundant multinucleated stromal floret-like giant cells, arborizing network of capillaries, and areas of hyalinized collagen. Our second case is in a rare location (scrotum extending into penile soft tissue) in an overweight 55-year-old male. This lesion exhibits striking smooth muscle hyperplasia. Lack of staining by antibodies against murine double minute 2 protein and cyclin dependent kinase 4 and absence of high mobility group AT- hook 2 transcription factor rearrangement by fluorescence in situ hybridization support our diagnosis of massive localized lymphedema in both cases.

The many faces of pheochromocytoma.

OBJECTIVE: To recognize and manage pheochromocytomas in unusual settings. METHODS: Three case reports are presented with clinical, biochemical, imaging, and operative findings. The pitfalls in diagnosis of pheochromocytomas and management are addressed. RESULTS: We begin with a 27-yr-old gravida 2, para 1 Caucasian woman with unexplained tachycardia and hypertension during a routine pre-natal visit at 30 weeks estimated gestational age. Urinary studies revealed elevated catecholamines. Magnetic resonance imaging localized a 6.6-cm right adrenal mass with features consistent with a pheochromocytoma. She was medically managed with phenoxybenzamine and propranolol until 35 weeks, after which she underwent a combined Cesarean section, and open right adrenalectomy. Another patient, a 36-yr-old African-American woman presented to a hospital in cardiac arrest, with elevated serum troponins, and underwent cardiac catheterization, which revealed normal coronary arteries. A computed tomography (CT) scan revealed a left adrenal mass and CT-guided biopsy was consistent with a pheochromocytoma, although prior studies were negative. Finally, we present a 49-yr-old Caucasian woman who had a right adrenalectomy 10 yr prior and presented to the clinic with fluctuating blood pressures, headaches, and palpitations. Further testing revealed she had a recurrent metastatic pheochromocytoma. The challenges behind treating these patients are further explored. CONCLUSION: Antenatal diagnosis of pheochromocytoma, though challenging, is associated with lower maternal and fetal morbidity and mortality. The differential diagnosis for cardiac arrest in the presence of normal coronary arteries should include a pheochromocytoma. Finally, treatment with iodinated metaiodobenzylguanidine may be a therapeutic option for those patients with metastatic pheochromocytomas.

Nonsurgical delay of dorsal rat cutaneous flap using a long-pulsed 1064-nm Nd:YAG laser with a contact cooling device.

BACKGROUND: This study evaluated the efficiency of a long-pulsed neodymium:yttrium-aluminum-garnet laser, operating at 1064 nm and equipped with a contact cooling device, in the delay of a caudally based dorsal rat skin flap (10 x 3 cm). This laser has deeper tissue penetration and has not been used for this purpose before. METHODS: Twelve male Sprague-Dawley rats were used in each of six groups. The delay effects of three different laser treatment patterns (only longitudinal borders, cephalic and longitudinal borders, and entire surface of the 10 x 3-cm flap) were compared with an acute untreated control flap as well as two surgical delay methods (incision of longitudinal borders and incision of longitudinal borders plus flap undermining). The laser effects on the cutaneous vasculature and perfusion were assessed by intravenous fluorescein injection, histologic study, microangiography, and in vivo real-time video monitoring. RESULTS: Selective thermocoagulation of subdermal vessels was achieved using a 6-mm spot, 140-J/cm fluence, and 40-msec pulse width. In the cephalic and longitudinal borders laser-treated group, a delay effect was achieved. The maximum delay effect was achieved by the surgical delay group that used the method of incision of the longitudinal borders plus flap undermining. Laser treatment of only the longitudinal borders did not improve flap survival, whereas treatment of the entire flap surface significantly reduced flap survival. CONCLUSION: Nonsurgical delay of a dorsal rat cutaneous flap is possible by selective occlusion of the subdermal plexus at the longitudinal and cephalic borders of the planned flap using a long-pulsed 1064-nm neodymium:yttrium-aluminum-garnet laser equipped with a contact cooling device.

Comparison of ThinPrep and conventional smears in detecting carcinoma in bile duct brushings.

BACKGROUND: Bile duct brushing cytology is a common procedure for the exclusion of adenocarcinoma in the bile duct. The authors evaluated the use of ThinPrep (TP) to determine whether the information obtained is equivalent to that found with conventional smear cytology (CS). METHODS: Thirty-eight prospectively collected endoscope retrograde cholangiopancreatography-guided bile duct brushing samples were split in the following manner. First, two to four CS were prepared and immediately spray-fixed or wet-fixed. Second, the remaining sample was rinsed in PreservCyt (Cytyc Corp., Boxborough, MA). In the laboratory, one TP slide was prepared from each sample. TP and CS were stained by routine Papanicolaou stain. For the current study, TP and CS were reviewed independently by two cytopathologists. The diagnoses made by the two methods were compared with the final histology. RESULTS: The cytologic diagnoses for both TP and CS were categorized into five main groups: 1) unsatisfactory, 2) negative, 3) reactive, 4) suspicious for malignancy, and 5) malignant. The diagnoses on the 38 TP bile duct brushings and CS were categorized as follows: 1) unsatisfactory-2, 4; 2) negative-7, 4; 3) reactive-10, 14; 4) suspicious for malignancy-9, 9; and 5) malignant-10, 7, respectively. Histologic follow-up was available in 14 cases (reactive-4, suspicious for malignancy-1, and malignant-9). The sensitivity was 77% for TP and 66% for CS. The specificity was 100% for both methods. CONCLUSIONS: The two methods described in the current study detected equivalent disease on bile duct brushings. TP was found to provide better preservation and cytologic detail. However, the diagnostic criteria may require modification.

Symptomatic nephrogenic metaplasia of ureter: a morphologic and immunohistochemical study of four cases.

Nephrogenic metaplasia of the bladder and urethra has been the subject of extensive studies in recent years. However, information about ureteral involvement is still limited because of the rarity of the lesion. We described four cases of nephrogenic metaplasia of the ureter. They occurred in two men and two women whose ages ranged from 46 to 69 years. Three patients had stones, and one had multiple episodes of cystitis and chronic pyelonephritis. The lesions led to ureteral obstruction that in two patients was radiographically suspicious for carcinoma. Microscopically, three lesions were composed of tiny mucin-containing microcysts and medium-sized tubular structures lined by cuboidal cells that showed cytologic atypia characterized by enlarged vesicular nuclei and prominent nucleoli. However, there were no mitotic figures. Two lesions invaded the full thickness of the wall of the ureter and exhibited an infiltrative growth pattern highlighted by cytokeratin stains. The remaining two lesions were confined to the lamina propria. The cells of nephrogenic metaplasia were immunoreactive to cytokeratin 7 and AE1-AE3. They lacked reactivity for monoclonal and polyclonal CEA and p53. The MIB-1-labeling index was <5%. The cytologic atypia and infiltrative growth pattern of ureteral nephrogenic metaplasia should not be misinterpreted as evidence of malignancy. All four patients are alive and symptom free 8 months to 7 years after diagnosis.

Diagnostic utility of the HepPar1 antibody to differentiate hepatocellular carcinoma from metastatic carcinoma in fine-needle aspiration samples.

BACKGROUND: The cytopathologic distinction between hepatocellular carcinoma (HCC) and metastatic carcinoma (MC) in the liver can be problematic, especially in patients with poorly differentiated HCC, in whom a trabecular pattern, bile production, and Mallory bodies may not be apparent on small fine-needle aspiration (FNA) samples. HepPar1 (OCH1E5) is a monoclonal antibody specifically developed to react with hepatocytes. It rarely reacts with bile duct and nonparenchymal liver cells. METHODS: FNA samples (cell blocks) from 75 liver tumors were selected. These included 50 moderate to poorly differentiated HCC cases, 5 cholangiocarcinoma (CC) cases, and 20 MC cases (4 from the breast, 4 from the stomach, 4 from the pancreas, and 8 from the colon). Immunohistochemical staining for HepPar1 was performed to differentiate HCC from MC. RESULTS: The HepPar1 antibody was positive in 50 of 50 HCC cases (100%). The positivity was cytoplasmic, diffuse, and granular. All 5 cases of CC were found to be negative (0%). Although focal positivity within tumor cells was noted in one case, cytologically these were entrapped normal hepatocytes between the tumor cells. In addition, 3 of 20 MC cases (15%) also were positive for HepPar1. All three cases originated from gastric primary tumors and exhibited diffuse, granular cytoplasmic staining. CONCLUSIONS: The results of the current study demonstrate that HepPar1 is an effective marker with which to differentiate between HCC and CC and/or MC. HepPar1 was found to demonstrate 100% positivity in HCC cases, compared with 0% and 15% positivity, respectively, in CC and MC cases. In addition, HepPar1 is extremely helpful in limited tissue samples from FNA. Although 15% of the MC cases in the current study were found to be positive, with the help of clinical correlation and other immunohistochemical stains a definite diagnosis could be rendered. Potential pitfalls include residual benign hepatocyte staining within a non-HCC malignancy, as was observed in one of the CC cases in the current study.