Subcutaneous abscess due to gallstones lost during laparoscopic cholecystectomy.

No complications caused by gallstones lost during laparoscopic cholecystectomy have yet been described in the literature. In one animal study in rats, it has been shown that pigment calculi, but not cholesterol stones, lead to severe local inflammation of the abdominal cavity. We present a case of a chronic subcutaneous and subfascial abscess in the lower abdomen, which included multiple pigment calculi, six months after laparoscopic cholecystectomy. During the procedure, multiple small pigment calculi had been lost into the free abdominal cavity.

Fine needle aspiration cytodiagnosis of subacute (de Quervain's) thyroiditis in an endemic goitre area.

Between 1977 and 1989 252 fine needle aspirates (FNAs) of the thyroid from patients with a clinical suspicion of subacute granulomatous (de Quervain's) thyroiditis were examined in the Department of Pathology of the University of Innsbruck, Austria. In the same period 31 cases with preoperative FNA were diagnosed histologically as subacute thyroiditis. Only in three of these cases were the cytological features of de Quervain's thyroiditis found in the preoperative FNA. However, in 13 of these 31 cases a cytological suspicion of malignancy was obtained. Subsequent histological examination revealed an acute phase inflammation of de Quervain's thyroiditis in most of these cases. We conclude that an accurate FNA diagnosis of de Quervain's thyroiditis, particularly in the acute stage, may cause difficulties due to a lack of typical features and the appearance of atypical thyroid follicular cells. For the cytopathologist, accurate clinical information relating to the possibility of de Quervain's thyroiditis is essential if unnecessary surgery is to be avoided.

Immunohistochemical comparison of chromogranins A and B and secretogranin II with calcitonin and calcitonin gene-related peptide expression in normal, hyperplastic and neoplastic C-cells of the human thyroid.

Normal and hyperplastic thyroid C-cells and 14 cases of medullary thyroid carcinoma were investigated immunohistochemically with antibodies against chromogranins A and B, secretogranin II, calcitonin and calcitonin gene-related peptide (CGRP). Normal and hyperplastic C-cells showed strong calcitonin and chromogranin A immunoreactivity whereas CGRP, chromogranin B and secretogranin II expression was less intense. Strong calcitonin and chromogranin A immunoreactivity was also found in the majority of tumour cells in medullary thyroid carcinoma. The CGRP, chromogranin B and secretogranin II staining observed was present in variable patterns. In some cases CGRP, chromogranin B and secretogranin II could only be demonstrated in isolated tumour cells with elongated processes suggestive of neuronal differentiation of these cells. The biological function(s) of the chromogranins/secretogranins remain(s) still unclear. There is evidence that these proteins are pro-peptides which give rise to functionally active compounds. Studies on normal C-cells and medullary thyroid carcinoma may elucidate the role of chromogranins/secretogranins in endocrine and neuronal cells.

CA 19-9 expression in subacute (de Quervain's) thyroiditis: an immunohistochemical study.

Carcinoma antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) expression was immunohistochemically investigated in 48 cases of subacute granulomatous (de Quervain's) thyroiditis, two of focal lymphocytic thyroiditis, three of Hashimoto's thyroiditis, two of Graves' disease, and seven follicular adenomas, 27 follicular carcinomas, and eight papillary carcinomas of the thyroid. CA 19-9 expression was found in all cases of subacute thyroiditis, lymphocytic thyroiditis, and papillary carcinomas examined and in approximately 50% of follicular adenomas and carcinomas. The strongest CA 19-9 staining was demonstrated in late stage subacute thyroiditis and in papillary carcinomas with marked sclerosis. Occasionally CA 19-9 expression was present in seemingly normal thyroid parenchyma adjacent to the thyroid lesions investigated. CEA was found in the center of the granulomatous lesions in acute stage subacute thyroiditis. All neoplasms were CEA negative. CA 19-9 and CEA could be demonstrated occasionally in multinucleated giant cells of subacute thyroiditis, which may suggest that these giant cells are of either histiocytic or follicular cell origin. Immunohistochemical investigation with antibodies against CA 19-9 and CEA may help to histomorphologically define subacute granulomatous thyroiditis.

Metastatic tumors in fine needle aspiration biopsy of the thyroid.

A series of almost 25,000 thyroids examined by fine needle aspiration (FNA) biopsy was reviewed to ascertain the incidence and presentation of metastatic cancers in thyroid FNA samples. Metastatic cancers in FNA samples from the thyroid were identified in 25 cases (0.1%); the primary tumors were carcinomas of the kidney (8 cases), lung (7 cases), breast (5 cases), cervix uteri (1 case) and colon (1 case) and 1 case each of malignant melanoma, malignant pleural mesothelioma and rhabdomyosarcoma. FNA cytology was positive in all 25 cases. In 11 cases, the primary tumor was clinically known at the time of FNA biopsy; of the other 14 cases, cytology suggested that the malignancy was metastatic in only 5. Metastases of renal and mammary adenocarcinomas were almost indistinguishable from follicular and papillary thyroid carcinomas on cytologic grounds. The results demonstrate the rarity of this finding and the difficulty of diagnosing a metastatic tumor in the thyroid by FNA biopsy, in the absence of a clinical history of a prior primary neoplasm.

[Tumor recurrence at the neck in papillary thyroid gland cancer. A statistical analysis of the recurrence probability after radical surgery]. / Das Tumorrezidiv am Hals nach papillärem Schilddrüsenkarzinom. Eine statistische Analyse zur Rezidivwahrscheinlichkeit nach Radikaloperation.

308 cases of papillary thyroid carcinoma (82.6% of our patients operated on between 1952 and 1987) who had undergone potentially curative surgery were analysed postoperatively. The follow-up ranges from 1 month to 29.4 years (median 4.58 years). In 32 cases (10.4%) a cervical tumour recurrence (local recurrence and/or cervical lymph nodes) was found. 8 of these are not free of tumour at the end of the follow-up, 6 had died of thyroid carcinoma (case fatality rate 18.8%, mortality rate 66.7%, in the entire material 2.9% and 29.0% respectively). The cumulative recurrence rate is 9.98% after 5 years and 16.98% after 10 years. A statistical analysis of the probability of recurrence was carried out only for patients who could be followed at least 5 years or those who died within 5 years. Age, sex, stage of tumour and histological criteria were taken into account as statistical variables. The state of cervical lymph nodes, the differentiation of the tumour and the patients' sex turned out to be determining factors for tumour recurrence after 5 years. In order to improve the recurrence rate a differentiated surgical radicality, depending on the above mentioned variables, is recommended.

Surgical aspects of diseases of the thyroid gland in childhood.

The treatment of juvenile struma is the domain of the pediatrician, and operations are rarely necessary, even in struma-endemic regions. An absolute indication for surgery is diagnosed or suspected struma maligna: relative indications are hyperthyroidism and euthyroid goiter. The operative procedure in benign thyroid diseases is based on the pathogenesis: a tissue-saving technique is mandatory to prevent postoperative hypothyroidism. Therapeutic strategy in malignant diseases, i.e., the radicality of surgical and postoperative management, depends, as in adults, on the prognostic relevance of variable parameters.

Chromogranin A and B in parathyroid tissue of cases of primary hyperparathyroidism: an immunohistochemical study.

Routinely processed parathyroid tissues from 26 cases with primary hyperparathyroidism (19 adenomas, 7 multiglandular hyperplasia) and 8 normal human parathyroid glands were investigated with antibodies against chromogranin A and B and parathyroid hormone (PTH). Normal parathyroids were immunohistochemically positive for PTH and chromogranin A but negative for chromogranin B. Hyperplastic glands showed a focal staining for PTH and chromogranin A without correlation of the staining pattern on serial sections. Adenomas were either uniformly positive for both PTH and chromogranin A or showed a staining pattern similar to that seen in hyperplastic glands. Focal chromogranin B positivity (less than 10% of cells) was found in 3 cases (1 hyperplastic gland and 2 cases of parathyroid adenoma with an immunohistochemical staining pattern similar to hyperplastic glands). Our immunohistochemical results may support previously published findings that most parathyroid adenomas are monoclonal neoplasms whereas hyperplastic glands are of polyclonal origin.

[The thyroid gland scintigram. A decision aid for the surgical approach in thyroid gland diseases?]. / Das Schilddrüsenszintigramm. Eine Entscheidungshilfe für die Operationstaktik bei Schilddrüsenerkrankungen?

For the operative proceeding thyroid scintiscan seems widely dispensable in many routine cases as it leads neither to a different operative strategy nor to an improvement of surgical results. In a few selected cases, however, operative proceeding is determined by scintigraphic results. Thus the question of the importance of scintigraphic methods for thyroid diagnostics and therapy as well as for the selection of patients for surgery cannot be answered and must be subject of a separate examination.

[Malignant hemangioendothelioma of the thyroid gland. Pathology, clinical aspects and prognosis]. / Das maligne Hämangioendotheliom der Schilddrüse. Pathologie, Klinik und Prognose.

Malignant hemangioendothelioma (MHE) of the thyroid still constitutes a relatively important part of our surgical material, with 23 MHE (2.0%) among 1153 primary thyroid tumors diagnosed between 1952 and 1987 (biopsy material of the Innsbruck Pathology Institute). 18 of these cases were investigated immunohistochemically; in 14 cases the data on clinical findings and follow-up were complete. Immunohistochemical results confirm the endothelial origin of this tumor and allow MHE to be definitively distinguished from anaplastic carcinomas. Follow-up and prognosis are determined by the aggressive nature of local tumor spread. 13 patients died after a median survival period of 2.4 months (R: 1.2-9.4). Only one patient has remained alive since over 4 1/2 years now. An improvement of the hitherto dismal prognosis is thought to depend on early tumor diagnosis and an ameliorated combined modality treatment.

Malignant hemangioendothelioma of the thyroid. Its immunohistochemical discrimination from undifferentiated thyroid carcinoma.

Eighteen cases of malignant hemangioendothelioma (MHE) of the thyroid and 16 cases of undifferentiated thyroid carcinoma were investigated immunohistochemically with antibodies against endothelial cell specific markers (factor VIII-related antigen, BMA 120, blood group isoantigens, Ulex europaeus agglutinin I), thyroglobulin, and the intermediate filament proteins vimentin and cytokeratin. All MHE were positive for factor VIII-related antigen and vimentin, in 14 of 18 cases for BMA 120, and in 9 of 18 cases for U. europaeus. All other markers were negative in MHE. Endothelial cell specific markers were commonly negative in undifferentiated carcinomas with one exception (one case was moderately positive for U. europaeus). Twelve of 16 undifferentiated carcinomas showed vimentin positivity, and 8 of 16 showed cytokeratin positivity. Four cases showed a vimentin/cytokeratin coexpression. It is concluded that the endothelial origin of MHE can be shown by certain endothelial cell markers in almost all cases.

Fine needle aspiration cytodiagnosis of anaplastic carcinoma and malignant haemangioendothelioma of the thyroid in an endemic goitre area.

Between 1970 and 1987, 20,028 fine needle aspirates (FNA) of the thyroid have been examined in the Department of Pathology of the University of Innsbruck, Austria. During this period 92 cases of anaplastic carcinoma and 16 cases of malignant haemangioendothelioma (MHE) of the thyroid were diagnosed. Forty-three out of these 108 highly malignant tumours of the thyroid underwent FNA pre-operatively (39.1%). Thirty-seven FNA contained numerous cells of a highly malignant tumour. Five specimens (11.8%) contained only necrotic material and inflammatory cells. In one case of an anaplastic carcinoma no malignant cells could be demonstrated in FNA. We conclude that pre-operative FNA of highly malignant thyroid tumours may contribute substantially to subsequent clinical management.

Frequency of medullary thyroid carcinoma in an endemic goiter area.

A series of 41 poorly differentiated follicular carcinomas of the thyroid gland without histopathological features of medullary or papillary carcinoma and 9 cases of undifferentiated thyroid carcinoma of the small cell type (diagnosed between 1967 and 1983) were investigated immunohistochemically. Two poorly differentiated follicular carcinomas showed a considerable number of calcitonin-positive cells in addition to the weakly thyroglobulin-positive tumor cells. One of these cases revealed several areas with calcitonin-positive tumor cells with additional squamous metaplasia with keratinization. No medullary carcinomas could be demonstrated among the 9 cases previously diagnosed as undifferentiated thyroid carcinomas of the small cell type. From the epidemiological point of view the application of immunohistochemistry does not significantly increase the proportion of medullary carcinomas detected in our endemic goiter area. The incidence of medullary carcinoma remains surprisingly low when compared with nonendemic areas.

Clinicopathologic management of tumors of the thyroid gland in an endemic goiter area. Combined use of preoperative fine needle aspiration biopsy and intraoperative frozen section.

In total, 15,325 fine needle aspiration (FNA) biopsies of the thyroid were examined in the Department of Pathology of the University of Innsbruck, Austria, between 1976 and 1985, with the cytologic results histologically verified in 3,112 cases. Since (1) it is frequently impossible to distinguish benign from malignant encapsulated follicular thyroid tumors by cytologic criteria and (2) there is a high level of follicular thyroid carcinoma in our endemic goiter area, we have adopted a diagnostic strategy that accepts a high percentage of false-positive cytologic results in order not to miss highly differentiated follicular carcinoma. To avoid unnecessarily extensive surgical treatment, 1,079 intraoperative frozen section examinations of the thyroid were performed in the same time period in (1) patients with preoperative suspicious or positive FNA cytologic findings, (2) cases with suspicious clinical and anamnestic data and (3) tumors with a suspicious macroscopic appearance without preoperative FNA or with negative or unsatisfactory cytologic findings. In 48 cases (4.5%), the frozen section diagnosis had to be revised after examination of paraffin-embedded tissue. An intraoperative false-positive diagnosis was obtained in 3 cases (0.3%) while a false-negative diagnosis was made in 45 cases (4.2%). The main effort in examining frozen sections should be concentrated on avoiding false-positive errors, which can lead to unnecessary thyroidectomies.

Papillary carcinoma of the thyroid gland. Analysis of 94 cases with preoperative fine needle aspiration cytologic examination.

From 1979 to 1983, 94 papillary carcinomas of the thyroid gland were examined histologically in our institute after a preoperative cytologic examination. Material for cytologic examination was obtained using fine needle aspiration (FNA) biopsy. Eighty-five (90.4%) of the 94 examined cytologic smears were representative. Among these 85 cases suspicion for malignancy or malignancy itself was found in 64 cases (75.3%). The remaining 21 smears, classified as cytologically not as suspect for malignancy, were reclassified and the previous diagnosis had to be revised in one case. In the other 20 cases no clue for malignancy could be demonstrated even after reexamination. In the 85 cases with representative cytologic findings, tumor size was determined on surgical material, in order to establish how many carcinomas with a diameter less than 3 cm could not be reached by FNA biopsy. Except for one case, all carcinomas with negative preoperative cytologic findings had a diameter less than or equal to 3 cm. The question arising is the possibility of improving the accuracy of FNA biopsy in tumor detection within cold nodules of the thyroid by combined use of scintigraphy and ultrasound-guided FNA biopsy.

Small cell carcinoma of the thyroid. A reclassification of cases originally diagnosed as small cell carcinomas of the thyroid.

99 cases of undifferentiated carcinomas of the thyroid and nine cases of primary malignant Non-Hodgkin lymphomas of the thyroid were examined from 1967 to 1983 in our institute. Among the undifferentiated carcinomas nine cases were classified as small cell subtype. Over the years, the histopathological handling in regard to small cell subtype of undifferentiated carcinoma and primary malignant Non-Hodgkin lymphoma has changed. The frequency of primary malignant Non-Hodgkin lymphoma has increased conspicuously in the last few years, whereas the number of small cell carcinomas decreased. A reclassification, based on immunohistochemical investigation for tumor markers of the nine cases originally diagnosed as small cell carcinomas from 1967 to 1983 revealed that five cases were poorly differentiated carcinomas or undifferentiated carcinomas of the spindle cell type. In three cases the primary diagnosis had to be revised into malignant Non-Hodgkin lymphoma of the diffuse "histiocytic" type. The postmortem examination of the patient with the remaining small cell carcinoma "of the thyroid" revealed a clinically undetected small cell carcinoma of the lung with metastases to the cervical lymph nodes and the thyroid gland. These findings are in agreement with the results of several recently published papers indicating that true small cell carcinoma of the thyroid must be a very rare tumor.

A fourteen year practice with the fine needle aspiration biopsy of the thyroid in an endemic area.

In our institute from 1970 to 1983 12,829 fine needle aspiration biopsies (FNB) of the thyroid were cytologically examined. Cytologically unsatisfactory specimens were found in 17.7%. 2,709 patients with representative cytological findings were operated and histological examinations were performed. The cytological and histological findings were correlated. There was a false-negative rate of 2.0% and a false-positive rate of 18.4%. Furthermore we divided the results into two time periods (1970-1977 and 1978-1983) because of a change in the indication for surgery in the last years. Although the indication has changed, cytological findings of both time periods investigated were almost similar.